Heart: An American Medical Odyssey (25 page)

I acknowledged that the vice president had unique medical coverage in that Lew or one of his people was always nearby with an external defibrillator, but I reminded him that there were times when those precautions would be inadequate, for instance, when he was alone in his office or sleeping or showering. The ICD would be a 24/7 internal sentry. I told the vice president that if he received an ICD but never needed it, the decision to place it would still be correct.

Mr. Cheney asked Sung Lee some questions about the procedure itself and device durability, and finally said, “It makes sense.”

•  •  •

Mary Matalin called a few days later to talk about the ICD and how the public announcement would be made. She told me that she cried when the vice president told her what we were planning to do. I reassured her that he was going to do well and that the device would protect him.

The plan was to bring the vice president to George Washington University Hospital early in the morning on Saturday, June 30. She said the vice president was going to make the announcement himself, in the White House briefing room on the Friday before the procedure, and they wanted me to join him there to answer questions from the press.

“That’s a bad idea,” I said.

“The president’s people really want you to do it,” she replied. “You’re going to have to give me something to convince them.”

“Tell them that if I have to field questions before the procedure, I almost certainly will be asked, ‘What can go wrong?’ ”

“What can go wrong?”

“We can put a hole in a lung, or a hole in the heart, or cause severe bleeding,” I responded. “After the procedure on Saturday, when there are no complications, no one will ask us what could have happened but didn’t.”

“Done,” Mary said.

•  •  •

Instead of having me answer questions prior to the procedure, the White House released a statement I wrote. In it, I described the findings on the Holter monitor that prompted this procedure and stated that we were going to first do a test to verify that the vice president was indeed at risk, and if the test was abnormal, the vice president would receive an ICD:

The electrophysiology study scheduled for June 30 involves the analysis of waveforms acquired from wires passed into the heart through the veins accessible at the top of the leg. This test will help assess Mr. Cheney’s future risk of developing a sustained cardiac arrhythmia and determine if an implantable cardioverter defibrillator should be placed during the same procedure. An implantable cardioverter defibrillator (ICD) is a small electronic device, roughly the size of a small pager, weighing less than 80 grams, that is placed under the skin of the upper chest and has the capacity to continuously monitor and analyze a patient’s heart rhythm. The ICD’s main function is to interrupt rapid heart rhythms. If the ICD detects an arrhythmia, it can terminate the abnormal rhythm with either a pacemaker function or the delivery of a low-energy electrical shock. The device, which is designed to last 5–8 years before needing replacement, is placed with the aid of local anesthesia and intravenous sedation. Patients are usually discharged from the hospital later the same day and may return to work the next day.

Vice President Cheney’s motorcade arrived at George Washington University Hospital early the next day, and we escorted him to the cath lab, where Sung Lee again reviewed the planned procedure, as well as its risks and alternatives, and the vice president signed the informed consent.

Sung was a graduate of the Medical College of Virginia and had completed a residency in internal medicine at the University of Maryland
before spending four years as a research fellow at the National Institutes of Health. I was a few years ahead of Sung when he came to do his fellowship at George Washington University Hospital and was glad that he accepted a job with our group when he finished his training. He is a smart, easygoing guy with a warm spirit, but in the electrophysiology (EP) lab he is all business.

I’d sat down to talk with Sung the day before Cheney’s procedure because he looked uncharacteristically nervous.

“What are you worrying about?” I asked.

“The press conference,” he said a little sheepishly.

“The press conference?” I said, laughing. “I’ll take care of that; you just concentrate on not killing the vice president.”

With the vice president asleep on the examination table, Sung introduced a catheter into a vein in Mr. Cheney’s leg and maneuvered it to the heart. Without much difficulty, Sung was able to induce ventricular tachycardia by stimulating the heart with three premature impulses, additional evidence that the vice president was prone to this arrhythmia. Outside the hospital, this heart rhythm could lead to death, but in the controlled environment of the electrophysiology lab, Sung quickly terminated the dangerous rapid rhythm.

