Lifesaver or Nightmare? : Experts Debate the Future of the 3-Year-Old Artificial Heart

It has been nearly three years since Dr. William DeVries made medical history by permanently implanting an artificial heart in a dentist named Barney Clark.

The controversies triggered on that historic occasion at the University of Utah continue to plague a program that some see as a potential lifesaver for thousands, but others view as a dream that has become a nightmare for those it is intended to benefit.

The four researchers who have implanted nine of the 11 artificial hearts--joined by Dr. Christiaan Barnard, who helped pioneer human heart transplants, and Dr. Robert Jarvik, who designed the most widely used artificial heart--met here last week to discuss the future of the device. The meeting was sponsored by the Foundation for American Communication, a nonprofit organization whose aim is to assist journalists in improving their ability to report on major issues.

While there was no consensus, most seemed to agree that artificial hearts will be increasingly used, but more likely as a temporary bridge to a human transplant rather than as a permanent implantation.

Stroke Threat Cited

A discussion by the surgeons revealed that the threat of strokes, caused by blood clots that form on the device’s inner walls when it is used long term, has tempered their enthusiasm for permanent implants.

Only DeVries said he plans to continue giving patients the implant for life, although he added that he is also looking at the possibility of interim use.

Since Clark, three patients at Humana Hospital in Louisville, Ky., and one in Sweden have received permanent implants of the Jarvik-7 heart. Four other patients at the University of Arizona, Penn State University and the University of Pittsburgh have received a Jarvik or other type of artificial heart as a temporary “bridge” to sustain them while awaiting heart transplants. Before those implants, Dr. Denton Cooley of the Texas Heart Institute had in 1969 and 1981 kept two patients temporarily alive with an early version of the mechanical heart.

In the view of many, however, none of the operations has been a spectacular success.

All of the recipients have experienced roller coaster health after the surgery, punctuated by serious complications that often have ended in death. Three of those in whom the heart has been permanently implanted and who are still alive have been stricken with paralyzing strokes that have been associated with the new heart itself.

Nevertheless, the researchers involved see this course of events as the natural consequence of pioneering efforts that are being continually upgraded.

Dr. Jack Copeland of the University of Arizona told the meeting that there is a place for the artificial heart, but only as a temporary device because the models “inevitably” will fail within 200 to 400 days. Human heart transplants, he said, are “here to stay” because they give patients “an alternative to death.”

As patients see it, Copeland continued, the device is a “monstrous machine” that many refuse because they are “worried about complications, bleeding, strokes and kidney failure.”

Implants Halted

Dr. Bjarne Semb, the Swedish surgeon who permanently implanted a Jarvik-7 heart last April in a patient at the Karolinska Institute, said he will do no more implants until the stroke problem has been solved. He said he is working on a newly designed artificial heart as well as on methods to prevent the formation of blood clots on the device’s interior surface by making changes in its surface.

“I don’t share the pessimism (of some) for this project in the future,” Semb said.

Pointing out the high mortality rates in the first open-heart and valve replacement surgeries 25 years ago, Semb said those procedures might have been abandoned then if they had had what he says is the same press scrutiny that artificial hearts have had. Open-heart and valve surgery have since become widely performed and highly successful operations.

The history of artificial heart transplants has been marked by conflicts between reporters and researchers over how much detail about the patient’s condition should be released daily.

Both Cooley and Barnard, who works at Oklahoma City’s Baptist Medical Center, deplored use of the artificial heart as a permanent implant.

‘Better Alternative’ Available

“I think that experience ought to show when to move back into the lab (to make improvements),” Barnard said. “We have a better alternative--a transplant--and we must give patients the best that is available at the moment.”

Cooley’s Texas colleague, Dr. O. Howard Frazier, praised human heart transplants “as the best treatment for a lethal disease that we can offer today.”

None of the surgeons, however, had a solution to the shortage of heart donors.

Only DeVries, who has performed all but one of the four permanent artificial heart implants done in the world since that on Clark, said he is willing to do more.

“We’re ready to use the Jarvik as it stands, as a permanent or as a temporary,” he said.

DeVries ‘Frightened’

Later, on a national TV program, DeVries said he would be “frightened” to tell a patient that he is receiving the artificial device temporarily as a bridge for a transplant. The reason, he said, is that the patient may have to keep the device forever if he has a stroke that no longer makes him a transplant candidate.

Jarvik, designer of the most widely used device that also bears his name, said development of a more advanced model--the Jarvik-8--has been suspended to spend more time improving the Jarvik-7. He said while it is assumed the strokes are related to the heart itself, other factors dealing with anticoagulant drugs that may play roles are also being investigated.

Jarvik said surgeons from more than a dozen centers have been trained to implant the heart and six to 10 more will be trained next year.

Arthur Caplan, an ethicist from the Hastings Center, an Upstate New York nonprofit group concerned with issues of medical ethics, said he has not been persuaded by the surgeons’ argument to justify use of the artificial heart on grounds that the patient would soon die without it.

“I am not persuaded either that death wins out over everything or that life is better than death,” he said.

Improper Consent an Issue

Caplan said in some cases the procedure has been done without proper informed consent. The press and others, he said, have focused on the existence of the written form itself. But the important thing, he said, is not only the existence of a consent form, but also the transmission of information that truly informs the patient and family about the procedure’s risks and benefits.

“Informed consent (forms) become a defense by researchers against criticism that they didn’t get consent,” he said.

Caplan also questioned whether the media have drawn sufficient public attention to the large amount of money spent on artificial hearts for a small number of people, while at the same time large numbers of other patients are being denied more standard kinds of care.

“On a national level,” he asked, “is it a good expenditure?”

Waxing philosophical, DeVries told the session that the Clark experience opened his eyes to “the multivalue system” that researchers encounter when their work is appraised by others.

Depending on whether it’s the patient, the patient’s family, researchers, the medical profession, the hospital chains, the Food and Drug Administration or the press that is doing the evaluating, the answer is different, he said.

Eventually, DeVries said, the public will determine how much of the experimental research that technically can be done will be done.

But unanswered was the question of how society will go about making that decision.