American College of Physicians: Internal Medicine — Doctors for Adults ®

Tuesday, February 8, 2011

Cheney's got heart

Dick Cheney's heart troubles have been well-documented. Now comes the news that the former Vice President is considering a heart transplant. On Jan. 30 he turned 70, an age at which most transplant programs in the U.S. consider patients too old for the rigors of transplant surgery.

Currently, Cheney's life depends on an artificial pump known as a left ventricular assist device (LVAD). LVADs have only been in mainstream clinical use for the last 15 years. They are an adaptation of heart-lung bypass machines, used for decades in coronary artery bypass surgery. Cardiothoracic surgeons realized that damaged hearts could themselves be bypassed to keep patients alive while awaiting a new pump--either the mechanical kind (an "artificial heart," still a work in progress) or a heart from a cadaveric donor. Over the years, LVADs have been refined to the point where they weigh only 500 grams (slightly more than a pound) and can safely be powered by external batteries. Consequently, patients with LVADs are now able to move around freely and leave the hospital, unlike the early days of assist devices, when patients were literally tethered to the wall.

An LVAD is placed under the skin of the abdominal wall (in front of the stomach), with its blood entry port inserted into the heart's left ventricle, and the exit spout directed into the aorta, the body's main blood vessel. The LVAD's power wire (about the thickness of your pinkie, called a "drive line") tunnels from the device under the skin of the abdominal wall, and out the right side of the abdomen where it's connected to a battery. When at home, a patient like Cheney needs to always be vigilant to charge his batteries so that he can have adequate range. The batteries are worn externally, ideally tucked in the pockets of a garment like a hunting vest.

At present, the longest a patient has survived with an LVAD is six years and counting. As more high visibility patients like Cheney use the devices, their transition from temporary option to permanent solution becomes more the norm. So what are the downsides?

Patients with LVADs require anticoagulation. They have to take medicine such as warfarin to make their blood 50% thinner than normal. This requires careful monitoring: blood thinned too much can cause hemorrhage; blood that's too close to normal can lead to formation of clots which in turn can embolize and cause strokes. The other big risk is infection; foreign material planted in the body is more susceptible to causing bacterial infestation of the blood stream which can seed other organs. Consequently, procuring a new heart would seem preferential for any patient with severe heart damage. No need for batteries. No drive line. No risk of hemorrhage and dramatically lessened chance of clots or infections.

Sign me up for transplant, right? Yet as with all things in medicine the reality is much more complicated than the sales pitch.

Let's assume for the moment that obtaining a heart isn't a problem. Tissue-typing to the recipient remains a challenge for all patients with severe heart failure. Patients like Cheney are often highly "sensitized," which means that they carry antibodies that will hasten rejection of the transplanted heart. This occurs because throughout the course of their illnesses, heart patients often receive blood transfusions or other foreign material (e.g. heart valves or vascular grafts) that induce high levels of antibodies. Even when the tissue matches sufficiently, recipients require lifelong expensive immunosuppressive drugs to lessen the likelihood of rejection. These drugs are potent, toxic, and raise the risk of opportunistic infections since they dampen the entire immune system.

Okay, so now a heart is available. The match is good. The patient has insurance or sufficient finances to be able to obtain and manage the necessary medication and postoperative care (this is determined during the screening evaluation). Can the patient survive the surgery? Obviously, this is a judgment call. If a patient has kidney problems, diabetes, or liver disease, he'll be unlikely to withstand the rigors of the surgery and the post-transplant care. In Cheney's case, the information he's chosen to make public does not address this issue. Let's continue our thought experiment and assume that other than his heart, he's fit as a fiddle. Should he allow himself to be listed as a candidate for transplant?

Currently, there are about 3,200 Americans waiting for hearts. Every year roughly 2100 patients get transplanted. Of those that get transplanted, the percentage in Cheney's age category (65+) hovers between 11-14%. Most transplantation programs in the United States use 65 as an age cutoff when considering who to transplant. Yet age is used as a "relative" rather than an "absolute" contraindication, when the patient in question has limited damage to other organs and a longer life expectancy.

From the viewpoint of an individual patient wanting to extend his life and avoid the inconvenience of walking around hooked to a medical device, a decision to go forward with transplant makes perfect sense.

Yet from the perspective of a society struggling to control stratospheric health care costs, such a decision by Cheney would be counterproductive. He's functioning well enough with his LVAD to continue his memoir (longhand) and make television appearances. Given the scarcity of transplantable hearts, seeing Cheney claim one that could otherwise go to a younger patient would reinforce his low regard for the social contract with fellow Americans. Further, it would exemplify how virtually all of our political leaders fail to grapple with placing reasonable limits on medical care that is exorbitantly costly but only marginally effective. A Cheney decision to forgo transplant, however, would send a clarion call of political and economic rectitude that would help erase the memory of his famed quip about conservation being merely a "sign of personal virtue."

Author's Note: Thanks goes to Dr. Savitri Fedson of the University of Chicago Medical Center for technical consultation on this post. Opinions herein are solely those of the author.

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university's human rights program. His blog, GlassHospital, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people that inhabit them.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

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Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

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David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

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Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

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Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

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Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

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Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

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Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

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PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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