Heart: An American Medical Odyssey

by Cheney, Dick

  In October, Lew Hofmann again updated the vice president:

  I would like to close by sharing with you that the White House Medical Unit took the lead several years ago in preparing for bio/chemical terrorism. On September 11th, in an uncertain environment, we took broad measures to defend against attack. . . . As we have discussed, you are now effectively immunized against anthrax and the antibiotics you are taking should protect you from plague and tularemia. We have an effective plan in place to treat an attack with botulism, and we stand prepared with vaccination to prevent you from smallpox infection if you are exposed. Please advise me if you require additional information, and I truly appreciate the opportunity to serve.

  As if the concerns about a possible attack with anthrax, smallpox, botulism, tularemia, and plague weren’t enough, in September 2001, a dead crow that tested positive for West Nile virus was found on the grounds of the vice president’s residence in Washington.

  • • •

  Several weeks later, I met Lew and two of his White House colleagues for an early lunch a few blocks from my office at Mr. K’s, an elegant Chinese restaurant that for years was a favorite haunt of lobbyists and K Street lawyers. When we arrived, the restaurant was eerily quiet.

  “Do you have a reservation?” the maître d” asked.

  We didn’t. He didn’t seem to notice that his restaurant was completely empty. After some head scratching and flipping back and forth in his reservation book, he sat us alone in a large formal dining room, the tables set with golden flatware and porcelain chopsticks rests.

  It had been about a year since I first met Lew Hofmann, and he was quickly becoming a close friend. Lew’s specialty is family medicine, which, the American Academy of Family Physicians states, “encompasses all ages, both sexes, each organ system and every disease entity,” an excellent background for a doctor who may be called on to treat trauma, tonsillitis, or ventricular tachycardia. Despite rising to one of the most prestigious postings in military medicine, Lew managed to maintain a sincere humility, an admirable and uncommon trait in Washington.

  Over lunch, the conversation veered toward some of the biological threats that had been in the news. I was curious whether the smallpox vaccine administered to everyone born before 1971 would still offer protection. Lew said that the best estimate was that the old vaccination would probably not keep you from getting the disease but might prevent you from dying of it.

  Other tables were starting to fill with customers, and as we continued our not-so-light lunchtime conversation, a man I recognized approached our group. It was the prominent Washington lawyer Bob Bennett, who had represented President Bill Clinton. Bennett had been sitting at a nearby table with his brother, William Bennett, the former secretary of education, and he looked a little annoyed.

  “Listen, guys,” he said without a smile. “I can hear your conversation, and I really don’t want to.”

  Such was the mood in Washington in the wake of the attacks, and for the vice president, bioterrorism countermeasures became an unexpected adjunct to his cardioprotective regimen that included aspirin, Plavix, and Lipitor.

  • • •

  When my home phone rang on a Saturday morning in late December 2001, the caller ID was blank. Expecting to hear a telemarketing pitch, I reluctantly answered the call, and when I did, a familiar voice on the other end said, “Hi, Jon, it’s Dick Cheney.”

  The vice president was in Jackson, Wyoming, and was calling to report that he had been short of breath the previous night. He described the sensation as feeling that he wasn’t able to take a full breath, but he denied experiencing any chest pain or difficulty with exertion and hadn’t noticed any change in his weight. Unable to sleep, the vice president had gotten up and read for a while, but when he went back to bed, he still felt short of breath and didn’t sleep for the rest of the night. When we spoke in the morning, he said he felt okay and thought his symptoms were similar to an episode a few years before that at the time we thought was altitude sickness.

  Altitude sickness is a common constellation of mostly annoying symptoms such as headache, nausea, and insomnia that may occur at elevations higher than eight thousand feet. High-altitude pulmonary edema (HAPE), by contrast, is a potentially life-threatening condition involving fluid retention in the lungs, encountered unpredictably by otherwise healthy climbers and skiers, also usually occurring at altitudes above eight thousand feet. Untreated, extreme forms of HAPE can lead to death.

  I thought it was probable that Cheney’s symptoms were altitude related, but it was also possible that he was developing early signs of congestive heart failure (CHF); it was really impossible to tell for sure over the phone. Fortunately, the vice president traveled with medical support, and I was able to speak with Captain Thomas Waters, a White House physician’s assistant, who examined Mr. Cheney. Together we surmised that the altitude was probably to blame, but in view of the vice president’s known cardiac dysfunction, we prescribed a low dose of Lasix, a diuretic, which would help if the symptoms were due to CHF.

  I told the vice president that I would call later to check on him, but after I hung up, I realized that I had neglected to ask for the phone number in Jackson.

  “Why don’t you press star six nine?” my wife, Charisse, suggested.

  “Don’t be ridiculous. I’m sure that’s disabled.”

  Surprisingly it wasn’t, and when I called later that evening, I was glad to hear that all was well. Although I still thought the thin mountain air was probably the cause of the breathlessness, Jackson is only about a thousand feet higher than Denver, and I was left with a lingering concern that Mr. Cheney’s symptoms might have represented some early heart failure.

