Donna Jackson's heart, on the verge of failing two years earlier, had
made a strong recovery. By spring 2013, she no longer needed the left
ventricular assist device, or LVAD, that had been implanted in
her chest almost three years earlier. It got in the way of things she
wanted to do, like swim with her grandchildren. But her doctors at
Stanford Hospital & Clinics believed the 70-year-old resident of
the Central Valley would have trouble surviving the surgery to remove
the mechanical heart pump. So they decided to find another way.
Their solution — a minimally invasive, catheter-based procedure
unlike any previously reported that allows Jackson to live free of the
LVAD's batteries, controller and external driveline — is described in
a paper that will be published in the August issue of the Annals of
Other minimally invasive techniques to deactivate the LVAD already
existed, but they would require small incisions in the chest and the
abdomen — more than the Stanford team wanted. "We decided the
best thing to do was to use a catheter-based approach because it would
involve only a small incision in her groin and the smallest amount of
anesthesia possible," said the study's senior author, Richard Ha,
MD, clinical assistant professor of cardiothoracic surgery at the
Stanford School of Medicine and surgical director of the hospital's Mechanical
Circulatory Support Program. The lead author of the paper is
Sanford Zeigler, MD, a cardiothoracic surgery resident.
Jackson's doctors 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 returned home from Stanford Hospital five days after the procedure.
She has inspired the Stanford team to begin research on how to
predict which LVAD patients might be like her. "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 co-author Dipanjan
Banerjee, MD, clinical assistant professor of cardiovascular
medicine and medical director of Mechanical Circulatory Support
Program. "And many of these patients will not want nor 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 on a path toward
needing 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. But an estimated 1 to 2 percent of LVAD patients' hearts
recover enough to do fine without that mechanical support. Younger
patients are able to tolerate the major surgery required to remove the
LVAD completely, but the surgery poses major risks for older patients.
To plan the new procedure, Ha and Banerjee consulted with two of the
paper's other authors: Philip Oyer, MD,
PhD, associate chair of cardiothoracic surgery, and the first
person to successfully use the LVAD as a bridge to transplant; and
interventional radiologist Michael Dake,
MD, professor of cardiothoracic surgery and medical director of
Stanford's Catheterization and Angiography Laboratories.
"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."
For Ha, who met Jackson in 2010 at Stanford Hospital when she was
evaluated for heart transplant, the LVAD deactivation completes a
circle. "She had come in so sick and the LVAD saved her life, and
she was really grateful for that," Ha said. "But, as
sometimes happens, people do so well with it, they want to do things
they've done in the past."
Jackson has gone back to work 20 hours a week as a notary public.
Without her LVAD battery pack and monitor, it was much easier for her
to get on a flight to Arizona to visit family. And, best of all, after
her surgery this summer, she was able to swim. "I feel better
than I have in years," she said.
Other Stanford authors are Ahmad Sheikh, MD, clinical assistant
professor of cardiothoracic surgery at Stanford; Peter H.U. Lee, MD, a
former clinical instructor; and former resident Jay Desai, MD.
Information about the Department of Cardiothoracic Surgery, which
helped to support the work, is available at http://ctsurgery.stanford.edu.