Cheney Should Have Died Years Ago

By Kent Sepkowitz, The Daily Beast

26 March 12

Also See Below: How Dick Cheney Got His New Heart

At 71 years old and after a 20-month wait, former vice president Dick Cheney finally has a new heart. He is recovering at a Virginia hospital after receiving the organ from an unknown donor. Cheney's waiting period was a bit longer than usual, but his age may have complicated things - transplants are generally recommended for patients under 70.

He's had five heart attacks, and could soon seek a transplant. Dr. Kent Sepkowitz on the extraordinary history of Dick's ticker - and how government health care keeps him alive.

hursday's news that former Vice President Dick Cheney had received a left ventricular assist device, or LVAD, is the latest installment in America's longest-running medical drama, a story extending back to 1978, when Cheney had his first of five heart attacks. With the insertion of the LVAD, Cheney has completed a rare quadrifecta of heart procedures, costing about a half of million dollars in all - and led left-wingers, cardiologists, and left-wing cardiologists to wonder how a man with such a bad metaphoric and anatomic heart can keep on kicking. Or as Firesign Theater once famously asked of George Tirebiter, "How does an old man like you stay alive?"

But before going to the actuarial tables, we need to review his truly remarkable medical history - keeping in mind all the while that what we know about Dick and his heart is of uncertain accuracy. After all, Cheney is a maniacally secretive man famous for such tours de force as stonewalling attempts to discover what his National Energy Policy Development Group, aka the energy task force, was up to in the early months of his vice presidency. So it does seem rather odd that the one set of facts he actually is entitled by law to keep his trap shut about - his medical history - is the only area for which he readily has given up total unfiltered information.

Cheney's miraculous longevity is… exhibit A in the argument for intrusive and overarching government programs to ensure the public's health.

The heart has four main parts, each relatively independent of the other, each with its unique roster of ailments and remedies. Cheney has had serious problems with three of them. First there are the valves, those mechanical open-close governors of forward blood flow. People with valve problems develop heart murmurs and may eventually need valve replacement. To date, this is the only part of Cheney's heart still in tip-top shape.

Next is the wiring, the nerves that control rate and rhythm, referred to as the conducting system. Dick, alas, has had some difficulties here. There are two basic flavors of heart rhythm problems - "atrial," including the common condition atrial fibrillation; or ventricular, which may manifest as the often-fatal ventricular tachycardia, or, worse yet, ventricular fibrillation. Cheney has required electrical shocks twice for the atrial problem (not cheap) and in 2001 implantation of an automatic implantable cardioverter defibrillator (AICD) (call it $25,000-$30,000) to respond to any ventricular turbulence.

The third component of the average heart is the set of coronary arteries, the blood vessels that feed blood to the heart itself. Trouble here can require coronary artery bypass graft (CABG) surgery, which Cheney underwent in 1988; he received a quadruple bypass, probably reflecting the widespread nature of his arterial narrowing ($100,000 to $200,000). In 2000, at the height of the Florida non-recount, one of these arteries clotted off, resulting in his fourth heart attack and the need for a stent - a stiff pipe placed to pry the artery open and maintain its capacity (also not cheap).

Finally, this month, he needed help to treat the fourth component of the heart: the muscle. The heart muscle does what the heart does - it pumps blood forward. When the heart can no longer do this adequately, the condition is called heart failure. And in the last few months, Cheney has developed intractable heart failure. The best remedy for severe heart failure is a heart transplant, which, according to the Los Angeles Times, Cheney is considering. But for those who need help before a heart is available, or for whom a transplant is too risky, we have a gizmo called the left ventricular assist device, a $200,000 item. The LVAD is a cumbersome almost-artificial heart that requires the recipient to wear heavy batteries, a shoulder sling with various parts, tubes going through the chest and into the heart and abdomen, and other substantial inconveniences. It helps push a portion of the heart's blood forward, doing the work the failing ventricle no longer can accomplish. Once used only to stabilize people awaiting heart transplant, it now is referred to, not ironically, as a "destination therapy" - the exact intervention that you want, not the half-assed loaner you are stuck with till the real McCoy arrives.

So there you have it: the curious case of Cheney and his Wondrous Heart. But what about the basic question from above: Why on earth is anyone with this cardiac history still alive? Could it be some odd demonic possession or other explanation better suited for True Blood than for the medical textbooks?

Six years ago, the doctor and medical historian Howard Markel, writing in The Atlantic, assembled seven fancy cardiologists and discussed Anonymous Patient C's medical history with them; all were surprised that he was still puttering along, and even more surprised to then be informed that he was at the time their vice president. Stated most simply, he should have died long, long ago. Most people with his heart, his weight and sedentary habits, his history of cigarette smoking and who knows what else already have heard the bell toll. But not Cheney - pointing out that, though useful to define national trends, population-based statistics are completely useless for predicting the fate of an individual. The extremely unlikely happens every day, all of the time: Just as it's the rare person who wins the lottery, or is struck by lightning, or rolls snake eyes 50 times in a row, so too does a bad guy with a worse heart beat all the odds to stay alive.

Oil baron, draft dodger, professional paranoid, and all-around Blue Meanie, Cheney's miraculous longevity is nothing so much as the happy product of the heavily tax-subsidized and regulated American health-care system, exhibit A in the argument for intrusive and overarching government programs to ensure the public's health. Though the free-marketeers would argue the exact opposite - that the invention of such sci-fi devices as the LVAD are the product of unfettered capitalism - this completely ignores the reality of how such inventions are tested, monitored, and reviewed. Devices are studied in hospitals propped up by Medicaid and Medicare dollars organized by doctors funded by federal grants. Patient safety is assured by government bean-counters spread throughout windowless Washington offices via a process that is noticeable only when it fails - when, for example, a pacemaker is found to be defective, or a medication proves toxic.

