Cheney transplant puts spotlight on heart failure treatments
Former United States vice president Dick Cheney’s ongoing recovery from a long awaited and “lifesaving” heart transplant, combined with his 20-month survival after receiving the HeartMate II — a left ventricular assist device (LVAD) — has rekindled interest in interventions that can extend the lives of patients with advanced heart failure.
Doctors interviewed by MedPage Today, Reuters, Agence France Presse, Associated Press and the New York Times all agree that Cheney’s situation has enhanced public awareness of advanced heart failure and available treatment options.
“Cheney’s situation demonstrates that we can provide really great care for patients with advanced heart disease and it no longer needs to be considered a desperate situation,” Dr. Clyde Yancy, a past president of the American Heart Association (AHA) and chief of cardiology at Chicago’s Northwestern University told MedPage.
On March 24, the office of Cheney released a statement saying he was “recovering in the intensive care unit of Inova Fairfax Hospital in Falls Church, Virginia, after undergoing heart transplant surgery.”
“Although the former vice president and his family do not know the identity of the donor, they will be forever grateful for this lifesaving gift,” the statement added, without giving further details on his condition.
Cheney, 71, who served under former president George W. Bush, was in end-stage heart failure after suffering five heart attacks in his life. He had been on the waiting list of a new heart for 20 months.
Since his first attack in 1978 at age 37, Cheney’s care has run the range of interventions — ranging from coronary stents to keep blocked heart arteries open, a quadruple bypass surgery in 1988 to re-route blood flow around diseased arteries, an implant of a heart defibrillator in 2001 to safeguard against dangerous rhythms.
And in July 2010, when Cheney suffered his fifth heart attack, doctors implanted an artificial heart pump called a left ventricular assist device — or LVAD — used to take over the pumping function of a diseased heart for patients in end-stage heart failure.
Heart experts say the device offers a way to keep organ systems working well enough until a patient can accept a donor heart. VADs often serve as bridges to a transplant, they say, and Cheney agreed. Saying this was a “miracle of modern technology,” Cheney also said in a 2011 interview with NBC News that it was a “temporary measure.”
In his long political career, Cheney served in Congress, the White House and as defense secretary. But it was as vice president that he gained prominence. He was a central figure in the “war on terror” launched by the U.S. in the wake of the September 11 terror attacks.
He was seen as “dark and heartless — the Darth Vader of the administration,” because under his watch, controversial measures were allowed: the use of harsh interrogation methods that met global definitions of torture and the wiretapping of U.S. citizens without a warrant. Cheney was also heavily involved in the subsequent decisions to invade Afghanistan in 2001, and Iraq in March 2003.
Cheney as VAD poster boy
Now he’s the “face” of heart failure interventions.
Cardiologist Dr. Yancy thinks that Cheney’s recent heart transplant provides a needed opportunity to make people aware of the existence of effective treatments for heart failure — medical therapies, implantable cardioverter-defibrillators, revascularization procedures, ventricular assist device (VADs) and transplant.
Cheney’s survival shows that the time has come to consider VADs as part of the treatment strategy, Dr. Yancy says.
By receiving the mechanical assist device and talking about it, Cheney “changed people’s perception of the therapy,” says Dr. Mary Norine Walsh, spokesperson for the American College of Cardiology and Medical Director of the Cardiac Transplant Patient Program at St. Vincent Heart Center in Indianapolis.
Dr. Walsh says she often mentions Cheney when speaking with patients about treatment options because his high profile and his active lifestyle since implantation that involves book tours and TV appearances facilitate these discussions.
His situation helped lift the veil on the technology, facilitating discussion about the device with patients with heart failure, she tells MedPage Today. Dr. Walsh also believes that the fact that Cheney didn’t only survive — but transitioned as well from being very ill to being a candidate for heart transplantation — further highlights the success of the device.
Now he’s the poster boy for heart transplants as well. These transplants involve implanting a donor heart into the patient to replace the diseased heart that’s no longer able to pump enough blood to keep the other body organs working properly.
To qualify for a heart transplant, patients don’t only have to have end-stage heart failure — they also have to be healthy enough to undergo heart transplant surgery.
Risks of ventricular assist device
But some cardiologists also point out that patients with end-stage heart failure who have a VAD implanted to take over the pumping function of their diseased hearts also face risks like bleeding, infection and stroke.
“Therefore, heart failure cardiologists and surgeons reserve their use (VAD) to patients who are at risk for not surviving to transplant, or who aren’t candidates for transplant — so that the benefits outweigh the risk,” writes Dr. Patrick McCarthy, chief of cardiac surgery at Northwestern University in an email to ABC News and MedPage Today. But he admits, “trials are ongoing using the device in less sick patients as the risks of VAD use today are much lower than in the past.”
Dr. Timothy Gardner, and a past president of the AHA and medical director of Christiana Care Health System’s Center for Heart & Vascular Health in Newark, Delaware also notes that long-term VAD use can pose some complications, including GI tract bleeding.
Battling heart failure: costly and wearisome
When the heart has become too weak to pump blood — that’s heart failure. The disease is unstoppable and relentless: without enough blood flow, the arms, legs and lungs fill up with water. Patients can feel as if they’re drowning — and when the disease gets really bad, they literally do.
