Three patients, three stories of how UCLA's cardiology and cardiac-surgery programs are changing the course of people's lives.
- By Dan Gordon * Illustrations by Penelope Dullaghan
AS THE PLANE she and her husband had boarded in Maui for their flight to Los Angeles began its ascent, Debbie Iida stared pensively out the window. Looking down at the picturesque Hawaiian Islands with Harold in the seat next to her, she thought about what a good life they had. Their five children were nearly all raised, and Harold, at 63, was about to retire from his job in the printing department of the local newspaper. One daughter was weeks away from graduating at the top of her college class. A son would be getting married later in the year.
Now, with a one-way ticket to the mainland, where her husband would undergo an intricate operation at UCLA to repair a leaking valve in his heart, Debbie Iida was quiet. “I looked down and couldn’t help thinking, ‘Please let us come back to this same exact life,’ ” she recalls.
Tom Cohan wanted a different life – one without the constant specter that his implanted cardioverter defibrillator (ICD) would unexpectedly jolt him with powerful electrical currents. The ICD was meant to shock Cohan’s heart back to its normal rhythm when he went into life-threatening ventricular tachycardia. But before Cohan was finally referred to UCLA, the excessive firings – as often as twice a day – had created a life of misery for the self-employed businessman, still only in his early 50s. “It felt like you were being shocked by a 220-volt line,” Cohan says. “I never wanted to be in public because I knew that when it fired I would have to dive to the floor, and I would usually shout out a cuss word or two.”
Edward Cooper figured he was living on borrowed time. His heart had gone through the wringer – three heart attacks, the first in the late 1970s, when he was still in his 30s. On more than one occasion, paddles had been required to shock his heart back into action. He had been told that little could be done about his condition, short of trading in his weakened heart for a new one. The extent of scarring in his heart muscle made bypass surgery problematic. After yet another attack of angina, Cooper was airlifted from a community hospital in Bullhead City, Ariz., to Santa Monica and transported by ambulance to UCLA, where, after extensive testing (“I was introduced to machines I didn’t even know existed,” Cooper recalls), he was offered the opportunity to participate in a clinical trial: Would Cooper like to be the first patient in the United States treated with cell transplantation – a therapy in which the patient’s own skeletal cells were implanted in the heart in an effort to promote recovery in the damaged areas? Cooper didn’t hesitate. “Where do I sign up?” he asked.
Today, the Iidas have returned to living the good life on Maui. Cohan is back to working up to 60 hours a week while also setting aside time for regular trips to the gym and frequent travel with his wife. As for Cooper, he required a heart transplant two years after the experimental therapy; fortunately, he was a patient at one of the nation’s largest and most successful heart-transplant programs, UCLA Medical Center. With a new heart beating in his chest and a new lease on life, Cooper is now in active retirement in Laughlin, Nev., where he is a member of the Town Advisory Board, the Metropolitan Volunteer Police and the Volunteer Homeland Reserve Unit.
These, and countless other, patients might not be alive today, much less leading normal, active lives, were it not for the worldclass cardiology and cardiac-surgery clinical programs and research of a comprehensive center like UCLA. Individually, the programs in cardiac surgery, interventional cardiology, electrophysiology, heart failure, heart transplantation, cardiovascular imaging and cardiovascular research are world leaders. But as Iida, Cohan and Cooper learned, the whole of UCLA cardiac care is far greater than the sum of its parts.
FOR THE FIRST FIVE DECADES OF HIS LIFE, Tom Cohan was healthy as a horse. That changed dramatically beginning in March 2002, not long after he turned 52, when Cohan suffered a heart attack. A month later, a routine sigmoidoscopy revealed that he had early-stage colon cancer. After surgery to remove the tumor, he resumed normal activities – until November of that year when, while working in the yard of his home near Los Angeles, he passed out. It happened again the next day. Cohan was checked into an area hospital so that his heart could be monitored to determine the cause of the syncope. Several days later, he went into cardiac arrest. Cohan was given an angioplasty, and an ICD was implanted, designed to fire when it needed to save him from any more episodes of ventricular tachycardia – the life-threatening rapid heart beats that had caused him to faint. He had only been home a couple of days when he began to experience the first of what would become regular ICD fi rings. After several readmissions, more angioplasty and various drug regimens failed to improve his condition, he was sent to UCLA for evaluation for possible heart transplant.
