Heart: An American Medical Odyssey (42 page)

In October 2010, Vice President and Mrs. Cheney finally returned to Jackson, a big step in his recovery. A photo that Mrs. Cheney took exactly three months after his emergency surgery to implant the VAD shows the vice president driving his Jeep (the same vehicle in which he had a sudden cardiac arrest while backing out of his driveway ten months earlier), the beautiful Teton range visible in the distance.

After he came back from Wyoming, the vice president returned for a follow-up visit. Shashank wrote:

An echocardiogram was done in the hospital, which I was able to oversee. He continues with severe LV dysfunction. His aortic valve remains closed throughout the cardiac cycle. He has 1+ aortic insufficiency [mild], which remains stable. . . .

Overall, I am very happy with his continued progress. He will return to VAD clinic in 1 week’s time.

The standard protocol for a patient with a VAD includes routine surveillance echocardiograms, and Cheney’s echo was startling. For the entire time I knew the vice president, he had always had an abnormal echo, notable for a dilated ventricle that didn’t contract well. Now, Mr. Cheney’s left ventricle was essentially motionless, and with all the blood flow going through the VAD, the aortic valve no longer opened.

On November 2, Mary Cheney sent me a photo of her dad on a pheasant-hunting trip, resplendent in high-visibility orange, a shotgun in his left hand. What’s not visible under all the gear is the VAD spinning at 9,600 RPM, enabling him to do so much more than simply survive.

After the New Year, we met again and the vice president looked even better:

January 21, 2011

Dear Dr. Reiner:

I had the pleasure of seeing Mr. Cheney in the VAD clinic today in follow-up. Happily, you were present during this visit. I will reiterate the events of this visit for our records.

He has truly turned the corner. His energy level is excellent. He has no shortness of breath with his activities. He is very active and is traveling extensively. He is able to climb up more than one flight of steps energetically and does not have shortness of breath at the top. He has had no difficulties with his VAD driveline or controller. His wound is well healed and he has no further drainage. . . .

My impression is that Mr. Cheney is doing well and remains status 1B awaiting orthotopic heart transplantation. His VAD continues to perform well. On interrogation he has had no significant alarms. I am happy to see that he has returned to a near normal quality of life. . . .

Thank you for allowing me to participate in the care of Richard Cheney. Contact me directly if questions arise.

Sincerely,

Shashank Desai, MD

January 2011 marked two landmark events for Dick Cheney; on the thirtieth of the month, he turned seventy years of age, and after meeting again with the team at Fairfax, he made the final decision to proceed with transplant.

The decision to recommend the VAD had been easy. There was no doubt that Cheney would have died without further support, and a VAD was his only option. Now, seven months later, the decision to push ahead with transplant was a bit harder. Mr. Cheney had just barely survived the last hospitalization, but now that the smoke had cleared, he was well. After all that he had been through, the idea of sending him back for more surgery was almost too much for me to contemplate.

If Cheney was going to opt for transplant, now was the time to do it. Although at seventy, he was still a candidate for the operation, that window would close over the next couple of years, and there would be no going back. If he elected to have surgery, there were no guarantees he wouldn’t succumb to the kinds of postoperative complications that nearly killed him in July. It was a difficult choice.

Ultimately it came down to a risk-reward analysis. If the vice president was willing to take the risk, the reward might be great (the first patient to undergo heart transplant surgery at Fairfax, in 1986, was still alive). In the forty-five years since transplant surgery was introduced, refinements in organ preservation, candidate selection, immunosuppression, and rejection surveillance have dramatically increased the life span of patients with a transplanted heart. For patients who underwent heart transplantation in 2009 and survived their first year (the vast majority),
the median predicted survival is fourteen years. A successful transplant would give Cheney a legitimate chance of reaching eighty. There were still many rivers to fish and graduations of grandchildren to attend. Cheney wanted the transplant.

