Best Doctors 2014: Change of Heart
With a flick of his wrist he wrenches the chest open — click, click, click — a half inch, then an inch, metal braces splitting the left rib cage farther from its right twin. As the cavity yawns to the size of a football, two sets of hands dive past fat cells that bubble like curdled milk in search of a still-beating heart.
It's Jan. 26, and the Cleveland Clinic's Dr. Nader Moazami is moments into his second heart transplant of 2014. Last year, Clinic surgeons implanted 44 patients with donor hearts.
The spotlight strapped across Moazami's forehead makes his fingers principal dancers on a stage of twisted cherry-red tissue, remnants from the last time Garlan McCruter's chest was opened for heart surgery. That procedure inserted a lifesaving left ventricle assist device.
The surgeon whips one of four light disks, which hover like a spacecraft above the operating table, closer to his head, flooding the maw with fluorescent illumination. Dr. Franjo Siric, a cardiac surgeon fellow, softly drags a pen-shaped tool across the cavity, cauterizing the tissue in swift, searing swipes.
The smell of sawdust rises with the smoke of each heated cut that brings the doctors closer to McCruter's hidden heart. Pink flesh peels back as the pen vibrates across the cavity, and Moazami grasps at the ribbons with tweezer-sized tongs, piercing the flesh with a needle curved like a fisherman's hook.
He tugs black thread through the tissue, pulling it over the metal braces to the blood-stained teal cloths, where he sews the string in place. Now pinned to his rib cage, another layer of McCruter's scar tissue is revealed.
Deeper and deeper into the bloody pit they plunge. A surgical assistant vacuums the fluid through a clear tube, depositing the excess into a metal bowl, its contents like watery tomato soup.
Inside the chest, a small cantaloupe shape appears.
The heart pulses from top to bottom, a fish out of water flopping from head to tail.
A steel knob protrudes from the heart's base, a crinkled white tube winding from the silver and into to the abdomen, where it disappears into waves of intestines — McCruter's LVAD. The electricity- and battery-powered, pint-sized machine pumps blood from this failing heart's left ventricle into its aorta and through the body, keeping McCruter alive for the last 354 days.
Amid a cacophony of beeps — of erratic, unfamiliar sounds reflected across four flat-screen TVs and on monitors observed by an anesthesiology team, pulses of heart rate, blood pressure and oxygen level — a household noise disturbs the din.
The phone is ringing.
It's 5:18 p.m.
McCruter was 30 when his father died. A truck driver, McCruter was heaving a load onto a boxcar when his foreman approached.
"I have some news," the foreman said, urging him from the lot to a table in the Mansfield warehouse. "Your father just passed."
Robert McCruter, 65, died of congestive heart failure — a long fought battle in the McCruter family that also claimed the lives of three of Garlan McCruter's uncles.
"My father got up every day, went to work, sacrificed so he and my mother could get an organ so that I could learn how to play," McCruter says.
The now 58-year-old McCruter rests against a gurney inside the Cleveland Clinic's Miller Family Pavilion intensive care unit, awaiting the transplant. "We were told to get checkups and stuff, which I did, but I just never thought it would get to this point this fast."
He tugs beneath his yellow gown at a cord that runs from inside his abdomen to a computer-assisted machine and into an electric outlet — his LVAD, his lifeline. Without it, McCruter's heart functions at just 12 percent capacity.
"Remember before you had the LVAD?" his wife, Pat, asks from his side. "For two years, you got out of bed and had enough strength to clean up, get dressed, come downstairs to go on the couch and go back to sleep."
He nods. "It almost gives you a feeling of uselessness," McCruter admits, "but you know it's for a reason."
McCruter most recently worked as a General Motors Co. carpenter, building rooms, fixing floors, assembling desks. He played the piano in off-Broadway plays, recorded four Christian albums and manned the organ at his church for 44 years.
In Mansfield, he raised two sons, two nephews and two nieces with Pat. When he punished them, he'd return later with a $5 bill.
