Heart: An American Medical Odyssey

by Cheney, Dick

  • • •

  On Monday morning, March 5, 2001, only four days after our White House visit, Debbie Heiden called and asked if I had a moment to speak with the vice president.

  “Of course,” I said.

  A moment later, the vice president was on the line. Calmly, almost matter-of-factly, Mr. Cheney reported that he was having some chest pain.

  Chest pain? I just saw you a few days ago and you were fine.

  The first episode occurred two days before, on Saturday, after about thirty minutes of exercise. The vice president described the discomfort as a “burning” that lasted about five minutes and dissipated without any treatment. The second episode occurred the next day at rest after Mr. Cheney awoke from a midafternoon nap and was relieved by a nitroglycerin tablet. Over the weekend, the vice president and Mrs. Cheney had moved into the newly renovated official residence at the Naval Observatory on Massachusetts Avenue, and on Sunday evening he felt well enough to attend a seventy-fifth birthday party for Alan Greenspan, the chairman of the Federal Reserve. It was now Monday morning, and the vice president had developed another episode of chest burning, this time after showering. Again, nitroglycerin relieved it. At the time of the call, Mr. Cheney said he felt fine.

  We spoke about the possibility that we might need to repeat the cardiac catheterization, and I told the vice president that I would arrange for an EKG to be performed by the WHMU. At 2:45 p.m. Vice President Cheney walked over to the clinic in the White House residence for an EKG. On his way back to the West Wing, he had more chest pain, and when he called me to report his symptoms I told him we should repeat the catheterization.

  “Where should I go?” he asked.

  “There’s going to be no way to keep this quiet,” I said, stating the obvious.

  “Don’t worry about that.”

  “Just go to the emergency room,” I said. “I’ll meet you there.”

  He told me he was on his way.

  • • •

  Unique logistics accompany a hospital admission for the vice president of the United States. The first necessity is to identify secure and private accommodations, ideally a location without much through traffic, where access can be limited to authorized personnel. It’s helpful to provide family members with an adjacent but separate room, which can be used for meetings with staff or as a lounge while the patient is resting or needs some privacy. The vice president travels with a military aide who carries the “nuclear football,” electronic gear for communicating with military leadership during a national emergency, and if the vice president will be in the hospital overnight, the aide needs a place to stay. The Secret Service deploys a large number of agents and tactical personnel in and around the hospital, and a conference room is typically provided for their use as a command post. The patient also needs a pseudonym, security needs to be configured to keep the press and paparazzi out of the hospital, and the same as it would be for anyone, the patient must authorize the release of any health information.

  George Washington University Hospital is only six blocks from the White House, so I hung up the phone and quickly dialed the emergency room to tell the attending physician on duty that the vice president was about to walk through their door. Next, I called the cath lab and told Julia that we were going to recath Cheney as soon as everyone was ready. I informed the hospital administration of the plan and also let Alan Wasserman know what was happening and asked him to inform medical center leadership. Finally, I called Charisse and told her I wouldn’t be home for dinner. By the time I finished making the calls, Vice President Cheney was in the emergency room.

  • • •

  The introduction of coronary stents in the 1990s made angioplasty a dramatically safer procedure. A balloon exerts its therapeutic effect by fracturing a coronary’s atherosclerotic plaque and also literally stretching the vessel. Sometimes the “cracks” created in the plaque can obstruct the flow of blood, and the scaffolding properties of a stent greatly reduce this risk. Stents also prevent the stretched arterial wall from recoiling and renarrowing the vessel over time.

  The Achilles” heel of stenting is a biological process called restenosis. After a stent is expanded, it becomes embedded in the arterial wall, and over the next several weeks, tissue begins to cover the metallic struts. A small amount of tissue growth is desirable, as it “heals” the vessel and reduces the likelihood that a clot will form within the foreign body. In 20 to 30 percent of patients who receive a stent, however, the tissue growth progresses unchecked, resulting in significant renarrowing of the stented vessel segment, typically occurring within the first six months following stent implantation and often resulting in a recurrence of the patient’s symptoms. In 2000, when Dick Cheney’s stent was implanted, there were about 1,025,000 coronary angioplasty or stent procedures performed in the United States, about 25 percent of them for treatment of restenosis.

