Heart: An American Medical Odyssey (37 page)

“He’s in North Carolina trying to get back,” Shashank said.

Most VADs are implanted during elective procedures, and Cheney’s had originally been scheduled for the following week. The plan was for Dr. Burton to do the surgery, but he was on the Outer Banks with his family. He was trying to find a flight but might not be able to get back until the morning.

“I don’t think we can wait until morning,” I said.

Shashank agreed and called Dr. Anthony Rongione, the other designated VAD surgeon at Fairfax, who said he would come right over.

Liz, who had been in her father’s room when I arrived, came out to talk with us. I asked Liz where her sister, Mary, was. Liz told me that Mary had a cold and had decided to stay home because she didn’t want to risk transmitting it to her father before a big operation.

“Tell her to come,” I said.

When Mary arrived, Shashank, Rongione, and I met with the family in the vice president’s room to update everyone on where we stood.

I cut right to the chase and told Mr. Cheney that his numbers were worse, and despite the late hour, we thought it was prudent to proceed with the VAD right now.

“Right now?” Cheney asked, his surprise evident.

“Yes, sir,” I replied. “Tonight.”

We described his drop in cardiac output despite the increase in intravenous medication, and I told the vice president that I was worried he might suddenly get into trouble during the night. We had a window of opportunity to do this, but it was closing fast, and I was afraid that if we waited much longer, it would disappear.

Mrs. Cheney asked if Dr. Burton was back.

“Not yet, but fortunately Dr. Rongione is here.”

Anthony Rongione was one of two surgeons at Fairfax who, in addition to the usual portfolio of bypass, valve, and aortic surgery, also had expertise in the placement of VADs.

Vice President Cheney turned to his family and asked what they thought. I would usually leave a family to discuss such matters without hovering, but Mrs. Cheney, Liz, and Mary immediately looked at each other, nodded slightly, and told him he should have the surgery tonight.

“Okay, let’s do it,” the vice president said, his voice clear.

I’ve watched tears and fear well in the eyes of patients as I tell them they need surgery. Usually I try to allay their concerns by telling them all the reasons they should do well. In this case, I was the person who
was fearful. Cheney was dying. I knew he might not survive the night. Although I had no doubt that he needed the VAD, and right now, the odds were not in his favor. Cheney’s kidney and liver function were deteriorating, and as he had gotten sicker, his appetite had dwindled, wrecking his nutritional status. One of the main reasons for trying to buy some time before placing the VAD was to rebuild his overall metabolic state, but we had simply run out of time.

In his eulogy for President Ford in 2006, Vice President Cheney had called his former boss “the still point in the turning wheel.” That metaphor aptly described Cheney himself. Despite the tumult attendant to preparations for emergency surgery, Vice President Cheney exhibited an uncommon serenity and personal courage I’ve rarely witnessed in any patient during my twenty-seven years as a doctor. Come what may, he was ready.

It was past 9:00 p.m., and as the nurses readied the patient, Mrs. Cheney came out into the hallway to talk with us.

“You’ve already had a long day. Aren’t you too tired to operate tonight?” Mrs. Cheney asked Dr. Rongione.

“Are you kidding? I have triplets,” a beaming Rongione said. “At this time of the night, I’m just getting started!”

•  •  •

I have a recurring nightmare where I find myself alone late at night in a deserted hospital struggling to keep a supersick patient alive. It’s my version of the classic insecurity dream, but it couldn’t be further from reality. Even at night, a major medical center like Fairfax or GW is well staffed to take care of a critically ill patient, and when Shashank and I entered the operating room, the place was bristling with people.

When I arrived, Dr. Elmer Choi, a Harvard-trained cardiac anesthesiologist, already had Cheney asleep and was busy adjusting the transesophageal echo probe he had just inserted. On the other side of the anesthesia screen, the surgeons—Dr. Rongione, Dr. Paul Massimiano, and Dr. Alan Speir—were well into the operation.

Surgery to place a VAD requires access to the heart, typically by
opening the sternum, but in a patient like the vice president who has had prior cardiac surgery, this can be a bit dicey as important anatomic structures (like the right ventricle) can become adhered to the underside of the bone. Indeed, when Dr. Rongione opened the chest, he found thick adhesions everywhere, requiring a meticulous dissection to free the heart from the surrounding scar tissue.

