For many years, I had been on various anticoagulants to minimize the possibility of developing blood clots leading to an embolism or a stroke. In January 2010, not long after returning from the holidays in Wyoming, I began to experience serious nosebleeds. The most worrisome was an arterial nosebleed I developed one afternoon when Lynne and I were at our home in McLean. Every time my heart beat, blood shot in a stream from my nose. When I tried to stop the bleeding with pressure, blood ran down the back of my throat. I called Dr. Reiner and told him I was heading for the emergency room at George Washington University Hospital.
Our Secret Service protection had just ended, so Lynne rushed me down the George Washington Parkway to the hospital. Since she hadn’t driven herself in almost a decade, the drive there wasn’t without its own risks. Once we arrived at GW, the doctors packed my nose and stopped the bleeding. I was released and Lynne and I went home.
Just a few hours later, the bleeding started again, and this time it was even worse. We made the drive again to the emergency room, this time with me holding a trash can in my lap to catch the blood. At the hospital, I was rushed into the operating room, sedated, and the artery cauterized. For a long time afterward, I carried a small packet of materials designed to stop a nosebleed should one occur. It turned out this episode may have been more life threatening than all the coronary episodes that had taken me to emergency rooms over the years.
A month later, in February 2010, Lynne and I were at our house St. Michaels on the Eastern Shore of the Chesapeake Bay, where we had bought a home after the 2004 election. We had a number of friends in the area, enjoyed the beauty of the region, and I loved to hunt duck and geese there in the fall. My health was also a factor in our decision. I knew that as I grew older and my heart disease progressed, I would find it increasingly difficult to spend time in the Tetons in Wyoming because of the high altitude.
After dinner one evening, I developed some chest discomfort that I thought might be related to my heart. I did not have other symptoms, but I was sufficiently concerned that I wanted to check it out. Lynne drove me the twelve miles to the nearest hospital, in Easton, Maryland. On arrival, I was examined, and the preliminary judgment was that it might be another heart attack. After contacting Dr. Reiner at GW, we decided to return and check my condition there. We used a life-flight helicopter service to fly me from Easton back to Washington, DC. I had flown on helicopters thousands of times all over the world, but this was the first time I was flat on my back, strapped to a gurney with an IV and blood pressure cuff on my arm. The crew was experienced and very competent. Since George Washington University Hospital did not have a helicopter landing pad at that time, we had to land in the parking lot at the Washington Nationals baseball stadium and complete the journey to GW by ambulance. At the hospital, doctors determined I had suffered my fifth heart attack. Although it was relatively minor, it was further evidence of my deterioration.
Later that spring, I visited King Abdullah of Saudi Arabia to discuss developments in the Middle East. I also took the opportunity to stop in Abu Dhabi to see my friend the crown prince Mohammed bin Zayed. The meetings in both capitals were good ones, both interesting given the challenging events unfolding across the region. But I recall that between the meetings, all I wanted to do was sleep. I was experiencing a definite decline in energy level that I chalked up to jet lag and time zone changes.
Lynne and I flew to Jackson Hole for Memorial Day as we had done most years. If any more evidence was needed of my deteriorating situation, it came during that visit to Wyoming. For several years, Memorial Day had marked the beginning of my fishing season. My good friend Dick Scarlett always organizes two days of fly-fishing on the South Fork of the Snake River along the Wyoming-Idaho border. The spring runoff from the mountains is always a problem, but a dam on the border catches the runoff in Palisades Reservoir. The water below the dam is high in May, but it is clear and fishable. The tailwater fishery below the Palisades Dam on the South Fork is one of my favorite stretches of water. I was looking forward to getting back on the river with my fly rod.
The first night home in Jackson, I experienced considerable difficulty breathing. I had trouble climbing stairs. I couldn’t sleep. I was going to have trouble spending a week at sixty-two hundred feet. We went to the local hospital and transmitted the data from my ICD to Washington so Dr. Reiner could review it.
The report indicated that I was having an episode of atrial fibrillation. While A Fib is less serious than V Fib, it can lead to the development of blood clots. I needed to go back to Washington, DC. A friend loaned us his plane, and a doctor and nurse from St. John’s Medical Center flew with Lynne and me back to Washington. I wasn’t sure I would ever see Wyoming again.
By the beginning of June 2010, I was approaching end-stage heart failure. As I went through the month, I found it increasingly difficult to carry out any tasks around the house. Walking to our front gate to get the morning paper was no longer possible. I could no longer climb the stairs to get to the second floor. My world was getting smaller and smaller. The one evening I felt slightly more energized was when we attended the annual reunion of the White House staff and cabinet from the Ford administration. The rest of the time, I just felt exhausted. Every morning when I woke up, all I wanted to do was get to the overstuffed easy chair in my office, put my feet up, and go back to sleep.
I felt no pain or physical discomfort associated with this stage of my disease. But I was conscious I didn’t have much more time to live. Over the years that I had suffered from coronary artery disease, I had believed that sooner or later, I would run out my time and that the end would come as a result of heart failure. What was happening was hardly a surprise.
I was losing my appetite. There wasn’t much I wanted to eat, but the things I craved were foods from my childhood—my mother’s chocolate chip cookies, for example. Mary baked batches for me using my mom’s recipe. My family was trying to keep my strength up, so they also spent a good deal of time making me milk shakes with protein powder sprinkled in. They were deeply worried about me.
I wasn’t fearful or anxious about my situation. I had lived a wonderful life, and now it was ending. Contemplating my death was much harder for my family than it was for me. I felt a need to express my wishes with respect to final arrangements, but it was a difficult subject to bring up with my family. They didn’t want to face what we all knew was happening.
By this time, we had used nearly all the technology and medical procedures available for dealing with my disease. My doctors had equipped me with a small pump that kept me supplied with a steady dose of milrinone, or “rocket fuel,” to assist my weakened heart, but it was a short-term expedient and would soon lose its effectiveness. At this point, there were only two remaining possibilities. One was a transplant. But the demand far outstripped the supply of transplantable organs, and the average waiting period was twelve months. It was clear I would not live long enough to work my way up the transplant list.