At UCLA, Cohan was seen by Dr. Gregg C. Fonarow, director of the Ahmanson-UCLA Cardiomyopathy Center, who ordered a series of diagnostic tests designed to determine how to better manage his heart failure and whether coronaryartery- bypass surgery might be possible. In addition to the expertise of his center’s team, Dr. Fonarow had the advantage of being able to access state-of-the-art imaging tools for diagnosis. To tackle Cohan’s repetitive ICD firings, he had another vital resource: the electrophysiologists at the UCLA Cardiac Arrhythmia Center. Several million Americans have cardiac arrhythmias – problems with the electrical system that controls the heartbeat. Though most arrhythmias are benign, atrial fibrillation, one of the most common heart problems seen by physicians, increases the risk of clots and strokes when untreated. Medications traditionally used to treat rhythm disorders are often ineffective and can have signifi cant side effects. Radiofrequency catheter ablation has emerged as an important treatment – under X-ray guidance, one or more catheters are inserted into the blood vessels and directed toward the heart muscle, then radiofrequency currents are applied through the catheters to electrically alter the structure of the heart’s atrium, destroying the heart-muscle cells that cause the arrhythmia. “This is one of the major advances in cardiology, and more patients with these conditions need to be made aware of that,” says Dr. Kalyanam Shivkumar, director of the UCLA Cardiac Arrhythmia Center. But few centers are able to perform the ablation technique with consistently good results.
Fortunately for Cohan, he was at one that could. Working as a team, Dr. Fonarow and Dr. Shivkumar fi ne-tuned the programming of Cohan’s ICD and altered his medical management. Meanwhile, Dr. Fonarow’s team concluded that the bypass surgery that previous doctors wouldn’t attempt on Cohan – his ejection fraction was in the 20-percent range, low enough that in the hands of a less-experienced team the risk of fatal complications from bypass surgery would be considered too high – was, in fact, feasible. During the bypass, Dr. Shivkumar’s team would map Cohan’s rhythm problem to determine the region of origin and ablate intraoperatively.
Heart transplantation is a remarkable advance that, particularly when performed at top transplant centers such as UCLA, has transformed patients from near-death to normal lives. But given the limited supply of organs, the necessity of immunosuppressive drugs and other factors, it is always preferable when patients can keep their own hearts. Today, Cohan has his own heart, and it is beating in rhythm, without the ICD shocks that once plagued him. “With state-of-the-art facilities for diagnosis and management, along with top surgeons, electrophysiologists and cardiologists with expertise in heart failure, we were able to manage Mr. Cohan with revascularization, medication adjustments and followup care so that he avoided heart-transplant surgery that otherwise would have been urgently indicated,” Dr. Fonarow says.
With its cutting-edge research and sophisticated clinical programs, UCLA tends to serve as cardiology’s version of the court of last appeal – the place where the most difficult cases are sent in search of answers that have eluded the community. But Dr. Fonarow stresses that tending to the sickest of the sick using the most-advanced diagnostic and therapeutic tools doesn’t come without equal attention to the less flashy but equally important facets of comprehensive care for all patients, including lipid management, patient education and family support. Indeed, during his recovery, Cohan has benefited from the approach to heart-failure disease management pioneered by Dr. Fonarow and colleagues at UCLA – including the use of multidisciplinary teams of cardiologists and advanced-practice nurses, which was shown to improve patients’ outcomes and reduce the risk of hospitalization for heart failure by 85 percent.
“What we have learned from caring for patients with the most advanced heart disease has helped us develop programs to benefi t a broad group of cardiovascular- disease patients, even those with very early disease,” notes Dr. Fonarow. Findings from CHAMP (Cardiovascular Hospitalization Atherosclerosis Management Program) at UCLA have become the basis of the American Heart Association’s “Get With the Guidelines” program, which has been implemented by more than 1,400 hospitals nationwide to help ensure that the care they provide to coronary-artery disease, stroke and heart-failure patients follows the latest scientific evidence.