After the dissection was complete, the VAD’s outflow graft was created by sewing a woven Dacron conduit onto the ascending aorta using suture about a tenth of a millimeter in diameter. Next, Tony cored out a piece of the tip of Cheney’s heart using a specially designed cylindrical knife, removing a piece of muscle the diameter of a thumb. The VAD’s inflow cannula was placed inside the heart and secured with thick sutures. Finally, the VAD itself was placed just below the heart, connected to the inflow and outflow cannulas, and the electric driveline tunneled under the skin, exiting the body over the right side of the upper abdomen. The VAD was then activated, and the revolutions per minute of the device gradually increased until it was more than doubling the output of the depleted left ventricle.

Shortly after the VAD went in, around 2:00 a.m., Dr. Nelson Burton entered the operating room. He’d been unable to get an evening flight from North Carolina, so he got into his car and drove five hours to Virginia. Rongione and Massimiano updated Dr. Burton as he scrubbed into the operation.

Although the VAD had gone in without a hitch, Cheney was not out of the woods. The dissection to free the heart of adhesions and peel off segments of his lungs had taken a very long time, and Cheney had bled a lot. When a person bleeds, intrinsic components of the clotting system are consumed, and the more one bleeds, the harder it becomes to stop. Over the next five hours, Rongione and Burton worked to stop the bleeding. Mr. Cheney would ultimately receive more than twenty units of blood and blood products.

When dawn broke, the bleeding had largely stopped, and the VAD, spinning at more than nine thousand revolutions per minute, was doing its job, providing a cardiac output the vice president hadn’t seen
since the 1980s. Cheney had been in the operating room all night. Against all odds, the vice president now had a chance of surviving due to the superb skill and dedication of Drs. Anthony Rongione and Nelson Burton and the rest of their team.

•  •  •

Vice President Cheney had gone into surgery sicker than most other patients and his recovery was likely going to take longer than most. Complicating matters was the unhappy surprise of the large amount of scar tissue in the vice president’s chest and the bleeding its dissection had precipitated. The net result had been a long operation that would require an even longer recovery.

Cheney returned to the ICU on four intravenous drips to sustain his blood pressure and cardiac function. Although the vice president’s left ventricle was fully supported by the VAD, the right ventricle was not, and it was struggling. Dr. Jason Vourlekis, the director of the cardiac surgical ICU, was waiting for Cheney when he returned from the operating room and would oversee the care of the vice president until he was stable for transfer to the step-down unit.

By Friday, only forty-eight hours post-op, Vice President Cheney had improved to the point where he could be taken off the ventilator. Over the next few days, he remained relatively stable, making slow but steady progress, but four days later, on Tuesday, July 13, the vice president became short of breath and a chest X-ray revealed a new abnormality in the right lung consistent with pneumonia. Antibiotics were prescribed, but over the next few days, Cheney’s respiratory status declined.

On Sunday, July 18, eleven days following surgery, Shashank Desai, Jason Vourlekis, Gigi El-Bayoumi, Nelson Burton, and I met at Fairfax to discuss Cheney’s status. Over the prior few days, the vice president’s chest X-ray had worsened. It was becoming increasingly hard for him to breathe. After a long discussion with Mrs. Cheney, Liz, and Mary, we made the decision to place the vice president back on the respirator.

Recovery from a critical illness is often not complication free, and although it was disappointing to lose ground, I remained optimistic.

“This is a setback, not a catastrophe,” I explained.

The vice president was kept sedated, his antibiotic regimen was broadened, and he remained on the respirator for the next five days. During these difficult first few weeks, not a moment went by that a member of the vice president’s family wasn’t with him. Mrs. Cheney, Liz, and Mary took turns sleeping in the room adjacent to his.

On July 23, two and a half weeks after his VAD surgery, Cheney was once again extubated.

Relieved that he was off the respirator, and no doubt anxious to hear how his patient was feeling, Dr. Vourlekis said, “I think you look good, Mr. Vice President. What do you think?”