There was one other possibility, which Dr. Reiner had mentioned to me earlier in the year: a left ventricular assist device (LVAD). At that time, my condition hadn’t deteriorated to the point where I was a candidate. Now I was there. Dr. Reiner arranged for us to visit with the surgical team at Inova Fairfax Hospital in Northern Virginia. The team, headed by Dr. Nelson Burton, briefed us on the LVAD that would be installed in my chest to assist my heart in providing an adequate supply of blood to my vital organs. They showed us a model of the device and explained how it worked. One end would be connected to the bottom of my left ventricle and the other to the aorta. A small pump inside, operating at nine thousand RPM, would push blood from the ventricle through the aorta and the rest of the circulatory system. The pump itself is powered by a driveline that goes from the pump through your chest wall to a control element/computer worn on the outside of your chest, powered by batteries or a base power unit plugged into an electrical outlet.
When I first saw an LVAD, I was intrigued by the technology. Under ordinary circumstances, the idea of putting a device operating at nine thousand RPM into my chest, attached to my heart and to a driveline running through a hole in my chest wall would have seemed a little off-putting. But it was an option, and I was out of other options.
The LVAD was developed as a transition device to sustain a patient long enough to become eligible for a transplant. The original LVADs were not user friendly. They were so large that they were not portable. The patient’s bed would be wheeled into the room with the LVAD, and the patient hooked up to the device. Significant progress in recent years, however, had transformed the LVAD to a size that allowed its external elements to be worn on a harness or a vest so the patient could lead a more normal life. Some patients decided to live with the LVAD and not go to a transplant. If the LVAD surgery were successful, I would have the opportunity to decide at some future date if I wanted to go the transplant route.
Surgery was scheduled for July 8, 2010. Because it was expected to be difficult surgery, I checked into the hospital on July 6, two days early, so the doctors could attempt to stabilize my condition and improve my overall health as much as possible before the surgery. I was given additional doses of milrinone on July 6, but it wasn’t working. Indeed, it was becoming clear that my heart was failing rapidly and my liver and kidney functions were crashing. I have a vivid memory of that evening with my doctors and my family gathered together around my hospital bed, telling me they believed it was essential to implant the LVAD on an emergency basis that night. I didn’t have two more days. After I heard from the doctors, I asked Lynne, Liz, and Mary, one by one, what they thought. It was unanimous. I looked around the room at everyone and said, “Let’s do it.”
Like a tornado, water entering a drain begins to rotate, forming a cone-shaped whirlpool triggered by the downward suction of the departing fluid. In the idiomatic and indelicate language of medicine, a patient who is “circling the drain” has entered the sinking spiral of accumulating medical issues. In the beginning, the problems gather slowly, but as the patient descends lower, the vortex spins faster and the complications come more quickly, leading inexorably to the patient’s demise. It’s not always apparent when someone enters the terminal spiral, but once it becomes obvious, it is almost impossible to stop.
The year 2009 was a tough one for Dick Cheney. There had been debilitating back pain requiring spine surgery, an episode of congestive heart failure, and in the final days of the year, a cardiac arrest resuscitated with a shock from his implanted defibrillator. Viewed individually, each of these events had a successful resolution; surgery fixed the back, diuretics resolved the CHF, the defibrillator restored a normal rhythm. In reality, however, these were not isolated incidents but rather a continuum of the same process. The vice president’s chronic cardiac disease led to a decrease in his overall physical fitness, which increased the likelihood of a back injury, the surgical repair of which provoked an episode of congestive heart failure, which in turn increased the chance of developing sudden cardiac arrest.
• • •
In January 2010, the vice president experienced a nosebleed that required cauterization at George Washington University Hospital. For more than a year, Mr. Cheney had been treated with warfarin (Coumadin), a powerful anticoagulant used to prevent strokes in patients with atrial fibrillation. Warfarin is a synthetic derivative of dicoumerol, a naturally occurring blood thinner that was initially discovered in spoiled sweet clover animal feed and was developed seventy years ago at the University of Wisconsin (part of the name derives from “Wisconsin Alumni Research Foundation’) and introduced in 1948 as rat poison. The drug has been used for decades as both a therapy and prophylaxis for clots in a variety of settings, including deep vein thrombosis, pulmonary embolism, the use of mechanical heart valves, and atrial fibrillation. Patients taking the strong anticoagulant must be closely monitored with blood tests and watch their diet, because foods like green leafy vegetables can decrease the effectiveness of the medicine, while other medications taken at the same time, such as antibiotics, can dramatically raise the effectiveness of warfarin. The major side effect of the medication is bleeding, which can be severe or even fatal.
Three weeks later, Cheney’s bleeding recurred. A nosebleed is a common ailment, particularly in the dry air of winter. The hemorrhage can be impressive, even in an otherwise healthy person who is not taking any medication. For a patient, such as the vice president, who is being treated with an anticoagulant like warfarin, bleeding, once started, can be hard to stop.
When she called, I told Mrs. Cheney to bring the vice president to the George Washington University Hospital emergency room right away.
“How do I get there?” she asked.
Nine years of Secret Service protection for the Cheneys had concluded just the day before, and Mrs. Cheney was going to have to drive the vice president into Washington by herself, something she hadn’t done in almost a decade. I gave Mrs. Cheney directions to the hospital and told her to come to the ER entrance, where we would meet them.
After calling the emergency room to let the attending physician on duty know that the Cheneys were on their way, I tracked down Dr. Nader Sadeghi, a GW ear, nose, and throat surgeon, and Dr. Jehan “Gigi” El-Bayoumi.
Gigi had taken over as Vice President Cheney’s internist after Ryan Bosch left GW several months earlier and had quickly become indispensable to the Cheneys (and to me). She is an extraordinary physician and role model whose exceptional clinical skills are surpassed only by her astonishing compassion and personal care for her patients. Not surprisingly, she cares for many of DC’s political elite but somehow manages to deliver her remarkable VIP care to every patient, prominent or not, in her large practice.
Dr. Sadeghi examined Mr. Cheney, identified the problem vessel, which had already mostly stopped bleeding, applied a silver nitrate cautery, and packed the nostril with gauze. We watched the vice president for a while and considered keeping him in the hospital overnight for observation, but a few hours later, when there was no further bleeding, he was allowed to go home.
