by Mimi Swartz
But Cooley was getting older—in 2000, he was eighty and, like DeBakey, was never terribly interested in any succession plan. He continued operating until he was eighty-seven, and then turned to legacy building, traveling, lecturing, and working on an autobiography. But handing over the reins of his beloved Texas Heart Institute? Not on his to-do list. For a man on such intimate terms with the universality and unpredictability of death, Cooley was surprisingly difficult to engage on the subject of his own mortality.
It was left to St. Luke’s CEO, a shrewd administrator by the name of Michael Jhin, to bring up the subject with Cooley. The two men had been a remarkable team for over a decade; they built St. Luke’s into a five-star colossus. The Texas Heart Institute surgeons were, of course, the big draw. It was important to the doctors, the hospital, and even the city of Houston to keep THI’s reputation glowing and St. Luke’s income growing. But who would make sure that happened once Cooley stepped down?
On a flight to New York, relaxing in first class over drinks, Jhin brought up to Cooley the name of a young surgeon who was making quite a name for himself at Harvard. Of course, his skills in the operating room couldn’t match Cooley’s, but he had charisma kind of like Cooley’s. He was a natural performer, and his enthusiasm was contagious, qualities that would be needed for attracting new donors and keeping old ones. And he was inventive too, an innovator, always ahead of the pack. And—drumroll, please—he was from Houston. He’d grown up here and graduated from Baylor College of Medicine, and he seemed anxious to come back. Maybe Cooley should take a look at this guy, Jhin suggested with all the care and delicacy of a soldier tiptoeing through a mine field.
Cooley nodded. He would think on it, he said.
* * *
As it turned out, Billy Cohn was indeed anxious to get back to Houston. He was starting to feel that his only option was private practice—he had reached a dead end in Boston: “I did not just spend sixteen years to work with uninspiring guys, and I was really depressed.” He was, after all, a heart surgery innovator, and the best place to do that was still the Texas Heart Institute. His idols in the medical field were Denton Cooley and Bud Frazier.
In the past, Billy had made a point of introducing himself to Bud at medical meetings and conferences. When he tells these stories, they have the rosy glow of hero worship, like Jimi Hendrix introducing himself to B. B. King. In each meeting—at least to hear Billy tell it—Bud remembers him a little more clearly than in the last, until finally, several years later, the bromance blossomed.
Bud is still fond of claiming that at a medical conference years ago, Billy told him that a pulseless/continuous-flow artificial heart would never work. To which he replied with his favorite punch line: “Well, I’ve got a calf down in the basement of the Texas Heart Institute that says otherwise.”
It is a story that makes Billy wince. Yes, he had some questions, but they had to do with the lymphatic system and blood flow and a whole lot of technical stuff that most people have no interest in. “Am I the kind of guy who would say that any kind of technology wouldn’t work?” he asked after being assigned the straight man role one time too many. “Bud takes great satisfaction in saying I knew it wouldn’t work. Of course I knew it would work.”
The interchange, repeated many times over the years, serves as a pretty good encapsulation of their relationship. That and the fact that Billy had no equal in building things and Bud understood the body with a savant-like sixth sense. They complemented each other; moreover, they needed each other in order to realize their ambitions.
As it turned out, Billy’s designation of heir apparent had only been apparent to Michael Jhin. In fact, his invitation to join Texas Surgical Associates in 2004 did not even ensure that he was welcomed into the fold. There were already plenty of surgeons in the practice who were quite adept at performing heart surgery, and they made it clear they had no intention of making room for the hotshot from Harvard, even if he was from Houston. On a visit to Boston, Bud had warned Billy that he would have to cultivate his own group of cardiologists for referrals if he wanted to get in the operating room. But Billy didn’t want to do that, because Billy wasn’t interested in building a private practice.
He became like a racehorse put out to pasture. After two years at THI, in fact, it looked as though his career might be shifting in another direction: ABC asked Billy to audition for a new reality show called Miracle Workers, which, consciously or not, was developed to demonstrate that technology had made doctors the good guys again; it was a small assist in the wake of ever-increasing medical costs and the fallout from managed care. The show was sort of a combination of Queen for a Day, Marcus Welby, MD, and the Discovery Channel.
A new kind of celebrity doctor was on the rise. If Cooley and DeBakey were the stars of their generation, alternative medicine guru Andrew Weil, and Mehmet Oz, an esteemed cardiothoracic surgeon at Columbia University’s Medical School, were turning themselves into brands. Both enjoyed the kind of multiplatform success—websites! books! products! Oprah!—that most day-to-day docs, warring with insurance companies and personal injury lawyers, could only dream of. (Oz did run into trouble when he endorsed diet pills that a Senate panel in 2014 deemed useless.)
But this was not to be Billy’s future. The network canceled Miracle Workers after six episodes. The final show depicted an LVAD implanted by Billy and Bud on a woman whose cancer meds had destroyed her heart. Like the show, she didn’t make it.
13
HEARTMATES
In 2003, a young man from El Salvador, with a thatch of lustrous dark hair that belied his weakened frame, came under Bud’s care. He was dying of heart disease. THI was the last stop before he was forced to give in to his fate. The man’s command of English was limited, and his family was not wealthy. He had worked as a car mechanic before he got sick.
