Heart: An American Medical Odyssey

by Cheney, Dick

  • • •

  The hospitalization to implant the VAD had been an ordeal for the patient and his family. When Cheney was finally taken home by ambulance on August 9, 2010, he had been in the hospital for thirty-five days, the vast majority of that time in the intensive care unit, including a week on a respirator. There had been so much to contend with, including bleeding, a kidney injury, pneumonia, respiratory failure, and a pneumothorax (air leak from the lung), that the ICU director, Dr. Jason Vourlekis, at times looked like a plate spinner at a circus.

  Vourlekis, whom I hadn’t known prior to the vice president’s hospitalization, is a very well trained pulmonary/critical care medicine physician who, prior to coming to Fairfax, had worked at National Jewish Medical and Research Center in Denver and the National Cancer Institute. He distinguished himself during the vice president’s complicated ICU stay and somehow managed to retain his dry sense of humor.

  The hospitalization had also been hard on Cheney’s family. Mrs. Cheney, Liz, or Mary slept in the hospital almost every one of the nights he was hospitalized. When he was in the intensive care unit, a family member was with him 24/7, and on most days Gigi El-Bayoumi would come by to offer her irreplaceable counsel and endlessly compassionate ability to listen.

  The vice president left the hospital about forty pounds lighter than when he went in, a consequence of his severe illness and many days without any oral nutrition. Unfortunately, the drop in weight also came at the expense of muscle mass. Cheney was going to require a lot of rehab to regain the strength he had lost, not just during the hospital stay but also in the weeks of declining health leading up to the VAD.

  Although the HeartMate II VAD is approved by the FDA for use as either a bridge to transplant or as destination therapy, some patients use it as a bridge to decision, giving them time to decide whether to pursue transplantation or to stick with the VAD. In the immediate aftermath of the vice president’s long hospitalization, the question of what to do next was really moot. In the near term, even if a heart were to become available unexpectedly, Cheney was in no condition to undergo another operation or, for that matter, even to decide whether he wanted a transplant. What did make sense was to get in line.

  • • •

  In the United States, organ transplantation is governed by a highly codified system of rules and procedures managed by UNOS (the United Network for Organ Sharing), a nonprofit organization that maintains the Organ Procurement and Transplantation Network, a unified transplant network established by Congress in 1984. UNOS manages the national transplant waiting list, develops the policies and procedures that govern organ allocation, and maintains a database that catalogues every transplant performed in the United States.

  Each patient placed on the heart transplant waiting list is assigned a status. Patients who have the highest urgency for transplant (the sickest) are called status 1A; these are patients on high-dose intravenous cardiac medications, those requiring ventilator support, and patients with VADs who are experiencing complications such as clots or infection. Patients in status 1B are those with VADs who are relatively stable, as well as the patients maintained on home intravenous infusions of cardiac medications. Status 2 patients are the least sick and don’t meet the criteria for status 1A or 1B.

  Two days after the vice president’s surgery to implant the VAD, the transplant committee at Fairfax reviewed his case and wrote to him on July 12, 2010, informing him of their decision:

  Dear Mr. Cheney

  Following completion of your transplant evaluation, your case was recently presented to the Heart Transplant Committee for review. I am happy to report that you have been accepted for listing by the committee. You were listed on July 8, 2010.

  Insurance authorization has been obtained and you are listed with UNOS (United Network for Organ Sharing) and your referring physician has been notified.

  Attached is a letter from the United Network for Organ Sharing (UNOS). It describes the services and information offered to patients by UNOS and the Organ Procurement and Transplantation Network.

  While waiting for your transplant, you will see Dr. Shashank Desai in the transplant clinic at Inova Fairfax Hospital. The frequency of those visits will be determined by your clinical condition.

  If you get sick or are hospitalized while waiting for your heart transplant, it is your responsibility to ensure that the heart transplant program is notified. Changes in your condition may necessitate a change in your waiting status and therefore your position on the list.

  Should questions arise prior to your next appointment, please feel free to contact us.

  Sincerely

  Carolyn Rosner, RN

  Heart Transplant and Listing Coordinator

  The Heart Transplant Program

  Inova Fairfax Hospital

  Entering the transplant queue obviously did not commit Mr. Cheney to receiving a heart, but it started the clock so that if and when he decided to pursue that option, he would have already accrued time.

  • • •

  I never intended the VAD to be a permanent solution for the vice president. Although Cheney was in his late sixties when his cardiac status began its precipitous slide, his noncardiac-related health was actually quite good. He had no sign of carotid disease and had never had a stroke, he did not have high blood pressure, there was no history of cancer or diabetes, and when his heart was working well, so were his kidneys. Cheney’s entire complicated and interlocking puzzle of medical problems was entirely due to his dying heart. The shortness of breath, fatigue, arrhythmias, DVT, renal function, bleeding, and swelling were the consequences of heart failure. If we could fix the heart, everything else would go away.

  • • •

  In spring 2010, as Mr. Cheney required multiple hospitalizations and the interludes of relative stability became shorter and shorter, I spoke with a colleague at GW involved in his care. It quickly became clear that the person he was worrying about was me.