I picked up a phone in the lab and called the control room on the other side of the glass to tell Alan Wasserman that we had found what we were looking for and Sung was going to implant the ICD. From the table, Sung said he might try to induce the arrhythmia one more time, and when I relayed that to the control room, Alan said, “Tell Sung if he tries to do that again I’m going to have the Secret Service shoot him.” When the laughter subsided, the tension in the room had abated noticeably, no doubt just what Alan had intended.

Sung infiltrated lidocaine under the skin near the vice president’s left collarbone and then made a small incision. A large vein, the subclavian, courses under the collarbone, and Sung promptly found it with a needle. He then passed two thick wires into Cheney’s heart, anchoring one in the right atrium and the second larger lead in the right ventricle.
Sung worked quickly but not hurriedly, and next made a small pocket under the skin for the ICD.

The 2.75-ounce device, less than half the size of a deck of cards and the price of a small Lexus, is the direct descendant of Michel Mirowski’s original invention and a triumph of bioengineering. Inside the smooth, sealed titanium enclosure sits a sophisticated programmable computer for rhythm analysis and treatment customization, a pulse generator for pacing, and capacitors for defibrillation. The battery will last on average about six years, when the entire ICD has to be replaced.

A few days prior to the procedure, before it was announced that we were going to implant a defibrillator in the vice president, I’d asked Sung to acquire an ICD still sealed in its original packaging and lock it away. A manufacturer’s representative typically attends all defibrillator implants and will select a device from a giant bag of mobile inventory at the time of insertion. For this case, however, I thought it would be safer to choose a random ICD before anyone knew for whom it was destined.

Using a special screwdriver, Sung tightened the leads securely into the device before slipping it under the skin. Because the ICD is intended to treat ventricular fibrillation, the only way to know for sure that it will work is to induce the lethal arrhythmia in the lab and watch the device administer a shock. The vice president, who had been groggy but arousable after getting IV sedatives during the procedure, was given a dose of propofol, a short-acting hypnotic that induces sleep very quickly but dissipates rapidly when it is discontinued. With the patient asleep, a programming command was given to the ICD, which a moment later induced ventricular fibrillation.

We looked at the monitor and watched as the vice president’s EKG suddenly changed from its slow, stable rhythm to a fast and chaotic pattern that, left untreated, would kill him in a few minutes. We watched as the ICD recognized the arrhythmia and charged its capacitor. The process took an excruciatingly long fifteen seconds. The device is programmed to check again for the arrhythmia before delivering its energy
and, still detecting it, the ICD delivered a low-energy shock. There was a muffled
pop,
and Vice President Cheney shuddered under the sterile drapes. All eyes turned to the EKG monitor, which demonstrated that Cheney was still in V Fib. The device recharged, and while we waited for the ICD to deliver a higher-energy shock I saw Julia instinctively move closer to the external defibrillator, the backup plan in case the second ICD shock also failed. Again Cheney jerked a little with the shock. This time, the monitor showed that he had been successfully restored to a normal rhythm. Satisfied that the higher-energy setting would defibrillate the vice president, Sung grabbed a needle driver and suture and began to close the small wound as everyone in the room congratulated him on his cool performance. Julia called Sung a “rock star.” I couldn’t agree more.

•  •  •

I waited for Sung to finish, and together we walked over to tell Mrs. Cheney that all was well. The vice president’s family was waiting in a secure area that during the week served as a small postprocedure recovery room, but had been dressed up for the occasion to function as a family lounge with a couch, food, TV, and Internet access. Sung and I were in good spirits when we entered the room, but right away it was apparent that Mrs. Cheney was not.

