Heart: An American Medical Odyssey Read online

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  Contents

  Prologue

  1. A Prime Candidate

  2. Echoes of Ike

  3. Into the Heart

  4. Cura Personalis

  5. A Tale of Two Drugs

  6. Bypass

  7. Post-Op

  8. Fitness to Serve

  9. Recount

  10. White House Calls

  11. Treating the Vice President

  12. Slippery Slope

  13. Downhill

  14. Transplant

  Epilogue: Days of Grace

  Photographs

  Acknowledgments

  About Dick Cheney and Jonathan Reiner, M.D.

  Notes

  Index

  To my family, my medical team, and the donor of my heart

  —DICK CHENEY

  To Charisse, Molly, and Jamie, who fill my heart with joy

  —JONATHAN REINER, MD

  Prologue

  VICE PRESIDENT CHENEY

  June 2010

  If this is dying, I remember thinking, it’s not all that bad. It had been thirty-two years since my first heart attack. I’d had four additional heart attacks since then and faced numerous other health challenges. Now, in the summer of 2010, seventeen months after I left the White House, I was in end-stage heart failure.

  On a trip to Jackson Hole, Wyoming, in May, it had become clear my weakened heart could not tolerate the high altitude. I returned to Washington on an emergency flight, and as the plane took off, I realized I might never see my beloved Wyoming again. Since then, my wife, Lynne, and I had been at our house in McLean, Virginia. When I got up in the morning, all I wanted to do was sit down in my big easy chair, watch television, and sleep.

  What was happening to me was hardly a surprise. I had lived with coronary artery disease for many years, and I had long assumed it would be the cause of my death. Sooner or later, time and medical technology would run out on me. Now my heart was no longer providing an adequate supply of blood to my other vital organs. My kidneys were starting to fail. I believed I was approaching the end of my days, but that didn’t frighten me. I was pain free and at peace, and I had led a remarkable life.

  I thought about final arrangements. I wanted to be cremated and have my ashes returned to Wyoming. It was a difficult subject to broach with my family. They weren’t eager to discuss it. For them, talking about it made an already difficult situation even worse. But I needed them to know. And I needed to say good-bye. As my condition deteriorated that summer, my cardiologist, Dr. Jonathan Reiner, had raised the possibility of having a left ventricular assist device (LVAD) implanted in my chest, and I agreed to be briefed on it at Inova Fairfax Hospital in Northern Virginia, which has one of the most active LVAD programs in the country.

  The LVAD transplant team showed me the device, which connects to the left ventricle, the main pumping chamber of the heart. The LVAD passes blood through a small pump operating at nine thousand revolutions per minute and returns it to the aorta, the largest artery in the human body, ensuring an adequate blood supply to the vital organs. The device is powered by a driveline that passes through the wall of the chest to an external set of batteries or an electrical outlet.

  The idea of being kept alive by a battery-driven piece of equipment operating at high speed inside my chest was a bit daunting at first, but it soon became apparent that this option offered real hope and the possibility of extending my life long enough to be eligible for a new heart. Previously we had never really considered a heart transplant as an option for me because I clearly wouldn’t live long enough to work my way up the transplant list to become eligible for a heart. The average wait was about twelve months. The medical team explained that although the LVAD was originally designed as a bridge to a transplant, some patients were deciding to live with the device.

  I was impressed with the individuals on the LVAD/transplant team: they clearly knew their business. It was also apparent that they respected and welcomed Jon Reiner, who although he practices at George Washington University Hospital, would be included as an integral part of the team. That carried great weight with me given all that Jon and I had been through together over the past fifteen years.

  The preceding weeks had been challenging. I not only had many of the symptoms of a failing heart, I was also, due to the anticoagulants I was taking, suffering severe nosebleeds, including one so massive it required emergency surgery and a number of blood transfusions. On more than one occasion that spring, we had found ourselves speeding down the George Washington Parkway in Northern Virginia toward my doctors and the emergency room at George Washington University Hospital in the District of Columbia. In addition, my heart failure was causing severe sleep apnea. As soon as I nodded off to sleep, I would find myself awake again, gasping for air.