A little before 10:00 p.m., Mrs. Cheney called again, and now I could hear fear in her voice. Once again, the vice president was bleeding, now much more vigorously than earlier in the day. They were on their way back to the hospital. When Mr. Cheney arrived in the emergency room, blood was pouring from his nose, and a garbage can he had been bleeding into during the ride from Virginia was filled with clots. After manual compression failed to staunch the flow of blood, the vice president was rushed to the operating room, where, under general anesthesia, Dr. Sadeghi located and recauterized the bleeding artery but not before the loss of about one liter of blood (20 percent of his body’s total supply).
We had stopped Cheney’s Plavix after the first bleed three weeks earlier, and now we needed to stop the warfarin as well. These drugs, both of which impair the ability of blood to clot, had been prescribed in an effort to prevent a host of potentially lethal thrombotic events, such as recurrent DVT, stroke from atrial fibrillation, clotting of his stents, and recurrent heart attack. Unfortunately this last hemorrhagic event was severe: we needed to let the dust settle, and the troublesome vessel heal, before restarting one or both of these drugs.
• • •
During the evening of Sunday, February 21, three weeks after the nearly exsanguinating event, Vice President Cheney experienced about thirty minutes of chest burning. The Cheneys had been spending time on the Eastern Shore of Maryland, and I told them to go to the nearest emergency room, which was Memorial Hospital in Easton, for evaluation. After speaking with the ER doctor there, we decided that in view of the typical cardiac nature of his symptoms, it would be best to bring the vice president back to Washington and arranged to fly him the seventy-five miles by medevac helicopter.
When Cheney arrived at George Washington University Hospital, he was pain free, and his EKG was similar to his prior tracings. Although the first two sets of blood tests used to assess whether the heart muscle had sustained any damage were normal, the third set was mildly elevated, consistent with a small heart attack. The next morning we brought the vice president back to the cath lab to see what had changed.
The last time Cheney had undergone coronary angiography was nine years earlier, in March 2001, when he had developed chest pain caused by restenosis in the coronary stent that had been implanted four months earlier, during the presidential campaign. The procedures in 2000 and 2001 had been performed by accessing the femoral artery through a needle puncture at the top of his right leg. By 2010 we had largely abandoned the groin approach in favor of the radial artery of the wrist because of the increased patient safety and comfort when using this approach. My colleague Dr. Ramesh Mazhari joined me for the procedure, and through a two-millimeter puncture in Cheney’s right wrist, we advanced our catheters up through the arteries of his arm, under the clavicle, and down into the chest.
In March 2001, we had been criticized for not performing intracoronary radiation therapy (brachytherapy) when the vice president presented with chest pain and restenosis. The New York Times even published an article with the headline “The New Treatment Cheney Did Not Get.” In that piece I was quoted as saying, “When you look at a technology in its infancy, I think it is often appropriate to be a little circumspect about applying it, especially using something like gamma radiation.” Within a few years, brachytherapy would be shown to mostly only delay the onset of restenosis, not prevent it, and the technology would soon be relegated to the dustbin of abandoned devices by a new generation of “drug-eluting” stents coated with potent inhibitors to the formation of the scar tissue inside stents that causes restenosis.
Now, looking at Cheney’s coronaries for the first time in nine years, we noted that the diagonal stent we placed in 2000, and then ballooned again in 2001, was wide open, a very good thing as it supplied blood to a large portion of the vice president’s limited amount of remaining viable heart muscle and had likely helped keep him alive. Cheney’s coronary anatomy was remarkably similar to what we found almost a decade earlier, with the exception of a grape-sized aneurysm that had since formed in the left anterior descending, the other major artery supplying the still-contractile muscle. We surmised that a clot had probably formed in the aneurysm, eventually tumbling downstream (embolizing) and causing the small heart attack.
It wasn’t a coincidence that Vice President Cheney’s latest heart attack came less than a month after we stopped his anticoagulants. Blood thinners had precipitated the nosebleeds, but those drugs had also helped to prevent harmful clots like the one that caused this most recent event. If we didn’t restart the blood thinners, the vice president would be at risk of another heart attack, but if we did, he would be at risk for another bleed. The medical care of a complex patient like Vice President Cheney is often filled with such conundrums and catch-22s, and after much deliberation we decided to cautiously restart the Plavix.
A little more than one year after leaving office, Cheney had been through worsening heart failure, a sudden cardiac arrest, severe bleeding, and now his fifth heart attack. The vortex was spinning faster.
• • •
Although the clinical signs and symptoms of heart failure had been known for hundreds of years, there were only a limited number of options to improve a patient’s symptoms and nothing a physician could do to alter its inevitably bad outcome until late in the twentieth century.
For three millennia, the practice of bloodletting, literally the therapeutic draining of blood from a patient, was used to treat a variety of ailments. The Egyptians introduced the technique in about 1000 B.C., and it was continued until about a hundred years ago. When the Council of Tours in A.D. 1163 barred monks and priests from performing bloodletting, barber-surgeons (still identified by the familiar red and white barber pole) became the primary practitioners of the art.
Bloodletting was typically accomplished by incising a vein and was used to release what were thought to be evil spirits or bad humors and treat plethora (an excess of body fluid, that is, congestive heart failure), divert blood away from another actively bleeding site, decrease the body’s heat (treat an infection), and treat a variety of other maladies, including gout, “madness,” and seizures.
In December 1799, George Washington became ill with “inflammatory quinsy” (probably a peritonsillar abscess). When his pain became so severe that he could no longer swallow, eighty ounces (five pints) of blood was drained from Washington’s arm in a single day. That evening, the first president of the United States was dead. More than two centuries later, it is unclear whether General Washington died as a consequence of his likely bacterial throat infection or the well-intended but at best ineffective and probably harmfully exuberant, bloodletting.
Giorgio Baglivi, a seventeenth-century Italian who was physician to Popes Innocent XII and Clement XI, described the use of bloodletting for the pulmonary edema often encountered in heart failure. Although crude, bloodletting did improve the symptoms of congestive heart failure by decreasing the overall volume of blood in the body, and consequently, the amount of blood returning to the heart. This phlebotomy continued into the middle of the twentieth century and was then largely replaced by powerful diuretic medications that harnessed the kidneys” natural ability to remove fluid from the body. When I was a medical resident in New York in the late 1980s, I struggled one night to keep a patient with advanced heart failure alive. Having exhausted all the options I knew, I called the patient’s attending to apprise him of the grim situation and to ask if he had any suggestions.