"He would go behind my back," Pat laughs. "I would say, 'Honey, why do you punish the children if you're just going to give them money?' And he would say he was just letting them know he loved them."
Symptoms sneaked up in 2001. He would push a lawn mower across his 40-foot front yard and have to stop. "I was getting tired real quick," he says.
A Mansfield physician encouraged McCruter to manage the early stages of heart failure with medicine, advice that continued even after doctors at Cleveland Clinic — which has boasted the highest-rated heart program in the nation for 19 years — diagnosed him in 2007 with dilated cardiomyopathy, a weakened and enlarged heart that can't pump blood effectively.
"They kept tweaking the medicine," McCruter says. By 2011, he was swallowing more than 18 pills a day.He retired from work, retired from playing the organ at his church.
"Stuff I used to do I wasn't able to do — playing gigs, earning money," McCruter says. "I haven't been on a vacation in 13 years. I can't lift more than 40 pounds."
Two days after his 56th birthday on Aug. 28, 2012, McCruter collapsed on Pat, gasping for help. At a local hospital, McCruter's heart stopped three times.
"They were pretty much shutting his organs down," Pat says. "They told me to call the family in."
"They just landed at the airport," a nurse says to Moazami. "The heart will be here in 15 to 20 minutes."
Moazami slides his fingers beneath McCruter's struggling heart, raising it forward and upward until its tail faces the ceiling. From this elevated angle, the surgeon and his fellow, Siric, can put McCruter on bypass.
To do so, they puncture the aorta, the largest artery; the superior vena cava, the vein that trails through the upper body; and the inferior vena cava, the blood's transportation to the lowest extremities, with tapered tubes called intravenous cannula. Blood rushes from the right side of the heart, through the superior vena cava and inferior vena cava cannulae — a roller coaster that rises over the sheet-covered hills of the chest, down to the floor and chugs into the cardiopulmonary bypass machine.
In this heart-lung machine, the blood moves between four canisters the size of gallon paint cans. It's filtered, cooled, oxygenated, then pushed through the aorta cannula and back into the body. It acts as McCruter's heart, as his lungs.
It will allow Moazami to cut out a flaccid, bloodless heart.
Within moments, double doors at the front of operating room swing open, and a pair of nurses wheel in a navy Rubbermaid cooler. Its white lid is covered with a sticker: HEART.
Moazami reaches back into the chest with a cross clamp, closing it across the aorta and stopping McCruter's heart. "This is the point of no return," he says.
In 2012, McCruter was at Med Central Hospital in Mansfield for four days before he awoke. His blood pressure was 23/15 — a healthy man's blood pressure might be 110/70. "Where am I?" he asked his wife.
"I said, 'You're in Mansfield,' and he said, 'Get me out of here,' " Pat recalls.
She called the Cleveland Clinic, which sent its critical care transport team and a surgeon. "I will never forget," she says. "That surgeon asked everyone to get out of the room. He said if it took two hours or two days, he wouldn't stop until they got him stable."
It took two hours.
Stabilized, the team drove McCruter to Cleveland, where heart specialists gave him an ultimatum: McCruter needed an LVAD or he'd die.
"I was against taking the LVAD," McCruter says. "I was fighting it. I thought I could still get better without it.
"But I didn't. I got worse and worse, to the point where I knew it was take the LVAD or I would die."
On Jan. 15, 2013, surgeons implanted the device during an eight-hour surgery. In the previous year, 65 patients received a mechanical circulatory support device at Cleveland Clinic.
McCruter received his LVAD as a bridge to transplant, its use intended in his case is only for a year or so until his heart could be replaced. The device assists his heart's left ventricle by pumping blood into the aorta and throughout McCruter's 6-foot-7 frame. It's battery-powered, but lasts only nine hours before needing charged.
Each night, McCruter plugs the device into an electric outlet, through a cord that runs from his stomach and into a wall. "It's long enough for me to go to the bathroom and get back to bed," he says.
