Heart: An American Medical Odyssey (36 page)

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George Washington University Hospital discontinued its heart transplant program in the 1990s, but over the last several years, our group has collaborated with the advanced heart failure and cardiac transplant program at Inova Fairfax Hospital, about twenty minutes away in Northern Virginia. I asked Dr. Shashank Desai, the director of the program, to join us at GW for a meeting with the vice president to talk about VAD and transplant options.

Desai is an instantly likable, supersmart guy with a big smile and a usually
beautiful suit, who several years before had been recruited from the University of Pennsylvania. Shashank brought along Lori Edwards, an experienced nurse practitioner who was the VAD coordinator at Fairfax.

The meeting on Friday, June 18, 2010, with Mr. and Mrs. Cheney lasted about two and a half hours. Earlier in the week, the vice president had been volume overloaded, and although his breathing was better after the diuretic-induced loss of several pounds of fluid, he still had no energy. I took Cheney’s blood pressure; it was 86/70, much lower than usual.

The vice president’s increased fatigue was likely related to his very low blood pressure, but the more salient matter was that his heart no longer had the capacity to move an amount of blood sufficient to meet his body’s needs. Although Mr. Cheney was sick and getting sicker, there were still a few options remaining, and one of them was heart transplantation.

Shashank described in great detail the evaluation process and the general criteria that define a “transplant candidate.” And at first glance, Cheney appeared to be eligible, but there was one catch: he had to live long enough to get a heart.

Once a person is accepted for transplant, the wait for a donor heart can be anywhere from six months to three years, depending on the blood type and the patient’s level of acuity. At any given time in the United States, about three thousand people are on the wait list for a heart, but annually there are only about two thousand transplants. Shashank told Mr. Cheney that if he chose to be listed for transplant, it might be difficult to sustain him using medical therapy alone until a heart became available, but his odds would improve significantly with a ventricular assist device. Used as a bridge to transplant, a VAD can completely supplant the function of a failing left ventricle and support the patient until a donor heart is found.
Recent data from a National Heart Lung and Blood Institute registry show one-year survival rates greater than 80 percent for patients implanted with a continuous-flow VAD used as a bridge to transplantation.

Lori Edwards had brought with her a HeartMate II VAD and all of its necessary accoutrements. Methodically she reviewed the equipment, and what the Cheneys would have to do every day to maintain it.

The HeartMate II LVAD, manufactured by California-based Thoratec, is a ten-ounce titanium cylinder about three inches long, not much bigger than a saltshaker. It has only one moving part, the internal rotor, a modern adaptation of Archimedes” 2,300-year-old pump. The VAD contains an electrically powered motor that magnetically spins the rotor at speeds up to 10,000 RPM, capable of pumping ten liters of blood per minute, enabling the device to replace the function of a dead ventricle. The VAD is surgically implanted in the chest and connected to the heart by an inflow conduit sutured into the left ventricle and by an outflow graft sewn to the aorta. Blood entering the VAD from the heart travels through the inlet conduit, is accelerated by the spinning rotor, and is ejected into the aorta through the outflow graft. The system receives electricity through a driveline that exits the skin at the upper part of the abdomen a few fingerbreadths below the rib cage, and is connected to a controller and two camcorder-sized batteries. The batteries can provide about twelve hours of power; at night, patients usually plug into a tabletop unit. The driveline that exits the skin in the upper abdomen must be kept clean and covered with sterile gauze to prevent an infection from developing in the wire tract, and anticoagulants are prescribed to prevent clots from forming inside the pump.

Shashank and Lori explained to the Cheneys that many patients with a VAD feel well enough to return to work and can resume a variety of recreational activities with the exception of swimming. The Cheneys had a few questions about the durability of the device, and Shashank noted that there were a few patients approaching five years, but since the technology was relatively new, it was difficult to know precisely how long the VAD could last.

I wanted Vice President Cheney to leave the meeting knowing that we had not given up on him, there was still much we could do, and that using a VAD as a bridge to a heart transplant was a realistic possibility and
my recommendation. Cheney said he would think about it and let us know.