“Take off five hundred cc of blood,” he said.
Skeptical of the quaint approach but knowing that there was nothing to lose, I followed the senior physician’s recommendation, removing half a liter of blood. I was surprised, and humbled when the patient rallied.
• • •
Although both sides of the heart can “fail,” impairment of the contractile function of the left ventricle is more common and may occur as a consequence of prior heart attacks, valvular disease, viral infections of the heart, toxins like alcohol, certain types of chemotherapy, or unknown (“idiopathic’) causes. When the right ventricle fails, it is most commonly the result of failure of the left ventricle: the blood that backs up into the lungs increases the pressure in the pulmonary vessels, which strains the usually thinner-walled, less muscular right ventricle.
As the left ventricle becomes progressively impaired, it compensates by dilating (getting larger and holding more blood) and beating faster. Over time, its ability to compensate declines, and the patient increasingly develops the symptoms of heart failure, such as fatigue and shortness of breath; toward the end, organs shut down. Right ventricular failure, by contrast, typically presents as swelling in the legs and abdomen, caused by the backup of the blood that would normally be returning to the heart.
As a heart begins to fail, the body responds by activating several compensatory mechanisms resulting in the elaboration of hormones that increase salt and water retention, constrict blood vessels, and increase the heart’s contractile force and rate. These responses turn out to be very helpful if the drop in cardiac output is the result of an acute process like bleeding, but they become counterproductive over time if the cardiac output has declined because of an intrinsic problem with the heart. The concept that the physiological response to declining heart function might be “maladaptive” was developed in the 1980s and led to the use of vasodilators and beta blockers for patients with heart failure.
Vasodilators, which include angiotensin II–converting enzyme (ACE) inhibitors like lisinopril or enalapril, are drugs that dilate blood vessels and reduce resistance to cardiac emptying, making it easier for the heart to eject blood, increase cardiac output, and help prevent the heart from dilating. Clinical trials in the late 1980s proved that ACE inhibitors improve the survival of patients with heart failure, and ACE inhibitors and other related vasodilators have become a standard component of therapy for congestive heart failure.
Beta blockers (metoprolol, carvedilol, and others) are drugs that attach to sites on myocardial cells (beta receptors) that normally bind epinephrine and norepinephrine, adrenaline-like hormones that stimulate the heart in the “fight-or-flight” response, and are also elaborated in heart failure. Although it is somewhat counterintuitive, the beta blockers (which are cardioinhibitory) have been shown to decrease mortality and increase the cardiac output in patients with impaired ventricular function.
• • •
In April 2010, Liz Cheney called and asked if I had a few minutes to talk. I had been driving home through the mountains of western Maryland, and despite my GPS, I was a little lost, so I pulled over.
“My dad is dying,” Liz said plainly.
The vice president had clearly deteriorated over the past few months, and although at the moment he appeared quasi-stable, there was no question where his trajectory was heading. The heart attack in February, although small, had taken muscle Mr. Cheney couldn’t spare, and he was requiring higher doses and more frequent adjustments of multiple medications to keep him out of heart failure.
“Is it true that there isn’t anything else that can be done for him?” Liz asked, not waiting for me to respond to her first statement. I had gotten to know Liz fairly well over the prior decade and spoke with her occasionally, usually when there was an issue related to her father’s care that needed clarification. Although I didn’t know it at the time, she was calling because her father had taken her aside to tell her that he thought the end was near and that she needed to accept it.
“No, that’s not right,” I said. I explained to her that six months earlier, I had told the vice president that should the circumstances warrant, he could be eligible for a mechanical ventricular assist device and even potentially a heart transplant.
“He’s not too old for that?” she asked.
I reassured her that he was not. Although the assessment of the severity of her father’s illness was correct, I thought he definitely still had options.
• • •
Heart failure kills more than fifty-six thousand Americans every year, about the same as breast cancer. Although people with heart failure live longer and better than in the past, 50 percent of people with a new diagnosis of heart failure will be dead within five years. Acknowledging the need for better options for patients with end-stage heart disease, in 1964 the federal government began funding a program intended to spur the development of mechanical cardiac assist devices, eventually investing over $400 million in the technology.
One of the early proponents of this initiative was Dr. Michael DeBakey, the legendary Houston heart surgeon and prolific innovator whose contributions to cardiac and vascular surgery spanned three-quarters of a century. In 1932, at the age of twenty-three, while still a medical student, Dr. DeBakey invented the “roller pump,” which was used for decades to transfuse blood and later became a central component of the heart-lung machines created by Dr. John Gibbon and others. Dr. DeBakey developed surgical techniques to repair aortic aneurysms and carotid artery blockages, introduced Dacron as a material for synthetic vascular grafts, invented over fifty surgical instruments, and helped to create the concept for the mobile army surgical hospital (MASH) unit. He was said to have performed over sixty thousand heart operations during his extraordinary life and claimed to have accomplished the world’s first coronary bypass graft operation in 1964. At the time of his death in 2008 at age ninety-nine, the New York Times fittingly described Dr. DeBakey as a “rebuilder of hearts.”
In the early 1960s Dr. DeBakey and his team created several pumps intended to temporarily support or even replace the function of an ailing heart. In David K. C. Cooper’s book Open Heart: The Radical Surgeons Who Revolutionized Medicine, Dr. DeBakey described his rationale for developing these ventricular assist devices (VADs):
We became interested in the artificial heart as an extension of the heart-lung machine. As we developed more experience with the heart-lung machine, my feeling was that there were high-risk patients who would only be able to be weaned from the machine if we continued using it for, say, several hours. My reasoning was that if you could support them for a longer period of time, perhaps the heart might recover.
The heart is really composed of two pumps. The pump on the right side (the right ventricle) receives returning venous blood from the body and propels it into the lungs, where oxygen is swapped for carbon dioxide. The oxygenated blood then returns to the left side of the heart, where the thicker and more muscular left ventricle thrusts it back into the body at much higher pressure. Theoretically a mechanical device could replace the function of the left ventricle (left ventricular assist), the right ventricle (right ventricular assist), or the whole heart (total artificial heart).