McCruter was lying in bed, plugged in, half asleep on a Sunday when his cellphone rang at 7:40 a.m. It was the Cleveland Clinic. They'd found him a heart.
He leaped from the bed and walked toward his wife, who stood in a nearby room. But his 9-foot leash yanked him back. He couldn't reach her, couldn't shout while he was still on the phone, so he waved until he caught his wife's gaze. He motioned a message: He pointed to the phone, curled his hand into a C, twice, for the Cleveland Clinic. He moved his fingers to his chest and traced a heart.
"In my head," he says, "I thought this can't be right."
Nurses open the cooler as Siric and Moazami return to scrape away the vessels trapping the heart inside McCruter's chest. From crushed ice, they remove a clear, plastic tub. Like a Russian doll, it contains another plastic tub that holds a bag with a heart.
A nurse lifts the last piece, the bag filled with saline, from the smaller tub and cradles it on an electronic scale. In its liquid pouch, it weighs 89.1 ounces — almost as heavy as a 5-pound sack of potatoes.
Sodium chloride bubbles from a basin, turning the clear liquid into icy slush. As one nurse places the bagged heart into a metal bowl, another scoops the frozen saline into his cupped hands and tosses it into the dish. He cuts away the plastic bag, and the heart settles into the ice.
At the operating table, Siric strikes the LVAD's white tubing with his pen, and the plastic cracks and splits from its lower half. He works from bottom to top: He slices the superior vena cava, the inferior vena cava, the aorta, the pulmonary artery and four pulmonary veins, leaving remnants of the blood vessels behind, the veins to which the new heart will cling.
Laying the pen on the table, Siric reaches in with his left hand, scooping his fingers beneath McCruter's still heart.
He gives a pull. "This thing is so f--king stubborn," he hisses beneath his breath, unable to wiggle the heart free.
After a few more snips, Moazami reaches into the chest with his right hand and plucks out McCruter's heart. It's too large to fit in the palm of Moazami's hand, but he holds it for a second before dropping it into a 6-inch-wide dish. It fills the space.
It's 5:58 p.m.
McCruter hasn't eaten in more than 12 hours, and his stomach growls.
"I feel nervous," he says, waiting in the ICU. "Then I get a little scared, then I go back to nervous, then I get scared — then I remember that I'm hungry."
He asks to smell Pat's crackers. "No, you can't smell my crackers!" she squeals.
What he really wants, he admits, is a cheeseburger.
He's also working on finding peace.
"I had a problem knowing I would get a heart, because I knew someone else had to pass on before I could do this surgery, and that bothered me. I knew it wouldn't be my fault, but the fact that somebody else would have to leave ..." McCruter can't finish the sentence as a tear crawls down his cheek.
He wipes beneath his eyes with his hand, pushing his brown- and gold-framed glasses toward his forehead. "But, you know, life is what it is. I trust in God, and I hope that person was OK in their own spirit. When I was little, they taught us the 23 Psalm, and that's what I believe."
He recites it now in the ICU, just minutes before he's wheeled away:
"The Lord is my shepherd, I shall not want. He makes me lie down in green pastures, he leads me beside quiet waters, he restores my soul. He guides me in paths of righteousness, for his name's sake. Even though I walk through the valley of the shadow of death, I will fear no evil, for you are with me."
Moazami turns the donor heart over in a bowl. He probes its aorta with his index finger and thumb, studying the slight blood vessels that lay limp at its sides.
"Awesome," he says.
He swaps his blood-stained latex gloves for a new pair, stretching them over his long-sleeved blue dressing gown, before dipping both hands back into the bowl, grabbing the heart and dropping it — plop — into McCruter's chest.
The surgeon peers in, before he pulls the heart back out. Like a tailor refining his pattern, he snips the small vessels of the healthy organ with scissors until they unfurl ever larger to match the diameter of McCruter's veins.