  Almost four months had passed since we implanted the stent in Vice President Cheney’s diagonal coronary artery, and because the odds favored restenosis as the cause of his symptoms, it was likely that we would need to do another angioplasty. I asked Dr. Alan Wasserman to join me in the cath lab. Alan had practiced interventional cardiology for many years before becoming chairman of GW’s Department of Medicine, and I welcomed his wise counsel.

  Following a brief stop in the emergency room, the vice president was brought to the cath lab, and Julia again assisted him onto the padded table. Shortly after Cheney’s procedure in November, this lab had been gutted and replaced by a latest-generation system manufactured by Philips, the huge Dutch multinational company, and we had only recently resumed using it for cases. In the old cath lab, images were recorded on 35mm movie film. This new room did away with the quaint celluloid and stored the much better quality images in a state-of-the-art digital archive.

  After Julia prepped and sedated Mr. Cheney, I used our X-ray system to guide a catheter to the heart. When we injected contrast into the coronaries, we quickly found that the four-month-old stent had a very tightly narrowed restenotic segment, undoubtedly the cause of the vice president’s pain.

  Okay, no problem. This can be fixed.

  Without difficulty we passed a wire beyond the obstruction, and over the wire we slid an intravascular ultrasound catheter (IVUS) into the narrowed stent. An IVUS catheter has a miniaturized ultrasound transducer small enough to fit inside a coronary artery and uses high-frequency sound waves (ultrasound) to create detailed, inside-out images of a vessel’s architecture. The study demonstrated that although the stent was well expanded, we could see a very short segment of bulky restenotic material inside it.

  We removed the IVUS catheter and easily positioned a balloon within the narrowing. After leaving the balloon inflated for about a minute, I stepped on the foot pedal to reactivate the fluoroscopy.

  The screen was blank.

  I stepped on the pedal again, but still there was no image on the monitor.

  My technologist, Fernando Najera, announced that the system was frozen and needed to be rebooted, a process that takes about five minutes.

  That’s really great. I have a balloon inflated inside the heart of the vice president of the United States and my brand-new million-dollar cath lab doesn’t seem to work.

  “Okay, reboot it,” I said as I deflated the balloon and removed it without being able to see what I was doing. It was a risky maneuver, but the balloon had to come out.

  After five minutes, Fernando said, “Okay, try it again.”

  Still nothing.

  “Reboot it again, Fernando.”

  After waiting what seemed like much longer than five minutes, I again depressed the foot pedal. The screen was still blank.

  Forgetting for a moment whom I had on the table, I shouted a profanity and then, remembering, hoped he was asleep.

  “Get Philips on the phone,” I said, and also asked the staff to set up the lab next door. If we were going to finish the procedure, it was looking as if we were going to ne
ed to move Cheney to a different room. Cath labs are complicated systems, and they do crash occasionally, but this time we had the vice president of the United States on the table. This couldn’t have come at a worse moment.

  Fernando rebooted the lab one last time and miraculously, perhaps aided by several silent Hail Marys from Julia, the system came back online. With a functional cath lab, we injected the coronary and found that the vessel looked much better. After one more balloon inflation, we were done.

  • • •

  The procedure had taken less than an hour to complete, and Alan and Gary Malakoff and I walked upstairs to hospital administration to brief Mrs. Cheney. When we entered the suite, there were a lot of people around. The CEO of the hospital, Dan McLean, was there, as was the medical director, Dr. Richard Becker, and Dr. John “Skip” Williams, the dean of the medical school. There were university and hospital media people, some staff of the vice president and Mrs. Cheney, and, of course, the Secret Service.