The earliest designs for these systems were relatively crude and were constantly refined as animal research and clinical experience progressed. In a review article written nearly forty years after the fact, Dr. DeBakey described the first successful implant of a left ventricular assist device (LVAD):
Our first clinical application of this pump was on August 8, 1966, in a white woman with heart failure caused by severe aortic insufficiency and mitral stenosis. After replacement of both valves, it was impossible to wean the patient off the heart-lung machine despite prolonged support, and the bypass pump was then attached to the patient. With a pump flow of 1,200 mL/min, it was possible to wean the patient off the heart-lung machine. On the 10th postoperative day, it became possible to discontinue the use of the bypass pump as the heart maintained normal function. The patient recovered completely and returned home to resume normal activities. Unfortunately, she was killed in an automobile accident 6 years after the operation.
On April 4, 1969, Haskell Karp, a forty-seven-year-old man with congestive heart failure awaiting transplant, was taken to the operating room at St. Luke’s Hospital in Houston for a procedure scheduled as a surgical excision of a thinned and infarcted segment of his left ventricular wall. The procedure that was ultimately performed would make history and also engender a nearly forty-year feud between two of the world’s greatest heart surgeons.
Mr. Karp’s surgeon was Dr. Denton Cooley, who years earlier had been recruited to Houston by Dr. DeBakey (and three decades later would be asked by the Bush campaign to vet the health of Dick Cheney). In Cooper’s book, Dr. Cooley recounts the events surrounding that operation:
In 1968, it was evident to me that it was time to try the artificial heart. We were having a number of frustrations in watching people die who could have been saved with a heart transplant. One of my colleagues was a fellow by the name of Dr. Domingo Liotta, who had spent time trying to develop an artificial heart. He came to me rather frustrated, saying DeBakey was apparently not interested in going forward with its clinical application. . . . I knew that if I went to Dr. DeBakey to get permission from our department of surgery, we would get only delay and further negative response. So I decided that the time had come to take a bold step. The opportunity arose to go ahead and do it, and suffer any repercussions that might follow. We did just that.
We had the ideal candidate who was dying and needed a cardiac transplant, a gentleman named Haskell Karp. We were just interested in seeing if you could sustain a human life with an artificial device. Sure enough, that proved to be the case. The patient did very well with the artificial heart, but unfortunately he died following his transplant because of an infection. I have no regrets for having taken that step.
Dr. DeBakey later countered that since the device could not keep an animal alive for a prolonged period of time, he would not use it in a human. Dr. Cooley’s brash implant of the unapproved, and unproven, total artificial heart led to a schism with Dr. DeBakey that continued for nearly four decades. The surgical legends reconciled just months before DeBakey’s death.
• • •
Over the past two decades, mechanical cardiac assist devices have become the real “time machines,” giving patients struggling after cardiac surgery time to recover (“bridge to recovery’), patients on the transplant list the endurance to survive until a donor organ is located (“bridge to transplant’), and an option for patients with advanced heart failure who are ineligible for an organ transplant and have historically had no options (“destination therapy’).
The initial VADs created pulsatile flow, mimicking the heart’s rhythmic movement of blood, and were driven pneumatically by compressed gas delivered through drivelines mated to a large external console. Later iterations of the technology incorporated electrically powered pumps that could be run from battery packs, offering patients more freedom. Although these systems greatly increased the survival rate of patients waiting for transplants, the pumps were relatively large and prone to mechanical failure.
Newer-generation VADs have moved to a different technology and incorporate a rapidly spinning internal rotor to create a continuous (nonpulsatile) output of blood. Compared to their forerunners, these continuous-flow VADs have far fewer internal moving parts (which increases their reliability and durability), need less anticoagulation therapy, are much smaller, and can run for many hours on easy-to-carry external batteries.
• • •
In mid-June 2010, Vice President Cheney redeveloped atrial fibrillation and fluid retention, necessitating the reluctant reinstitution of blood thinners to protect him from a stroke and also a big slug of diuretics to clear the fluid. As is typical for a patient with severe heart failure, it was becoming increasingly difficult to keep him in any semblance of clinical balance.
Dick Cheney had done well for many years, but in less than eighteen months, he had morphed from one of the most powerful men in the world to the sickest patient in my practice, someone requiring nearly constant medical attention. Clearly we were reaching the limits of contemporary medical therapy. If Cheney was going to survive beyond the next few months, he was going to need a VAD. I had broached the topic with the vice president the previous fall, but at that time he was still relatively well and the conversation was brief and maybe a bit premature. Now he was really sick, and it was starting to look as if we may have waited too long.
• • •
George Washington University Hospital discontinued its heart transplant program in the 1990s, but over the last several years, our group has collaborated with the advanced heart failure and cardiac transplant program at Inova Fairfax Hospital, about twenty minutes away in Northern Virginia. I asked Dr. Shashank Desai, the director of the program, to join us at GW for a meeting with the vice president to talk about VAD and transplant options.
Desai is an instantly likable, supersmart guy with a big smile and a usually beautiful suit, who several years before had been recruited from the University of Pennsylvania. Shashank brought along Lori Edwards, an experienced nurse practitioner who was the VAD coordinator at Fairfax.
The meeting on Friday, June 18, 2010, with Mr. and Mrs. Cheney lasted about two and a half hours. Earlier in the week, the vice president had been volume overloaded, and although his breathing was better after the diuretic-induced loss of several pounds of fluid, he still had no energy. I took Cheney’s blood pressure; it was 86/70, much lower than usual.
The vice president’s increased fatigue was likely related to his very low blood pressure, but the more salient matter was that his heart no longer had the capacity to move an amount of blood sufficient to meet his body’s needs. Although Mr. Cheney was sick and getting sicker, there were still a few options remaining, and one of them was heart transplantation.
Shashank described in great detail the evaluation process and the general criteria that define a “transplant candidate.” And at first glance, Cheney appeared to be eligible, but there was one catch: he had to live long enough to get a heart.