And although there’s been progress on the medical device front, drug companies have found it difficult to develop new medicines for the end stages of the heart disease, despite their best efforts.
A drug for hospitalized heart failure patients was developed by Johnson & Johnson — Natrecor for — but worries about kidney damage and overuse emerged and sales plummeted. New entrants from Abbott Laboratories and Merck have failed in trials so far reports Forbes health reporter Matthew Herper.
Because drug companies have failed to come up with treatments to help hospitalized patients, slowing the progression of heart disease becomes vital.
Careful weight management to catch fluid buildup early and a handful of blood pressure drugs can help save lives and prevent hospitalizations.
For heart failure, doctors recommend:
• To cut blood pressure, an angiotensin-converting enzyme inhibitor
• To control blood pressure and improve heart function, a beta blocker
• To keep excess fluid off, a diuretic
But patients have to follow the doctor’s advice religiously. When they do, their health situation invariably improves. Some patients are barely able to walk after diagnosis, but after carefully taking all the prescribed medications, exercising and taking care to eat a balanced diet, they find that they can walk several miles most days and use an elliptical trainer.
“We know how to treat this disease; we know how to help patients live longer and feel better,” says Dr. Yancy.
The problem is, many elderly patients don’t get all the treatments they should — or have trouble managing on their own. One solution might be to hire nurses and physician assistants to monitor patients.
But overall, treating heart failure can be expensive: Most patients stay in the hospital for about a month after surgery, and recent studies estimate that first-year costs for a heart transplant and follow-up care are close to US$1 million. Heart failure is one of the most expensive diseases for Medicare, costing US$33 billion a year, reporter Herper estimated in 2009.
According to the Heart Failure Society of America, about five million Americans have heart failure, and an estimated 400,000 to 700,000 new cases of heart failure are diagnosed each year.
Between VAD and heart transplants
On any given day, some 3,000 Americans are on the waiting list for a heart transplant. But only about 2,000 donor hearts are available each year, according to the National Heart Lung & Blood Institute.
Still, Cheney had to wait longer than average for a heart, says Dr. James Kirklin, a recent past president of the International Society of Heart & Lung Transplantation and director of cardiothoracic surgery at the University of Alabama at Birmingham. “He waited quite a long time — nearly two years on a device,” Dr. Kirklin tells Reuters. “Even though the waiting lists are very long, that would be an extended wait for a heart transplant.”
Dr. Walsh surmises that maybe that was because the former vice president had been considered “moderate” in terms of urgency because he had been living with an LVAD since 2010.
Because of VADs, Dr. Walsh says, fewer heart failure patients today die waiting for a transplant. Used as a bridge to a transplant, VADs offer a way of keeping organ systems in good working order for the patient to accept a donor heart.
And thousands of end-stage heart failure patients have gotten these mechanical devices. One such device — a new one — from AbioMed, may allow a tiny pump to be temporarily implanted via a catheter. Thoratec, the biggest maker, had 2008 sales of US$313 million.
But VADs are increasingly becoming a permanent solution for some patients and some doctors believe Cheney could have stayed on the VAD.
Blood clots and infections are complications linked to VAD, so doctors say it’s possible Cheney was moved up the transplant list if his VAD device had caused problems.
Heart surgeons have come a long way from 1967, when South African surgeon Christiian Barnard performed the first heart transplant. Today, the operation is common — but it remains a risky, costly and arduous procedure.
In 2009, there were 2,211 heart transplants performed in the U.S. — 72 percent in men, because they have a higher rate of heart disease compared to women, according to a statistical report published in the journal Circulation. Looking at transplants between 1997 and 2004, the survival rate at one year after surgery for men was 88 percent, and 73 percent at five years.
But outcomes are significantly worse for older patients, according to a 2008 study in The Annals of Thoracic Surgery. The study found that in patients over 55:
• 63 percent were still alive five years after their transplant
• 48 percent survived a decade
• 35 percent were living 15 years later
Hospitals have traditionally set 65 as the upper limit for heart transplant. But there’s no absolute cut-off age and older patients increasingly are getting these transplants.
At 71, former Vice President Dick Cheney was older than average for a heart transplant. In fact, Dr. Valluvan Jeevanandam, the University of Chicago Medical Center’s chief of cardio-thoracic surgery says his hospital has been doing transplants on increasingly older patients.
“They’re not that different. The key is co-morbidities,” he says. What he meant was that other chronic conditions affect the outcome of a heart transplant, more than age.
Thus, older patients are made to undergo a rigorous evaluation and are screened for kidney and liver dysfunction, neurological abnormalities, cancer, and other problems.
“They have to be an excellent candidate without significant risk factors because age itself is a risk factor,” says Dr. Randall Starling, a specialist in cardiac transplants at the Cleveland Clinic.
If Cheney’s kidneys and other organ systems were working properly at the time of the transplant — and if his body doesn’t reject the organ — the latest procedure could extend the former vice president’s life by a decade or so, Dr. Startling estimates.
Doctors also point to advances in care that make it possible for older patients to still be good transplant candidates.
Meanwhile, scientists are advancing stem-cell research for heart disease — although a possible treatment or therapy would be quite a way off.