The Heart Healers (27 page)

Marc’s ECG in the emergency room was perfectly normal. It was that little throwaway end-of-the-conversation remark about itchy skin that gave the clue to his diagnosis. The next day a rash appeared, a track of blisters limited to the precise area of his chest pain. Marcus Stuart had shingles, an intensely painful viral infection of the nerves that lie between the ribs. The medical term for shingles is herpes zoster, the virus that causes chicken pox. It is more prone to infect the elderly and patients taking immunosuppressive drugs. Marc had both risk factors.

Marcus recovered from the shingles. With his new heart, he was vastly energized. About a year later I got a call. “Jim, I am sitting here taking a rest on some God-forsaken railroad track out in the middle of nowhere. Shooting a movie. Not much for my wife and me to do at night here. I am wondering, can you prescribe me some Viagra?” I chuckled. His new heart was able to love just like his old one.

Before his movie opened, Marcus invited my wife and me to a special showing of his new film. It was a terrific movie. When it ended, Marcus stood in the packed theater to a standing ovation. In the glow of the moment our eyes met for an instant as, like an Oscar winner, he graciously thanked all those who had made this moment possible. I beamed at this image of a healthy seventysomething, his secret intact.

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AND THE REST
of the Story? At a more recent annual Academy Awards ceremony, Marcus Stuart was called to the stage to receive the Lifetime Achievement Award, the Academy’s highest honor. After expressing his gratitude, he said, “I’m here under false pretenses … Eleven years ago I had a heart transplant, a total heart transplant. I got the heart of, I think, a young woman who was about in her late thirties. By that kind of calculation you may be giving this award too early because I think I’ve got about forty years left.” As the audience sat uncertain how to react at this most personal of revelations, he added advice to others with terminal heart failure. “Your doctors know what they’re doing. I mean, they really know what they’re doing. While you’re in their hands, you just have to say, ‘I’ll do my part.’ As much as you can. You do your part.” Eleven years from our first meeting, Marcus Stuart had turned the tables. I was the speechless one, looking at my feet, glassy-eyed.

Although he made a public revelation of his heart transplant as millions watched on television, Marcus Stuart never released me from my promise to never mention his name, so I honor that promise today. Marcus passed away in his eighties from a blood disease.

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SINCE THAT VASTLY
overhyped December 1967 morning in Cape Town, over 100,000 patients have received cardiac transplants. Last year, about 3,600 cardiac transplants were performed in 225 centers worldwide. We perform about 2,000 cardiac transplants each year in the United States. My hospital has the world’s largest annual volume, about 100 per year.

Cardiac transplants are reserved for people knocking on death’s door, unlikely to survive a year, or at most two years. In fact, a substantial number of candidates pass away before a suitable heart is found. Ironically, the most common cause of death in the years after successful transplantation is accelerated atherosclerosis, a problem that stands a reasonable chance of substantial resolution as we reduce mortality from CAD. For those who receive a transplant, the improvement in quality of life is dramatic.

Today if you or a family member is a transplant candidate, here are some things to know. Assignment of transplants in the United States is managed by the nonprofit United Network for Organ Sharing (UNOS). Recipients are matched to donors using two major principles: the sickest patients are given first priority, and patients are selected based on tests that assess the likelihood of rejection. Since we have a shortage of available hearts, the wait for a suitable heart varies from days to many months or even a year.

Donors and recipients are typically in different hospitals and different cities. When a match is made, the recipient is summoned to the hospital. At the donor hospital, the donor heart is stopped with an injection of potassium chloride, removed, and packed in ice for transport to the recipient’s hospital. Since the ice only preserves the heart for four to six hours, the logistics of rapid transport are critical. When the heart arrives, it is transplanted and then shocked back into a normal rhythm. With a new heart, the recipient begins a lifetime of drugs that suppress his/her immune response to the new heart. Depending on the recovery from surgery, our patients return home in one to two weeks, and then come back for periodic checks of their immune system. Most recipients can return to work within six months of surgery.

How much have we improved since the year following Barnard’s groundbreaking surgery, when almost no one survived for a year after surgery? About 90% of our transplant recipients now survive the first year, and 70% are alive five years after the procedure. The average survival following cardiac transplantation currently is fifteen years.

