Living on Borrowed Time

By Claudia Wallis

Barney Clark gets the first permanent artificial heart

Shortly after he awoke last Thursday morning in Salt Lake City, Barney Clark recognized the familiar sight and voice of his wife Una Loy, who was near by. There was also an unfamiliar noise: a soft, rhythmical clicking coming from his chest. And he realized, to his surprise, that he was still alive.

Clark, a 61-year-old retired dentist from Des Moines, Wash., had just become the first human to receive a permanently implanted artificial heart. As he stirred to consciousness, Clark signaled Surgeon William DeVries that he was not in pain. For DeVries, 38, that satisfying moment was the culmination of the three years he had spent perfecting the technique that made the implant possible, and waiting for a patient who met the rigorous criteria established for implant candidates by the Food and Drug Administration. No wonder DeVries described the 7 1/2-hr. operation as being "almost a spiritual experience."

When he flew to Salt Lake City on Monday, Clark was clearly dying. Once a vigorous man and an avid golfer (handicap in his prime: six), Clark was suffering through the final stages of cardiomyopathy, a progressive weakening of the heart muscle that inevitably leads to congestive heart failure. The only permanent cure for cardiomyopathy is replacement of the heart, but at 61 he was eleven years over the usual age limit agreed upon by surgeons for a transplant.

Last September, Clark visited the University of Utah Medical Center to review his only real option: a pneumatically powered heart developed there by Dr. Robert Jarvik, a 36-year-old medical prodigy who began to design his first invention, a surgical stapler, at age 17. Clark toured a facility where several sheep and calves are kept alive by Jarvik's hearts, and even witnessed an implantation. A calf named Tennyson set the survival record of 268 days before succumbing to an infection last year.

Clark went home because his condition "wasn't bad enough," recalls r. Chase Peterson, vice president of the Utah hospital. But in recent weeks Clark's heart deteriorated rapidly, and he became bedridden. Finally, says Peterson, "he called us last Saturday and said, 'It's time.' "

It was almost too late. When Clark arrived at the hospital, his heart was pumping one liter of blood per minute, one-fifth the normal rate. Surgery was set for 8 a.m. Thursday. Clark had already been approved by the hospital's selection committee. In addition to suffering from a fatal heart condition with no alternative treatment, he more than met the criteria for psychological stability and a strong will to live. "This man was worth waiting for," said Committee Member Peg Miller.

On Wednesday night, Clark's heart began to beat irregularly. "Why don't we get this over with?" he murmured to his wife. A few minutes later, DeVries decided to do just that and readied himself for his third operation of the day and the most significant of his career.

As a gentle snow began to fall outside, Clark was wheeled into a specially equipped surgical suite. Already assembled was a 17-member team with Jarvik as an observer. Working quietly and steadily to the hushed strains of Ravel's Bolero, DeVries made a 9 1/2-in. incision from the breastbone to the abdomen and carefully completed the delicate task of connecting Clark to a heart-lung bypass machine that would pump and oxygenate his blood until the plastic heart was in place.

Then DeVries removed the two pumping chambers (or ventricles) of Clark's heart, leaving the two atria, which function as storage chambers for blood. In all, about two-thirds of the heart were cut away. The cavity in the chest of the 6-ft. 2-in. Clark could easily accommodate the Jarvik-7. "There's room enough for two!" said DeVries with delight. The prosthesis is slightly larger than an average heart and too large, in fact, for most women.

Next came trouble. Before the artificial heart could be put in place, Dacron connectors had to be sewn onto the ends of the two atria, the aorta and the pulmonary artery. The heart snaps into these grooved, circular connectors in a manner that DeVries says is "like closing Tupperware." However, when he attempted to install the connectors, he found that the tissue around Clark's heart "would tear like tissue paper." Slowly, gingerly, DeVries managed to attach the four cuffs and finally to snap in the Jarvik-7. The device was primed with blood, but DeVries was dissatisfied with its performance. He resutured the connectors and tried again. Still no good. Finally DeVries decided to install a second left ventricle "that we had on the shelf. It worked beautifully." Clark's blood pressure slowly rose to a normal 119/75, compared with a feeble 85/40 before surgery.

"He's through the worst part," said DeVries after the operation, "but there are many more hurdles to come." Clark cleared one on Saturday when, after he had been taken off the critical list, he was ordered back into surgery for minor repairs. The operation went well, but Clark still faces a high risk of blood clotting, pneumonia and especially infection, which could develop around the tubes that enter his chest; they carry the pulses of air that drive the heart. But the artificial organ does have a key advantage over one from a human donor: since the plastic device contains no tissue, Clark's body is less likely to reject it.

No matter how long he survives, life will not be easy for Barney Clark. He is permanently tethered to 375 Ibs. of equipment that includes two compressors, a back-up compressor, a three-hour supply of pressurized air to operate the heart in case of a power failure, a drier to dehumidify the air, and mechanisms that control the air pressure and heart rate. All of this gear can be placed on what his doctors call a "shopping cart," which must always be within six feet of the patient, the length of the power lines that emerge from just below Clark's rib cage.

The operation costs $15,000, and the equipment, including the heart, $16,450. The hospital estimates that the family will have to spend $2,700 to adapt an apartment to the patient's needs. Clark's activities will, however, be limited not only by the reach of his life lines but by the fact that the heart cannot pump enough blood to support more than moderate activity. In the past, DeVries has commented that "sex may be the most strenuous thing these patients do."

Given these limitations, what is the role of the permanent artificial heart? "The best solution remains the heart transplant," insists Dr. Christiaan Barnard, the South African surgeon who pioneered that solution. Transplants have kept patients alive for up to 14 years. (In the U.S., some 500 people have received transplants since 1967; the current five-year survival rate is 42%.)

But there are simply not enough donor hearts around for the up to 75,000 U.S. patients who need them each year. For this reason, Barnard's fellow pioneers, Michael DeBakey and Denton Cooley, say the Utah heart is an important breakthrough. Both believe, however, that it should be used only temporarily to sustain patients until donors can be found. Cooley has in fact twice used a more primitive apparatus than Jarvik's for this purpose. Says Cooley: "I've never thought of the artificial heart and transplant as being competitive. They complement each other."

Future patients may look forward to Jarvik's electrohydraulic heart, a fully portable model powered by an implantable pump and a 5-lb. battery belt worn strapped to the waist. Jarvik hopes to have the device ready in three years. He has tested it in animals. But there is already heavy demand for the model, used last week, despite all its limitations. Still, De Vries says, "I'm not prepared to do it again until we can get Dr. Clark worked out."

The dentist's progress has already exceeded everyone's expectations, including his own. Before the operation, Clark had told his son Stephen that he did not expect the surgery to succeed. By week's end, however, Dr. Peterson reported that Clark "had gone from a man who was blue from not enough oxygen before surgery to being pink." He was also talking, moving his arms and legs and, thanks to a stalwart plastic heart, beginning to enjoy a life on borrowed time.

--By Claudia Wallis. Reported by Cheryl Crooks/Salt Lake City

With reporting by Cheryl Crooks/Salt Lake City

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