Another Setback in Louisville

By Claudia Wallis

He had been dauntlessly enthusiastic over the prospect of receiving an artificial heart. "If you get it in right," Jack Burcham, a former railroad engineer, promised Implant Surgeon William DeVries, "I'll make it work." Getting it in right proved to be just the first of many difficulties faced by doctor and patient at Humana Hospital Audubon in Louisville. The cheerful father of four from Leroy, Ill., never really recovered from the initial surgery. Last week, just ten days after becoming the fifth and oldest human recipient of the Jarvik-7 heart, Burcham died, at 62. As DeVries later admitted, it was not clear whether the artificial heart had extended his patient's life or shortened it.

Like his predecessors, Barney Clark, William Schroeder, Murray Haydon and Swedish Patient Leif Stenberg, Burcham was a dy- ing man who gambled on the artificial heart to win a few extra months of life. "We were hoping that he would be able to live like Schroeder," said Jack B. Burcham, 41, the < patient's son, "but Dad was just too weak." (Schroeder has survived more than 150 days with his artificial heart; Barney Clark died after 112 days.)

Burcham's cascade of medical problems began during surgery, when doctors discovered that his chest cavity was too small to accommodate the grapefruit- size Jarvik-7. DeVries was forced to pare away at the breastbone and twist the heart's chambers around to make it fit. "It was like putting a round peg in a square hole," he said. The struggle to implant the artificial heart probably contributed to Burcham's massive bleeding over the next 24 hours. In all, he lost more than five gallons of blood--four times the total volume in an average-size adult. Only continual transfusions kept him alive until a second operation stanched the flow.

Even before his implant surgery, Burcham had been experiencing kidney failure, a common complication of advanced heart disease. The stress of the back-to-back operations and the need for multiple transfusions aggravated the problem, and twice last week Burcham had to undergo dialysis. It was during the second treatment on Wednesday afternoon that a nurse, listening to Burcham's chest with a stethoscope, noticed that his breathing was labored in the left lung. X rays showed that a large amount of fluid had collected in his chest. Doctors later learned that the fluid was blood that had congealed into a jelly-like glob and was pressing against the upper left chamber of Burcham's natural heart (the Jarvik-7 actually replaces only the lower, pumping chambers). This pressure, known as cardiac tamponade, prevented blood from entering the artificial heart and caused it to back up into the left lung (see illustration).

Though cardiac tamponade is easily recognized in a patient with a normal heart, the presence of the artificial device masked the usual signs. By the time a sudden drop in blood pressure alerted doctors to the danger, said DeVries, lifesaving efforts "were doomed to failure." The surgeon was summoned to the hospital from downtown Louisville, where he was attending a conference on heart replacement, but he arrived too late: Burcham had already stopped breathing and had no blood pressure. "I was there for about 15 minutes, 20 minutes," DeVries said, "before we turned the key (to the Jarvik-7 power unit) off."

Burcham's rapid decline and death are the latest in a series of disappointments and unforeseen disasters that have plagued the artificial- heart program. Both Clark and Schroeder, who is now living in a specially equipped apartment across the street from the hospital, suffered serious neurological problems that left them mentally impaired. Haydon, who was hailed two months ago at the time of surgery as the best implant candidate of all, has yet to be weaned from a respirator. At the Louisville conference, DeVries for the first time publicly presented his most recent findings on the array of complications associated with the artificial heart. All four American recipients of the Jarvik-7, he noted, had developed a serious kidney condition, known as acute tubular necrosis, which generally started within four days of surgery and lasted up to two weeks. For reasons that remain obscure, all four experienced impairment of their immune systems in the weeks following surgery, and all suffered from some form of infection, ranging from urinary-tract problems to pneumonia. Experience with the four patients has also shown that the artificial heart batters the red blood cells, causing a form of anemia. As a result, said DeVries, "if you have an artificial heart, you can expect to have blood transfusions once or twice a month."

As Burcham's death has shown, one of the most vexing problems in implant patients is bleeding. The loss of blood is especially hard to manage, DeVries noted, because patients face the equal and opposite threat of too much clotting. (Blood clots forming in the vicinity of the artificial heart are suspected of having caused Schroeder's strokes.) Said DeVries: "The tightrope that we walk between over- and undercoagulation will have to be examined again a little closer."

The drawbacks of the artificial heart have led many doctors to conclude that the device should be used only as a temporary measure to sustain a patient until a human donor heart can be found. "I'm not sure that it should be considered a permanent transplant," says famed Houston Heart Surgeon Michael DeBakey.

Still, few physicians are openly critical of the implants; many point out that pioneering efforts in open-heart surgery and human heart transplants also met with many disappointments and failures. "This is a new technical endeavor, and naturally it is going to be fraught with complications," observes Dr. Floyd Loop, chief of cardiac surgery at the Cleveland Clinic Foundation. Loop is confident that "with a few more cases" DeVries and his colleagues will learn to control problems like bleeding. Transplant Surgeon Philip Oyer of Stanford concurs. Says he: "This is not the time to say stop."

For his part, DeVries insists that his work is largely experimental and if anything is to be gained from it, more experience is needed. "You must realize that heart transplantation has (been tried on) almost 800 patients, and we're looking at five. We're still in our embryonic beginnings."

With reporting by Barbara B. Dolan/Louisville