On Monday morning Mr. Cheney called and said that he was feeling a bit better, and that over the weekend he had spoken with his family and decided that he would be interested in getting a VAD. I told him that I thought that was the right decision and that we would begin the necessary tests. Four days later, Mrs. Cheney called and said that the vice president was much weaker and asked if we could see him right away.

Vice President Cheney arrived in a wheelchair, appearing short of breath and very lethargic. It had been only a week since his last visit, but the deterioration was startling. Shashank, Gigi El-Bayoumi, and Carolyn Rosner, a VAD/transplant nurse practitioner from Fairfax, joined us for the visit. We ran some blood tests in the office suite using a handheld analyzer and found that the vice president’s kidney function had worsened over the past week, a marker that his heart could no longer provide an adequate supply of blood to the organs.

I told the vice president that his heart was failing, and I recommended admitting him to the hospital immediately to start intravenous medication that should be able to stabilize him and that we quickly move forward with arrangements for a ventricular assist device. Without much discussion, Mr. Cheney agreed to the plan.

My wife, Charisse, asked me later if the vice president looked sad when I told him he needed a VAD.

“Not sad,” I said, “just weary.”

Medical Faculty Associates

The George Washington University

July 1, 2010

Vice President Richard Cheney returned for follow-up today. Mr. Cheney was discharged from GW Hospital 3 days ago after being admitted 3 days before that with deteriorating renal function,
severe fatigue and dyspnea and a low flow state. After admission the patient underwent right heart catheterization. . . .
IV milrinone was begun and clinical status and cardiac output significantly improved. At discharge serum creatinine had returned close to baseline at 1.6. Mr. Cheney was discharged 3 days ago on home IV milrinone at 3.75 mcg/kg/min.

On 6/28/10 Dr. Gigi El-Bayoumi and I visited Fairfax Hospital where we met with members of the Fairfax LVAD/transplant program including Drs. Desai and Burton. VP Cheney and family visited Fairfax on 6/29/10 and also met with the medical and surgical team there.

Today VP Cheney states that overall he feels a little better than yesterday and much better than last week. He sat outside for 2 hours yesterday and was able to walk to Executive Health this afternoon without the aid of a wheelchair. Wt. this AM was 203 (down 1lb from yesterday). . . .

In summary VP Cheney has made a very nice recovery and is stable on home milrinone.

Plan is for LVAD insertion at Fairfax on 7/14/10.

Jonathan Samuel Reiner, MD

Shortly after admitting the vice president to the hospital, we brought him to the cath lab to measure the pressures in his heart. We did this by inserting a catheter in a vein in his leg and passing it through his right atrium and right ventricle into the pulmonary artery, the large vessel that carries blood from the heart to the lungs. The data gained from this procedure, as expected, demonstrated that Cheney’s cardiac index was severely reduced and well below the level necessary for adequate perfusion of his organs. The cardiac index is the volume of blood pumped by the heart per minute divided by the patient’s body surface area, a measure of the cardiac output adjusted for body size. A normal cardiac index is 2.6 to 4.2 liters per minute per square meter. A cardiac index below 1.8 is considered cardiogenic shock. Cheney’s was 1.7. We began to administer intravenous milrinone, a drug that can increase myocardial
contractility and at least temporarily increases cardiac output. Soon after the infusion was started, Cheney’s hemodynamic parameters and kidney function improved.

Milrinone can improve the performance of a failing heart but not indefinitely. The plan was to continue the drug using home IV infusion, allow Cheney’s kidney function, overall clinical status, and nutrition to improve, and then bring him to Fairfax Hospital for a scheduled VAD insertion in about two weeks, at which time he should be better able to withstand the rigors of heart surgery.

Initially the vice president felt quite well and was able to walk modest distances with a small portable intravenous pump nestled in a shoulder bag. After several days, however, his kidney function began to decline again.

