Transplant

by John A. Elefteriades, MD

Genres: Medical Thrillers

Synopsis

What do you do when you have to choose between saving a life or saving yourself?

Renowned cardiac surgeon Dr. Athan Carras’s first concern has always been the welfare of his patients. Then he’s approached by the very wealthy and even more powerful Terry Flynnt—a man who is used to getting what he wants, no matter what.

Flynnt’s son is dying, and his only chance of survival is to receive a donor heart—one that Terry intends to obtain by whatever means necessary. Athan is immediately opposed to performing an illegal and immoral operation, but Flynnt is not about to let that stop him.

Now, caught in the crosshairs of a man with unlimited means and influence, Athan finds his own life—and the lives of those he loves—being torn apart. And he will have to decide how far he’s willing to go, and what he is willing to sacrifice…

Release date: August 26, 2014

Publisher: Berkley

Print pages: 400

Sample

ACKNOWLEDGMENTS

JOHN A. ELEFTERIADES, MD

CHAPTER 1

“Doctor, I cannot forbid you to perform that procedure,” said the clipped, nasal voice in Athan Carras’s ear, “but I emphatically withhold the permission you are seeking from the committee.”

You vindictive son of a bitch, Carras thought, but into the phone he said, “You don’t have that authority, doctor. You are just the vice-chair of the Human Investigations Committee. Only the chairman has the right to grant or withhold approval.”

There was a silence on the line, then Carras could hear the thin smile in Dr. James Bonar Auldfield’s voice when he said, “You should have read the committee’s terms of reference more closely, doctor. In the absence of Dr. Bentham, all of his powers devolve to me.”

“For God’s sake,” Carras said, “that’s Cory Goldenberg on my operating table. Leave aside that he’s a friend and colleague to both of us, he’s one of the top cardiologists in the world. If the technique works, he could live another ten years, save hundreds of lives. But if I don’t do it, he’ll be dead before morning. Guaranteed.”

Auldfield’s voice was bright with a cold glee. “I’ve told you, doctor, it’s entirely your decision,” he said. “You agreed that there will be no human experimentation until the HIC has seen long-term results from the animal trials. However, if you want to disavow the covenant you have made with the committee, you are free to break your word.”

“But you won’t cut me an inch of slack, will you, ‘Boner’?”

Carras heard the sniff that preceded Auldfield’s final remark. “I must do as my conscience dictates. You do as you wish.” There was a click and the line was dead.

Shouldn’t have called him Boner, Carras thought. Auldfield hated the nickname he’d acquired when they’d been students together. But Carras realized it wouldn’t have made any difference if he’d abased himself to flatter the other man’s delicate ego.

Back in Operating Room 15 of Yale Medical Center, Craig Mason looked up from the dials of the heart-lung machine that was keeping Cory Goldenberg from sliding into death and said, “Are we go?”

Carras took up his customary place on the patient’s left and swept his gaze over the monitors before answering. “Bentham’s on some kind of retreat in Montana. Left his cell at home. Can’t be reached before the end of the week.”

“So who’s on deck for him?” Mason said, then his eyes widened as he answered the question for himself. “Oh, fuck me. Boner, right?”

Carras sighed. “And Boner says we’re on our own.”

“Well fuck him with the broomstick he rode in on,” said Mason. “Like I’m going to let Cory die because that little pissant thinks he’s Pontius Pilate? Let’s do this, Ath. Now.”

“Let me think.”

*   *   *

CORY GOLDENBERG SHOULD HAVE KNOWN BETTER. ALTHOUGH HE was a senior cardiologist with Harvard Medical School, he suffered from a condition known as aortic regurgitation: a weakness in his heart’s outflow valve that did not let it be a one-way-only door. After expelling all the blood in the left ventricle, it didn’t slam shut and stay tight; instead, the valve let a little blood leak back into the heart. The result was a progressive weakening of the organ.

Any heart surgeon knew the answer to aortic regurgitation: cut out the faulty natural valve and put in an artificial one. These days it was a routine procedure and postoperative complications were next to nil. Goldenberg could have had his operation anytime over the several years since the onset of his condition.