•  •  •

The heart transplant waiting list managed by UNOS stratifies patients by level of acuity, time spent on the list, and blood type. To avoid immediate
rejection, a donated heart must be the same blood type as or a compatible blood type to the recipient’s. Organs from patients with blood types A, B, or O require organs from donors of the same type. Patients with blood type AB (the universal recipient) can receive a heart of any type, and those with blood type O (the universal donor) can donate to a patient of any type. Other factors are important to the allocation of specific organs, including the size of the donor and recipient (you can’t put a heart from a hundred-pound donor into a two-hundred-pound recipient), and the presence of certain antibodies in the blood. The vice president’s blood type was A, a common group shared by 42 percent of the population. A large percentage of donor hearts are type A, but so are many of the patients on the waiting list.

Despite an increase in the number of people being listed for transplant between the years 2000 and 2011, there was essentially no change in the number of heart transplants performed in the United States during that same period of time (about two thousand per year), a consequence of the lack of growth of organ donation.
There are currently about thirty-five hundred patients in the United States waiting for a heart transplant. The mean age for patients on the list is fifty-one, but the number over the age of sixty-five has been rising.

•  •  •

As the months passed, life returned to normal for the vice president, who traveled extensively, adjusting the VAD to his lifestyle rather than his lifestyle to the VAD. The one-year anniversary of the implant surgery came and went, and while there had been movement on the transplant list, there were still several patients with the same blood type ahead of him.

In fall 2011, the vice president started to lose a little ground. Cheney developed some edema, and an echo revealed that his aortic valve was leaking more. For years the vice president had mild aortic insufficiency, a valvular abnormality whereby blood seeps back from the aorta into the left ventricle when the aortic valve is closed. It was starting to get worse and beginning to hamper the effectiveness of the VAD.
The device was still doing its job, pumping blood out of the ventricle, but now some of that blood was immediately leaking back, creating an ineffective loop. Cheney also redeveloped atrial fibrillation, and he had an episode of ventricular tachycardia that his ICD stopped.

January 20, 2012

Dear Jonathan:

I had the pleasure of seeing Richard Cheney back in the VAD clinic today in follow-up. He was in Wyoming for the holidays and continues to do well. He had a mild viral illness but does not have any fevers, chills, or sweats currently. He has had one episode of a nosebleed, but this did not progress. . . .

On physical examination his mean blood pressure is 92mmHg. His LVAD is set to 9800 rpm with a flow of 5.7 . . .
he is well appearing and in no distress. . . .
Lungs are clear to auscultation bilaterally. Cardiac exam reveals normal VAD sounds without audible heart sounds. . . .
Driveline is clean, dry and intact. . . .

My impression is that Richard Cheney has an appropriately functioning LVAD which was implanted on July 6, 2010. He has overall deterioration of his cardiac function under this. He is exercise limited. Additionally he has progressive aortic insufficiency; when last checked, this was moderate in volume. This is very likely the result (cause) of his OptiVol [fluid measurement] being above threshold, as well as the return of his atrial fibrillation. Now he has fast VT requiring therapy. To this end I have asked him to increase his antiarrhythmic therapy of Toprol XL to 100 mg daily. I believe his blood pressure will tolerate this. . . .

Overall my general concern about his deteriorating course continues to escalate. . . .

Thank you for permitting me to participate in the care of Richard Cheney. Contact me directly if questions arise.

Sincerely,

Shashank Desai, MD

A month later the vice president’s hematocrit began to drop, prompting a search for a source of his blood loss that included upper and lower endoscopy, both of which were unremarkable. It was unclear whether the VAD was starting to hemolyze (break open) some of Cheney’s red blood cells or whether there was another yet-to-be-determined cause of his anemia. What was clear was that once again, the clock was ticking.

•  •  •

March 23, 2012. Midnight.

“Say that again,” I whispered, although I heard it clearly the first time.

“We have a heart for Cheney,” Shashank said.

Although I had been waiting for this call for more than twenty months, and had known for much longer that one day it would probably come to this, it was still a shock.