  On July 4, I’d experienced internal bleeding in my thigh and was rushed to George Washington University Hospital as fireworks lit up the night sky. At the hospital, they gave me narcotic painkillers, which, as we were on the way home and stuck in holiday traffic, caused me to be sick to my stomach. The list of things I could not do grew. I’d stopped climbing the stairs. I could no longer walk to the end of the driveway to pick up the morning newspapers. I barely had the strength to walk the length of the hallway between our bedroom and my office. My world shrank until I was barely able to leave my bed. By the time I was admitted to Inova Fairfax Hospital on July 6, 2010, it was clear that there really was no choice: without the LVAD surgery I would not survive.

  My last memory of that evening is of Jon Reiner and the other doctors and my family gathered around my bed in the intensive care unit. The doctors explained that although they had originally scheduled the surgery for July 8, my situation was worsening and they recommended taking me immediately to the operating room. After I listened to the doctors, I asked Lynne and our daughters, Liz and Mary, what they thought. One by one, they each agreed that we should not delay. “Okay,” I said, “let’s do it.”

  DR. REINER

  July 6, 2010

  The numbers in the morning were bad; now, after 8:00 p.m., they were even worse. Dr. Shashank Desai and I agreed to meet in the cardiac surgery intensive care unit (ICU) to check on our patient one last time before we left for the night. Shashank runs the advanced heart failure program at Inova Fairfax Hospital just outside Washington, DC, where we had admitted Dick Cheney, the former vice president of the United States, earlier in the day. When I entered the second-floor cardiac surgery ICU, I found Shashank standing just outside the vice president’s corner suite. Through a glass partition, I could see Cheney staring at a television across the room. He had an oxygen cannula under his nose and a glowing red pulse oxymetry sensor taped to his thumb. Telemetry leads ran from under his hospital gown, coalesced into a loose bundle, and spilled over the raised bedrail on their way to the adjacent rack of electronics. A blood pressure cuff around his bicep automatically inflated and deflated every few minutes, displaying its relentless march of numbers, waveforms, and alarms on a wall-mounted touch-screen monitor. A nurse exited the room and handed us a flow sheet with the patient’s latest labs. “These can’t be right,” I said softly, although I knew they probably were.

  The prior months had not been good for Cheney. In December an arrhythmia would have killed him had his implanted defibrillator
not delivered a resuscitating twenty-five joule shock. Six weeks later, an exsanguinating arterial nosebleed, intensified by anticoagulants, required emergency late-night surgery. At the end of February, Cheney had chest pain while staying on the Eastern Shore of Maryland and was taken by helicopter to George Washington University Hospital for treatment of a heart attack. In May, he had acute shortness of breath within hours of arriving in Wyoming that necessitated an immediate turnaround and admission to GW’s intensive care unit. Now, for the last week and a half, Cheney had required a continuous home infusion of milrinone, intravenous “rocket fuel” administered via a small, portable pump.

  Milrinone typically is reserved for use in end-stage congestive heart failure, when the heart’s declining ability is no longer capable of sustaining vital organ function. Cheney’s initial response to the drug was impressive: his breathing and energy improved almost immediately. The benefit was short-lived, however, and at the end of June, his condition took an abrupt turn for the worse. The vice president’s weight rose by several pounds, indicating retention of fluid, and his energy sharply waned, largely limiting him to a reclining chair or bed. On July 4 he again bled spontaneously, this time into his leg. The next day, labs obtained by a visiting nurse at Cheney’s home in Northern Virginia revealed a precipitous drop in his kidney function, triggering our decision to admit him to the hospital.

  The kidneys, which are essential not just for fluid management but also for the regulation of blood pressure, electrolytes, and acid-base balance, account for only about 0.5 percent of a human’s total weight but receive about 25 percent of the total cardiac output (the volume of blood ejected by the heart each minute). So in patients with congestive heart failure, the kidneys act like a canary in a coal mine. When cardiac performance drops, the kidneys are often the first to take the hit.

