by James Salter
“Yes.”
“I learn a new word every day.”
Kolff is the sort of man who inspires affection. With his high forehead and face filled with confidence and humor, one feels he knows things, and not merely about the work to which he has devoted his life.
The first heart that Jarvik designed was never tried in an animal. The second was not very good, either. Developed from an idea of Kolff’s, it was flat and in fact was called the pancake heart. Jarvik had begun work on another model when Kolff summoned him.
“When is your new heart going to be ready?” he asked. “We’ve been beaten. Dr. Nosé has beaten us.”
Nosé was a former associate in Cleveland who stayed there when Kolff left. Experimenting with the idea of a flocked surface inside the heart that was meant to encourage an organic layer to form on it, he had had a calf that survived seventeen days, a record at the time. Kolff was determined to surpass it. Jarvik was by then in medical school—he had gotten in with Kolff’s help—but he was still employed at the lab. All through Christmas that year he remembers working on the new heart.
The first calf they tried it in lived six days. It died from a massive blood clot—the inside of the heart hadn’t been cleaned well enough in this case, but the formation of clots was a constant problem in the beginning. Jarvik and Kolff were using a smooth inner surface, as smooth and nonirritating to the blood as possible.
After four or five tries, just before the ASAIO (American Society for Artificial Internal Organs) meeting that year, they had a calf that went nineteen days.
“It was so exciting,” Elaine Jarvik says, “those two weeks. It was so intense. Your parents called every night.”
“Every day was a new milestone,” Jarvik agrees.
All the early hearts were made of silicon rubber. Polyurethane was thought to be a better material, more durable, very abrasion resistant, smoother and less damaging to the blood, but the hearts made of it didn’t stand up, the diaphragms broke after a few days or weeks on the tester. Then Jarvik had an idea. It was to use several layers of polyurethane with Dacron mesh between them for support. Pharmaceutical mesh cost too much so he bought some in a fabric store for $4.95 a yard.
The first calf they tried it in went three months. That was in 1974. The record had been thirty-six days.
The new heart was called the J-3.
“That was the first thing I did that was inventive,” Jarvik says. “We used that heart, in that form, for quite a long time. We got up to about four, four and a half months.”
Each animal was a journey into the unknown, a major operation, a complete medical history. Infection was coming in where the air lines that drove the heart entered the body, and there were still blood clots forming at the seam where the diaphragm joined the wall of the chamber. Kwan-Gett, who designed early hearts, had wanted to cover the inner surface with liquid polyurethane. There would be a shallow concave mold at the bottom of the heart and the polyurethane formed by it would be the diaphragm. Jarvik took this idea which had never worked for Kwan-Gett and made a heart. It was seamless, the J-5.
With it, in 1977, they got the first six-month survival, a calf named Abebe. There have been a lot of long-lived calves since—Sirius, Claudius, Romulus, Fumi Joe, among others, and Tennyson who lived 268 days, nearly nine months. There the record stands. All of the long survivors have been with J-5 hearts except Fumi Joe who had a J-7, the model designed for human implantation. One limitation has become the animal outgrowing the heart, becoming too large for it and dying of cardiac insufficiency. Sheep, though they are difficult to work with, might solve the problem. When Jarvik came to Salt Lake City no animal with an artificial heart had lived more than three days.
The next step will be in the hands of a tall (six-foot-five), whippet-lean surgeon named William DeVries. The chief of Cardiothoracic Surgery at Utah, he has had a long acquaintance with the artificial heart. “I just sort of grew up with it,” he says. He was one of Kolff’s first new employees and like Kwan-Gett built early hearts for him. When permission for clinical testing is received from the FDA, it will be DeVries who performs the actual operation.
