Heart: An American Medical Odyssey

by Cheney, Dick

  In the cath lab, I try to make all of that disappear and focus instead on the technical tasks: the artery to be punctured, the lesion to be crossed, the stent to deploy. I gazed down the table at Cheney and tried not to think about who he was, or his family waiting down the hall, or the election, and I consciously avoided looking through the leaded glass window at the control room filled with anxious medical center leadership.

  My colleague Dr. Conor Lundergan joined me after a hurried drive from his home in Maryland, some of it on the shoulder of the road, and together we again reviewed the images looping on the video displays suspended from the ceiling. Conor agreed that we should fix the large diagonal, and I gave Julia a “shopping list” of equipment I wanted, most of which she had already set aside.

  I told Cheney that we had identified the problem and were going to take care of it. Although he appeared to be sleeping, he immediately acknowledged what I said and responded, “Good.”

  Take a deep breath; you’ve done this thousands of times.

  I inserted a guide catheter (essentially, a one-meter-long, steel-reinforced, hollow tube with a shaped tip, roughly the diameter of a soda straw) into the sheath in Mr. Cheney’s right femoral artery and maneuvered it with the aid of fluoroscopy to the origin of his left main coronary artery. I then advanced a thin (.014-inch diameter) guide wire through the guide catheter into the left anterior descending coronary and out into its diagonal branch, the culprit for Cheney’s chest pain.

  A diseased coronary artery is a slender structure that flexes in concert with the underlying beating heart and is filled with ragged outcroppings of calcified plaque, creating a moving three-dimensional environment. Manipulating a device inside an atherosclerotic coronary is like crawling through a tight cave filled with stalactites and stalagmites while the cave jumps up and down.

  Without too much difficulty, we succeeded in wiggling the soft tip of the wire beyond the tight coronary narrowing into the relatively less diseased vessel segment downstream, step one in repairing the artery. Next we loaded the back end of the wire into the central lumen of the balloon, like threading a needle, except the eye is about the same diameter as the thread, and then we slid the balloon over the wire into the coronary. With a bit of coaxing, the balloon slipped into the tightly restricted section of the diagonal. The inflation device, a large syringe with a screw-in plunger, filled with diluted X-ray dye, was connected to the balloon, and as we twisted the plunger clockwise, the 2.5-millimeter balloon expanded inside Dick Cheney’s coronary artery.

  I checked the hemodynamic monitor and his pulse, blood pressure, and rhythm were all fine. I looked to my left down the table, and Cheney was sleeping.

  So far so good.

  After about a minute of dilation, the balloon was deflated and removed, and another set of pictures revealed a still narrowed, but somewhat improved, appearance of the vessel, step two.

  The final part of the procedure was delivering and then expanding a stent in the diseased segment, a task that is sometimes easier said than done. Although a lot of engineering has gone into increasing stent flexibility, the metallic device has an intrinsically rigid architecture, and in order to pass it through an angulated vessel, either the artery or the stent has to bend. The more inflexible either structure is, the harder it is to deliver the device to the intended target.

  We watched on the monitor as the stent entered the left main and then the LAD. It’s not so easy to see the actual stent, but the balloon on which it is crimped has visible markers at both ends, identifying the leading and trailing edges of the device. With a bit of effort, we were able to get the stent to make the ninety-degree turn into the diagonal, but there was a second acute bend to negotiate, and the stent would go no farther.

  I backed the stent off a few millimeters and tried again. No luck. We removed the stent and re-dilated the artery with a balloon. Still, the stent would not pass. We changed to a different type of stent, but that too would not make the second turn into the short segment with the worst disease.

  I don’t usually perspire much during a case because the rooms are kept cool, and I’ve performed these procedures so many times, but the scrubs under my protective lead were soaked by now. As hard as I tried to tell myself that this was just another angioplasty, the growing crowd in the control room, the Secret Service outside the door, and the camera trucks outside the hospital were constant reminders that while the medicine might have been routine, nothing else was. Although the success rate for coronary interventions is very high, it’s not 100 percent, and occasionally a lesion can’t be fixed. There’s no shame in that. But in this particular case, to paraphrase NASA’s Gene Kranz, “failure was not an option.”

  We had long since passed the two-hour mark, and I looked over again to see how Cheney was doing. I turned to Julia and asked her if we had any juice.

  “Sure,” she said, as she went to the refrigerator outside the room, returning quickly with a small round container of apple juice, a flexible straw protruding from its foil cover.

  “Here you go,” she said, offering Cheney the juice.

  “Not him, Julia, me,” I said.

  “Oh,” she said, pivoting away from the patient with a nervous laugh.

  Sometimes it’s best to press the pause button. When an initial attempt to solve a problem fails, there’s a natural tendency to try the same approach over and over again, creating an endless, unsuccessful loop. I could feel some frustration beginning to fester, and I was also really thirsty. It was time to stop for a moment.

  Julia slipped the straw under the side of my mask, and I downed the cold liquid in a single slurp.

  Okay, let’s try something else.

