Some people wear their hearts on their sleeves. Joe Dolan wears his, or at least part of his, in his modified ballistic vest.
It holds two batteries, one on each side, each about the size of a phablet. They connect to a controller. If his pant pockets aren’t big enough, Dolan, 72, can carry the controller in the modification to his ballistic vest – a “marsupial pouch,” he calls it, that his wife Sandy sewed in. The controller connects to a driveline, and the driveline connects to what is, functionally, an artificial heart.
Technically, it’s called a left ventricular assist device, or LVAD. Feb. 3 marked the second anniversary of the surgery that implanted it at UCHealth University of Colorado Hospital. Call it a “VADiversary,” as his care team does at UCH, the only hospital in the region combining the diverse array of medical, surgical and support expertise needed to serve heart failure patients like Dolan whose lives depend on getting VADs. They come in from as far away as southern New Mexico and Montana for the surgery.
In 2006, Dolan was a retired anatomy and physiology professor living in Cheyenne, Wyoming. He had always liked to draw and had a knack for it, so he took up painting: landscapes in watercolor and abstract pieces in acrylic. The paintings were good enough that people bought them. He and Sandy were at his booth in a Sterling, Colorado, art show when his heart went into ventricular fibrillation and fluttered rather than pumped. Dolan collapsed.
His art might well have saved his life that day. A doctor and an off-duty police offer had been checking out his paintings at that very moment. They performed CPR until the paramedics arrived to shock his heart back into rhythm. Soon thereafter, the medical team at UCHealth Medical Center of the Rockies (MCR) in Loveland implanted a defibrillator. Over the next few years, it saved his life more than once, too. But each shock was “like getting kicked by a horse,” as Dolan put it, sending him to the hospital for a couple of days. His heart failure worsened after such episodes, which, as Sandy put it, “really pull the rug out from under him.”
In 2013, the Dolans had moved to Greeley to be closer to his MCR providers. By late 2015, his heart failure had progressed. He wasn’t painting; golfing, another passion, was out of the question. He was largely relegated to a recliner.
“You have the feeling that something’s dreadfully wrong,” Dolan said. “I had lived with this for so long and thought, ‘This is the end of the line.’ And I was willing to accept that.”
His cardiologist at MCR, Tristan Dow, MD, referred him to Amrut Ambardekar, MD, a University of Colorado School of Medicine cardiologist at UCH. Ambardekar consults regularly at MCR; he specializes in heart failure and ways to treat it, including heart transplants and VADs.
Dolan wasn’t eligible for a heart transplant. Two years earlier, he had had a melanoma removed from his arm. The need for organ transplants far outstrips organ availability, so transplant candidates are carefully vetted. You need to be cancer-free for five years, generally, because transplant antirejection drugs rein in the immune system and open the door to relapse. By that point, Dolan would be too old for a heart transplant (the cutoff is 70). But he could be a candidate for a VAD, Ambardekar told him.
By January 2016, Dolan’s kidneys were failing, his liver was shutting down, and he had serious gastrointestinal pain, all from the lack of sustenance from his heart failure. At UCH, Dolan did the presurgical testing including a treadmill stress test, a drug-induced stress test, an echocardiogram and a heart catheterization to check for obstructions and quantify blood flow. A healthy heart might pump out 70 percent of the blood in its ventricles (the lower chambers that do the real pumping) with each heartbeat; Dolan’s struggled to deliver less than one-fifth as much.
The night before the operation, Joseph Cleveland, MD, the cardiac surgeon who has done the lion’s share of the more than 300 VAD implantations performed at UCH in the past two decades, stopped into Dolan’s inpatient room. He asked Dolan what he liked to do. Dolan said he liked to golf.
“I’m a golfer myself,” Cleveland said. “Are you right-handed or left-handed?”
Dolan’s a lefty.
“I’m glad to know that, because I’ll put the driveline on your right side so it won’t affect your swing,” Cleveland said.
Cleveland is one of two surgeons and two cardiologists leading a national clinical trial of the latest edition of Abbott’s HeartMate VAD. Dolan enrolled in the trial. It involves comparing the HeartMate 3 with Abbott’s mainstay HeartMate 2 (UCH also implants Medtronic’s HeartWare VAD). The U.S. Food and Drug Administration approved the HeartMate 3 as a bridge to transplant in August 2017; this trial is to see how well it works for long-term “destination therapy,” where a heart transplant isn’t in the cards. Dolan had read up on the new device, which uses maglev (for magnetic levitation) technology to suspend as well as rotate the pump’s whirling impeller. That and some other features were designed to go easy on blood cells and minimize clotting that was an occasional problem with the HeartMate 2. Dolan wanted the new one, but being part of a trial, it would be a matter of chance.
A UCH Mechanical Circulation Support Program team member handed him a quarter. Dolan asked, “Do I get to flip for it?”
No, but the quarter, the staffer said, was a lucky one.
Dolan held it in his hand during the computerized randomization. It assigned him a HeartMate 3.
“The quarter’s still on my dresser. I wouldn’t get rid of that for anything,” he said.
Dolan’s son and daughter and four grandchildren were among those he said goodbye to before going into surgery. Sandy worried that her husband lacked the strength to pull through the eight-hour procedure. He described himself as having been at peace. “I knew it would be OK. I felt that I was in the best hands that anyone could hope for because of my discussions with the medical staff here. I think they’re just amazing.”
It is a complicated surgery. The VAD must be inserted into the base of the weakly beating heart’s left ventricle, from which it will draw blood into a tube that connects to the aorta, the main thoroughfare for the body’s oxygenated blood supply. Then the drive line must emerge from the abdomen.
Fortunately, UCH surgeons have gotten very good at it. Surgical mortality used to be in the 10 percent range, says Jay Pal, MD, PhD, who recently succeeded Cleveland as the surgical director of UCH’s Mechanical Circulation Support Program. Now, thanks to smaller VADs and improved approaches, that’s down to the 1 to 2 percent range despite the perilous health of many of these heart failure patients, he said.
Pal would like to drive that number down further while reducing surgical complications and speeding recovery time. He’s launching a trial at UCH to compare the outcomes of traditional VAD surgeries, which go straight through the center of the chest, with an alternative called a thoracotomy through the side of the chest. It’s another example of the UCH team having an impact “not just for the patients we take care of, but on the field as a whole,” he said.
Andreas Brieke, MD, a UCHealth cardiologist and medical director for UCH’s Mechanical Circulation Support Program, has seen VADs evolve from devices that could be relied on to keep a patient alive long enough for a heart transplant – perhaps 18 months, tops – to one in which 60 percent of patients are on destination therapy. They can now realistically hope to see VADiversary after VADiversary. The longest-serving VAD implanted at UCH made it more than eight years, he said. Patients typically succumb to other health problems unrelated to the VAD, he added.
“It’s helping patients get their lives back,” Brieke said. “It has been a game-changer.”
So it is for Joe Dolan. He’s painting, he’s doing cabinetry, he goes to his grandkids’ sporting events, he travels – among other trips, to conferences as an Abbott HeartMate 3 ambassador – and he golfs every chance he gets. There are hassles: in addition to the batteries in his ballistic vest, he carries extras as well as a spare controller in a small shoulder bag wherever he goes. Sandy carefully cleans the driveline entry point twice a week. But it’s a small price to pay, he said.
“I am absolutely living life. I cherish every day,” he said. “To this point, I’ve been given two years of quality life that I wouldn’t have had, and if there’s another year, two more years, five more – whatever there is, I am going to make the most of it.”