DeVries is a Mormon and grew up in Salt Lake City. One of nine children, his father was a naval surgeon killed in the South Pacific during World War II. His mother is a nurse. DeVries himself has five children, coaches basketball, and is the legendary Westerner, lanky, drawling, straightforward. It was Kolff who stirred in him an interest in surgery. He was already in medical school when they met and later, with Kolff’s assistance, he obtained a prestigious residency at Duke, “I probably wouldn’t have got it by myself.” When his residency was completed it was only natural that he return to Utah which, at Kolff’s suggestion, he did. He had fully expected that an artificial heart would have been tried by then. “At the time I left the field,” he says, “I felt sure one would be put in in a few years.”
DeVries has operated on literally hundreds of animals including both Tennyson and Fumi Joe. His job has been to perfect the surgical techniques. “I know that I can put that artificial heart in better than anyone in the world right now,” he says confidently. He does about 200 heart operations a year. Of these, perhaps 5 percent are high risk—patients whose chances in cardiac surgery are not good, generally someone with poor left ventricular function. If at the conclusion of surgery the patient cannot be brought off the heart-lung machine despite all efforts, if the heart cannot be made to beat again, in short if someone is to be given up for dead, then the artificial heart will be implanted, with prior consent, of course.
“Last year I had maybe three patients who would fit the criteria,” DeVries says. He adds, “and they all died.”
The final act will be his alone. He will select the potential recipient according to a carefully prepared profile, he will decide at the crucial moment if the heart will be used, he will put it in. Two consulting cardiologists will approve his decision, but apart from that, his authority will be complete.
The result, if successful, will be someone permanently tethered to an array of bulky mechanical equipment, a control box, a large compressor, backup compressor, standby tanks of compressed air for an emergency, and the rest. To many people this seems disturbing. Kolff has always said from the beginning, however, that the comfort and happiness of the patient come first. He has even said that he would give the patient a pair of scissors and not keep him from using them if that was what he wanted.
The publicity has already begun. “We do not seek it,” Kolff says, “but it is unavoidable.”
“There’s been a tremendous amount . . . too much,” DeVries agrees.
Appearances on national television, stories, interviews. Last summer Jarvik was asked to design a heart to be used in a movie with Donald Sutherland, Threshold, about a surgeon who perfects an indestructible heart. When the movie was being made Jarvik met Sutherland and Denton Cooley, probably the best-known cardiac surgeon in the world, who kept a patient alive for several days with an artificial heart while waiting for a transplant donor in 1968. Cooley had instructed Sutherland in surgical matters and even made a brief appearance in the film. They were having drinks in a hotel in Toronto and Jarvik, convinced that Cooley had never heard of him, asked how he had become involved in all this. Cooley’s cold blue stare fixed on him.
“It’s about me,” he said.
The heart that Jarvik designed for Threshold is nuclear powered and the moment when the natural heart of the young woman who receives it is removed forever is a chilling one. This aspect of the artificial heart, that it represents an irreversible step, is one of the objections put forth against clinical testing. The NIH has shifted its support to an intermediate device which is, in effect, half a heart. It is a pump that can be temporarily attached to an ailing left ventricle to ease its work and allow it to recover—the natural heart would stay in situ. This is the LVAD, left ventricular assist device, now in limited use.
The LVAD makes sense but the results of it have not been very good. Used principally in Boston and Houston, about one patient in twenty has survived. Kolff’s people feel it has its place just as transplants do, but there are hearts that the LVAD cannot help.
One of the problems has been that the LVAD is used on patients who have been on the heart-lung machine too long and on whom everything else has been tried. There is massive bleeding because the coagulating power of the blood is gone. Even the doctors who support it say that results would be better if the LVAD could be put in sooner.
This could also apply to the first use of the J-7. The patient may have been on the heart-lung machine for five or six hours before every alternative is exhausted and the artificial heart can be used. This is too long.
Jarvik is outspoken about disagreeing with the way it will be done. He would use it on a voluntary basis, straight off, someone with cardiomyopathy—progressive disease of the heart muscle. “If the patient is on bypass six or seven hours,” he says, “I don’t think he’ll live.” DeVries agrees it is a problem.