  After the brief time-out, we reentered the vessel with a different balloon in a slightly different place, hoping that the inflation would alter the internal geometry of the artery just enough to allow passage of the stent. Now when we advanced the stent, it slid into position, and when it did, I could sense the collective sigh of relief. After a half dozen clockwise turns on the inflation syringe, the stent was finally deployed. We were done.

  I took off my gown and gloves and told Mr. Cheney what we had found and what we were able to do. As I left the room, I told the Secret Service agents that we would be bringing him back to his room in a few minutes, and they immediately began talking quietly into the microphones clipped discreetly inside their jacket cuffs.

  It was now after noon and while we were in the cath lab, Governor Bush had made a brief statement in Austin in which he said, “Dick Cheney is healthy. He did not have a heart attack.” The governor’s statement had been based on the first set of cardiac enzymes drawn shortly after Mr. Cheney’s arrival at the hospital, which were negative. The second set of enzymes, however, obtained a few hours later when we started the cath, specifically the highly sensitive troponin assay, was mildly elevated, indicative of a small heart attack. Governor Bush had not been told these results before he made his statement.

  Alan Wasserman, Conor Lundergan, Gary Malakoff, and I went to talk with Mrs. Cheney who was waiting in an office in the hospital’s administrative suite. I told Mrs. Cheney that the findings were quite similar to the cath five years earlier with the exception of the diagonal, which we were able to repair with a single stent. We talked about the mildly elevated cardiac enzymes and her husband’s very favorable prognosis. There was some discussion as to who would brief the media, and ultimately it was decided that Dr. Wasserman would do it.

  At about 2:30 p.m., Alan addressed the media.

  As I think everyone is aware, Secretary Richard Cheney came to the George Washington University Hospital emergency room with chest pain . . . early this morning.

  Neither his initial EKG nor his blood work indicated that he had a heart attack. After consultation with his internist, Dr. Gary Malakoff, director of the division of internal medicine, Dr. Jonathan Reiner, cardiologist and director of the cardiac catheterization laboratory and Dr. Richard Katz, chief of cardiology, and
when a second EKG showed minor changes, a decision was made to perform a cardiac catheterization. The results of the catheterization showed an increased narrowing in a side branch of artery, specifically the diagonal branch of the left anterior descending artery. The rest of his coronary anatomy is completely unchanged from a previous study performed in 1996.

  A decision was made to place a coronary stent in that area that showed some additional narrowing. After placement of the stent, the artery now appears normal. Mr. Cheney has returned to his hospital room and is doing well.

  While there is no evidence of any new heart muscle damage on either the heart catheterization or the follow-up electrocardiograms, a second set of cardiac enzymes tests was minimally elevated. He is in good condition and will be at bed rest for the remainder of the day as a standard protocol in procedures such as this. We expect a short hospital stay and expect that Mr. Cheney will be back to normal functions without limitations in a brief period of time.

  Alan took a lot of heat for his statement. While he clearly stated that the second set of cardiac enzymes was elevated, he hadn’t used the lay term heart attack. I was present throughout the hospitalization, and no one in Mr. Cheney’s family or the Bush campaign at any time tried to edit our disclosure or obscure the fact that there had been a small heart attack. In fact, to ensure that we were being fully transparent, we held a second press conference two hours later in which I participated. Before Alan introduced me, he passed out copies of Mr. Cheney’s cardiac enzymes and explained them more fully:

  The first value was obtained at approximately 8 a.m., and the values are completely normal. The second set of values were obtained, were available to Dr. Reiner sometime after noon today, while he was in the catheterization laboratory. The second set of values show an elevated level, a minimally elevated level that shows that there was a very slight heart attack. The third set of values shows that the levels have basically tapered off and have not continued to increase.

  It is generally accepted that plaque rupture is the typical trigger for an event such as Mr. Cheney’s. Inside the vessel, a cholesterol plaque becomes abraded, or “ruptures,” allowing a clot to develop and changing a lesion that the day before may have been only moderately narrowed into a much more significant blockage. Sometimes very minute pieces of clot can break off, lodge downstream, and cause the small enzyme elevations (small heart attacks) like Mr. Cheney’s. Angioplasty and stent placement can seal these roughened areas inside the artery and prevent these events from becoming much larger, clinically more significant heart attacks. I don’t think any heart attack is insignificant, but Mr. Cheney’s heart attack was small, and I described it at the press conference in the following way:

  We have biochemical markers that enable us to determine whether or not there has been any damage at all to the heart muscle. And over the last several years . . . we’ve had some new tools, much more sensitive markers which weren’t available several years ago which enable us to detect extremely small levels of heart muscle damage. . . . Two or three years ago we would simply—based on the biochemical data available then, we would simply have classified the event as just angina. But because we have more sensitive markers, we can detect extraordinarily minute elevations in these markers of heart muscle damage. So, you know, we’ve really had to rethink what a heart attack is.

