One of the first things I noticed about Donna Jackson -- 68 years old when I met her in 2011 -- was her decisive nature. She had a schedule filled with activity, and regardless of how many people (many of her children, grandchildren, great-grandchildren, in-laws and friends live very near at hand) came to visit in her modest home in Central California, she was a certain force of calm. She was also someone who did not like restrictions on what she could do.
Back then, she was just a few months out from surgery at Stanford Hospital to implant a mechanical pump, a left ventricular assist device or LVAD, on her heart. She knew it had saved her life, but she chafed at the battery, back-up battery and controller she had to wear at all times. Before the surgery, she had been a regular at a water aerobics class, and she loved to swim with her grandchildren. Even in those early months, Jackson was leaning on her Stanford doctors to find a way to get her back in the water. She asked her cardiologist, Dipanjan Banerjee, MD, to consider allowing her to swim in a wetsuit.
Banerjee did her one better. It had become apparent to him that she could be one of that small percentage of LVAD recipients whose heart recovers after the rest that the LVAD gives it and who no longer need the device. (He had been waiting, he said, to find a patient "who can be liberated from LVAD support.") By Spring 2013, a little less than three years after her LVAD implantation, Banerjee and Jackson's surgeon, Richard Ha, MD, put Jackson in an even smaller percentage. She became the first person to have her LVAD deactivated by catheter in the most minimally invasive approach yet.
The challenge set by Jackson for her Stanford team -- and its groundbreaking procedural response -- appears today in the August issue of the Annals of Thoracic Surgery. The lead author of the paper is Sanford Zeigler, MD, a cardiothoracic surgery resident. Ha, surgical director of the hospital's Mechanical Circulatory Support Program is the paper's senior author, and Banerjee, medical director of Mechanical Circulatory Support Program, is a co-author. As they explain in the paper, Jackson, nearing 71, was a high surgical risk for complete removal of the implant -- that would have required them to crack open her ribs again -- a procedure that's followed typically by a long and sometimes painful recovery. So, her doctors instead threaded a slim plastic tube through a small incision to her femoral artery in the groin and up to her aorta, allowed them to plug the flow of blood to the LVAD. Then, they cut, cleaned and capped the wiring powering the LVAD so it no longer emerged from an opening in her abdomen. (The LVAD remains inside Jackson's chest.)
The new catheter-based deactivation of the LVAD has value beyond Jackson's way of life, as the paper explains. She inspired the team to begin research on how to predict which LVAD patients might be like her and reach a point where they no longer need the LVAD. "If we can find out which patients are going to recover sooner, we can be more aggressive with them so they can be liberated from the LVAD," said Banerjee, "and many of these patients will not want or be able to tolerate a complete removal of the LVAD."
The LVAD's history of clinical performance and evolving technology puts it in a special category of devices whose usefulness continues to develop over time. The U.S. Food and Drug Administration in 1984 approved it as a bridge for patients waiting for a heart transplant. Physicians eventually realized that some of their patients did so well with LVAD support that they no longer needed a transplant, and the FDA approved the device for permanent use in 2010. Philip Oyer, MD, PhD, associate chair of cardiothoracic surgery at Stanford, and the first person to successfully use the LVAD as a bridge to transplant, was the first person Jackson's team consulted. The procedure was also possible because of the expertise of interventional radiologist Michael Dake, MD, professor of cardiothoracic surgery and medical director of Stanford's Catheterization and Angiography Laboratories. Both physicians are co-authors of the paper.
"You have to have the wire technology and the imaging and a person who knows how to send devices into the difficult areas of the heart and aorta," Ha said. "Dake is absolutely masterful at that."
As for Jackson. she has already done a lot of swimming since she was freed from the LVAD. And she's working 20 hours a week, too. As I said, she's not a woman who likes sitting around.
Previously: The story of an LVAD recipient