Still, everything has been practiced, everything anticipated. For a year and a half now DeVries has gone to St. Mark’s, the abandoned hospital in which the artificial heart program is housed, to do an implant every week. He has done them in cadavers as well as animals. Early in May the J-7 was tested in a woman who had been declared dead because her brainwaves were flat. The operation was done by Kolff’s son, Jack, who is a cardiac surgeon in Philadelphia. The heart was in for several hours, supported life, and worked well.
The scrub nurses have familiarized themselves with the operation, doorways have been checked to make sure the special equipment will fit through. When the FDA gives its permission, all systems will be go.
Not all medical opinion is favorable.
“What’s happening in Utah is an aberration,” says an important surgeon. “It’s way out in left field . . . In fact, it’s a very bad idea. Jarvik and DeVries are self-destructing. Old Kolff, he’s retired and his contact with medicine has been peripheral . . . We’re not at that stage where we’re ready for it.”
“There’s room for the artificial heart but I think it should require more work,” another says. “It took us five years to negotiate permission to implant the LVAD . . . Utah has a lot to learn.”
There are considerations that are not purely scientific.
“We’ve sold four hearts to Argentina, to Favaloro,” DeVries says. “His group may be the first to take one and put it in a patient. What if they say, you can’t do it here, and Argentina does it?”
Dr. René Favaloro is the surgeon who developed the coronary bypass operation when he was in Cleveland. More than 100,000 are now performed annually in the U.S. The clock is ticking.
A grotesque optimism, a blind push towards progress, science for the sake of science, and a perfect faith in the undiscovered—these are disquieting but they are not what motivate the team in Utah. Kolff, Jarvik, and DeVries, all doctors and sons of doctors, represent in a strange way a kind of nineteenth-century idealism striving to perfect what they see as an eminently useful device. They are not pursuing monstrous visions to whatever end. Nor do they seek, as some critics say, to create a race of invalids. Their goal is simpler and more direct: to heal the sick. Forever? Hardly. The body will find ways to die despite an imperishable heart.
Typescript
May 26, 1981
Man Is His Own Star: Royal Robbins
In Yosemite there is a great hotel, the Ahwahnee, with beautiful windows and chateau-like grounds. In sitting rooms the size of churches there are tables from England, rugs from the Caucasus, and lamps made from antique Japanese jars. There is also, friends tell me, a ten-year wait for Christmas reservations.
There used to be a nightly display for guests: at nine in the evening the rangers would light a huge pyre of bark slabs and wood and push it over a cliff. This ceremony was known as the Firefall. At the far end of the valley, on the vertical 2,000-foot face of Half Dome, climbers attempting its first ascent could see this river of fire from whatever narrow ledge they were bivouacked on for the night, and they chose the time to flash signals to their friends on the ground.
The climbers were led by a young, hatchet-faced Californian, aggressive, supremely talented, who had been famous since his teens. They were five days on the face of Half Dome, tormented by its immense scale and by the summit overhangs which would have to be crossed somehow. On the fifth morning they stuffed their excess gear into a hauling bag and threw it into space. They watched it fall endlessly, never once touching the wall, and finally hit the ground. Then they pushed on and, by means of a narrow ledge barely a foot wide, hanging from it by their hands at the end, they at last reached the top. It was the first Grade VI climb in America, a climb of the highest level of endeavor. The year was 1957. The twenty-two-year-old leader was Royal Robbins.
I drove to Yosemite National Park with Robbins not long ago. We pulled off the road at an overlook near the entrance to the valley and sat there in silence gazing out at it. The great glacial cliffs, the forests, the deep valley floor were still far off and appeared smaller than I had expected. Still, it was very moving, this first image he was letting me have without a word of description or reminiscence, standing back from it as it were and allowing me to see it with my own eyes. He, of course, had seen it countless times. He had spent, by his own estimate, more than a year in Yosemite, half of it on one climb or another and more than sixty nights bivouacked on the big walls.