Once a person is accepted for transplant, the wait for a donor heart can be anywhere from six months to three years, depending on the blood type and the patient’s level of acuity. At any given time in the United States, about three thousand people are on the wait list for a heart, but annually there are only about two thousand transplants. Shashank told Mr. Cheney that if he chose to be listed for transplant, it might be difficult to sustain him using medical therapy alone until a heart became available, but his odds would improve significantly with a ventricular assist device. Used as a bridge to transplant, a VAD can completely supplant the function of a failing left ventricle and support the patient until a donor heart is found. Recent data from a National Heart Lung and Blood Institute registry show one-year survival rates greater than 80 percent for patients implanted with a continuous-flow VAD used as a bridge to transplantation.
Lori Edwards had brought with her a HeartMate II VAD and all of its necessary accoutrements. Methodically she reviewed the equipment, and what the Cheneys would have to do every day to maintain it.
The HeartMate II LVAD, manufactured by California-based Thoratec, is a ten-ounce titanium cylinder about three inches long, not much bigger than a saltshaker. It has only one moving part, the internal rotor, a modern adaptation of Archimedes” 2,300-year-old pump. The VAD contains an electrically powered motor that magnetically spins the rotor at speeds up to 10,000 RPM, capable of pumping ten liters of blood per minute, enabling the device to replace the function of a dead ventricle. The VAD is surgically implanted in the chest and connected to the heart by an inflow conduit sutured into the left ventricle and by an outflow graft sewn to the aorta. Blood entering the VAD from the heart travels through the inlet conduit, is accelerated by the spinning rotor, and is ejected into the aorta through the outflow graft. The system receives electricity through a driveline that exits the skin at the upper part of the abdomen a few fingerbreadths below the rib cage, and is connected to a controller and two camcorder-sized batteries. The batteries can provide about twelve hours of power; at night, patients usually plug into a tabletop unit. The driveline that exits the skin in the upper abdomen must be kept clean and covered with sterile gauze to prevent an infection from developing in the wire tract, and anticoagulants are prescribed to prevent clots from forming inside the pump.
Shashank and Lori explained to the Cheneys that many patients with a VAD feel well enough to return to work and can resume a variety of recreational activities with the exception of swimming. The Cheneys had a few questions about the durability of the device, and Shashank noted that there were a few patients approaching five years, but since the technology was relatively new, it was difficult to know precisely how long the VAD could last.
I wanted Vice President Cheney to leave the meeting knowing that we had not given up on him, there was still much we could do, and that using a VAD as a bridge to a heart transplant was a realistic possibility and my recommendation. Cheney said he would think about it and let us know.
On Monday morning Mr. Cheney called and said that he was feeling a bit better, and that over the weekend he had spoken with his family and decided that he would be interested in getting a VAD. I told him that I thought that was the right decision and that we would begin the necessary tests. Four days later, Mrs. Cheney called and said that the vice president was much weaker and asked if we could see him right away.
Vice President Cheney arrived in a wheelchair, appearing short of breath and very lethargic. It had been only a week since his last visit, but the deterioration was startling. Shashank, Gigi El-Bayoumi, and Carolyn Rosner, a VAD/transplant nurse practitioner from Fairfax, joined us for the visit. We ran some blood tests in the office suite using a handheld analyzer and found that the vice president’s kidney function had worsened over the past week, a marker that his heart could no longer provide an adequate supply of blood to the organs.
I told the vice president that his heart was failing, and I recommended admitting him to the hospital immediately to start intravenous medication that should be able to stabilize him and that we quickly move forward with arrangements for a ventricular assist device. Without much discussion, Mr. Cheney agreed to the plan.
My wife, Charisse, asked me later if the vice president looked sad when I told him he needed a VAD.
“Not sad,” I said, “just weary.”
Medical Faculty Associates
The George Washington University
July 1, 2010
Vice President Richard Cheney returned for follow-up today. Mr. Cheney was discharged from GW Hospital 3 days ago after being admitted 3 days before that with deteriorating renal function, severe fatigue and dyspnea and a low flow state. After admission the patient underwent right heart catheterization. . . . IV milrinone was begun and clinical status and cardiac output significantly improved. At discharge serum creatinine had returned close to baseline at 1.6. Mr. Cheney was discharged 3 days ago on home IV milrinone at 3.75 mcg/kg/min.
On 6/28/10 Dr. Gigi El-Bayoumi and I visited Fairfax Hospital where we met with members of the Fairfax LVAD/transplant program including Drs. Desai and Burton. VP Cheney and family visited Fairfax on 6/29/10 and also met with the medical and surgical team there.
Today VP Cheney states that overall he feels a little better than yesterday and much better than last week. He sat outside for 2 hours yesterday and was able to walk to Executive Health this afternoon without the aid of a wheelchair. Wt. this AM was 203 (down 1lb from yesterday). . . .
In summary VP Cheney has made a very nice recovery and is stable on home milrinone.
Plan is for LVAD insertion at Fairfax on 7/14/10.
Jonathan Samuel Reiner, MD
Shortly after admitting the vice president to the hospital, we brought him to the cath lab to measure the pressures in his heart. We did this by inserting a catheter in a vein in his leg and passing it through his right atrium and right ventricle into the pulmonary artery, the large vessel that carries blood from the heart to the lungs. The data gained from this procedure, as expected, demonstrated that Cheney’s cardiac index was severely reduced and well below the level necessary for adequate perfusion of his organs. The cardiac index is the volume of blood pumped by the heart per minute divided by the patient’s body surface area, a measure of the cardiac output adjusted for body size. A normal cardiac index is 2.6 to 4.2 liters per minute per square meter. A cardiac index below 1.8 is considered cardiogenic shock. Cheney’s was 1.7. We began to administer intravenous milrinone, a drug that can increase myocardial contractility and at least temporarily increases cardiac output. Soon after the infusion was started, Cheney’s hemodynamic parameters and kidney function improved.
Milrinone can improve the performance of a failing heart but not indefinitely. The plan was to continue the drug using home IV infusion, allow Cheney’s kidney function, overall clinical status, and nutrition to improve, and then bring him to Fairfax Hospital for a scheduled VAD insertion in about two weeks, at which time he should be better able to withstand the rigors of heart surgery.
Initially the vice president felt quite well and was able to walk modest distances with a small portable intravenous pump nestled in a shoulder bag. After several days, however, his kidney function began to decline again.