  “He’s dying, Jon, and there’s nothing you can do to stop that,” my colleague said.

  “No, that’s not right,” I responded. “He can get a VAD, and then we’ll transplant him.”

  “No, he can’t get a heart transplant,” he said slowly, as if he were trying to break the bad news to me gently.

  “Yes, he can,” I said, and I walked away.

  • • •

  I viewed the VAD as a life raft for Cheney, not a destination. The boat was definitely sinking, but we were going to get off that boat, allow him enough time to rehabilitate, and give him time to work his way up the transplant list. That was the plan, and although he had told me early on that he was potentially interested in transplantation, he didn’t make his final decision until about six months after the VAD surgery when he was starting to feel well again.

  Week by week, Cheney started to improve. The VAD can move a lot of blood, and it provided the vice president with an essentially normal cardiac output. With reinvigorated blood flow, his kidney function returned to normal, as did his liver. The anorexia that accompanied his end-stage congestive heart failure dissipated, consequently improving his appetite and repleting his nutritional status. As Cheney’s metabolic parameters improved, his strength rebounded, and he was able to do more and more exercise.

  In a letter to me on September 30, 2010, Shashank Desai wrote:

  My impression is that Richard Cheney continues to improve nicely since implantation of his HeartMate II LVAD on July 6, 2010. I am happy to see how well he continues to recondition. I have encouraged him to increase his ambulation, and I am happy to see that he is actually traveling. Logistically, we have helped arrange delivery of oxygen to his high altitude locations, as well as ensuring he has backup batteries and controllers with him at all times. Arrangements have been made for a supply of dressings. Additionally, we have contacted the LVAD programs near to where he will be traveling.

  In October 2010, Vice President and Mrs. Cheney finally returned to Jackson, a big step in his re
covery. A photo that Mrs. Cheney took exactly three months after his emergency surgery to implant the VAD shows the vice president driving his Jeep (the same vehicle in which he had a sudden cardiac arrest while backing out of his driveway ten months earlier), the beautiful Teton range visible in the distance.

  After he came back from Wyoming, the vice president returned for a follow-up visit. Shashank wrote:

  An echocardiogram was done in the hospital, which I was able to oversee. He continues with severe LV dysfunction. His aortic valve remains closed throughout the cardiac cycle. He has 1+ aortic insufficiency [mild], which remains stable. . . .

  Overall, I am very happy with his continued progress. He will return to VAD clinic in 1 week’s time.

  The standard protocol for a patient with a VAD includes routine surveillance echocardiograms, and Cheney’s echo was startling. For the entire time I knew the vice president, he had always had an abnormal echo, notable for a dilated ventricle that didn’t contract well. Now, Mr. Cheney’s left ventricle was essentially motionless, and with all the blood flow going through the VAD, the aortic valve no longer opened.

  On November 2, Mary Cheney sent me a photo of her dad on a pheasant-hunting trip, resplendent in high-visibility orange, a shotgun in his left hand. What’s not visible under all the gear is the VAD spinning at 9,600 RPM, enabling him to do so much more than simply survive.

  After the New Year, we met again and the vice president looked even better:

  January 21, 2011

  Dear Dr. Reiner:

  I had the pleasure of seeing Mr. Cheney in the VAD clinic today in follow-up. Happily, you were present during this visit. I will reiterate the events of this visit for our records.

  He has truly turned the corner. His energy level is excellent. He has no shortness of breath with his activities. He is very active and is traveling extensively. He is able to climb up more than one flight of steps energetically and does not have shortness of breath at the top. He has had no difficulties with his VAD driveline or controller. His wound is well healed and he has no further drainage. . . .

  My impression is that Mr. Cheney is doing well and remains status 1B awaiting orthotopic heart transplantation. His VAD continues to perform well. On interrogation he has had no significant alarms. I am happy to see that he has returned to a near normal quality of life. . . .

  Thank you for allowing me to participate in the care of Richard Cheney. Contact me directly if questions arise.

  Sincerely,

  Shashank Desai, MD

  January 2011 marked two landmark events for Dick Cheney; on the thirtieth of the month, he turned seventy years of age, and after meeting again with the team at Fairfax, he made the final decision to proceed with transplant.

  The decision to recommend the VAD had been easy. There was no doubt that Cheney would have died without further support, and a VAD was his only option. Now, seven months later, the decision to push ahead with transplant was a bit harder. Mr. Cheney had just barely survived the last hospitalization, but now that the smoke had cleared, he was well. After all that he had been through, the idea of sending him back for more surgery was almost too much for me to contemplate.

  If Cheney was going to opt for transplant, now was the time to do it. Although at seventy, he was still a candidate for the operation, that window would close over the next couple of years, and there would be no going back. If he elected to have surgery, there were no guarantees he wouldn’t succumb to the kinds of postoperative complications that nearly killed him in July. It was a difficult choice.

