LOS ANGELES—Michelle Johnson, 40, doesn't have a heart. Or rather, the pump inside her chest is manufactured by SynCardia Systems. For months, the mother of three from San Diego has been tethered to a compact machine that she wheels around while she waits, once again, for the phone call. Diagnosed with congestive heart failure in her late 20s, Johnson received a transplanted heart in 2010; her body rejected it this past January. The Total Artificial Heart and its constant whooshing blurp-blurp should sustain her until another donor heart can be found; until then, she can't drive and has had to stop working as a unit clerk at the University of California San Diego Medical Center. The portable battery lasts two hours ("I can get my nails done, and that's about it"), so she always must bring a backup along as she runs errands and sees her doctor at Cedars-Sinai Medical Center for biweekly checkups. As spring turns to summer, Johnson is again nearing the top of the transplant waitlist. "I'm just ready to get back to normal life," she says.
The art of repairing injured hearts has come a very long way since the first successful cardiac operation took place in 1896, in Frankfurt, Germany. A 22-year-old man, stabbed in the chest, had suffered a wound in the lower heart chamber that pushes blood to the lungs. Surgeon Ludwig Rehn sliced through his ribs, using finger pressure to control bleeding and a needle and silk thread to suture the cardiac muscle. The patient lived. But heart surgery wouldn't truly hit its stride until more than 60 years later, when a safe heart-lung machine arrived to take charge of the pumping while the surgeon worked on a chemically calmed heart through ribs cracked wide. Today's repairs rely on an ever-expanding array of high technology, from ultra-precise imaging and surgical moves executed by robot to man-made heart parts—and hearts. They also depend, of course, on the sensitivity and skill of the physician wielding the scalpel.
U.S. News spent several days in May at Cedars-Sinai, watching the Heart Institute's cardiologists and surgeons at work. The center, No. 16 in cardiology and heart surgery in the 2012-13 U.S. News Best Hospitals rankings, has been first in the number of adult heart transplants performed in each of the past two years (87 in 2011, plus two heart-lung transplants). One morning brought the minimally invasive replacement of an aortic valve, which controls blood flow away from the heart. It is traditionally an open-heart surgery, but in this case a synthetic valve was snaked up into the patient's heart through the circulatory plumbing by pushing it through the femoral artery from an incision at his groin. The repair of another patient's mitral valve, between her heart chambers, involved an incision between her ribs and surgical tools wielded with exceptional dexterity by a precision robot, controlled by a surgeon seated across the room. Finally, word came that there would be a heart transplant, the hospital's 40th of 2012.
A few months before this Monday morning, Robert Noonan, a retired paper salesman from Thousand Oaks, Calif., found he was struggling to catch his breath. "The internist said I had a tight valve, and if I didn't fix it I'd die," says Noonan, 79. Specifically, he had aortic stenosis, in which the three-leaved flap between his left ventricle and the aorta, the large artery carrying blood away from the heart, was broken, unable to open completely and restricting blood flow. Noonan had no intention of dying, he says. So he talked to doctors at Cedars-Sinai and joined a clinical trial to fix his valve in a way unavailable to him a couple of years ago. The procedure should "add years to his life and life to his years," says Raj Makkar, director of interventional cardiology and the cardiac catheterization lab.
At 7:30 a.m., Noonan is prepped and wheeled to the "cath lab" for a procedure in which a series of wires and tubes are inserted into the femoral artery in his right leg. Just as a network of underground caves can take miners to a cache of gold without the need to blast in from above, the femoral artery leads the surgeon straight to the aortic valve. A compressed artificial replacement will be snaked up to Noonan's heart by a special delivery catheter guided by X-ray.
The so-called transcatheter aortic valve replacement uses a valve that got a Food and Drug Administration nod last year for people too sick for the standard open-heart version of the procedure. But it may hold great promise for other people with aortic stenosis, too, experts say. "Eventually, everybody would like to do this procedure on even ideal candidates for [open-heart] surgery, because it's much less invasive," says Makkar. But it's not without risk, and more data are needed on how well catheterization serves people who could undergo a full-fledged operation with only moderate risk, like Noonan, or with low risk.