Staying alive

Congestive heart failure remains one of the single largest causes of cardiac illness today. But thanks to new technology and innovative approaches to care, CHF patients like Elaine Madison are getting a new lease on life.

BY JOEL SCHLESINGER
Winnipeg Health Region
Wave Magazine, Summer 2010

It's easy to mistake Elaine Madison for the athletic type.

The 61-year-old Winnipeg woman has the lean look of a marathon runner. She even dresses like a jock, carrying a small, sporty-looking black canvas purse over her shoulder wherever she goes - be it a casual lunch or an elegant affair.

But the purse is not a fashion statement, and Madison's days of athleticism are long gone.

The reality is Madison suffers from a severe case of congestive heart failure, a condition that has left her heart muscle unable to pump oxygenated blood throughout her body on its own. And that little bag she carries around with her everywhere isn't for her wallet and makeup. It holds the controller for the HeartMate II - a cardiac pump that is keeping Madison alive until she can receive a heart transplant from a suitable donor.

Simply put, without the HeartMate II, Madison's heart would stop beating - a fact Madison understands only too well. Just one year ago, the mother of a daughter and son, and grandmother to a 15-year-old grandson, was flat on her back, her heart unable to keep pace with the demands of her body. "I couldn't even take a shower standing up," she says. "When I finished drying myself off with a towel, I had to lie down. I was that exhausted by the little things - I felt really awful."

Today, thanks to the HeartMate II, she has her life back. "It's just incredible," she says. "I haven't felt this well in 20 years - since I was first diagnosed with this condition."

The HeartMate II is just one example of how the Winnipeg Health Region's Cardiac Sciences Program is using new technology and innovative approaches to help patients in their battle with heart disease. Madison, for example, is the third patient in Winnipeg to be outfitted with the device since it was approved for use in Canada in 2006 and became available through the program last May.

A few years ago, the program did not have the technology or the medical expertise to offer the life-saving device to patients. Now it has two heart-failure specialists in place - Dr. Darren Freed, a cardiac surgeon, and Dr. Shelley Zieroth, a cardiologist - who, along with their multidisciplinary team, are able to implant these devices in patients, effectively giving them a new lease on life.

Although the number of patients who require a HeartMate II to stay alive is relatively small, the number of people who have congestive heart failure is large. Studies suggest that more than 250,000 Canadians report having have some form of congestive heart failure, including about 7,000 in Manitoba.

As the Head of the Region's Medical Heart Failure Program, Zieroth is well versed in the size and scope of the problem.

She explains that symptoms of heart failure can occur when the heart's ability to pump blood is reduced to below its normal capacity. This is often caused when heart muscle, responsible for pumping blood, has died off and blood flow to the rest of the body has diminished. Over time, vital organs - the brain, lungs and liver - are slowly starved of oxygen, putting them at risk of failure as well as the heart.

Common symptoms include shortness of breath and perpetual exhaustion. Patients can also appear bloated because the failing heart - the engine of the body's circulatory system - can no longer remove fluids. "Fluids back up into the lungs and that's why patients with this condition are often short of breath," says Zieroth. In severe cases, fluid build-up often leaves patients barely able to sleep because lying down makes it almost impossible to breathe. This only adds to their fatigue to the point where they do not even have the energy to perform simple tasks, like walking up a flight of stairs.

When the heart's pumping ability is reduced, other organ systems can begin to fail because they are not receiving enough oxygen-rich blood and because fluid is backing up in the organs, impairing their ability to function normally.

Many people diagnosed with congestive heart failure can lead normal lives by adopting lifestyle changes and following rehabilitation programs. But some patients - about 10 per cent - suffer from "advanced" congestive heart failure, which can be life-threatening. Interestingly, the increase in heart attack survival rates has actually contributed to the rise in the number of congestive heart failure cases.

A heart attack occurs when there is a sudden blockage in the coronary arteries that feed the heart muscle oxygen-rich blood. If the heart muscle is deprived of oxygenated blood long enough, it begins to die, reducing the heart's capacity to pump blood throughout the body.

But Zieroth says the primary cause of congestive heart failure is coronary heart disease. A diet high in saturated fat and salt, and low in fruits and vegetables increases risk of heart disease. Other risk factors include smoking, a sedentary lifestyle, obesity, stress and hereditary factors.

These risk factors can lead to a build-up of plaque in the artery walls that narrow the blood vessels and reduce blood flow. In medical terms, the condition is called atherosclerosis, an inflammation of the artery walls that thicken with fatty, bad cholesterol - sometimes referred to as low-density lipoproteins. When the build-up occurs in the coronary artery - the vessel that feeds the heart muscle blood - it's called coronary heart disease.

"Fifty per cent of heart failure patients have failure related to coronary artery disease with a symptomatic heart attack or silent heart attack," Zieroth says. "But there is probably a list of 100 things that can cause heart failure, including hereditary conditions, diabetes, alcohol, thyroid abnormalities, and inflammation of the heart (myocarditis)."

Some patients may be told they suffer from heart failure due to cardiomyopathy - or heart muscle disease - in which the heart muscle has deteriorated for any number of reasons, including toxin exposure during chemotherapy. In other cases, the cause is less clear. "There is a portion of patients for whom we never find out the cause of the heart failure," Zieroth says. "We use the term idiopathic, meaning 'we don't know why this has happened to you.'"