Siric calls to a nurse for his next tool, holding out his hand as a mechanic would awaiting a wrench. The nurse deposits forceps and a needle, whose curvature could cradle a dime, into the palm of the fellow's hand.
He sews the donor heart's left atrium to McCruter's veins. With each dip into the vessels, Moazami catches the suture, holding it in a loop, preventing it from tangling. Every pass takes mere seconds — a foot of suture is reduced to 11 inches, then 8, then 4 in just minutes, and Siric ties off the new bond with 10 single knots piled atop one another.
They move to the pulmonary vein, where Moazami becomes the seamster, Siric catching each suture. Moazami sews the aorta to McCruter's largest artery, too.
He tosses slushy saline from a metal bowl into McCruter's chest to cool the organ. As the crushed ice hits his new heart, it slides into the cavity and mixes with pooling blood. An assistant sucks up each new bath with a vacuum, a gurgling sound rising up each time he empties the basin and the tube fills with air.
McCruter's body is cooled to 35 degrees Celsius, but the sodium chloride melts in seconds. Moazami tosses more in before sticking a needle into the aorta, air entrapped inside escaping the heart in a silent whoosh, preventing a later embolism. He sews the new hole closed. The surgeon removes the clamp suffocating the aorta, and blood rushes into the donor organ for the first time in nearly four hours.
A nurse hands Moazami two paddles, spatulas with circular, silver ends. He places them into McCruter, one at the top of the heart, another at the bottom, holding still until another nurse calls, "Charged to 30."
Moazami touches the heart, top and bottom, with the disks. It leaps — and then lays still.
"Again," Moazami calls, and he zaps the heart a second time. It starts in shock and rests still once more.
Zap! again, and the heart lays limp. As if cautiously prodding a sleeping animal, Moazami nudges the heart gently with his index, middle and ring fingers. It jumps to life.
It's 7:30 p.m.
McCruter awakes Monday afternoon in the intensive care unit. "I was a hurtin' puppy," he says. "I thought it was still Sunday. You know, they tell you to count back from 100, but I didn't really hear him, so I said, 'Huh?' And that's all I remember."
Doctors moved McCruter from the ICU to a private patient room on Tuesday. By Wednesday, McCruter says, he started to recognize the staff and nurses from his last time on the fifth floor after his LVAD surgery. That same day, he walked for the first time. He shuffled from his room 30-some feet to an exit sign, turned and came back.
As he recounts that morning's feat, Moazami enters the room. The surgeon has performed three more heart transplants since McCruter's. He got the call for the next one while still in the operating room, minutes after swapping out McCruter's heart. He performed the second surgery five hours later.
"You recovered?" Moazami asks.
"I'm walking today. I got all my tubes out," McCruter boasts.
But soon, the men get down to the real issue. McCruter wants to know when he can have a cheeseburger.
"Don't tell anyone I said this," Moazami says, "but I think today. The cardiologists will kill me if they hear that."
"I'll keep it on the down-low," McCruter promises. "I'll drink it if I have to."
"The fact of the matter is, you don't have heart failure any more," Moazami says. "You can have that cheeseburger."
Ten days after surgeons replaced his heart, McCruter lifts himself into his bed in Mansfield. LVAD-free, he didn't plug into a wall, didn't rearrange wires so they wouldn't snag in the sheets.
"I didn't have to put on batteries to go downstairs," he says the next day. "I'm in heaven."
He'll take anti-rejection and viral medications for at least a year, and visit the Cleveland Clinic weekly. He'll have to make monthly trips in year two.
The risk of rejection and infection is highest in the first year after transplant — nationally, nearly 10 percent of patients don't survive it.
But 96.14 percent of patients treated at the Cleveland Clinic survive the first year, according to the most recent data.
"I'll do whatever I need to do," McCruter says. "My mother is 91 years old. I'd like to make it to 96."
12:00 AM EST
February 24, 2014