But Goldenberg was a conservative cardiologist. He had taught for years that surgery should not be an instant resort. Patients should wait until there was definite evidence that the heart was enlarging. With hearts, bigger is not better; bigger is certainly not stronger—an enlarged heart is a weak heart. Goldenberg taught that, until enlargement was evident, surgery should be put off, and he practiced what he preached.

In the meantime, he drove himself to a high level of fitness. He played tennis every day, between morning rounds and afternoon office hours, often taking on much younger opponents and beating them in straight sets. He rode a bike and trained with light weights. At sixty, he was lean, strong and looked fit.

“I’ve started to enlarge,” he had said, sitting in Carras’s long, shoe-box-shaped office in Yale’s venerable Farnum Building, between the modern medical center and the old red-brick morgue. They looked at the echocardiographic images from the lab. The enlargement was small—only one centimeter in diameter—but noticeable.

“No point waiting,” Carras said. “We’ll perform the procedure tomorrow morning.” He looked again at the echo results and said, “I wish you hadn’t waited.”

It was an argument as old as modern surgery. Clinicians like Goldenberg preferred to use noninvasive therapies—drugs, exercise, change of diet—to treat the myriad afflictions of which the human body is at risk. Surgeons opted to isolate the part at fault and if they couldn’t repair or replace it, they’d cut it out altogether and let the body’s systems adapt.

The body was designed with built-in redundancy. Life could go on without a gall bladder or a spleen, with only one lung or kidney or with substantial portions of the liver missing. But humans were issued only one heart and it had to last a lifetime, and Carras felt there was no point in unduly stressing the organ when a quick and simple surgical repair could avoid trouble.

Goldenberg thought surgery was inherently dangerous, even under gifted hands. A certain number of patients who went under anesthesia never came out of it—the fraction was tiny, but that didn’t make any difference when relatives arrived at the hospital to visit Uncle Waldo after his minor knee surgery and found him chilling in the morgue.

“You’re more likely to be hit by lightning,” Carras said. “Or bitten by a shark.”

“If I stay in during lightning storms and stay out of shark-infested waters, the chances of being hit or bit are zero,” Goldenberg answered. “As are my chances of dying on an operating table if I stay off one.”

“You won’t die on mine,” Carras said.

“Sometimes I wonder about you, Ath,” Goldenberg said. “It’s as if you see yourself in a head-to-head contest with death.”

“I wouldn’t put it so dramatically,” Carras said.

“Maybe not out loud,” the cardiologist agreed, “but I wonder if there are times when you look across the operating table and see the old reaper reaching for your patient, and then it’s not about the patient anymore. It’s about winning.”

“All right, sometimes I do feel defeated when I lose a patient. And I hate it. Don’t we all?”

“Sure, to some extent,” Goldenberg said. “Just don’t let it get too personal. Even when you’re operating on me. Remember, doctor, pride goeth before a fall.”

“I’m not the one who’s waited until his heart’s enlarged, doctor,” Carras said. “That looks to be a fair-sized stumble on your part.”

“Touché‚” said the clinician, “but a little below the belt, don’t you think?”

For a moment, Carras was tempted to say, Sorry, that was a low blow. But he and Cory had argued over similar cases so many times, in print and face-to-face at conferences, that the combative habit just naturally came to the fore. And when in combat mode, Athan Carras did not say sorry. Besides, he told himself, an apology’s not what Cory needs. He needs his heart fixed.

Carras fixed it the next morning, in an operation that was entirely routine from Goldenberg’s first shot of sedative to the postop visit by Carras in the intensive care unit. The new Pyrolite carbon valve was clicking away in the cardiologist’s chest and blood flow was normal. But would the moderately enlarged heart recover and return to normal?

It took five years for the definitive answer to come in. Cory Goldenberg’s heart had not recovered. Weakened, it had continued to grow larger and less powerful. Partly through medication but mostly by sheer willpower, the clinician had been able to carry on with his teaching and practice, but his condition deteriorated, at first slowly, then later at an accelerated pace. Now, at sixty-five, he was suffering from end-stage heart failure; the enlargement and contractile weakness of his left ventricle were so extreme that the eleven different medications he took each day could not compensate. He came to Carras for a transplant.