  In the morning, we escalated the milrinone infusion in an effort to squeeze just a little more function from Cheney’s depleted heart. Now, ominously, after several hours on the higher dose, his cardiac output had dropped, not risen. A normal cardiac output is about 5.5 liters per minute; Cheney’s was barely 2.

  “Where’s Nelson?” I asked.

  “He’s in North Carolina trying to get back,” Shashank replied.

  Dr. Nelson Burton, a talented, senior surgeon at Fairfax, had extensive experience implanting ventricular assist devices (VADs) in patients with advanced heart failure. Although all VAD surgeons perform the more familiar cardiac surgical procedures like coronary artery bypass and valve replacement, relatively few cardiac surgeons have experience implanting VADs. Burton had been on the Outer Banks of North Carolina with his family celebrating his son’s homecoming after a tour of duty with the Marines in Afghanistan. Surgery for the vice president to implant a VAD had originally been scheduled for the following week, and Nelson was planning to return in a day or two. That was going to be too late.

  Mrs. Cheney and Liz were with the vice president. I couldn’t hear what they were talking about, but I knew they weren’t prepared to hear what I was about to say. Liz saw us outside the room and came out to talk.

  “Where’s Mary?” I asked.

  Liz told me that her sister had a cold and was afraid to expose her father to it.

  “Tell her to come,” I said.

  Liz understood immediately and, without asking for an explanation, turned to call Mary.

  I had taken care of Dick Cheney for about fifteen years. I was young, just a few years out from training, when I assumed his care after his prior cardiologist, Allan Ross, a mentor to me, retired. In many ways, my career and life had become inextricably entwined with this patient. Although deep down I always knew one day we would arrive at this moment, the realization hit me very hard. Dick Cheney was dying.

  CHAPTER 1

  A Prime Candidate

  VICE PRESIDENT CHENEY

  I loved my mom’s dad, Granddad Dickey, very much. He and my grandmother lived a life that seemed full of adventure. At the start of World War II, they had left their home in Syracuse, Nebraska, when they got work on the Union Pacific Railroad. They lived in a railcar and cooked for the section gangs that repaired and maintained the tracks. For my brother, Bob, and me, visiting grandparents who lived and worked on a train was a dream come true. My granddad taught us two of the most important things a man can learn in life: how to cook and how to fish. He combined the two skills in a “recipe” he had for catching catfish. He’d take the guts he’d cleaned out of a chicken he’d fixed for dinner, put them in a glass jar, and let them “ripen” for a day or two. He swore the ripening made them especially appealing as bait for catfish. Judging from his success as a fisherman, he was on to something.

  Granddad loved to laugh. He also loved good bourbon, a game of cards, and a smoke. He had nicotine stains on his fingers from the unfiltered Camels he smoked until his first heart attack in the late 1940s. His doctors tried to get him to quit smoking then, and he compromised with them: he cut down to four cigarettes a day, but he switched from Camels to the much longer, and also unfiltered, Pall Malls.

  After my grandmother died in 1951, Granddad Dickey moved between the homes of his three kids every several months. One afternoon when he was staying with us, my parents were working in our yard, and I heard him call out to me from his bedroom: “Dickey, go get your mother.” I ran to the yard. Mom came inside, and moments later she was on the phone that sat on a desk in our hallway calling the ambulance. My dad sent me outside to wave down the ambulance driver and make sure he found our house.

  The paramedics rushed through our front door with their stretcher and medical equipment. Soon they were wheeling my grandfather down the hallway, toward the living room. I stood on the front porch, holding open the screen door as they carried him out to the ambulance. It was the last time I ever saw him. He had suffered a massive heart attack and died later in the afternoon. He was sixty-six. I was fourteen.

  • • •

  My mom and dad both smoked when I was growing up. My dad mostly stuck to pipes and mom smoked cigarettes. I smoked my first cigarette when I was twelve. Our Boy Scout troop met every week in the basement of the Baptist church near our home in Lincoln, Nebraska. There was an older, cooler kid named Jim Murphy who was the head scout in our troop. Jim also had a job at a local drugstore, which gave him access to the packs of cigarettes he brought to Scout meetings. On our way home from the meetings, a group of us would stop by the park near the church and smoke a cigarette or two.