Medical Faculty Associates

The George Washington University

July 5, 2010

9:25 AM

I spoke with the patient this am. Mr. Cheney came to the ER yesterday evening for evaluation of right thigh pain. The patient developed this in the morning yesterday. CT scan at GW yesterday revealed hematoma in right thigh. . . .
Patient was discharged with morphine for pain control. This am the patient notes discomfort in the right thigh which is improved with the narcotic. He is not SOB [short of breath] but hasn’t done much exertion because of the discomfort in his leg. Weight is up 2 lbs compared with yesterday. OptiVol today shows continued rise.

I told VP Cheney that it is likely that we will proceed with LVAD sooner than originally scheduled. I think it will be difficult to maintain clinical stability for next 10 days and would prefer to schedule LVAD later this week. The patient is in agreement. 9:03 PM

I spoke with the VP. Still has significant pain in his right thigh
and has been using wheelchair to get around house. Morphine helps with the pain. No SOB. Has slept OK. There has been a gradual increase in BUN/creatinine despite recent increase in weight by 2 lbs. I told Mr. and Mrs. Cheney that I do not think it is reasonable to try and temporize until next week for LVAD. I have suggested that we proceed with surgery this week with admission tomorrow AM to Fairfax Hospital for optimization . . .
prior to planned LVAD insertion later in the week. The patient is in agreement.

Jonathan Samuel Reiner, MD

On Tuesday morning, July 6, Vice President and Mrs. Cheney drove the short distance from their home in McLean to Inova Fairfax Hospital. Mr. Cheney, unable to walk more than a few steps, was met in the garage by a nurse and brought by wheelchair to the cardiac surgery intensive care unit on the hospital’s second floor. The plan was to tune up Cheney for a few days in the ICU using intravenous diuretics and higher doses of milrinone, and toward the end of the week, when he would presumably be in a little better shape, we would take him to the operating room.

I stopped by Fairfax early in the day to make sure that Mr. Cheney was getting settled in. The design of the cardiac surgery ICU contains an ideal corner suite of two adjoining rooms, one of them was set aside for the patient, the other for use as a family lounge. To help ensure his privacy, Mr. Cheney was registered using a pseudonym, and a security guard was posted outside the suite. When I entered the vice president’s room, he was in good spirits as nurses tethered him with EKG monitoring leads, IV lines, and nasal oxygen cannula. I stayed just long enough to review the plan with Shashank and the patient, and I told them both that I would see them later in the evening.

After spending the day at GW, I returned to Fairfax in the evening to check on the vice president. Earlier in the day, an echocardiogram was performed, documenting a huge heart, easily twice the normal size, which barely moved. Cheney’s ejection fraction (the percentage of the
volume of blood in the heart that is ejected with each contraction) was estimated to be 10 percent (normal is 55 to 65 percent).

Shashank repeated a right heart catheterization to measure the pressures in the heart and lungs, and he calculated Cheney’s cardiac index at 2.0 liters per minute per square meter—not great, but a little better than before the milrinone was started ten days earlier. In an effort to wring just a little more cardiac performance, we ratcheted up the milrinone another notch.

As I entered the unit through the locked power doors, I could see Shashank standing outside the vice president’s room at the end of the corridor. Just as I approached, a nurse exited the room and handed us a printout with Cheney’s latest lab values.

Shashank and I reviewed the data in stunned silence. Despite the higher dose of milrinone, Cheney’s cardiac index was rapidly dropping.

“These can’t be right,” I said.

I looked through the window into Cheney’s room. He was awake, staring at a TV screen on the opposite wall, a remote control gripped in his right hand. These labs couldn’t be correct. They were the numbers of a patient in shock, someone about to die. We asked the nurse to send off a repeat sample of blood to verify the result, an act equal parts prudence and denial. Within a few minutes, the results were back. They were just as bad. In retrospect, I don’t know why this final turn for the worse was so surprising. For years, I had known this moment would come, and for the last several months, it looked increasingly imminent, but now that it was here, it still came as a shock. There was no escaping the fact that Dick Cheney had very little time left, probably only hours.

“Where’s Nelson?” I asked, referring to Dr. Nelson Burton, a Fairfax cardiac surgeon.