The room was silent while we awaited Cheney’s response. The vice president looked up at Vourlekis and, mist bellowing from the humidified oxygen mask on his face, said, “I think you’re full of s—t.”

Of all the procedures I have undergone since that first heart attack in 1978, the LVAD surgery was by far the toughest. The actual operation was complicated by the fact that I was very weak with a failing heart and rapidly declining liver and kidney functions at the time of the surgery. It was especially difficult because it required going in through the scar tissue left from my bypass surgery in 1988. The network of blood vessels that had developed on the site created serious bleeding problems for the surgical team. I needed twenty units of blood during the surgery, and I was on the operating table for more than nine hours the night of July 6 and the morning of July 7, 2010.

My hospital stay lasted five weeks. Some of that time I spent on a respirator, heavily sedated. At one point, the respirator was removed, but when I contracted pneumonia, I had to go back on it. I was fed intravenously and lost more than forty pounds. When I saw myself in the mirror for the first time some weeks after the surgery, I saw my dad, shortly before he died of heart failure just before his eighty-fourth birthday.

When I came out from under the sedation, I was asked what, if anything, I remembered from that period. I said I had very vivid memories of living in a villa in a small village north of Rome. I recalled the streets of the village and small, attractive cafés where I ate great Italian food and drank good Italian wine. I had walked through the same street every morning to get coffee and a roll for breakfast and to pick
up my morning newspaper. There was an American couple there that I talked to on occasion. The man was there for some kind of medical procedure. I had the feeling I was also there for a medical procedure, but it was never clear what kind and I never saw any evidence of any medical facilities or personnel. I also had a vivid recollection of sitting out on a patio overlooking a long dirt road with a car on it climbing up a hill to get to the village, but it never got there. Sometime later, while watching one of my favorite movies,
Saving Private Ryan
, I recognized that scene. In the movie, Private Ryan’s mother watches the car from the window of her kitchen. When it arrives in the yard outside her door, two passengers emerge, an army officer and a priest. They are there to notify her that three of her four sons had been killed in action in World War II.

At other times I believed the hospital was located at LAX in Los Angeles or on the Sioux Indian Reservation in South Dakota. I remembered a visit from Dr. El-Bayoumi, our family physician. I had tried to persuade her to help me escape from the hospital because, I told her, “I don’t belong here; there has been some kind of mistake.” But the overwhelming memory was of my Italian interlude. My family wanted to know if they were with me, and unfortunately I had to tell them they were not—which wasn’t the right answer. Their experience had been the direct opposite of mine. They had been extremely worried about my condition and my prospects, especially when I contracted pneumonia and had to go back on the respirator. At the least, they said, I could have taken them to Italy.

When I discussed my long dream with my doctors, they said they had no idea what goes on in the heads of patients when they spend a long time heavily sedated, as I had. My family and I speculated the fact that one of my principal surgeons was named Rongione might have been responsible. I also had been reading a novel by Dan Silva, a friend and one of my favorite authors, set in Italy. Lynne and I and our family have had many occasions over the years to travel to Italy. It is a place we love. It was not at all surprising that if I was going to take a vacation
someplace while I underwent everything that was being done to me, I had chosen Italy.

•  •  •

After regaining consciousness and getting off the respirator, I was still very sick and weak. I developed a craving for crushed ice. The doctors didn’t want me to drink large quantities of liquids, but they would let me eat ice. I remember lying in bed while Lynne, Liz, and Mary took turns feeding me small spoonfuls. My doctors were most concerned that I had completely lost my appetite. I was wasting away because I didn’t want to eat. It wasn’t just hospital food. Things had a different taste than they ever had before, and nothing seemed appetizing. Until I resumed eating normally, there was no prospect that I could recover from the surgery or begin the long, demanding process of rehabilitation.

Eventually I regained my appetite when the doctors agreed I could have some of my favorite foods. I developed an immense craving for milk, which I hadn’t drunk on a regular basis since I was a youngster. Häagen-Dazs vanilla ice cream was a hit. My daughter Mary brought me homemade chocolate chip cookies baked according to my mother’s recipe. I finally convinced my doctors that what I really needed was a Big Mac and a large order of fries. I got them, although they were not part of the normal menu for patients in the ICU.