BEFORE ARRIVING AT UCLA, Edward Cooper had been told that the extensive scarring in his heart muscle rendered bypass surgery problematic. At UCLA, that meant he was a candidate for the clinical trial being run by Dr. Fonarow and Dr. W. Robb MacLellan, director of the UCLA Cardiovascular Stem Cell Research Center. On May 29, 2001, Cooper became the first person in the United States to receive cell injections in the heart muscle during bypass surgery. It was an effort to buy him more time before a transplant would be necessary.
The Phase I trial, designed to test the feasibility and safety of the procedure, involved taking Cooper’s progenitor cells (early cells with the capacity to turn into muscle), growing them in cell culture and then injecting them back into Cooper’s heart at the time of the bypass. “We don’t have perfect treatments yet for most heart diseases,” says Dr. James N. Weiss, chief of the UCLA Division of Cardiology. “A community hospital can be excellent at implementing the known therapies, but here we can offer patients the next level – what’s not yet an established treatment but is looking very promising.”
Cellular therapy is just one of many research strategies under investigation in UCLA’s cardiology and cardiothoracic-surgery programs, and the breadth and depth of the university’s expertise on the topic – from the cell biologists and bioengineers to the interventional and surgical researchers – illustrates why the institution is strongly positioned to capitalize on what Dr. Weiss sees as a particularly exciting time for the field. “We’re in a period in which the basic-science advances are starting to merge with the clinical investigations in ways that are going to directly affect the future of cardiovascular care,” he says.
Many of the treatment approaches under investigation are aimed at the increasingly common problem of heart failure: from cellular therapy and new drug therapies to new medical devices and improvements in heart transplantation. Others are focusing on arrhythmias, where catheter ablation and the development of new pacemaker-type devices to monitor the heart are among the most-promising strategies. UCLA’s interventional cardiologists and cardiac surgeons are at the forefront of the use of implantable mechanical devices for new purposes, including replacing heart valves and closing holes in the heart. The interventional cardiology and cardiothoracic-surgery programs are beginning investigations toward the ultimate goal of placing artificial heart valves using a catheter approach.
Work in vascular biology by a group headed by Dr. Alan M. Fogelman, executive chair of the Department of Medicine and director of the Atherosclerosis Research Unit, is yet another example of UCLA’s broad approach to addressing the issues of heart disease. Dr. Fogelman and his group have built upon an exceptional record of pioneering work at UCLA to develop a new strategy for protecting the heart against atherosclerosis. As part of that effort, research by Dr. Judith Berliner and Dr. Andrew Watson has elucidated the role of oxidized lipids in the inflammation that causes coronary heart disease. Following that lead, Dr. Fogelman found that for people with certain forms of atherosclerosis, high-density lipoprotein (HDL, so-called “good” cholesterol) increases the inflammation caused by oxidized lipids. Working with scientists at the University of Alabama at Birmingham, Dr. Fogelman and his UCLA colleague, Dr. Mohamed Navab, embarked ucla medicine 13 on a program to fi nd molecules that mimic Apo-A1, the major protein associated with the good qualities of HDL. Their search led them to 4F, a peptide that has dramatically reduced arterial-plaque buildup in animal studies and is proving to be promising in early clinical trials that are ongoing.
As for cellular therapy, the results have been mixed. A number of clinical trials have been completed, and Phase II studies, using cells from different sources, including bone marrow, are in progress. “There have been studies that have shown exciting positive results and a number of negative ones, though no study has shown harm to patients,” says Dr. MacLellan, who is currently conducting research in the laboratory aimed at learning more about which cell types are best and which patients are most likely to benefit from the therapy.
After the bypass and cell injections, Cooper responded well. He went on with his life for two years, taking his medications and making regular visits to UCLA, where Dr. Fonarow and Dr. MacLellan closely monitored his condition. By the end of 2003, his heart had begun to weaken, and he went back on the transplant list. The call came 10 months later: A 23-year-old man was brain-dead from an accident while driving a truck; Cooper would receive his heart. He couldn’t have picked a better place for the life-saving operation. Survival rates for UCLA’s heart-transplant populations are considerably higher than the national average, and it’s no accident: It comes from the program’s basic and clinical research that has improved outcomes for patients, along with the experience that comes from having one of the world’s largestvolume programs.
