Heart Pump
Chemotherapy helped Mayra Rodriguez survive cancer but damaged her heart. A heart pump saved her life. Here she sits with son Gabriel, 11, and their dog, Tico. Photo by Yvonne Albinowski
In 2005, Mayra Rodriguez was diagnosed with non-Hodgkin’s lymphoma. Aggressive chemotherapy vanquished the cancer but severely damaged her heart. Shortly after giving birth to her son, Gabriel, in 2007, she was diagnosed with cardiomyopathy. She nearly died—twice—but a remarkable medical device saved her life, giving her the gifts of renewed health and the ability to watch her son, now 11, grow and thrive. “I’m so blessed that I had that surgery,” she says. “It gave me a second chance.”
Her surgeon, Dr. Margarita Camacho, surgical director of Newark Beth Israel Hospital’s cardiac transplant program, witnessed the first-ever U.S. procedure to implant an LVAD (left ventricular assist device), a mechanical heart pump, marketed as HeartMate, that assists a failing left ventricle. The pump (one of several FDA-approved ventricular assist devices on the market) is now in its third generation and is considerably more compact than its predecessors—smaller than a human fist.
The surgery: Typically, the pump is inserted into the heart via open-heart surgery (similar to a heart valve), but as the devices have gotten smaller, some are being inserted in a minimally invasive procedure through small incisions in the chest; the procedure is considered investigational at this point. In addition to LVADs, there are RVADs (sometimes used when the right ventricle is diseased), and BIVADs (used when both ventricles are damaged and sometimes when only the right is damaged). Right-sided VADs are only used as bridges to heart transplant surgery, not as so-called destination surgeries.
Who’s a candidate: Patients suffering heart failure due to one or more failing ventricles.
Before surgery: Patients are generally asked to stay as physically fit as possible and to stop smoking.
Recovery: As with most open-heart surgeries, recovery takes about six weeks, and patients generally leave the hospital after two. The patient is allowed to resume normal activity, with the exception of sports and heavy lifting.
Possible complications: The two major complications are pump thrombosis (a blood clot in the pump) and a disabling stroke. Patients with HeartMate 2 have a 12.2 percent incidence of thrombosis and a 10 percent incidence of stroke; with the newer HeartMate 3, those rates are 0 percent and 19 percent, respectively.
Post recovery: Most patients return to full activity. Rodriguez regularly hikes with her husband, loves to dance, and runs a 5K every Mother’s Day. “It’s a whole new life,” she says.
Life span of the device: At least five years for the HeartMate 2 and possibly 10 years or more for the HeartMate 3, though it’s still too early to tell. Camacho notes that the surgery to replace a failing device is generally easier than the original procedure.
Knee
Forty years ago, knee replacement was considered a challenging procedure; today, says Bedminster orthopedic surgeon Dr. Robert D’Agostini, “it’s fairly routine.” While the devices and the surgery have changed over time, “the real evolution,” D’Agostini says, “has been in pre- and postoperative management.” Today, patients are asked to lose weight, if necessary, and to strengthen the quadriceps before surgery, and they’re up and walking only hours after the procedure. That early mobility has cut the rate of postsurgical blood clots from 25 percent to about 1 percent. But D’Agostini stresses that better outcomes depend on the patient’s active involvement before and after replacement surgery.
The Procedure (total or partial knee arthroplasty): In a total knee replacement, the top of the tibia, the bottom of the femur and the back of the kneecap are removed and replaced with a device made of metal—most likely titanium or cobalt-chromium—and plastic. Patients suffering from damage to only one compartment of the knee may need only a partial replacement, though the procedure isn’t widely performed in the United States.
Who’s a candidate: If conservative treatments like medication, exercise, physical therapy and injections haven’t alleviated the patient’s knee pain, and if that pain is interfering with the ability to carry out routine activities, the patient may be a candidate for a replacement.
Before surgery: If patients are overweight or have unmanaged diabetes, they may be asked to lose weight and/or get their diabetes under control. Like many surgeons, D’Agostini asks patients to strengthen their quadriceps, the muscles in the thigh that support the knee.
