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May 12, 2004

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Palo Alto Online

Publication Date: Wednesday, May 12, 2004

The gift of life The gift of life (May 12, 2004)

Stanford a leader in heart transplants

by Terry Tang

Robert St. Laurent didn't set out to be part of a pioneering heart procedure at Stanford Hospital. But, in this case, he had pretty strong motivation.

"The surgeons told me I had approximately 24 hours to live," said St. Laurent. "They had just gotten approval from the FDA to use the LVAD and (asked) would I be willing to have surgeons place it."

In 1984, St. Laurent, the general manager for an aluminum company in Miami, was suffering from grave heart failure. With no available heart, time was running out. His "make-or-break" predicament made him a candidate for a LVAD -- a Left Ventricular Assist Device. The mechanical heart pump had previously only been tested on animals.

"He said if it doesn't work out for me, at least they will learn something that can help our children or other people," said Cynthia, St. Laurent's wife.

After the procedure, which can take two to three hours, St. Laurent remembers waking up the next morning without pain. Soon, he was sitting up and watching a tennis match on TV. More importantly, the LVAD kept him going until a donor heart was found.

Twenty years later, St. Laurent's place in medical history as the first human fitted with the bridge-to-transplant device brought him back to Stanford on April 14. Besides attending Stanford's annual reunion of heart and lung transplant recipients, he reunited with the transplant team that performed the operation. Although the 71-year-old put a human face on the device's importance, he shrugs off trailblazer status.

"I figured I was at the right place at the right time," St. Laurent said.

Since 1970, Dr. Peer Portner, currently a consulting professor of cardiothoracic surgery at Stanford, led the LVAD's research and progression. Originally, he and Dr. Philip Oyer worked together toward the goal of a permanent implant. Prior to any clinical tests, the mechanism was partially implanted in 3-month-old calves. According to Portner, calves had a similar cardiac physiology to humans. As their experiments became longer, they switched to sheep. Some withstood an implant for a hundred days.

"Our expectation, initially, was that the implant wouldn't last for more than a week or two," Portner said.

Subsequently, the FDA gave the go-ahead on the LVAD for severely ill heart transplant patients. Oyer implanted the LVAD in St. Laurent. Portner still recalls how elated he was when the device appeared to work.

"Our expectation was a good outcome," Portner said. "But with a patient like Bob, who had terminal heart failure, ...there is a fear that you've intervened, but what if you've intervened too late."

In its early stage, the device received electric power from a huge external console that typically weighed up to 150 pounds. Thus, patients were tethered to the machine and forced to remain stationary. For 24 hours a day, an engineer had to monitor the entire operating system, which constantly emitted a loud clicking noise.

"It was like a big hi-fi stereo set," said Bill Rainford, who, 18 years ago, was the third Stanford patient to be fitted for a device. "Engineers were in there running the machines. These men were basically running my heart."

Although St. Laurent and Rainford essentially consented to be human guinea pigs, many patients at Stanford were fearful of such a novel device. An assistant priest living in Santa Cruz, Rainford, 65, utilized his experience to counsel other patients. For two years following his transplant, he frequently visited Stanford clinic for post-op care. During these visits, hospital staff encouraged him to talk with ailing patients about the device.

"There was a lady from Salinas who just freaked out," Rainford said. "They wanted to show this lady someone who survived having the LVAD ... Doctors can do all the talking and give percentages. But, to meet a real person who went through it, that's the best support."

Today, the pump can be carried around like a wardrobe accessory. The heavy machinery power source has been replaced by an external battery pack. The batteries and controller, which weigh four pounds, can be worn on a belt or kept in a shoulder bag.

At two pounds, the pump itself is somewhat bigger than a human heart. Surgeons make a pocket for the LVAD under the skin in the abdominal wall muscles. Meanwhile, doctors drive two conduits through the diaphragm. The pump sends blood from the inflow conduit, attached to the left ventricle, to an outflow conduit connected to the aorta. The battery pack sends power through the patient's skin and into a tube affixed to the pump.

For patients, the compact size means achieving some normalcy in their lives. Most LVAD users can continue physical activity such as golfing, hiking or skiing. Furthermore, the pump functions at a quieter noise level. With a minimal risk of complications, patients can monitor the device on their own.

"If you imagine running a car for four years without servicing it -- that's the comparison you have to look at," Portner said. "The device is very reliable and has a very low failure rate. There is a wear-out mechanism that can be tracked so you know when it's at the end of its life."

On average, the pump can help sustain a heart patient for at least 10 months. Some have been known to last for a few years. However, a future where this device replaces transplantation altogether isn't far off. The pump's sophisticated technology will keep evolving simply out of necessity.

"There's a gap between 2,300 donors and 50,000 to a 100,000 patients," Portner said. "Mechanical support is the only immediate and logical way to go."

The pump, however, is not a one-size-fits-all apparatus. Currently, there are some smaller external pumps attainable to more petite or juvenile patients. To date, said Portner, the smallest recipient weighed 100 pounds.

"As we move down the road, there will probably be different sizes for different patients," said Portner. "I think the youngest patient was 13 years old. But (an LVAD) is too big for a child."

More than a hundred Stanford patients have benefited from the LVAD. Still, for Stanford's cardiothoracic team, there will always be a special bond with St. Laurent. They credit him for willing to take a risk.

Beyond anyone's expectations, the LVAD kept St. Laurent alive for eight days -- until Sept. 13. That day, he received the heart of an 18-year-old car accident victim. Despite other past health problems including diabetes and a kidney transplant five years after the heart procedure, St. Laurent is considered in good health.

Every day, said Cynthia, she and her husband think about how their good fortune also came from someone else's sacrifice. And every Sept. 13, Stanford surgeons think of them.

"We celebrate it like an anniversary," Cynthia said. "It's a gift. Even Dr. Portner calls every year to wish us well."


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