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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