And what about quality of life after cardiac transplantation? It can be pretty darn good. Most recipients can return to work within six months of surgery. Southern California transplant recipient Kelly Perkins travels the world with her husband promoting awareness of organ donation through her blog
The Climb of My Life
. She has climbed the peaks of Mount Kilimanjaro, the Matterhorn, Mount Fuji, and Mount Whitney. Edmonton, Canada’s Dwight Kroening runs marathons and became the first recipient to complete an Ironman completion in 2009, twenty-two years after his cardiac transplant. Norwegian-American golfer Erik Compton qualified for the Professional Golfers’ Association (PGA) tour at age thirty-two after his second heart transplant. The longest survivor after cardiac transplantation, Ohioan Tony Huesman, received his heart from Norman Shumway way back in 1978, before the discovery of our primary immunosuppressive drug cyclosporine. Huesman survived thirty-one years, dying of cancer in 2009. In Shumway’s era an advertisement for Virginia Slim cigarettes, a prime cause of heart attack, boasted, “You’ve come a long way, baby.” In treatment of “end-stage” heart failure, indeed we have.

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CARDIAC TRANSPLANTATION GAVE
us an answer to another of CAD’s most devastating complications, chronic heart failure caused by extensive muscle damage. It was a technical tour de force beyond imagination. And yet, although it is a lifesaving answer for an individual, it is impractical as a solution for society. Transplant requires two teams of cardiac surgeons and prolonged hospitalization, intensive follow-up, and expensive medication. It costs hundreds of thousands of dollars, and consequently is a therapeutic option for only to a few thousand people each year. As I completed my cardiology training in Boston and moved to Los Angeles, the world was initiating cardiac transplantation. Even with the euphoria that surrounded Barnard and Shumway I knew that we were reacting long after the horse had left the barn, that we needed more effective treatment for a heart attack as it was happening.

15

MERGING STREAMS

Our Lord has written the promise of resurrection, not in books alone, but in every leaf in springtime.

—MARTIN LUTHER, SIXTEENTH-CENTURY GERMAN PRIEST

WHEN I FINISHED
my cardiology fellowship training at Harvard, and returned to Los Angeles, my generation was questioning the wisdom of our fathers. In my own world, I found I could hardly speak to my father—a staunch Iowa Republican—about the Vietnam War. The world of cardiology mirrored society. My new mentor in Los Angeles was Dr. Jeremy Swan. Born in Sligo, Ireland, Jeremy had been both an amateur boxer and a thespian in his youth. Now middle-aged with a square face and flowing white hair, he was one part quick Irish temper, one part Irish creativity, and every inch charismatic Irish leader. He had come to create Cedars of Lebanon’s (now Cedars-Sinai) first academic division of cardiology, devoted to teaching and research. Starting with a program that was largely unknown, he began by hiring six young cardiologists, among them me. Jeremy came from the Mayo Clinic Catheterization Laboratory, where he had worked with John Kirklin and the other Minnesota surgeons who had pioneered cardiac surgery. Jeremy’s passion was to improve the outcomes of patients who had suffered a heart attack.

I was surprised to learn that Jeremy wanted to employ my catheter skill in the CCU, not the cath lab. Jeremy opened the topic by asking me, “Jim, what do you think are the three most important problems in treating heart attack? I want you to pick one and solve it.” The biggest problem, we quickly agreed, was acute heart failure, and Jeremy thought he knew how to solve it. But he had started by asking me to think independently. He wanted me to question authority. Even if I was about to pursue his idea, he still wanted me to feel it was my own.

Jeremy appointed me director of our Myocardial Infarction Research Unit, funded by the National Institutes of Health (NIH). I secretly felt, although I did not admit, that I was not qualified for this role—my two years of specialty cardiology training were spent in the cath lab. Although I knew cardiology, I had little direct experience managing patients with a heart attack. But Dr. Swan had no one else to take the role. He must have thought that in some sense I looked the part since I was from Harvard and had published a manuscript in
The New England Journal of Medicine
. So I spent the first few months in fear of being exposed as a fraud. Oddly none of the doctors on the staff noticed. Maybe they had the same affliction and were too caught up in it to notice my uncertainty. I was reminded of that time recently when singer Barbra Streisand said in an interview that she had refused to do public performances for twenty-three years, fearing public failure and humiliation. She finally overcame the fear and so have I. But if you have ever known the feeling, that makes three of us.