HAROLD IIDA’S DOCTOR HAD THE STETHOSCOPE on his chest during a routine examination when she noticed something was awry. “She said, ‘Do you know you have a heart murmur?’ ” Iida recalls. It was the first Iida knew of any problem. He felt good – walked every day with no shortness of breath. His doctor referred him to a cardiologist, who told Iida he had leakage of the mitral valve – the valve, situated between the left atrium and left ventricle, that regulates blood flow between the chambers. There was nothing to worry about yet, but he should return for regular rechecks. Over the next two years, Iida began to tire more easily. Eventually, his cardiologist told him the leakage of his mitral valve had become severe; part of the valve had ruptured and was prolapsing. Iida’s heart was enlarging to accommodate the leakage, and was beginning to deteriorate. It was urgent that the valve be repaired or replaced.
In the past, patients in Iida’s condition had their valves replaced with artificial devices, but more recently top heart surgeons have often been able to repair the valve tissue using special techniques not unlike those employed by plastic surgeons. Iida’s cardiologist learned that UCLA had just recruited as the chief of its Division of Cardiothoracic Surgery Dr. Richard J. Shemin, a leading heart surgeon from Boston known for doing complex valve repairs using a minimally invasive approach enhanced by surgical robotics. She referred Iida to Dr. Shemin as a candidate for the first such procedure ever done at UCLA.
Unlike traditional surgery, which opens the chest to direct visualization and manual manipulation, the surgery on Iida would involve a three-inch incision to insert a camera for magnified vision; then, working through tiny holes to cut and sew, and aided by robotic devices that move more precisely than the surgeon’s hands that control them, the valve is repaired.
“For the patient, the surgery hurts less, recovery is faster, length of stay in the hospital is often reduced and, because we work between the ribs as opposed to opening the sternum and cutting through any bone, the patient loses less blood so there is not as much need for postoperative transfusion,” Dr. Shemin explains. “And as far as the ability to achieve a durable repair of the valve, the results are equivalent to traditional open surgery.”
But not many robotic mitral-valve surgery programs would have tackled a case as complex as Iida’s. Mitral valves have two moving parts, called leafl ets. Most repairs involve only the posterior leafl et; Iida’s heart needed both the posterior and the anterior leafl ets fi xed to get the valve to close and function normally. With Dr. Shemin on the UCLA faculty, there was now expertise in this complex, minimally invasive repair.
A writer of novels, Debbie Iida was fastidious about doing her research, and she liked what she had read about the invasive robotic approach Dr. Shemin would be taking. At the same time, she saw a certain irony. “Here we were, practically off the grid living in Maui – we’re simple people who still hang our clothes outside to dry – and Harold was going to an outer edge of medicine.” She was reminded of that as she sat in the waiting area nervously anticipating any news about the surgery. “After two hours, a nurse called to tell me they had rolled in the robot and the procedure was under way,” Debbie Iida recalls, laughing. The tension was momentarily broken. “I thought, this is just too much!”
Harold Iida was prescribed pain medication to make him more comfortable during his recovery, but he never needed it. He soon resumed his normal 45-minute walks at his usual brisk pace. “The valve is now working perfectly normally, with no residual leakage,” says Dr. Shemin. In the vast majority of mitral-valve repairs, he notes, the valve continues to hold up even a decade after the initial surgery. As the plane she and her husband had boarded in Los Angeles for their flight to Maui began its descent, Debbie Iida looked out the window and reflected on the successful journey. They had spent 19 days in L.A. – the longest they had ever been away from home – and now they were returning to the life they had known, just as she had hoped. With a feeling of overwhelming relief, she looked down at the island and its deep-blue waters and white-sand beaches. It was even more beautiful than she remembered.
Dan Gordon is a freelance writer in Los Angeles and a regular contributor to UCLA Medicine Magazine. * Photograph by Pete McArthur