But his timing was good. By that time, LVADs were losing their experimental reputation. A clinical trial of 129 patients with end-stage heart failure at Columbia University Medical School showed that the pumps reduced the risk of death by 48 percent, as compared with medication, and also substantially improved their quality of life. Bud groused about the trial at the time, claiming that it was unethical and unnecessary because everyone (i.e. him) already knew that the pumps worked better than meds.
Bud had been working with one of the device companies, Nimbus, on a new nonpulsatile implantable pump, which would eventually be called the HeartMate II. The pump was intended to be a great leap forward in heart assist devices: the HeartMate II was another axial flow pump, but it was much smaller. At an inch and a half long and weighing about twelve ounces—the size of Bud’s thumb—it could fit in women, children, and smaller men. It was also designed with two speeds, one fixed and one called auto-speed, a kind of a manual transmission, whereby a patient could adjust the speed of the pump if he or she was feeling short of breath or was playing golf and needed a little boost.
The calf experiments went extremely well, and the FDA granted permission for human trials. That’s when things began to go south: of the first ten patients, nine died. The one who lived did so because the surgeon took the pump out after two weeks. The FDA was about to put a stop to the trials when Bud and the team realized what was wrong: the manufacturer had used something called sintered titanium on the ends of the pump, a substance that roughed up the surface in pulsatile pumps, which made a safe place for clots to form on the membranes inside the device instead of clogging up the blood flow. But in a rapidly spinning pump the surface coating had the opposite effect: it grabbed bits of blood and gave it a place to settle, forming the clots that caused the fatal strokes in the early patients. The problem hadn’t shown up in calves because calves had a higher blood pressure, which literally sucked blood through the pump, and covered up the problem. The solution seemed simple: to stop using sintered titanium. The FDA agreed to let the team try.
But there was another problem.
By early 2000, Nimbus was nearly broke from its failed R&D. A couple of representatives flew to Houston to ask Bud to donate $600,000 to the company to keep going. But, as he told them, he was an academic surgeon. He was also helping to support his grown son Todd’s career as a composer of operas—the Eastman School of Music and Juilliard graduate had created an opera about heart transplants called Breath of Life—and his daughter Allison’s work as a writer and therapist. Both had spouses and children, and it was hard for Bud to deny them anything. “I make more than an English professor, but I don’t have $600,000,” he explained. In turn, they asked about Dr. Cooley. Would he contribute? “Remember Scrooge McDuck?” was Bud’s response. If it hadn’t been for another angel investor—the new head of a telecom company, who suffered from heart disease himself—the HeartMate II would have never come to be.
With the infusion of cash, Nimbus could afford to try again. Bud presented the option of experimental surgery to the dying young man from El Salvador, who agreed to take the chance. The operation went well. So well, in fact, that the man either didn’t understand the nurse’s instructions after his release from the hospital or didn’t care. He didn’t reappear for his follow-up appointment. In fact, he disappeared. Months went by with no sign of him. He literally vanished with $600,000 worth of experimental hardware in his chest.
It wasn’t until a year later that he reappeared on Bud’s doorstep, and that was only because he’d developed a small infection in the drive line of his device, a common problem with any sort of catheters, any medical apparatus that is exposed to the air.
What was a medical problem for the young man was something else entirely to Bud. He put his stethoscope to the patient’s heart—and heard virtually nothing but the whooshing sound of the machine. The HeartMate II, which was supposed to keep the left ventricle going, had taken over almost all heart function. It was strong enough not just to push the blood out of the left ventricle into the body but to take up the work of the right side, getting blood into and out of the lungs as well. The machine had totally replaced his heart.
“Why didn’t you come back?” a somewhat dazed Bud asked him.
The man shrugged. “I felt fine,” he said.
It was then that Bud began to wonder—if a single HeartMate II worked that well, what would happen if someone could figure out how to put two HeartMate IIs together, one for the left side and one for the right, to make a permanent artificial heart?
* * *
That someone was Billy Cohn, working with Thoratec, which by this time had grown into one of the country’s largest medical device companies. It boasted a team of engineers who had once worked on DeBakey’s old LVAD—the one that was so close in design to the Jarvik 2000 but had been abandoned by its hedge fund backers.
Bud’s simple-sounding idea would involve a pretty complex feat of biomedical engineering: a device designed to pump blood from the left side of the heart into the body would have to be redesigned to work with the right side, delivering blood to the lungs for oxygenation. The angles in the design of the HeartMate II would have to be changed to fit a different system, as would the pump speeds, to mimic a different rate of flow in a completely different part of the body. The right side of the heart was also more prone to clots; the lungs filtered them out only if they were small. Oddly enough, the right side of the heart also seemed to work better with some pulsing action. So the engineers had to figure out a way to build a faint pulse back into the HeartMate II.
With Thoratec’s engineers engaged, Billy focused on a set of connectors to bridge one machine to the aorta and the other to the pulmonary system. He started shopping for parts, as always, at Home Depot, twisting cones out of various materials—silicone, rubber, drywall tape—until he had something that he thought might work.