  I make it a practice to talk to family members immediately after finishing a procedure because I know how hard it is to wait to hear about a person you love, and I usually prefer not to discuss these very personal details in a busy place. As Alan and I sat down, I could tell that Mrs. Cheney was also not comfortable with the large assembled crowd, and she politely but firmly asked everyone else to leave. They moved quickly, as if a fire alarm had gone off, but Dr. Williams, who in addition to being dean of the medical school was also the university’s vice president for medical affairs, was reluctant to go. As Alan and I averted our gaze, Mrs. Cheney again excused Dr. Williams, who said, “These guys work for me.”

  Without hesitating, Mrs. Cheney smiled and said, “That’s okay. This is about my husband,” and she calmly ushered the dean to the door.

  The fact was that I didn’t work for Skip, I worked for Alan, but at that moment, there was no question who was in charge in that room.

  With the suite cleared, we told Mrs. Cheney about the restenotic stent and the good result we were able to get with repeat angioplasty. We told her that there was no evidence the vice president had suffered a heart attack and that we thought he would be fine.

  Mrs. Cheney called Mary Matalin, counselor to the vice president, and over a speakerphone discussed how we would handle the press conference. The initial release of information concerning the November heart attack hadn’t gone well, and no one wanted a repeat of that. I argued for immediate full disclosure, and without any debate, it was agreed that Alan would make a brief statement and then I would answer the media’s questions.

  No classes in medical school cover the essential skills for holding a press conference, but the experience in November taught me a lot. If the press thinks you haven’t been forthright, they will sense blood in the water and react like sharks. I do believe doctors should be advocates for their patients, but it’s best to leave the spinning to others and focus instead on explaining the medicine, and presenting the facts and the best estimate of the outlook.

  Alan began by making a brief, crystal-clear statement about the procedure and the vice president’s condition and stated unequivocally that there was no evidence of a heart attack. Then, still wearing our scrubs, we answered questions for forty minutes until no one had anything left to ask.

  During the press conference I described the cause of restenosis in the following way:

  This is a specific response to injury from the stent . . . what we know is that when an artery is stented . . . the stent itself initiates a series of events, normal events—response-to-injury events which in about 20 percent of patients results in renarrowing. . . .

  Picture a garden hose that starts to fill with sediment. Cut the hose in half and you’d see the hose itself is the same size it always was but the effective channel inside the hose is narrowed.

  I tried to explain that clinical events such as Vice President Cheney’s occur from time to time in patients with heart disease and I didn’t consider it a crisis:

  The vice president clearly has chronic coronary artery disease, and he has probably had it for many decades, although it was first discovered when he had his first heart attack in the 1970s. And this is what coronary artery disease has become. It’s become a chronic disease, affecting millions of people in this country.

  When asked about what could happen next, I replied:

  I wish I could predict the future. I think there’s a very high likelihood that he can finish out his term in his extremely vigorous . . . capacity.

  The next morning I arrived early, and the coronary care unit nurse told me the vice president had spent an uneventful night. I reviewed the morning EKG and some labs and was pleased to note that his cardiac enzymes remained normal, meaning he had not had a heart attack. The agent posted at Cheney’s door greeted me with “Morning, Doc,” and after knocking, I found the vice president alone and in good spirits, reading a newspaper and watching TV, having already eaten his breakfast. I pulled up a chair and described again what we had found at cath and what we were able to do.

  The vice president was remarkably relaxed. “It sounds like you had a little trouble with the equipment yesterday,” Cheney said with a slight smile.

  I guess he wasn’t asleep after all.

  While we spoke, the Today show ran an update on the vice president’s condition, and we stopped talking to listen to NBC’s Tim Russert. Russert was wondering whether Cheney should resign, and he said that the vice president might have to make a choice between spending the last days of his life in office or spending them with his family.