Medical Faculty Associates
The George Washington University
July 5, 2010
9:25 AM
I spoke with the patient this am. Mr. Cheney came to the ER yesterday evening for evaluation of right thigh pain. The patient developed this in the morning yesterday. CT scan at GW yesterday revealed hematoma in right thigh. . . . Patient was discharged with morphine for pain control. This am the patient notes discomfort in the right thigh which is improved with the narcotic. He is not SOB [short of breath] but hasn’t done much exertion because of the discomfort in his leg. Weight is up 2 lbs compared with yesterday. OptiVol today shows continued rise.
I told VP Cheney that it is likely that we will proceed with LVAD sooner than originally scheduled. I think it will be difficult to maintain clinical stability for next 10 days and would prefer to schedule LVAD later this week. The patient is in agreement. 9:03 PM
I spoke with the VP. Still has significant pain in his right thigh and has been using wheelchair to get around house. Morphine helps with the pain. No SOB. Has slept OK. There has been a gradual increase in BUN/creatinine despite recent increase in weight by 2 lbs. I told Mr. and Mrs. Cheney that I do not think it is reasonable to try and temporize until next week for LVAD. I have suggested that we proceed with surgery this week with admission tomorrow AM to Fairfax Hospital for optimization . . . prior to planned LVAD insertion later in the week. The patient is in agreement.
Jonathan Samuel Reiner, MD
On Tuesday morning, July 6, Vice President and Mrs. Cheney drove the short distance from their home in McLean to Inova Fairfax Hospital. Mr. Cheney, unable to walk more than a few steps, was met in the garage by a nurse and brought by wheelchair to the cardiac surgery intensive care unit on the hospital’s second floor. The plan was to tune up Cheney for a few days in the ICU using intravenous diuretics and higher doses of milrinone, and toward the end of the week, when he would presumably be in a little better shape, we would take him to the operating room.
I stopped by Fairfax early in the day to make sure that Mr. Cheney was getting settled in. The design of the cardiac surgery ICU contains an ideal corner suite of two adjoining rooms, one of them was set aside for the patient, the other for use as a family lounge. To help ensure his privacy, Mr. Cheney was registered using a pseudonym, and a security guard was posted outside the suite. When I entered the vice president’s room, he was in good spirits as nurses tethered him with EKG monitoring leads, IV lines, and nasal oxygen cannula. I stayed just long enough to review the plan with Shashank and the patient, and I told them both that I would see them later in the evening.
After spending the day at GW, I returned to Fairfax in the evening to check on the vice president. Earlier in the day, an echocardiogram was performed, documenting a huge heart, easily twice the normal size, which barely moved. Cheney’s ejection fraction (the percentage of the volume of blood in the heart that is ejected with each contraction) was estimated to be 10 percent (normal is 55 to 65 percent).
Shashank repeated a right heart catheterization to measure the pressures in the heart and lungs, and he calculated Cheney’s cardiac index at 2.0 liters per minute per square meter—not great, but a little better than before the milrinone was started ten days earlier. In an effort to wring just a little more cardiac performance, we ratcheted up the milrinone another notch.
As I entered the unit through the locked power doors, I could see Shashank standing outside the vice president’s room at the end of the corridor. Just as I approached, a nurse exited the room and handed us a printout with Cheney’s latest lab values.
Shashank and I reviewed the data in stunned silence. Despite the higher dose of milrinone, Cheney’s cardiac index was rapidly dropping.
“These can’t be right,” I said.
I looked through the window into Cheney’s room. He was awake, staring at a TV screen on the opposite wall, a remote control gripped in his right hand. These labs couldn’t be correct. They were the numbers of a patient in shock, someone about to die. We asked the nurse to send off a repeat sample of blood to verify the result, an act equal parts prudence and denial. Within a few minutes, the results were back. They were just as bad. In retrospect, I don’t know why this final turn for the worse was so surprising. For years, I had known this moment would come, and for the last several months, it looked increasingly imminent, but now that it was here, it still came as a shock. There was no escaping the fact that Dick Cheney had very little time left, probably only hours.
“Where’s Nelson?” I asked, referring to Dr. Nelson Burton, a Fairfax cardiac surgeon.
“He’s in North Carolina trying to get back,” Shashank said.
Most VADs are implanted during elective procedures, and Cheney’s had originally been scheduled for the following week. The plan was for Dr. Burton to do the surgery, but he was on the Outer Banks with his family. He was trying to find a flight but might not be able to get back until the morning.
“I don’t think we can wait until morning,” I said.
Shashank agreed and called Dr. Anthony Rongione, the other designated VAD surgeon at Fairfax, who said he would come right over.
Liz, who had been in her father’s room when I arrived, came out to talk with us. I asked Liz where her sister, Mary, was. Liz told me that Mary had a cold and had decided to stay home because she didn’t want to risk transmitting it to her father before a big operation.
“Tell her to come,” I said.
When Mary arrived, Shashank, Rongione, and I met with the family in the vice president’s room to update everyone on where we stood.
I cut right to the chase and told Mr. Cheney that his numbers were worse, and despite the late hour, we thought it was prudent to proceed with the VAD right now.
“Right now?” Cheney asked, his surprise evident.
“Yes, sir,” I replied. “Tonight.”
We described his drop in cardiac output despite the increase in intravenous medication, and I told the vice president that I was worried he might suddenly get into trouble during the night. We had a window of opportunity to do this, but it was closing fast, and I was afraid that if we waited much longer, it would disappear.
Mrs. Cheney asked if Dr. Burton was back.
“Not yet, but fortunately Dr. Rongione is here.”
Anthony Rongione was one of two surgeons at Fairfax who, in addition to the usual portfolio of bypass, valve, and aortic surgery, also had expertise in the placement of VADs.
Vice President Cheney turned to his family and asked what they thought. I would usually leave a family to discuss such matters without hovering, but Mrs. Cheney, Liz, and Mary immediately looked at each other, nodded slightly, and told him he should have the surgery tonight.
“Okay, let’s do it,” the vice president said, his voice clear.