Cheney is alive today despite a lifetime spent trying to deprive the needy of basic human rights such as health care. Yet his continued survival shows both the impotency of his attempts and the potency of the American health-care system, a lumbering bureaucracy no doubt, but one that blindly cares for big-hearted Joes as well as heartless Dicks.

How Dick Cheney Got His New Heart

By Kent Sepkowitz, The Daily Beast

26 March 12

Let's not jump to any conclusions about 71-year-old Cheney leapfrogging a bunch of other worthies to get his new heart. As far as we can tell, he got his transplant simply because his number on a waiting list turned up. Plus, seven surprising facts about heart transplants.

hen last we left our hero, he was slowly dying, living out his sorrowful last moments tethered to a left-ventricular-assist device, waiting to shuffle off his mortal coil with calm resignation and karmic equipoise (OK, this last part, maybe not really). After all, he already had attained executive-branch closure by penning a remarkably vain autobiography.

Well, dry those tears, America - he's back! We all woke up Sunday morning with the chilling news that Dick Cheney has a new million-dollar heart and may be as good as ever, or as good as a 71-year-old man on multiple medicines who just underwent a major surgery can possibly be. Given his track record of opting never to die, we should figure he will be around and ready to go as VP for both Jeb Bush in 2016 and George Prescott Garnica Bush (one of the little brown ones - let's call him "P") in 2024. And never mind the minor business with the 12th and 22nd Amendments - Dick will take care of it.

How did this happen? No, not the Florida recount, but how could someone so old and frail be a candidate for that most precious commodity, the human organ? Did Dick do a dick thing and leapfrog a bunch of other worthies, people who aren't viewed by some as war criminals and evildoers but rather are decent folk decades younger, likelier to contribute to society and to provide a better return on investment for our taxpayer health-care dollars? We went through similar societal contortions when Mickey Mantle got his liver and Steve Jobs, surreptitiously, his, though we never made up our minds, celebrity being as powerful as it is.

With Cheney, let's not jump to any conclusions. Yet. First let's review the numbers which are tracked both by the United Network for Organ Sharing (UNOS), a nongovernment organization, and the Organ Procurement and Transplantation Network (OPTN), a slightly more arid government version. According to each, on Sunday, March 25, 2012, there were 113,639 people on the waiting list for an organ, of whom 72,822 were on the "active" roster, suggesting a more pressing need. That's a mighty long roster.

But many different human organs are transplanted each day, including hearts, lungs, kidneys, livers, intestines, corneas, and the pancreas. And that does not count the human tissue that gets moved around - faces, tendons, bones, skin. (These latter items don't count as "organs" in the 113,639 total.) In fact, a person who wants to really donate can at death contribute about a hundred different parts. Some of these parts (especially kidneys and the liver), can be borrowed from a living donor; for the rest though, the donor has to die and be young and healthy and noninfectious enough to be suitable.

According to OPTN, the vast majority of those on the waiting list are hoping for a kidney - more than 91,000 people. The kidney list can grow though, because dialysis affords an option for temporizing; the need for a lung (1,639 people) or a heart (3,162 people) is less forgiving. These latter waiting lists can be cruel: about 300 people a year die while waiting for a heart transplant.

So there is a real pinch on organs - doesn't that mean 71 is too old? Wrong again - at least no law dictates this. The transplant world is a Dick Cheney dream - a loosely regulated, market-driven free-for-all that follows whatever rules the local oligarchy sets forth. One hospital might set the cutoff at 20 or 50 or 100 years old, while another might figure 55 is the way to go. In a free market, people can find their own way.

Besides, he was not the only septuagenarian in the hunt. Granted, a recent government breakdown of those on the waiting list by age doesn't go above 64 years, but notes that 61 percent on the list are older than 50; the same source notes that 1,320, or 56.6 percent, of all heart recipients were older than 50. According to ABC, last year 332 heart transplants were performed on people older than 65, and according to the UNOS, 14 percent of heart recipients are older than 65. And do please ignore all the talk about how long (20 months compared with the typical one year or less) poor Dick waited for his blessed organ. This seems most like the groundwork of his omnipresent team of flacks working to blunt the inevitable criticism the surgery will attract.

So Cheney still has cut no corners - but what about Inova Fairfax Hospital, where Cheney had his surgery (and where, one might note, advanced age is a possible exclusion for transplant)? According to the (federally mandated) records, we can see just who else was waiting for a heart at Inova: on March 16, 2012, 31 people, of whom 15 were 50 to 64 and three were 65-plus (including our Dick), were on the list. And in 2011, two of the 19 people transplanted were at least 65 years old.

So as appalling as it may be, it is likely that Dick got a heart because he was a on a waiting list and his number turned up. (Maybe. We will never know if someone made a phone call for him any more than we will ever learn about his Energy Task Force). But don't feel bad - with his latest act of narcissism, Cheney has brought into focus a critical issue the very week when the Supreme Court is ready to review the constitutionality of the Affordable Care Act. He has made us think about whether health care is a commodity or a human right. Heady stuff, Mr. Cheney.

The problem for him and his is that he has shone the spotlight a bit too brightly on the wrong side of the debate. Old man Cheney and his million-dollar heart serve to remind us just how ugly health care can be when it is a simple commodity given to someone with friends in high places, even if he (possibly) did get the organ through routine channels. He now and forever is the poster child for why health care must be a right, not the latest luxe trinket for those few who can afford it.

Kent Sepkowitz is an infectious-disease specialist in New York City. He has contributed to The New York Times, Slate, and, oh-so-briefly, O magazine. He also writes academic medical articles that are at times pretty tough sledding.