In 2001, ICD therapy was unknown to most of the public, and even within the cardiology community, it was still very much a cutting-edge technology that had yet to be fully embraced. It’s easy to convince a patient who survives sudden cardiac death of the merit of a small implantable device that can prevent another episode, but it’s a much harder task when the patient seemingly is well. Gary, Sung, Lew, and I had discussed the rationale for our recommendations in depth with the vice president when we met with him earlier in the week, but we had not met with Mrs. Cheney, and I think she clearly still had some questions about the need for the procedure. Now that the device was implanted, Mrs. Cheney was concerned about the safety of
the ICD in the unusual environment in which the vice president lived, worked, and traveled.

Mrs. Cheney had done her homework and knew that ICDs could be affected by electromagnetic interference (EMI). Weak electromagnetic fields are emitted from all electrically powered equipment, but some types of gear emit significantly more EMI, which can mimic ventricular fibrillation and induce the ICD into inappropriately delivering a shock. Medtronic, the manufacturer of the vice president’s new implant, lists antenna and large radio transmission equipment as significant sources of EMI. Mrs. Cheney reminded us that the vice president’s limousine, residence, helicopter, airplane, and the White House itself were filled with high-power radio transmission gear, and she wanted to know how we knew it was going to be safe for her husband.

The truth is I didn’t know. I had been focusing on the treatment algorithm (low ejection fraction + ventricular tachycardia = ICD) but had neglected to fully consider the unique considerations that might accompany this patient’s job. It was a humbling moment, one that I was determined never to repeat.

Sung and I located John Naylor, the representative from Medtronic, who had been present during the implant, and explained Mrs. Cheney’s concerns. John got on the phone, and over the next several days, company engineers swept the vice president’s residence, offices, and vehicles for EMI. To our great relief, they found no areas that would be a safety concern.

The summers in Washington are long, but on this early September morning,
the cooler air and crystalline light offered a whispered promise of the fall to come. I
had an appointment at the White House with Vice President Cheney later in the day, so I
dressed in a dark suit, a bit more formal than usual, and headed off into the dense DC
morning traffic.

It had been about three months since Sung Lee implanted the defibrillator.
Lew Hofmann had arranged for one of the WHMU nurses to draw blood from the vice
president early in the morning and messenger it up to the lab at Bethesda Naval Hospital
that day, so the results would be available when we met with him. We planned to arrive
about fifteen minutes before our 5:00 p.m. appointment and review the labs with Lew
before we saw Cheney.

At 9:00 a.m. a small crowd gathered around a television mounted on a wall
in the hospital’s first-floor radiology waiting room.

“What’s going on?” I asked.

Someone said that a small plane had crashed into the World Trade Center in
Lower Manhattan. I stood with a growing group of patients and staff and watched as smoke
poured from the North Tower.

There is always something happening in New
York
.

I remembered the story of the B-25 bomber that struck the Empire State
Building at the end of World War II. On that day, there had been dense fog in New York,
but on this morning, there wasn’t a cloud in the sky.
A few
minutes later, United 175 hit the South Tower, setting that building ablaze. The crowd
of hospital staff and visitors stood in silence as the buildings burned; there were
screams when they fell.

“Nothing will ever be the same,” I said to no one in
particular.

•  •  •

It wasn’t long before we heard that the Pentagon had also been
hit. From the upper floors of our office building, we could see smoke billow from across
the river, and rumors began to circulate that another plane was headed for DC. The White
House and the Capitol were evacuated, and the streets filled with thousands of people,
some running, all trying to get out of town. I called Charisse and told her to go pick
up the kids from school. Charisse asked me to come home, but I told her that the
hospital had mobilized for casualties, and I was going to stay. Even if I wanted to
leave, there was gridlock everywhere and no way to get out of town.

I heard from Lew in midafternoon. He was with the vice president; they
were okay and soon to be on the move. He told me he would be in touch when he could.

Lew called again later. Despite the chaos of the day, the vice
president’s blood had somehow made it to the lab in Bethesda and the results were
back. The blood had been drawn early in the morning, and after everything that had
happened during the day, I had forgotten all about it. Lew told me that the vice
president’s potassium level was a potentially lethal 6.9.