The technical, legal, biological, governmental, financial, and, of course, interpersonal challenges were enormous, and five years passed in a heartbeat. By the mid-2000s, Billy and Bud had become the odd couple of THI, as different in their personalities as Jarvik and Wampler or DeBakey and Cooley. Billy was flamboyant, impulsive, and creative, someone who could envision a device in three dimensions long before it actually existed. Bud was erudite, thoughtful, and methodical; he could envision how a device would work in the body long before it was even built. The two men got on each other’s nerves and sometimes bickered like a couple of brothers separated by just a few years.
Still, the partnership worked. Bud was then in his mid-sixties and continuing to put in endless days and nights in the operating room. (Staffers made grim jokes about “Bud time,” because so many of his operations wound up taking place in the middle of the night. Bud was an easy touch when it came to interruptions.) Billy had a radically different sense of time—think speed of light versus glacial—and could put in more hours in the lab. Bud would have an idea—why not build in a septum, the central wall that separates the two sides of the heart?—and Billy would suggest reasons why that might not work, but then head home to his shop or the lab and start cobbling something together. Then the engineers would go to work, to come up with a working model. And Bud would razz Billy for being a doubter.
Billy and Bud tested iterations of this new double pump on more than forty calves. “We just did it and rigged ’em up,” was the way Bud put it. The only one that died was a calf that got startled, reared back, and pulled out his drive lines from the console.
Money wasn’t hard to come by. The Dunn Foundation, a fund supported by a Houston oil fortune, had long contributed to myriad enterprises in the Texas Medical Center. There was a Dunn Tower at Methodist Hospital, just for starters. Bud was well known to them, not just because of his international reputation but also because his best friend from the University of Texas was on the board. They pitched in half a million.
Their biggest problem, it turned out, was finding existing pumps to adapt and implant. At this point, the artificial heart business was going nowhere, while the LVAD business was rolling. At least five companies, along with Thoratec, were in the business in the United States alone—Berlin Heart, Medtronics, and more—and European and Asian companies were also getting in on the act. The medical device business in general had exploded in the last decade or so, and the more complex the device, the more expensive. Heart assist devices sold for around $700,000 and Bud needed two for each calf implant. By 2009 or so, the HeartMate II was the bestselling LVAD on the market, keeping as many as twenty thousand patients alive. A continuous-flow pump, the only parts of the HeartMate II that lay outside the body were the small controller and the battery packs. Patients, according to the literature, could “once again enjoy their favorite activities, such as travel, golf, visiting family members, dancing, and playing an instrument.”
Now Bud Frazier looked to be muddying the waters with another loony idea. Why should Thoratec devote time and money to an experimental total heart when the HeartMate II was already an enormous success, and the market for those needing total heart replacement was comparatively small? And, at $600,000 to $700,000 a pop, why should any medical device company hand over equipment for free, just to find out if two LVADs could work as well as a real heart?
So to get the parts they needed, Bud and Billy scavenged. In their earliest efforts to fuse two LVADs together, they used a Micromed pump—one of DeBakey’s old pumps. As Bud put it, “there were a lot left over” when the company went under. They used some of Jarvik’s pumps, but there weren’t as many of those around, because Jarvik had never been able to get very many manufactured. Finally they managed to convince Thoratec to come up with the rest, either as a result of Bud’s longtime association with the company or because he simply refused to go away.
By 2011, he was on the lookout for another end-of-life patient who was willing to take a chance on testing an experimental device, someone hovering in that fragile, twilit state closer to death than life. Someone who had exhausted all other options, but who still hoped for on
e more chance to live.
That’s when Craig Lewis appeared in the St. Luke’s emergency room.
* * *
When he wasn’t in the OR, in the lab, needling Billy, or trying to relax while watching The Wages of Fear or the like on his office television, Bud tried to reconcile two pieces of another, more challenging puzzle: making peace between his mentors, Michael DeBakey and Denton Cooley. It was a widely held belief at the time that the competition between the two surgeons had actually helped to make the Texas Medical Center a global force in the treatment of heart disease. But the world of medicine had grown ever more specialized and ever more expensive in the span of their careers; the competition between the hospitals in the Texas Medical Center meant that after more than fifty years there were lots of pricey redundancies. Maybe a little collaboration going forward wouldn’t be such a bad thing, especially since the enmity between the Cooley forces and the DeBakey loyalists included not just heart surgeons but the lowest tech, who probably hadn’t been born when the fight started.
Besides that, Bud knew that Cooley was bothered that his own chief still treated him like a pariah. As he moved into his eighties, Cooley spoke more and more often of wanting to make amends; he didn’t want to apologize, exactly—Cooley never stopped believing DeBakey would never have implanted Liotta’s heart in a human patient—but he did want to thank DeBakey for bringing him to Houston and inspiring him to launch all that followed. As for DeBakey, he continued to insist, as did his sisters and at least one son, that there had never been a feud. It was Team DeBakey’s way of saying that Denton Cooley had simply ceased to exist. Like a Soviet traitor in the old Politburo, he had been excised from their collective memory.