Contrary to my expectation, as I traversed the country from Boston to Los Angeles I spent the next seventeen years in clinical research directed at improving the care of patients with acute myocardial infarction (heart attack), and had a role in the development of CCUs.

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ALEXI KROON, A
thirtysomething guitar-playing member of a music group, was admitted to our unit. His scraggly long-haired scruffy look identified him as a committed member of the post-Woodstock counterculture generation. He wore the universal avatar of the cocaine user, a silver chain with tiny silver spoon around his neck. After his group’s evening performance, Alexi had spent the night and early morning hours drinking and snorting cocaine. He first noticed chest pain while he was having sex with a younger woman he had met backstage after the concert. The pain, he said, felt like an elephant sitting on his chest, and it radiated upward to his jaw. He graded the pain as eight on a ten-point scale. In our emergency room, he was sweating profusely and was gulping air in short, rapid breaths. His blood pressure was 110/82 and his heart rate was one hundred. His ECG showed signs of a “massive” heart attack. A heart attack or myocardial infarction (literally, heart muscle death) occurs when a segment of the heart muscle dies because it has suddenly been deprived of blood supply from its coronary arteries. The size of the heart attack is determined by how much muscle is supplied by the obstructed arterial segment. Alexi’s ECG indicated the obstruction was in the left anterior descending artery, close to its origin from the aorta. So we knew that the amount of heart muscle not receiving blood flow was about 30% of the entire left ventricle. Soon after arriving at our unit Alexi deteriorated further. His blood pressure fell to 85/60 (normal: 120 to 130/80 to 85), and his heart rate increased to 120 (normal: 60 to 100). When blood pressure falls into the 80s in patients with a heart attack, we call the condition cardiogenic shock. I took a deep breath. Alexi’s risk of mortality had now risen from 30% to 80%.

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WHEN I BEGAN
at Cedars, coronary care units (CCUs) were in their infancy. The paradox of the first appearance of the CCU is that it was unanticipated, yet absolutely logical in retrospect. As the newly minted cardiac surgeons battled heart block, ventricular fibrillation, and misdiagnosis in their 1950s operating rooms, not one of them imagined they were working toward a treatment of heart attack. Why should they? The business of cardiac surgeons was heart surgery; cardiologists treated heart attacks. In historical perspective, however, we can see that the development of the CCU was inevitable, because cardiologists caring for patients with acute myocardial infarction battled precisely the same disorders of cardiac rhythm. Unlike the brilliant intuitive leaps of the cardiac surgical revolution, the CCU simply required good organization. Someone had to figure out how to efficiently deliver defibrillators, pacemakers, and drugs to a patient who died suddenly. It is the difference between the brain’s right hemisphere and its left, between creativity and logic, between the Greeks and the Romans.

The critical breakthrough that triggered the subsequent emergence of the CCU illustrates how chance favors the prepared mind. While researching defibrillation in dogs, Johns Hopkins engineer William Kouwenhoven and Dr. James Jude noticed that when they forcefully applied the defibrillation paddles to the dog’s chest, it induced a pulse in the dog’s leg artery. From that observation came the technique of chest compression. In 1960 they tried chest compression in people who had died suddenly, then defibrillated the heart. When fourteen of twenty patients survived until hospital discharge, they had proven that sternal compression combined with artificial respiration could maintain life until they were able to accomplish external defibrillation, that resuscitation outside the controlled operating room environment was feasible.

The Hopkins group breathlessly announced in their publication, “Anyone, anywhere, can now initiate cardiac resuscitative procedures.” But it was simply not true. For the next few years, hospital physicians attempted resuscitation with absolutely dismal results. The reality was the precise opposite from the Hopkins team’s assertion: no one, nowhere was successfully initiating cardiac resuscitation. I had my own personal proof in my nightmare experience with Willie the Phillie. Cardiology had failed to recognize the huge chasm between the results of a few dedicated Johns Hopkins researchers and routine clinical practice.