Recovery: Most patients are up and moving within several hours of surgery and leave the hospital the next day. They undergo several months of physical therapy and may also be required to exercise at home. They should be relatively comfortable after three months, though stiffness and swelling can persist for a year.
Post recovery: Recipients should be able to swim, cycle, play doubles tennis, ski on intermediate slopes and “play golf to your heart’s content,” says D’Agostini.
Possible complications: Blood clots are rare but can occur.
Life span of the device: 10–25 years.
Ankle
Since the 1970s, when ankle replacements debuted, the surgery and the devices have been vastly improved, and earlier problems, like wearing out or loosening of the implants, have been mitigated. Nevertheless, like elbow replacement, the surgery is generally reserved for patients who are relatively sedentary. “These are people,” says Dr. Kevin White, an orthopedic surgeon in Hackettstown, “who tell me they just want to walk and do the normal activities of daily life without pain.”
The procedure (ankle arthroscopy): After removing damaged bone and cartilage, the surgeon connects a modular, three-part component replacement to the tibia and fibula bones. Implant materials are generally made of titanium; some include plastic.
Who’s a candidate: The ideal candidate is sedentary and over 60, without serious ankle deformities, diabetic neuropathy or a history of infection in the joint.
Before surgery: Since most patients are severely debilitated before the procedure, a strengthening regime isn’t usually recommended.
Recovery: Most patients go home the day of surgery wearing a splint. Two weeks later, the splint is replaced by a walking boot. At that point, patients are not walking, but start to do exercises to increase range of motion. After that, they start physical therapy to continue working on range of motion and to strengthen leg muscles and improve gait.
Possible complications: Blood clots; patients at high risk are given anticoagulants.
Post recovery: Recipients should be able to walk, take short hikes, swim and golf without pain.
Life span of the device: Between 5 and 10 years, possibly longer. But, says White, who uses the Stryker Star Series ankle implant, “I really can’t say that it’s going to last more than 10 years because it hasn’t been tested beyond that time yet.”
Hip
For five decades, orthopedists have replaced aging hips with a three-part mechanism closely approximating the original in form and function. If you needed a new hip 30 years ago, your surgeon could choose from three sizes of replacements, and the 2-1/2 hour surgery would have kept you in bed two or three days. “Today,” says Dr. W. Thomas Gutowski III, an orthopedic surgeon in Princeton, “surgery takes about an hour, and patients are up and walking within two to three hours of surgery. Most go home the following day, and some the same day.”
The procedure (hip arthroplasty): For arthritic hips, the diseased femoral head (the ball in the ball-and-socket joint that comprises the hip) is removed and the socket milled to a uniform sphere; a titanium shell, lined in plastic, is inserted into the socket. A titanium stem is inserted into the femur, and a ceramic ball is placed on the stem. (For broken hips, it may only be necessary to replace one part of the hip, depending on the location of the fracture.)
Who’s a candidate: Patients whose quality of life has continued to diminish despite other interventions (medication, physical therapy, weight loss)—they can no longer put on shoes and socks or get in and out of a car without pain, for instance—or who have broken a hip, are likely to benefit from a hip replacement.
Before surgery: Patients who are grossly overweight or have other serious conditions like cardiovascular disease or diabetes will likely be asked to lose weight and/or make sure those conditions are minimized.
Recovery: Most patients can walk 300 feet on the day of surgery with a walker or cane and go home the next day, followed by a month of physical therapy. The majority can return to work in four to six weeks.
Possible complications: Blood clots are a possibility. To mitigate the chances of developing one, patients are up and on their feet as soon as possible, wear compression stockings, and are given aspirin as a blood thinner.
Post recovery: Patients should be able to return to most or all of their normal activities.
Life span of the device: 20-plus years.
Leslie Garisto Pfaff is a longtime contributor on health and education. She is irreplaceable.
Thanks for this very informative article.
Its amazing what the new world of prosthetics is doing ! Just for an FYI, medical clearance is generally routine for any of these surgeries. Plus many hospitals and surgeons implement a preadmission infection screening and prevention routine.