Shashank told me what he knew about the donor and that his nurse practitioner, Lori Edwards, had already notified the vice president and arranged for him to be admitted to Fairfax. We discussed logistics for a few minutes and agreed to meet at the hospital in about an hour.

I hung up and dialed the vice president’s house in McLean. When he answered the phone, he was unbelievably calm.

“This is going to be a great day,” I said, unsure whom I was trying to reassure.

I dressed quickly and gave my wife a quick kiss good-bye. We were already packed and ready to leave in the morning for our annual spring ski trip, but now Charisse and the girls were going to have to fly to Colorado without me. I jumped in my car and sped down the driveway as I had done so many times before in the middle of the night for countless other patients.

Vice President Cheney never asked for, and never received, any special accommodation while he was on the transplant list, as some television pundits later insinuated. Cheney waited twenty months for the call that finally announced his new heart, almost double the usual wait.

When I arrived at Fairfax, the vice president had already changed into a hospital gown and was sitting with Mrs. Cheney and Liz in the same corner ICU suite in which he nearly died following surgery to implant the VAD two summers before. I had an uncomfortable moment of déjà vu when I entered the unit, but I reminded myself that this wasn’t the same patient we admitted in July 2010. This patient was well nourished, with great kidney function, excellent physical strength, and no evidence of clinical heart failure. That other patient had been dying.

The nurses were busy with their long preoperative checklist, and it would be several hours before the surgery began. A team would be going out to harvest the heart early in the morning, and Cheney wouldn’t be brought to the operating room for several hours. Hopefully he would be able to get a little sleep before then.

Shashank had some lingering questions about the donor and the heart. The only way to answer those questions was to physically evaluate the ultrasound and the donor ourselves. Without telling the Cheneys where we were headed, Shashank and I excused ourselves and left Fairfax.

•  •  •

At 3:00 a.m., we drove through mostly deserted streets to the hospital where the donor was being sustained on a ventilator and IV drips. When we entered the ICU, we found the transplant coordinator busily working the phones. Shashank and I introduced ourselves, and she pulled up the echocardiogram on a computer for us to review.

It’s often difficult to get good-quality echo images in a ventilated patient, but what we could see suggested that the heart was normal in size, with normal valves, and good function. It looked like a fine heart.

We asked the coordinator if we could see the donor, and she took us to the room. I entered filled with a mixture of sadness, respect, and gratitude, consciously reminding myself that I wasn’t looking at a patient who was dying but someone who had already died. The monitors in the room displayed blood pressure, pulse rate, and blood oxygenation,
and they all looked fine, but in this terrible setting, they told me nothing about the patient; they were just individual gauges of organ function. This patient was dead.

I found it impossible to look at this person, a few days ago full of life, and now lifeless, without the humbling reminder of how temporary everything in this world is.

•  •  •

I arrived home as the sun inched over the horizon and caught a couple of hours of sleep before returning again to Fairfax midmorning. The vice president had been brought to the OR early, and his operation began around ten o’clock. Simultaneously, surgery was under way at the other hospital to harvest the donated organs.

Because the success of the transplant is inversely related to how long the donor heart is without blood, surgery to remove the old heart cannot wait for the arrival of the new organ. Conversely, the actual surgery to remove the recipient’s damaged heart cannot begin until the team harvesting the donor heart is certain that the donor organ will be suitable, and that happens only when the harvesting surgeon physically examines the heart. Word came that it was a go, and the two surgeons, Dr. Anthony Rongione (who saved Cheney’s life twenty months earlier with his brilliant implantation of the VAD) and Dr. Alan Speir, the hospital’s director of cardiac surgery, who had trained in cardiothoracic surgery in Texas under Dr. Denton Cooley, got to work.

As was the case during the VAD insertion, the cannulas for the heart-lung machine were placed first, via the large femoral artery and vein at the top of the leg, so that if the surgeons encountered severe bleeding when they opened Cheney’s chest, they would be able to support his blood pressure with cardiopulmonary bypass.