  Ultimately it came down to a risk-reward analysis. If the vice president was willing to take the risk, the reward might be great (the first patient to undergo heart transplant surgery at Fairfax, in 1986, was still alive). In the forty-five years since transplant surgery was introduced, refinements in organ preservation, candidate selection, immunosuppression, and rejection surveillance have dramatically increased the life span of patients with a transplanted heart. For patients who underwent heart transplantation in 2009 and survived their first year (the vast majority), the median predicted survival is fourteen years. A successful transplant would give Cheney a legitimate chance of reaching eighty. There were still many rivers to fish and graduations of grandchildren to attend. Cheney wanted the transplant.

  • • •

  The heart transplant waiting list managed by UNOS stratifies patients by level of acuity, time spent on the list, and blood type. To avoid immediate rejection, a donated heart must be the same blood type as or a compatible blood type to the recipient’s. Organs from patients with blood types A, B, or O require organs from donors of the same type. Patients with blood type AB (the universal recipient) can receive a heart of any type, and those with blood type O (the universal donor) can donate to a patient of any type. Other factors are important to the allocation of specific organs, including the size of the donor and recipient (you can’t put a heart from a hundred-pound donor into a two-hundred-pound recipient), and the presence of certain antibodies in the blood. The vice president’s blood type was A, a common group shared by 42 percent of the population. A large percentage of donor hearts are type A, but so are many of the patients on the waiting list.

  Despite an increase in the number of people being listed for transplant between the years 2000 and 2011, there was essentially no change in the number of heart transplants performed in the United States during that same period of time (about two thousand per year), a consequence of the lack of growth of organ donation. There are currently about thirty-five hundred patients in the United States waiting for a heart transplant. The mean age for patients on the list is fifty-one, but the number over the age of sixty-five has been rising.

  • • •

  As the months passed, life returned to normal for the vice president, who traveled extensively, adjusting the VAD to his lifestyle rather than his lifestyle to the VAD. The one-year anniversary of the implant surgery came and went, and while there had been movement on the transplant list, there were still several patients with the same blood type ahead of him.

  In fall 2011, the vice president started to lose a little ground. Cheney developed some edema, and an echo revealed that his aortic valve was leaking more. For years the vice president had mild aortic insufficiency, a valvular abnormality whereby blood seeps back from the aorta into the left ventricle when the aortic valve is closed. It was starting to get worse and beginning to hamper the effectiveness of the VAD. The device was still doing its job, pumping blood out of the ventricle, but now some of that blood was immediately leaking back, creating an ineffective loop. Cheney also redeveloped atrial fibrillation, and he had an episode of ventricular tachycardia that his ICD stopped.

  January 20, 2012

  Dear Jonathan:

  I had the pleasure of seeing Richard Cheney back in the VAD clinic today in follow-up. He was in Wyoming for the holidays and continues to do well. He had a mild viral illness but does not have any fevers, chills, or sweats currently. He has had one episode of a nosebleed, but this did not progress. . . .

  On physical examination his mean blood pressure is 92mmHg. His LVAD is set to 9800 rpm with a flow of 5.7 . . . he is well appearing and in no distress. . . . Lungs are clear to auscultation bilaterally. Cardiac exam reveals normal VAD sounds without audible heart sounds. . . . Driveline is clean, dry and intact. . . .

  My impression is that Richard Cheney has an appropriately functioning LVAD which was implanted on July 6, 2010. He has overall deterioration of his cardiac function under this. He is exercise limited. Additionally he has progressive aortic insufficiency; when last checked, this was moderate in volume. This is very likely the result (cause) of his OptiVol [fluid measurement] being above threshold, as well as the return of his atrial fibrillation. Now he has fast VT requiring therapy. To this end I have asked him to increase his antiarrhythmic therapy of Toprol XL to 100 mg daily. I believe his blood pressure will tolerate this. . . .

  Overall my general concern about hi
s deteriorating course continues to escalate. . . .

  Thank you for permitting me to participate in the care of Richard Cheney. Contact me directly if questions arise.

  Sincerely,

  Shashank Desai, MD

  A month later the vice president’s hematocrit began to drop, prompting a search for a source of his blood loss that included upper and lower endoscopy, both of which were unremarkable. It was unclear whether the VAD was starting to hemolyze (break open) some of Cheney’s red blood cells or whether there was another yet-to-be-determined cause of his anemia. What was clear was that once again, the clock was ticking.

  • • •

  March 23, 2012. Midnight.

  “Say that again,” I whispered, although I heard it clearly the first time.

  “We have a heart for Cheney,” Shashank said.

  Although I had been waiting for this call for more than twenty months, and had known for much longer that one day it would probably come to this, it was still a shock.

  Shashank told me what he knew about the donor and that his nurse practitioner, Lori Edwards, had already notified the vice president and arranged for him to be admitted to Fairfax. We discussed logistics for a few minutes and agreed to meet at the hospital in about an hour.

  I hung up and dialed the vice president’s house in McLean. When he answered the phone, he was unbelievably calm.

  “This is going to be a great day,” I said, unsure whom I was trying to reassure.

  I dressed quickly and gave my wife a quick kiss good-bye. We were already packed and ready to leave in the morning for our annual spring ski trip, but now Charisse and the girls were going to have to fly to Colorado without me. I jumped in my car and sped down the driveway as I had done so many times before in the middle of the night for countless other patients.