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The incredible LVAD: No longer a bridge too far?Jul 16, 2011 16:08 EDT
Richard Froedge is a locally famous man who loves his family and his church. He is as familiar with local politics as the Kentucky roadways he traveled as a former Metcalfe County judge executive. He loves to be among friends and to eat out. He never got along well with dietary restrictions or the mountain of pills required by a man suffering from severe congestive heart failure. Over time, he began to fall, barely supported by legs so fluid laden that they wept. Beads of edema ran to his ankles, tiny warning signals that an irreparably broken heart was about to perform its final act of betrayal. It was as if his 75-year-old body had performed its own heart-failure trial designed to fail every single primary and secondary end point, plunging him and his entire family into a four-year odyssey, a Dante's Inferno of varying levels of torment. His crime? Being born with a cruel genetic blueprint and a less-than-optimal perception of what constitutes "good" food. The repetitive failure of that secondary end point of "recurrent hospital admission" was the kicker. Richard began to spend longer and longer stints in the hospital where I administered renal perfusion dopamine and dobutamine. He spent one week at the University of Louisville hospital for severe GI bleeding. This incredible interruption in his life is why Richard dove on the offer of a left-ventricular assist device (LVAD) like a fumbled football, the equivalent of a winning lottery ticket and the scientific miracle of all miracles for "the sickest of the sick" in the world of cardiology.
"Abandon all hope, ye who enter here."
Richard sensed he might be coming to the end of life's journey. With little quality of life, he still wanted more; more time with his family, more than mere existence; worse, he came to the realization there would be much more suffering. I asked him one day how far he was willing to go to fight for a better quality of life and more time with his family. He eagerly and courageously grabbed hold of the only real lifeline that could ever be thrown to him. Thanks to the team at Jewish Hospital in Louisville, KY, headed by Dr Mark Slaughter, Richard's been running, albeit with the drive-train of an LVAD in his hand, ever since.
"The path to paradise begins in hell."
|Richard has his battery and back-up with him at all times|
Devices for heart-failure management have drifted in and out of our practice since their inception. The earliest device sounded like a Maytag washing machine, leaving everyone in our waiting room wondering, "Where is that noise coming from?" My partner Dr Jim Whiteside bridged this first noisy LVAD patient, a young man with ischemic cardiomyopathy, to transplant. Another patient, a beautiful young African American woman, had the first prototype HeartMate II some time later. She dazzled us many years ago with no measurable blood pressure or pulse on her first office visit. With no coronary artery disease and an ejection fraction of less than 10% at presentation, her LVAD swept her to safety and eventually bridged her to a new heart. Then came the destination-therapy patient that our interventionalist Dr Venkata Reddy referred for an implant at the ninth hour as death swirled about her. Imminent demise was heralded by crimson ears, the tip of her nose as purple as polk berries. Her blood pressure of 70 mm Hg systolic left her "cold and wet," a category of heart failure from which there is often no return. Today, she has declined a heart transplant because she feels so well that she enjoys time in her garden and shopping.
Simultaneous to Richard's story is that of a young man I'll call John. He has brittle type 2 diabetes and has undergone two separate coronary-bypass procedures, blowing through them like a car running through a toll booth. At less than age 40, this father of five was desperate to see his youngest child make it to high school. He too grabbed that same lifeline and is alive and doing well several months postimplant. The determination to find a solution for these patients with little hope was fueled even further after one of our patients died from a catastrophic stroke following an AbioCor heart implant. I wish he could have been eligible for an LVAD instead.
"In that book which is my memory . . . appear the words, 'Here begins a new life.' "
|Richard proudly shows off his "computer" and his "new figure"|
Richard just spent an entire week on the lake in a houseboat with his family. He's been seen riding his four-wheeler many times. He goes to church, drives, eats out, and visits friends. "His feet look just like they did when we first got married," his wife said excitedly. "He's lost 82 pounds of fluid and is down to one insulin shot per day," she added. Nearly seven months after his implant, his occasional dietary indiscretion does not cost him a week in the hospital. The trade-off? Plugging in every night and unplugging every morning, monthly outpatient visits to the LVAD clinic 100 miles away, and having "to wear a big shirt to accommodate his lines." His quality of life has improved about a million percent, and he is alive and happy. I was glad when I asked if I could chase him down for a picture when his wife said, "I don't know if we are going to be home Sunday. That’s the day we like to go to church and run around." Today, he drove to my house to see me, his blue eyes once again sparkling with life that had shone so dimly back in December 2010. "Richard, what are you doing now that you couldn't do before you had your implant?" I asked today. "Living," he said, as he stood to walk unsupported toward my door.
Compared with the misery of repetitive hospitalizations, medications, shortness of breath, and liters of fluid endured by the average end-stage heart-failure patient, an LVAD is becoming much more attractive as a treatment option. "We should have done this four years ago," his wife said, and I agree, except four years ago, he only had one foot in the grave, not two. Unfortunately, the implant criteria are so stringent and the venture so costly, that many patients die before they can even be considered. Won't it be wonderful when we finally get to the point that we think no more of implanting an LVAD than we would an automatic internal cardiac defibrillator or even a simple pacemaker?
|Richard and Lora Belle Froedge enjoy life once again|
I continue to be amazed by Richard's recovery. The GI bleeding I feared would defeat our efforts never happened, a fact predicted by Dr Slaughter who told me that "when his PA pressures come down, the right heart will shrink, and those bleeders will close off." Obviously, they did. His renal function has improved, and he's handled the routine beautifully, in large part due to Richard's dogged determination; his dedicated wife, Lora Belle; and his three children and their spouses.
I wrote this article because I recently asked a patient from out of town who landed in our hospital with heart failure to consider an LVAD. He has inoperable CAD, is failing rapidly with shortness of breath, and starting down that slippery slope that often permits no respite. He said his usual cardiologist told him that patients "who have those things don't have any quality of life," folded his arms, and refused to consider it further.
Tell that to Richard Froedge.
"To get back up to the shining world from there, my guide and I went into that hidden tunnel where we came forth, and once more saw the stars."