  In 2001, about one in five patients who received a stent would develop restenosis similar to the vice president’s, and in most instances it was more an annoyance than a crisis. If Mr. Russert’s comment bothered the vice president, he didn’t show it. I was angry, but Cheney just laughed. I told Mr. Cheney that I was confident he would be fine and that I would tell him if I ever thought he was not capable of serving as vice president.

  Over the next couple of days, the newspapers and broadcast media weighed in about Mr. Cheney’s fitness to serve.

  The Los Angeles Times published an editorial:

  Cheney comes across as an unflappable fellow, the sort who keeps a cool head and steady hand when the stress is great. . . . But daily stress and a very high workload of essential duties are not a prudent combination for a man with Cheney’s health history. Cheney’s doctor insisted he could be perfectly capable of finishing his term “in his fully vigorous capacity.” Yet there is a difference between vigor and capacity.

  US News & World Report speculated about who might replace the vice president:

  White House officials concede there’s a contingency plan in case Cheney can’t continue in office. Bush confidants say any list of possible replacements would include Secretary of State Colin Powell, governors such as Pennsylvania’s Tom Ridge, and other Washington gray beards like Defense Secretary Donald Rumsfeld. In the meantime, Bush has barred aides from speculating because he considers it macabre.

  Arianna Huffington wasn’t just ill informed; she was outright nasty:

  The question remains: Is the vice president on a suicide mission—or just unable to overcome his type-A addiction to the adrenaline highs of his lofty position? After his last heart attack, he was asked if he was worried about having another one. “I don’t operate that way,” he replied. No, you just put the gun to your head and see if the next chamber is the one with the bullet.

  After Mrs. Cheney arrived, the vice president changed into a suit, and Alan and I accompanied them to the entrance to the hospital where the motorcade was waiting. As we walked through the lobby, I stopped to allow Mr. Cheney to leave the hospital alone, but he paused and motioned to me to join him. A barrage of clicking camera shutters greeted us as we passed through the door. The vice president turned to shake my hand, and the photo of that moment made the front page of newspapers around the country.

  • • •

  Lew Hofmann arranged for Gary and
me to return to the White House two weeks later. We planned to see the vice president in the residence clinic, and Lew met us at the gate and walked us over. As it would be a little while until the vice president arrived, we were told to make ourselves at home in Dr. Tubb’s office. Brigadier General Richard Tubb (also called Dick) had graduated from the Air Force Academy before going to medical school at the University of Wisconsin, and his office, just a few steps from the elevator leading to the president’s quarters, contained a mix of mementos, including a classic doctor’s bag and a ceremonial sword, reflecting his dual careers as physician and military officer. While I waited, a medical unit staffer suggested that I look out the window. The ground-floor office faces the South Lawn, and just as I parted the drapes, I watched as Marine One, a green Sikorsky VH-3D helicopter, landed, returning President Bush to the White House.

  When the vice president arrived, he looked well. He said that he had resumed exercising with a recumbent bike and elliptical trainer, and his weight was down a few pounds. Since the angioplasty two weeks earlier, there had been no chest pain, shortness of breath, or other symptoms. We spoke about the possibility that the stent could narrow again, and I told him that although there was a risk of that, I thought it was likely he would do well. During the press conference, I had quoted a 40 percent chance of restenosis, the textbook answer, but because Cheney’s specific lesion involved such a short segment of the stent, I thought it was probably half that. Mary Matalin had asked me about this a few days after the hospitalization, and I told her that I was intentionally lowering expectations, but I thought the vice president would do very well. Before the visit ended, I reminded the vice president that we still wanted him to wear a Holter monitor to continuously record his heart rhythm for twenty-four hours, and Lew said he would arrange for it.

  • • •

  In June, Lew obtained a Holter monitor (essentially a small recorder with a few EKG leads) from Bethesda Naval Hospital, and the vice president wore it over a weekend. During that interval, the monitor recorded quite a few isolated premature beats, a benign finding, but on two occasions four of these extra beats came one after another at a very fast rate, an ominous rhythm called ventricular tachycardia.