  Mr. Cheney’s hospitalization was brief and his recovery uncomplicated, but in an editorial a few days after Mr. Cheney was discharged, the New York Times said Americans “have reason to be concerned by the failure of Mr. Cheney’s aides and doctors to inform the public fully and promptly about his true condition,” an insulting allegation that was simply wrong. The Times went on to say, “Wednesday’s bumbling performance may not fall into the category of deliberate misinformation, but it did not cover anyone with glory.”

  Despite the tumult in the press, I was proud of the care provided to Mr. Cheney at GW, what the Wall Street Journal called, “aggressive, invasive treatment with cardiology’s state-of-the-art technology.”

  CHAPTER 10

  White House Calls

  VICE PRESIDENT CHENEY

  When I took the oath of office as vice president of the United States on January 20, 2001, I had been living with coronary artery disease for twenty-two years. I had survived four heart attacks, the last occurring just months before, and quadruple bypass surgery. Medical advances such as cholesterol-lowering drugs and stents had improved my life expectancy and justified my doctors” view that I was capable of serving as vice president. Without those advances, I would have long since been forced to retire and may not have survived at all. While I had not sought the second-highest office in the land, I had been chosen by the president, nominated by my party, and elected to serve. I was honored to do so.

  One of my first acts after being sworn in as vice president was to sign a letter resigning the vice presidency. I had asked David Addington, my longtime assistant and legal counsel, to review all of the procedures and authorities having to do with the continuity of government. What were the procedures, for example, if the president became ill or incapacitated? What about the vice president? How would we make sure the government could continue to function if we were attacked and either the president or vice president was unable to carry out his responsibilities? My most important responsibility as vice president was to be prepared to take over in the event something happened to the president. I wanted to be fully briefed on everything that would be involved in such a transition.

  After David completed his review, he came to see me. Looking over the Constitution and relevant statutes, he had discovered a potential problem that could be significant especially in my case.

  The Twenty-Fifth Amendment to the Constitution specifies a procedure for temporarily removing a sitting president if he is unable to perform the duties of the office. The vice president convenes the cabinet and puts the question of the removal of the president to a vote. If a majority of the cabinet concurs, the vice president becomes acting president, and the Speaker of the House and the president pro tem of the Senate are notified.

  The Twenty-Fifth Amendment also made provision for the president to appoint a vice president if there was a vacancy in that office. Nixon used it to appoint Gerald Ford when Spiro Agnew resigned. Ford used it to appoint Nelson Rockefeller when he became president upon Nixon’s resignation. There is no provision for replacing a vice president who becomes incapacitated, however. This is especially problematic since only the vice president can convene the cabinet to initiate the procedure for replacing a president. There is also the possibility that in the case of a president’s death, a nonfunctioning vice president would replace him. As a constitutional officer, the vice president cannot be fired. He can resign or be removed only through the impeachment process.

  At least once in our history, we have seen a president disabled: Woodrow Wilson suffered a stroke in October 1919 with seventeen months left in his second term of office. Given my medical history, I thought it was important to make a provision for the possibility that my abilities might be impaired by a stroke or a serious heart attack that would leave me still in office but unable to carry out the duties of vice president.

  The solution we came up with was for me to sign a letter of resignation dated March 28, 2001, just sixty-seven days after we were inaugurated. I addressed it to the secretary of state, the standard form for such a letter from a president or vice president, and printed it on my official stationery. I gave the signed letter to David Addington with very clear instructions that he was to hold on to the letter and if the need ever arose, he was to present it to the president. It would then be up to the president to decide if and when to forward it to the secretary of state. Once it was submitted to the secretary, the office of vice president would be vacant, and the president could appoint a successor using the provisions of the Twenty-Fifth Amendment. The only other person I told about this arrangement was President Bush. I thought it was important that he know about it.
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  When Governor Bush asked me to be his running mate, he made it clear that it would be a consequential post. I would be a full member of his team and help govern the nation. From our first week in office, he was a man of his word. California had been experiencing rolling brownouts, and Alan Greenspan, chairman of the Federal Reserve and an old friend of mine from the Ford administration, was greatly concerned that the power shortages could spread to other parts of the country and cause significant problems in the economy. After we talked about the matter in my West Wing office, we went together to see the president, and our meeting led to the creation of an energy task force to develop a new national energy policy, which the president asked me to chair.

  He also asked me to take on the task of conducting a review of a number of studies that dealt with the problem of “homeland security.” My national security background had been an important reason for his selecting me, and with his approval, I embarked on a series of visits to the Central Intelligence Agency, the National Security Agency, the Defense Intelligence Agency, and other parts of the intelligence community. I’d had a special interest in intelligence matters since my days on the House Intelligence Committee and as secretary of defense, but after eight years in the private sector, I needed to catch up.

  As vice president, I also served as the president of the Senate, which after the 2000 elections was evenly divided, with Republicans and Democrats each holding fifty seats. My tie-breaking vote placed the Republicans in the majority and allowed them to select the chairs of each committee. My Senate colleagues invited me to attend the weekly GOP policy lunch, which I did whenever I was in Washington.