  • • •

  For much of Mr. Cheney’s first term in office, he felt well, and our visits during those years were largely uneventful. The usual protocol for a patient with an ICD includes a quarterly evaluation during which the device is “interrogated” using an external programmer roughly the size of a large laptop computer, and during those visits, we always performed a quick history and physical examination. Often Lew Hofmann arranged for us to see Cheney in the vice president’s West Wing office, usually at the end of the day, and he would pre-position a programmer in an inconspicuous corner of the suite. We tried to keep these visits brief, assuming that the vice president had more important things to do than spend time with a handful of doctors. Typically Gary Malakoff, Sung Lee, and I would make the ten-minute walk to the White House together, and after Sung left for private practice in Maryland in 2004, Dr. Cindy Tracy, GW’s new head of electrophysiology, a nationally renowned electrophysiologist, took Sung’s place in what Lew called “the three amigos.”

  We made a conscious effort to be discreet, never wearing white coats or openly carrying medical equipment. On her first trip to the White House, Cindy met us on the street still dressed in operating room scrubs.

  “Cindy, you can’t wear scrubs,” I said.

  “Why not?” she asked, looking surprisingly surprised.

  “Because, we’re going to the White House! Also, if the press spots scrub-wearing doctors entering the West Wing, they’ll think Cheney’s having another heart attack.”

  “Okay,” Cindy said, and ran back to the hospital to change.

  • • •

  Most of the vice president’s staff was situated in the Eisenhower Executive Office Building next door to the White House, but the vice president worked out of the West Wing in a small suite of offices staffed by a few aides led by Debbie Heiden, his longtime assistant. Debbie was the only member of the vice president’s staff entrusted with any detailed knowledge of his personal medical history. She was also clearly the gatekeeper.

  I looked forward to the White House visits, in part because of the singular venue, but more and more because I enjoyed seeing the vice president. I didn’t really know him that well and had seen him only a few times before he decided to run in 2000, but over his two terms in office, I would spen
d dozens of hours with him at the White House, his residence, our offices, and the hospital.

  My father used to say that it’s one thing to have a disease, but quite another to let the disease have you, and clearly heart disease didn’t have Dick Cheney. Each time Cheney faced a serious health crisis, he seemed to respond not by slowing down but by doing just the opposite and taking on increasingly demanding jobs. After the heart attack in 1978, he was elected to Congress, eventually rising to a leadership position in the House. Ten years later, after another heart attack and bypass surgery, Cheney served as secretary of defense, managing the military during the Gulf War and the collapse of the Soviet Union. Another decade later, after another MI, he became the vice president of the United States. The man managed to live an extraordinarily full life despite having had to live with an extraordinarily aggressive disease for a very long time.

  In June 2001, when Vice President Cheney met with the White House press and announced that he was going to undergo testing the next day that might lead to the placement of an ICD, a reporter asked him if he was worried that his coronary disease might be getting worse. The vice president’s candid answer that day is a glimpse into how he has lived his life.

  Well, no, I’ve—it’s obviously a question I asked my doctors, in terms of what this might signify going forward. But as everybody knows, my history of coronary artery disease goes back to 1978. My entire career in politics, in elective office, in Congress, in the Defense Department, eight years in the private sector, now as vice president, it’s all taken place after the onset of coronary artery disease. It’s something you live with. And it’s my great good fortune that the technology’s gotten so good, that it’s kept pace with my disease, if you will, so we’ve been able to manage it through the years. And as I say, if there were any inhibition on my ability to function, if it were the doctors” judgment that any of these developments constituted the kind of information that indicated I would not be able to perform, I’d be the first to step down. I don’t have any interest in continuing in the post unless I’m able to perform adequately, and the doctors have assured me that is the case.

  About once a year, the vice president underwent a series of comprehensive examinations that took days to plan. Our goal was to create an efficient, tightly choreographed schedule that condensed the maximum number of clinical evaluations into the smallest amount of time. Lew and I called it “kabuki theater” because there was quite a bit of stagecraft involved in coordinating the various consultants, and we generated timetables that would make NASA flight controllers look like slackers.

  For a visit in July 2005, we assembled the following schedule:

  Naval Observatory

  Timeline for the Vice President’s Evaluation

  July 16, 2005

  08:00

  Arrive George Washington Hospital

  Proceed to Radiology Suite

  08:05

  Arrive CT Scan

  Change into Examination Attire

  08:10

  Intravenous Line Placement

  08:15

  Vascular CT Scan Leg Arteries and Aorta

  08:30

  Return to Arrival Attire

  Proceed to Ultrasound Suite

  08:35

  Arrive Ultrasound Suite

  Ultrasound of Neck Arteries

  09:05

  Proceed to Endoscopy Suite

  Change into Examination Gown

  Anesthesia Preparation and Monitor Placement

  09:20

  Commence Deep Sedation

  09:25

  Upper Scope

  09:45

  Complete Upper Scope

  Reposition for Lower Scope

  Colonoscopy

  10:35

  Recover from Deep Sedation

  Return to Arrival Attire

  11:05

  Synthesize Examination Findings

  Recommendations to Enhance Future Health

  Answer Questions

  11:35

  Depart Endoscopy Suite

  Proceed to Motorcade

  The ability to coalesce, into a single morning, multiple tests that would usually be separated by several days is a perk not typically available to the general public, but very helpful for a patient who must travel with a large protective detail. The vice president had been due for a screening colonoscopy and upper endoscopy, and the relative quiet of a Saturday morning was the ideal time to do it. Patients with unusual security requirements can create significant disruptions in the normal work flow of a hospital, and using off-hours is often easier for both the hospital and the patient.