The choice of a Yale surgeon by a prominent Harvard physician prompted some ironic comments in Ivy League circles. Carras had held his own in many a contentious academic debate, sometimes supplementing scientific fact with acid wit. He was not universally loved by his peers, of whom there were relatively few, and some of those he had bested detested him.

But as Goldenberg said in a widely reposted e-mail, “Sure, Carras can be arrogant, but he has every right to be. In my case, he was right and I was wrong, and if I come out of this alive, it’s because of him.”

The wait for a suitable donor heart stretched into weeks, then into months. Goldenberg was maintained on a continuous infusion of the drug dobutamine, which artificially strengthened his heartbeat and maintained an adequate outflow of blood from his failing left ventricle. The cardiotonic medication was delivered to his heart by a catheter connected to a pump. Some days, he used Carras’s office to work on a paper he was writing for the American Journal of Cardiology.

Goldenberg was at Carras’s desk when he finally collapsed from pulmonary edema—he began to drown from backing up of blood and pressure into his lungs. Fortunately, Carras’s secretary, Karen Ferguson, was keeping an eye on him and within minutes she had arranged for the cardiologist to be wheeled up the long glassed-in walkway between the Farnum Building and the recently built medical center’s coronary care unit. He was placed on a ventilator that sent high-flow oxygen into his bloodstream, the enriched mixture making up for poor blood flow from his weakened heart.

Two days later, they found a suitable donor heart. In Boston, a fifteen-year-old boy had discovered where his father had hidden the ignition key of his Yamaha 650 motorcycle and decided to take the bike out for a spin. Helmetless, leaning so far over that one knee almost touched the asphalt, the boy swept around a blind curve and smashed into an oil delivery truck. The surgeons at Boston General kept him technically alive for eleven hours while they assessed the neurological implications of his massive head injury, but the victim was brain-dead.

The boy was big for his age and had been a good athlete. His blood type was a match for Goldenberg’s. When the Yale donor team flew by Learjet to Boston and harvested the heart, the organ looked perfect. They also took a lymph node for tissue typing and the lab result was phoned through to Yale while the jet was carrying the team and the heart back to New Haven.

It was two a.m. when Carras heard they had a good match. He ordered Goldenberg prepped and transferred to OR 15, his favorite of the medical center’s five cardiothoracic operating suites. The heart arrived on time, safe in its ziplock bag of saline solution resting on a bed of ice in a cooler that would not have looked out of place on a picnic blanket—except for the large blue cross and the lettering that said HUMAN ORGAN—DO NOT TOUCH.

The operating team opened the patient’s chest and began to place the catheters that would allow them to connect to the heart-lung machine. The systolic pressure in Cory Goldenberg’s arteries was a limp eighty-five over forty, well below normal readings of one hundred twenty over eighty. That was as expected. The problem came when the catheter in the pulmonary artery reported pressure of seventy over forty in the cardiologist’s lungs, way above the twenty-five over ten pressure that would have been a normal.

“We’ve got pulmonary hypertension,” Carras said.

On the other side of the table, Craig Mason said, “How bad?” and when he saw the numbers on the monitor, “Oh, shit.”

Now a heart transplant could not guarantee the life of Cory Goldenberg. Years of progressive heart disease had thickened and scarred the blood vessels in the cardiologist’s lungs. Even a heart from a young, healthy fifteen-year-old might not have the strength to overcome the vessels’ acquired resistance.

Now that immunosuppressive drugs had controlled the problems of rejection of foreign tissue by a recipient’s immune system, pulmonary hypertension was the leading cause of death after heart transplants. The normal heart was put into a system that had adapted to abnormality. The normal heart often couldn’t handle the load. Fifty percent of such patients died not long after receiving new hearts. Cory Goldenberg’s numbers put him in the highest category of risk.

