A Beating Heart, Even After Death

The New York Times Opinions 1 month ago

Shows like HBO’s “Westworldand the “Blade Runner films depict a dystopian future where humankind and machine have merged, blurring the line between people and robots. As a cardiologist, I find myself face to face with both the promise and the peril of such a marriage — a reality for me and my patients rather than a distant hypothetical.

Tens of thousands of Americans today have mechanical pumps keeping them alive, offering the first serious glimpse of what the union of human and machine will look like. Left ventricular assist devices (LVADs) are sutured right into the hearts of patients with severe heart failure, mechanizing them to keep blood circulating throughout the body. While they don’t quite turn into cyborgs, most patients with LVADs don’t have a pulse, and if you put a stethoscope to their chest, instead of hearing the galloping of their heart, you would hear the hum of the pump.

As we move into the post-evolutionary phase of our species, for this union to be a boon to humankind rather than the bane of our existence, we need to ensure that ethical discourse and regulatory oversight keep up.

We have sought to restore our bodies with things like artificial hips to replace arthritic joints or contact lenses to sharpen blurry vision, but never before have we given a home inside our body to technology that fundamentally changes the human experience. LVADs are pushing bodies into places unforeseen: They can survive even if their hearts stop beating, something previously unimaginable. The devices are also teaching us what happens when blood flows continuously through the body rather than in pulses with every beat of the heart.

While many patients with LVADs can experience devastating complications such as strokes, bleeds and infections, many achieve previously unimaginable outcomes. The devices may soon help people with severe heart failure to live longer than those with the gold standard: a transplanted heart, which has shown to extend the lives of patients for an average of 11 years. A trial of the newest generation of pumps, called Momentum 3, showed that the two-year survival rate of patients with LVADs is creeping closer to that of patients who receive a human heart.

“LVADs are now more forgiving in terms of complication rates and the need for constant complex care,” said Mandeep Mehra, medical director of the at Brigham and Women’s Hospital’s Heart and Vascular Center, a professor at Harvard Medical School and principal investigator of the study. “The main objective of LVADs in elderly patients is to not just add years to their lives but life to their years.”

These improvements have led some of my patients with an LVAD to reject the opportunity to have it replaced with a transplanted heart. And just last year, researchers developed a prototype LVAD that charges wirelessly rather than through large batteries patients have to wear in special vests or in belts, making it easier to live with and letting many patients do what they cannot with current LVADs: swim.

“The next generation of devices need to become fully internalized like a pacemaker so that the person is not constantly reminded that they are a patient,” said Dr. Mehra.

I have witnessed LVADs giving some of my patients the opportunity to attend their grandchildren’s weddings and letting others to return to work, but this technology comes with its own set of drawbacks. While an LVAD, as long as it functions appropriately, is somewhat immortal and can be replaced with a surgical procedure, the rest of the human body continues to age. An LVAD can keep pumping blood, even as all the other organs in the body fall apart. It can push blood furiously through a body even after it has died.

The early days of new medical advances are often rocky, based on the incremental nature of technology, so it is critical that we fully prepare patients for what to expect. Yet as a 2017 study showed, when patients were provided unbiased information on the pros and cons of LVAD therapy, fewer went ahead with the implantation. Though the Centers for Medicare and Medicaid Services mandate involvement of palliative care for all patients receiving LVADs, many hospitals see this as only a box to check, providing lip service to this requirement. It should be mandatory for patients to be provided unbiased information and to have a formal consult with a palliative care clinician.

Despite what LVADs and other new medical technology can achieve, we need to ensure that the enthusiasm to advance the human condition does not circumvent appropriate regulatory oversight. Already there have been recalls of hundreds of thousands of pacemakers because of hacking vulnerabilities. Such safeguards need to be ensured for LVADs as well. The last generation of LVADs experienced an unexpected spike in the formation of blood clots in the pump. This was never fully explained, amplifying the need for continued vigilance.

We also need to ensure that everyone has access to medical technology, rather than only the affluent. We have seen this with expensive medications, but in a future where people upgrade their organs as they do crooked noses and slender lips, unequal access could very much lead to a caste system with a life span booster as much a status symbol as the artificial augmentation of the human body. We must debate about the consequences of these therapies as they are developed rather than react when the unforeseen occurs.

Finally, we need to ensure that LVADs help us to live not only longer but also better. Instead of focusing on individual organs, we should strive to look at the whole person and how an LVAD might fit in that individual’s and his or her caregiver’s life. The best way to do that is to ensure that we get people the help they need, including changes in lifestyle and evidence-based medications to prevent heart failure, such that an LVAD is never needed.

Haider Warraich (@haiderwarraich) is the author of “State of the Heart: Exploring the History, Science, and Future of Cardiac Disease.”

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