  That day, the vice president was also scheduled to undergo a CT scan to evaluate his aorta and the arteries of his legs. An earlier ultrasound had identified the presence of aneurysms (abnormal dilatations) in the popliteal arteries, behind Cheney’s knees, and we wanted to learn more about these. A localized weakening in a vessel wall can result in an aneurysm, and if it develops in the aorta or the brain, the principal risk is rupture, which can be devastating. An aneurysm in a popliteal artery doesn’t usually rupture, but the clot that forms in the dilated sac can embolize and threaten the leg downstream.

  The CT scan revealed that the aneurysm behind the vice president’s right knee was large, measuring more than 4 centimeters, about the size of a golf ball, and it contained a lot of clot. The aneurysm in the left leg was a little smaller but still fairly big. Popliteal aneurysms are typically seen in patients with atherosclerosis, almost always in men, and left untreated, they can begin to shed small clumps of clot, causing gangrene of the lower leg and foot, a disaster. In the mid-1990s, a report from the Mayo Clinic showed that many of the popliteal aneurysm patients who suddenly developed symptoms (e.g., cold and painful foot or toes) would ultimately require an amputation. It was clear that both legs needed to be repaired before something bad happened. The only question was how.

  • • •

  In 2005, the standard approach to repairing a popliteal aneurysm was surgery to open the back of the leg, excise the diseased vessel segment, and then restore arterial continuity with a bypass composed of either a vein from the patient or a synthetic vascular graft. The surgery usually required general anesthesia and a few days in the hospital. Overall, vascular surgery is considered a high-risk procedure, in large part because it is frequently performed on patients who also have heart disease, and I thought Vice President Cheney was particularly high risk for surgery.

  Although Cheney had not had any recent angina or overt episodes of congestive heart failure, I knew that he was delicately balanced. Earlier in the summer, an echocardiogram estimated his ejection fraction at 25 to 30 percent, somewhat lower than when he took office. Surgery to repair the aneurysm was going to require the harvesting of a vein, but surgeons had used the vein from his left leg during the coronary bypass surgery in 1988 and it wasn’t clear how much of the remaining vein in the right leg would be usable. A synthetic graft was less desirable. Anesthesia places a stress on the heart, as does the tachycardia that may result from pain or blood loss, and the surgical procedure itself makes it more likely that blood will clot, not a good thing for a patient with severe coronary disease. To make matters worse, Cheney was going to need two operations.

  I consulted Dr. Anthony Venbrux, GW’s director of interventional radiology, an internationally renowned physician who had come to George Washington University Hospital five years earlier after spending the first part of his career at Johns Hopkins. Tony is a brilliant radiologist and a truly gifted teacher, and one of the kindest people I have ever known. He proposed a new, less invasive method to treat the aneurysms. The procedure, called endovascular repair, would involve placing a Gore-Tex–covered stent inside the vessel (an “endograft’) to connect the relatively normal upstream and downstream arterial segments, thereby functionally excluding the aneurysm. The potential advantage of this technique was that it could be performed without general anesthesia, would not require the surgical excisi
on of a vein, and should be safer. Also, recovery would be quicker, and if all went well, it might be possible to treat both legs during the same procedure. The major negatives of this approach were its newness and the scarcity of long-term safety and efficacy data.

  Tony told me that Dr. Barry Katzen, the founder and medical director of Baptist Cardiac & Vascular Institute in Miami, was one of the world’s experts in this technique, and Tony said he would reach out to him and solicit his opinion without disclosing the identity of the patient. Barry agreed that endovascular popliteal aneurysm repair was a very reasonable option, particularly for high-risk patients, and that although it was relatively new, the evolving data were very favorable.

  Tony subsequently drafted a long document, basically a medical brief, in which he outlined the rationale for his proposed strategy to repair the vice president’s aneurysms with endografts:

  There are several clinical factors to consider regarding management of the bilateral popliteal aneurysms in this patient. Clinical comorbidities include significant cardiac history with previous harvesting of greater saphenous vein for CABG from one of the lower extremities. The patient also has had coronary artery interventions and placement of a pacemaker. The desire to preserve the remaining saphenous vein for potential future cardiac surgery is an important consideration. . . . Recognizing the lack of available longterm data, percutaneous access from an antegrade approach with aneurysm exclusion with a stent graft is a reasonable alternative given the medical conditions of this patient. . . . Given the current “state of the art” imaging available at GWUMC, percutaneous placement of such a device is feasible. The team at The George Washington University Medical Center is multidisciplinary and available to treat [the vice president] should he decide to proceed.