Robbins—even a chief rival calls him “Numero uno”—is forty-three now. He’s medium sized, strong, with blue eyes and straight brown hair. There is something neat, even academic about him. With his glasses and beard, his fine ears and high forehead, he might be an anthropologist with important work behind him. In fact, he is a high school dropout; his education came later. He speaks in a low, somewhat reluctant voice. His responses are often just a single word.
Yosemite rock, which he began to point out as we drove along, is all smooth, steep, and glacially polished. There are few handholds, and a climber must make use of characteristic vertical cracks. These often run for long distances, varying in width from several inches to two or three feet and then narrowing to a line no broader than that of a pencil. A very technical and highly evolved method of climbing is necessary, and even then climbs are not easy.
“Great climbing,” Robbins explained, “is steep rock without excessive difficulty. Yosemite steep climbs are often difficult. Yosemite tends to be discouraging and to require condition and endurance. Also, it’s not particularly exhilarating. They are problems you wrestle with rather than overcome with finesse.”
To one who does not climb, of course, steepness seems to be the most difficult thing to accept, the most demoralizing. I had mentioned this on another occasion and Robbins had said that very often something that looks hard actually isn’t.
“Steepness, for instance, isn’t one of the things that make a climb hard.”
“What are the things that do?” I asked.
“The lack of holds,” he said simply.
We had descended to the valley floor. In the late afternoon the trees seemed rich and green, the Merced River clear enough to see every pebble in its bed. Suddenly there loomed out of the dusk the top of a great, pale bulwark, like the blunt prow of an enormous ship facing not quite toward us. A thrill of recognition went through me, I had seen so many photographs: it was El Capitan. There was still a little light, and Robbins stopped the car, took a pair of binoculars from the glove compartment, and examined the face. There were several parties climbing, he commented, at least one on the Nose, and there was someone bivouacked above the Roof, a large overhang more than two thirds of the way up. Bivouacked meant attached to the face in a kind of hammock in which the climber would pass the night with 2,000 feet of empty air beneath him. A climb of El Cap by any of its routes takes severa
l days, and sometimes longer, depending on the conditions and the ability of the climbers. It is extremely difficult and exposed, and to have some idea of scale one must imagine a wall more than twice as high as the Empire State Building.
A few days earlier we’d had dinner at Robbins’s house in Modesto with another well-known climber, T. M. Herbert. It was a congenial occasion. Herbert is a schoolteacher in a small town near Merced and a man of great wit and vitality. He made what seemed to me a surprising confession: he said that as a boy he had been terrified of heights, and that the germ of that fear was still within him.
“T. M. never falls,” Robbins said. “He puts in protection every three feet and sometimes goes down the rope to double-check what’s already in.”
The longest fall he’d ever taken was thirty feet, Herbert admitted. Robbins, on the other hand, has fallen frequently. Generally speaking, among serious climbers there is no such thing as not falling. It is inevitable. These falls are protected by a belay rope, but they can be dangerous.
“Have you ever fallen when you didn’t more or less anticipate it?” I once asked Robbins.
“No,” he said. “Once, when I first began climbing, I leaned back on a piton I’d just put in and it pulled out. I fell thirty feet and broke my arm.”
It had been what climbers call a “ground fall,” meaning that one hits the ground. Thirty feet is a considerable distance—men have been killed falling from stepladders—but I had already heard of 150- and even 200-foot ground falls where the climber not only had lived but had gone back to climbing.
It’s disturbing, perhaps, to think of Robbins, one of the greatest climbers alive, as losing his hold and falling—after all, if he falls, then what about me?—but the reason has nothing to do with lack of ability. Robbins falls when he attempts something that is at the very limit of his powers, and it is his nature always to extend these limits. He expects a fall and is prepared for it.
Herbert and his wife were on their way to Yosemite the night they spent at the Robbinses’. Close to forty, Herbert was as passionate as ever about climbing. Earlier he had spent an hour by himself doing exercises in the living room. He was climbing as well as he ever had, he told Robbins. He was going to Yosemite every weekend. He was still in there. Climbing had changed, of course, he admitted. A new generation had appeared.