The Gormogons present: Your guide to Dick Cheney’s new Clockwork Heart®

The Royal Surgeon, Dr. J., writes in to Castle G to present his report on the former Vice President’s condition. Unclassified excerpts follow.

Dread and powerful Volgi, [Finally, someone consults the stylebook! —ŒV]

Your Royal Surgeon wishes Vice President Cheney a speedy recovery from his recent heart operation. He has been the Royal Surgeon’s favorite ‘adult in the room’ in D.C. since Ronald Wilson Reagan rode off into the sunset in 1989.

Mr. Cheney’s degree of congestive heart failure has progressed to the point where he was functionally very limited by his heart, getting short of breath very easily. Given the outstanding care he has received to date, we can presume that everything that could be done surgically (bypass), percutaneously (stents and an implantable cardioverter defibrillator, perhaps with biventricular pacing), and medically (pills and potions). When a patient gets to this point, where the heart’s ability to pump is incompatible with long term survival (usually defined as little chance at 1 year survival), there are three options.

First, is heart transplantation. This is limited by the finite number of organs available. Recipient size, ABO match, and severity of illness compared to other patients in the region determine wait time. Patients with poor social support or medical comorbidities (cancer, kidney failure, COPD, severe diabetes, chronic infections like HIV, or Hepatitis, or advanced age) tend not to be transplanted. There are exceptions, there are programs where senior citizens are eligible for hearts that otherwise would be rejected. There is a program where HIV+ hearts are being placed in HIV+ patients with HIV cardiomyopathy. Don’t laugh. Given the miracle of current HIV therapies, a patient with HIV cardiomyopathy’s life can be significantly shortened from what it otherwise would be.  Rejection is low in that population due to viral immunodeficiency.

Second is palliative care. For most patients with comorbidities there comes a time where it is clear to the doctor and the patient, especially if they have a healthy doctor/patient relationship, that all therapies have failed.  Fluid pills aren’t getting rid of the fluid, the defibrillator is shocking the patient with a sufficient frequency that it is clear that it is preventing the patient from appropriately surrendering his mortal coil, and/or their other organs are failing because the heart can’t adequately perfuse them.  

Now, for select patients there is a third option, a ventricular assist device. This device is typically plugged into the left ventricle and the aorta. Most of them have a continuous flow pump, rather than pulsatile flow, as it decreases the risk of clot and hemolytic anemia. As a consequence the patients, like GorT, are walking around without a heartbeat or pulse.  It does the work of the heart, perfusing the patients organs and giving them the energy to enjoy life. A number of patients awaiting heart transplant will receive these devices as a bridge to transplant. A second cohort of patients, receive the device as ‘destination therapy.’ That means that they will receive it in order to increase their quality and quantity of life, but will never go on to be transplanted. The individuals who receive these devices as destination therapy should be people who would have expected functional improvement with the device and have sufficiently few other medical problems that could result in complications from the device. In the best case scenarios, patients gain a few extra years that they otherwise might not have.

All therapies have tradeoffs. Current generation VADs have a lead, or wire that tunnels through the skin of the abdomen and is plugged into an external battery. The pumps, while dramatically improved from the earlier generation devices, still can generate clots. As a consequence patients who would have died of an arrhythmia or pump failure, now die of infection,  stroke, bleeding (from blood thinners to prevent clots), or device failure (from said clots).

According to varying reports, what Mr. Cheney has received is VAD as either destination therapy, or as bridge to transplant. It sounds like George Washington’s program offered to list him, but he’s pondering his options.  
Warmest Regards,

Dr. J
Royal Surgeon to the Gormogons

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