Elaine Madison is one of those mystery cases. An avid swimmer, walker and cross-country skier into her late 30s, Madison suddenly found herself short of breath while doing day-to-day tasks such as climbing the stairs.

Although she was in good health, Madison did have a family history of heart trouble. Her mother died in her 20s, as did her uncle. When her cousin died at age 30, the rest of the family decided to get checked for undiagnosed heart conditions. "I thought, 'It's probably nothing, but because of my family history, I just want to be sure.'"

It was a good thing she did. In 1988, Madison was diagnosed with cardiomyopathy. Her condition deteriorated in 2000, when she suffered a cardiac arrest. Her husband, Bruce Madison, recalls it happened after they had finished a family dinner with friends visiting from Red Deer.

"We had adjourned to the living room where we were sitting talking, and it was our black lab that noticed something was wrong first," says Bruce. The dog jumped up on Elaine and started to lick her face. "Normally, I wouldn't let him do that," says Elaine. "My daughter then noticed right away that something was wrong."

Madison was slumped back unconscious on the sofa. Her heart had stopped beating. Fortunately, her daughter remembered her CPR lessons and was able to provide care until paramedics arrived.

Since then, she has suffered cardiac arrest four times. Despite receiving almost every type of treatment, from blood-thinning and clot-busting drugs to medical devices such as an implantable pacemaker, Madison's heart continued to deteriorate.

Eventually, Madison received a device called a biventricular pacemaker. The small electronic box was implanted under her collarbone. Wires from the device were connected to her heart in order to keep it beating in a strong, synchronized fashion.

For patients like Madison who have severe heart failure, a biventricular pacemaker is often a temporary solution to a long-term problem. "About 70 per cent of patients who are referred for a biventricular pacemaker have a good response, and Elaine did have a good response for a couple of years," Zieroth says.

But by July of last year, Madison's condition had deteriorated to the point where she was placed on a priority list for a heart transplant. Winnipeg's heart transplant program is currently in development, so Madison was placed on program lists in Edmonton and Ottawa. "Patients are worked up here locally and discussed by teleconference and then listed for transplant," Zieroth says. Those who are most critically ill are moved to the top of the list.

But even being on a priority list can mean a long wait, as only a handful of donor hearts become available in any given year. And then, the patients must be healthy enough to undergo major surgery and sick enough to require a new heart.

"When you are considering somebody for a heart transplant, they are very carefully screened," Zieroth says, adding that only about 170 transplants are done a year in Canada. "There is no age cut-off, but if you're over the age of 60, we're more likely to find a reason why you may not be eligible for a heart transplant."

While waiting for a donor heart to become available, Madison became gravely ill last July, and was in and out of hospital for the next few months. Then, in October, Freed, who is the Head of the Region's Surgical Heart Failure Program, provided her with a ventricular assist heart pump, called an Impella. The device largely takes over the role of the heart, pumping blood to the rest of the body, unlike a biventricular pacemaker that assists the heart in its role. But it is also more cumbersome because most of the device's mechanism is external, leaving the patient virtually bed-ridden.

Then, after receiving the Impella, doctors sent Madison to Edmonton, hoping a heart would become available for a transplant. She waited for about ten days, but a suitable heart for transplant did not become available. Rather than let her leave Edmonton empty-handed, doctors chose to replace the Impella device with the HeartMate II on October 18. Originally, Madison was scheduled to receive the HeartMate II in Winnipeg, but the operation was cancelled when she was rushed to Edmonton.

The HeartMate II was in the news earlier this month when it was reported that former U.S. Vice-President Dick Cheney was outfitted with one. The U-shaped device is implanted underneath the muscle, below the diaphragm and just above the abdomen. The right side of the U is attached to the left ventricle, which receives oxygenated blood from the lungs. The left side of the U pumps that blood into the aorta, sending blood to the rest of the body. In between the two branches of the U is a small pump that connects to an external controller - via a cord leading out of the abdomen - that can adjust pumping speed. The controller is located on a belt around the recipient's waist and is connected to two lithium batteries, which power the system. The batteries are often carried in holsters under each arm. But Madison prefers the little black purse to carry the batteries because she says it's much more comfortable.

Once implanted and operating, the pump effectively takes over the duties of the heart's left ventricle. Just like a healthy ventricular chamber, it is able to pump about four to six litres of blood per minute.

As Zieroth explains, the left ventricle of Madison's heart is not pumping at all, so without the pump, "she wouldn't have any way to stay alive."

Following the implant of the Heart Mate II, Madison was in Edmonton again last March with the hope of receiving a heart transplant. Unfortunately, the heart was deemed unsuitable, and she continues to await a transplant.

Today, Madison remains undaunted. It's not just the HeartMate II that has given her new-found strength and resolve to face the future. Madison says she owes her life to the doctors, nurses and other health-care professionals who have helped her and her family through their darkest days.

"For every obstacle we've come up against, there were wonderful people that helped us," she says. "Everybody complains about the system, but I'll tell you I've had nothing but positive experiences."

Joel Schlesinger is a Winnipeg writer

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	About Wave Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books. Read the Summer 2010 issue of Wave