The right ventricle of the donor’s heart had only had to cope with normal systolic pressure in the maze of blood vessels that permeated the teenager’s lungs. It was, as is natural, a thin-walled chamber, only one fifth the thickness of the powerful left ventricle, which had to pump blood to the rest of the body.

But the right side of Cory Goldenberg’s heart had spent almost the same number of years pushing against blood that had backed up in his lungs because the weakened left side of the organ could not pull it along into the rest of the circulatory system with sufficient strength. To compensate, the right side of Goldenberg’s diseased heart had grown unnaturally thick and strong.

Carras had lectured on the problem often enough. “The right side of the diseased heart is like a body builder who has been curling fifty- and sixty-pound weights, building Schwarzenegger biceps. That’s the kind of muscle it takes to force blood into the congested lungs.

“But the normal heart is Joe Average, used to curling maybe twenty pounds. Now we put that heart into the chest of someone with serious pulmonary hypertension, and it’s like handing an ordinary person a great big dumbbell and saying, ‘Here, curl this. And keep curling it all day, and all day tomorrow and forever.’”

Carras had not only been lecturing on the problem, however; he had the kind of mind that, when faced with no as the answer to a scientific problem, shot back with, Why the hell not?

Cutting out a heart that had an unnaturally strong right ventricle and a desperately weak left one, and putting in an organ that was normal on both sides, simply didn’t work. There had to be another way, yet every logical approach he considered came up dry. But Carras had learned that when his rational mind had gone round and round a problem and found no logical answer, sometimes his unconscious would pull in a solution from way out of any conventional orbit. One of those wild surmises came to Carras one night as he lay dreaming.

He was in the old family kitchen, in the house on Philadelphia’s Market Street where he had grown up. He took a loaf of bread out of the zinc-lined drawer underneath the counter, but when he went to cut a slice from it, he saw that one end was covered in mold. He carried the loaf to the trash container under the sink and was going to throw it away, but then his father was there, young and dark-mustached as he’d been when Athan was a boy, wearing the stained coveralls from the service station that he owned.

He took the bread from Carras’s hand, put it back on the counter and sliced it in half. The moldy end he threw into the trash bin; the other half he held out to Carras, saying in Greek, “To miso eine kalo.” The half is good.

Carras came up out of the dream with the words still echoing in his mind. It was either a dumb idea or it was brilliant. Instead of removing the whole heart, why not take out only the diseased left side and sew the new organ to the Schwarzenegger half that remained? The patient would have a heart and a half, with two right ventricles to cope with the overly high ambient pressure in the lungs.

On the face of it, it was a wacko proposition. The heart was one mass of specialized cardiac muscle. No one had ever tried to separate the two halves. Even in folklore, a broken heart was fatal. How could he cut out half a heart, then stitch a foreign organ to what was left? Carras didn’t know, but once the idea took him, he had to find out.

He put together a small team, himself and Craig Mason plus some students and residents to assist. They started in the morgue, cutting and pasting the hearts of cadavers. Then they sought research funding and began experimenting with live animals.

Their research plan had estimated two or three years to develop the heart-and-a-half procedure or to prove that it was impossible. In the end, it was five years of part-time lab work. There were endless problems: bleeding from the cut edges of cardiac muscle after they were sutured to each other; interruption of the flow of nutrients to the heart’s muscle cells, so that they starved and died; interference with the network of nerves that acted as the heart’s internal pacemaker.

One after another, they faced the problems and solved them, until they could perform every aspect of the new operation routinely, efficiently and consistently. There came a day when Carras and Mason could say to each other with a confidence born of experience, “We could do this with a human being.”

Could, however, was not the same as should. Mason was ready to proceed immediately to a human trial. There were patients whose lives might depend on it. But Carras was not ready.

“Horseshit and hellfire,” Mason said, “it was your damn dream that started this. Listen to your unconscious and let’s schedule the first op.”

They were in the lab watching a pig that now had a heart and a half munch its way through a cabbage. The animal’s chest incision was almost fully healed.

“Look at Porky, here,” Mason said. “He’s happy as a pig in shit. There’s people who need this special thing we can do.”