I’ve watched tears and fear well in the eyes of patients as I tell them they need surgery. Usually I try to allay their concerns by telling them all the reasons they should do well. In this case, I was the person who was fearful. Cheney was dying. I knew he might not survive the night. Although I had no doubt that he needed the VAD, and right now, the odds were not in his favor. Cheney’s kidney and liver function were deteriorating, and as he had gotten sicker, his appetite had dwindled, wrecking his nutritional status. One of the main reasons for trying to buy some time before placing the VAD was to rebuild his overall metabolic state, but we had simply run out of time.
In his eulogy for President Ford in 2006, Vice President Cheney had called his former boss “the still point in the turning wheel.” That metaphor aptly described Cheney himself. Despite the tumult attendant to preparations for emergency surgery, Vice President Cheney exhibited an uncommon serenity and personal courage I’ve rarely witnessed in any patient during my twenty-seven years as a doctor. Come what may, he was ready.
It was past 9:00 p.m., and as the nurses readied the patient, Mrs. Cheney came out into the hallway to talk with us.
“You’ve already had a long day. Aren’t you too tired to operate tonight?” Mrs. Cheney asked Dr. Rongione.
“Are you kidding? I have triplets,” a beaming Rongione said. “At this time of the night, I’m just getting started!”
• • •
I have a recurring nightmare where I find myself alone late at night in a deserted hospital struggling to keep a supersick patient alive. It’s my version of the classic insecurity dream, but it couldn’t be further from reality. Even at night, a major medical center like Fairfax or GW is well staffed to take care of a critically ill patient, and when Shashank and I entered the operating room, the place was bristling with people.
When I arrived, Dr. Elmer Choi, a Harvard-trained cardiac anesthesiologist, already had Cheney asleep and was busy adjusting the transesophageal echo probe he had just inserted. On the other side of the anesthesia screen, the surgeons—Dr. Rongione, Dr. Paul Massimiano, and Dr. Alan Speir—were well into the operation.
Surgery to place a VAD requires access to the heart, typically by opening the sternum, but in a patient like the vice president who has had prior cardiac surgery, this can be a bit dicey as important anatomic structures (like the right ventricle) can become adhered to the underside of the bone. Indeed, when Dr. Rongione opened the chest, he found thick adhesions everywhere, requiring a meticulous dissection to free the heart from the surrounding scar tissue.
After the dissection was complete, the VAD’s outflow graft was created by sewing a woven Dacron conduit onto the ascending aorta using suture about a tenth of a millimeter in diameter. Next, Tony cored out a piece of the tip of Cheney’s heart using a specially designed cylindrical knife, removing a piece of muscle the diameter of a thumb. The VAD’s inflow cannula was placed inside the heart and secured with thick sutures. Finally, the VAD itself was placed just below the heart, connected to the inflow and outflow cannulas, and the electric driveline tunneled under the skin, exiting the body over the right side of the upper abdomen. The VAD was then activated, and the revolutions per minute of the device gradually increased until it was more than doubling the output of the depleted left ventricle.
Shortly after the VAD went in, around 2:00 a.m., Dr. Nelson Burton entered the operating room. He’d been unable to get an evening flight from North Carolina, so he got into his car and drove five hours to Virginia. Rongione and Massimiano updated Dr. Burton as he scrubbed into the operation.
Although the VAD had gone in without a hitch, Cheney was not out of the woods. The dissection to free the heart of adhesions and peel off segments of his lungs had taken a very long time, and Cheney had bled a lot. When a person bleeds, intrinsic components of the clotting system are consumed, and the more one bleeds, the harder it becomes to stop. Over the next five hours, Rongione and Burton worked to stop the bleeding. Mr. Cheney would ultimately receive more than twenty units of blood and blood products.
When dawn broke, the bleeding had largely stopped, and the VAD, spinning at more than nine thousand revolutions per minute, was doing its job, providing a cardiac output the vice president hadn’t seen since the 1980s. Cheney had been in the operating room all night. Against all odds, the vice president now had a chance of surviving due to the superb skill and dedication of Drs. Anthony Rongione and Nelson Burton and the rest of their team.
• • •
Vice President Cheney had gone into surgery sicker than most other patients and his recovery was likely going to take longer than most. Complicating matters was the unhappy surprise of the large amount of scar tissue in the vice president’s chest and the bleeding its dissection had precipitated. The net result had been a long operation that would require an even longer recovery.
Cheney returned to the ICU on four intravenous drips to sustain his blood pressure and cardiac function. Although the vice president’s left ventricle was fully supported by the VAD, the right ventricle was not, and it was struggling. Dr. Jason Vourlekis, the director of the cardiac surgical ICU, was waiting for Cheney when he returned from the operating room and would oversee the care of the vice president until he was stable for transfer to the step-down unit.
By Friday, only forty-eight hours post-op, Vice President Cheney had improved to the point where he could be taken off the ventilator. Over the next few days, he remained relatively stable, making slow but steady progress, but four days later, on Tuesday, July 13, the vice president became short of breath and a chest X-ray revealed a new abnormality in the right lung consistent with pneumonia. Antibiotics were prescribed, but over the next few days, Cheney’s respiratory status declined.
On Sunday, July 18, eleven days following surgery, Shashank Desai, Jason Vourlekis, Gigi El-Bayoumi, Nelson Burton, and I met at Fairfax to discuss Cheney’s status. Over the prior few days, the vice president’s chest X-ray had worsened. It was becoming increasingly hard for him to breathe. After a long discussion with Mrs. Cheney, Liz, and Mary, we made the decision to place the vice president back on the respirator.
Recovery from a critical illness is often not complication free, and although it was disappointing to lose ground, I remained optimistic.
“This is a setback, not a catastrophe,” I explained.
The vice president was kept sedated, his antibiotic regimen was broadened, and he remained on the respirator for the next five days. During these difficult first few weeks, not a moment went by that a member of the vice president’s family wasn’t with him. Mrs. Cheney, Liz, and Mary took turns sleeping in the room adjacent to his.
On July 23, two and a half weeks after his VAD surgery, Cheney was once again extubated.
Relieved that he was off the respirator, and no doubt anxious to hear how his patient was feeling, Dr. Vourlekis said, “I think you look good, Mr. Vice President. What do you think?”
The room was silent while we awaited Cheney’s response. The vice president looked up at Vourlekis and, mist bellowing from the humidified oxygen mask on his face, said, “I think you’re full of s—t.”