  By the time I got to high school, my buddies and I smoked cigars every once in a while. In the winter, we went ice fishing at Alcova Lake near Casper. While we waited for the fish to bite, we split a six-pack of beer and a five-pack of cigars.

  I went on to college where I smoked some. I wasn’t a heavy smoker then, mostly because I couldn’t afford it. I was saving every penny I could to make phone calls to Lynne, who was at college in Colorado.

  By 1964, Lynne was in graduate school, and I was just about to wrap up my bachelor’s degree. (I had been on a somewhat slower path than she was, but that’s another story.) That year the US surgeon general issued his first report on the dangers of smoking. I remember sitting in Lynne’s apartment at the University of Colorado campus in Boulder and hearing a story on the radio about the report. It registered enough that I remember it all these years later, but not enough to make me quit smoking back then.

  My habit really picked up once I got to Washington and was working for Don Rumsfeld, who was a counselor to President Nixon. In those days, just about everyone smoked in meetings, at meals, at home. It was pervasive. When Rumsfeld and I started working for President Ford, both Don and the president smoked pipes, and I had a supply of free cigarettes. Tobacco companies kept the White House stocked with presidential cigarettes that came in gold-trimmed white boxes stamped with the presidential seal. You could also get matches from Air Force One, Marine One (the presidential helicopter), and even Camp David. There was a certain cachet to pulling out a box of preside
ntial cigarettes and using a match from a pack labeled “Air Force One” to light up.

  Despite the growing evidence that smoking was bad for your health, we all did it. Even in a meeting in the Oval Office, it wasn’t unusual for most of the participants to be smoking. In one photo, taken by President Ford’s official photographer, David Kennerly, I am reaching across the president’s desk—while the president is sitting there—to put out my cigarette in his ashtray. We didn’t even think twice about it. Smoking seemed to keep you from gaining weight, and all the advertising made it appear cool and sophisticated.

  By the time I was in my early thirties, I’d developed a heavy smoking habit, my diet was terrible, and I didn’t get nearly enough sleep or exercise. I basically ate whatever anyone put in front of me. Many nights, dinner consisted of high-calorie, high-fat hors d’oeuvres at Washington receptions. Other nights, I’d arrive home late and whip up some eggs and bacon for dinner. Sunday mornings meant a trip to the local Krispy Kreme for a dozen doughnuts. I told myself the doughnuts were a treat for the kids, but Liz and Mary didn’t eat nearly as many as I did.

  I rarely got regular exercise. I was more of a weekend warrior, not always with good results. One weekend, I was playing a game of touch football and tore the cartilage in my right knee, leading to two months in a cast and ultimately surgery to remove all the cartilage. My sporadic activity increased my risk of injury without giving me much, if any, cardiac benefit.

  At that stage of my life, I believed there was a direct relationship between how well I did my job and how many hours I was at the office. I hadn’t yet learned to pace myself or recognize the difference between quantity of hours and quality of work. Nor did I feel that I was under stress. The fact that I was in a high-pressure job tackling challenging problems enhanced its attractiveness. I literally couldn’t wait to get up and go to work each morning. At thirty-four, I was White House chief of staff. I began and ended most days in the Oval Office with the president of the United States, the most powerful and influential man in the world. And not just any president but Gerald Ford, a man for whom I had and have tremendous admiration, a man who healed the nation after Watergate and the first-ever resignation of a sitting president. The war in Vietnam was coming to an end. We were negotiating major arms control agreements with the Soviet Union. We had signed the Helsinki Accords, putting human rights on the table for the first time in negotiations between the United States and the Soviets, and by late 1975 we were gearing up for a historic presidential campaign. Most of the people I knew in Washington would have killed for this job. And I absolutely loved it. I knew we were living through historic times, and I wasn’t just an observer; I was a participant.