A heart pump's boost of life

Device: Ronald Smith feared he would die before a transplant could be done, but a small plastic-and-titanium turbine kept him alive until a new heart was available.

Medicine & Science

March 31, 2003|By Jonathan Bor | Jonathan Bor,SUN STAFF

Ronald Smith's heart had grown so weak that he could barely cross the room without gasping for air.

Knowing he could die before a donor heart became available, surgeons created a small channel in his lower left chamber in December and planted a battery-sized pump inside. The plastic-and-titanium turbine gave his heart a needed boost, keeping him alive until a new organ turned up a month later.

"It bridged me from being down and out cold to being able to function," said Smith, 54, who got his transplant in January at the University of Maryland Medical Center and is doing well at home in Clinton. "Would I have died? It's a distinct possibility."

Someday, doctors might remove a failing heart and insert an artificial replacement -- a solution being studied in a small clinical trial that has drawn great attention. But today, with less fanfare, thousands of patients like Smith who suffer from congestive heart failure are being kept alive on smaller "assist" devices that help the heart do its work.

Mostly used to sustain patients waiting for a transplant, the pumps may play a bigger role as doctors envision the day when the devices might serve as a long-term remedy that would make some transplants unnecessary.

"I am convinced that in the not too distant future, we will be putting devices into patients for destination therapy -- final therapy," said Dr. Stephen S. Gottlieb, a heart-failure expert who treated Smith.

In the trade, the booster pumps are known as left ventricular assist devices -- LVADs -- because they work in tandem with the heart's main pumping chamber, helping it push blood to the rest of the body.

Never has the need to solve heart failure been greater. The disease, marked by the heart's inability to pump vigorously enough to nourish tissues throughout the body, afflicts an estimated 4.7 million Americans. It has many causes, including blocked vessels, leaky valves, infections and diabetes.

Many patients can be managed on drugs. Thousands, though, become gravely ill, either too sick for transplants or unable to get them because donor organs are scarce.

Smith grew weak and short of breath, and by 1990 was forced to leave his job as a computer systems designer for WorldCom Inc.

"It got to the point where I'd wake up in the morning and fix myself something to eat, then go back to bed," he said. "I'd wake up, do the dirty dishes, then go back to bed."

Last year, medications were no longer effective, and Smith was close to death. Doctors turned to more drastic measures. Smith got the pump, and his energy returned.

Most pumps are placed in the patient's abdomen and attached by tubes to the left ventricle. Blood flows from the heart to implant, which pumps oxygenated blood in pulses to the aorta, which feeds the rest of the body.

Smith, however, received a relatively new device, called a Jarvik 2000. It is considerably smaller that most pumps, sits inside the left ventricle, and whishes blood along in a continuous flow. His was adjusted to assume two-thirds of the pumping load, leaving the rest to the heart itself.

The pump's inventor, Dr. Robert Jarvik, also designed a total replacement heart that captured the public's imagination in the 1980s when three terminally ill patients were kept alive for up to two years before succumbing to strokes, infections and other complications.

Hospitals used a smaller version to bridge hundreds of patients to transplants, but gave up on using the device permanently. Jarvik abandoned the artificial heart and turned his attention to designing a less complicated booster pump.

Jarvik said it should be less risky because it is smaller and has fewer nooks and crannies where blood can collect and clot. Also, he hopes that it can be installed before the heart has fully deteriorated, giving it the break it needs to recover and grow stronger.

"I'm not saying we don't believe in the artificial heart, but I don't think you should cut out the heart except under very extreme circumstances," said Jarvik, president of a New York company that bears his name.

Doctors are probably years away from using the boosters routinely as long-term therapy, but they are inching in that direction. Last year, the Food and Drug Administration approved one device, called HeartMate, after a clinical trial showed that terminally ill patients on boosters survived longer than others who only received the best drug treatment available.

Survival, however, was a relative thing. After two years, 27 percent of the patients on heart pumps were living, compared with 10 percent of those on drug therapy. The pump patients had to undergo the ordeal of major surgery to implant the device, and many suffered bleeding, infections or strokes.

Gottlieb, who heads the UM medical center's cardiac care unit, said refinements in pump technology should eventually reduce the risks. But he noted that patients in the study were already gravely ill, so they faced particularly long odds.

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