“Human trials are a big risk,” Carras said. “Animal models aren’t always a reliable indicator.”

“Well, what do you want to do? We don’t have any half man, half animals to work our way up through.”

“Let’s take it to the HIC,” Carras said. “I talked to Charlie Vance and he said they’d be willing to assume responsibility for oversight.”

Carras’s longtime friend Charlie Vance was a dual degree holder, with an MD and a PhD in philosophy, who specialized in medical ethics—he described himself as a “doctor of philosophy and a philosopher of doctoring.” Vance was a member of Yale’s multidisciplinary Human Investigations Committee, whose purpose was to guide and regulate researchers through the complex thickets of moral questions that often sprang up between the orderly gardens of existing knowledge and the deep dark woods that were the unknown.

The committee met in the august Beaumont Room above the rotunda of the massive Sterling Library. Carras and Mason presented a summary of their work to date, much of it already familiar to the committee members from papers the two researchers had published in professional journals. “We are confident that we have validated the technique in the animal models and believe it is time to consider a human trial,” Carras concluded the presentation.

The committee’s chair, the renowned geneticist Taylor Bentham, looked to his left and right, peering over his half-glasses at the other HIC members ranged on either side of him behind the long antique table. “Responses?” he said.

Charlie Vance had always reminded Carras of Jack Nicholson playing Mr. Chips: the face was a close resemblance and the voice was almost identical. Now the ethicist leaned forward from one end of the panel and said, “I have complete confidence in Drs. Carras and Mason. It is good of them to have come before us, even though they did not have to. I say we define a set of conditions governing a first human trial and let them get on with it.”

Bentham nodded and again looked up and down the table, finding a general sense of agreement with the proposal. Then a nasal voice said, “I’m not as sanguine as Dr. Vance.”

“Oh, fuck me sideways,” Mason whispered to Carras. “When did Boner get on this committee?”

Carras’s only reply was a shrug, his attention focused entirely on Auldfield. “I don’t find the animal trials,” the small man continued, placing one delicate finger to his slim jawline, “to be suitably comprehensive.”

Vance said, “They’ve been at it five years.”

“The point of this procedure,” Auldfield said, “is to overcome the problem of pulmonary hypertension resulting from chronic heart disease. Yet all of the animal subjects have had normal lung and circulatory systems.”

“Shit,” said Mason. “He’s out to ream us.”

“No, he’s right,” said Carras. “We should have thought of that.”

“He only thought of it so he could ream us,” Mason said.

But Carras was already rising to his feet. “Dr. Auldfield is right. We will test the procedure on animals that have boggy lungs. We can find a way to induce iatrogenic pulmonary hypertension and challenge our operation against it.”

They took healthy pigs and injected a caustic drug that engendered a kind of congestion in their lungs that closely mimicked pulmonary hypertension in humans, left the animals in that condition for a few weeks, then performed the new procedure. Each time the new heart and a half began to beat, they watched the monitor and saw the enhanced organ steamroller through the high blood pressure in the lungs.

But when they went back to the committee, Auldfield said, “You have an experimental group but no control group. How do we know that an ordinary heart transplant might not have handled the induced lung pressures?”

Mason wanted to argue. “You know that regular transplants don’t handle the problem in humans. That’s why we came up with this procedure.”

But Carras again had to cede Auldfield the ethical high ground. An experiment without a control group proved nothing. So they went back to the lab and did normal heart transplants on pigs with boggy lungs. The normal hearts failed, just as they always had in humans, and the pigs died.

“All very good,” said James Bonar Auldfield when they appeared before the committee again, “but how long do your experimental subjects live?”

“What’s that got to do with anything?” Mason said. It was normal to sacrifice the experimental animals as soon as the results of the experiments were known. It was difficult to care for the creatures after major surgery, especially larger ones like calves and pigs. It was also expensive. “It’s not provided for in our budget,” he concluded.

“Are you comfortable performing this procedure on a human subject,” Auldfield said, “when you have no indication, even from animal models, what the long-term results will be?”

“He’s got us again,” Mason whispered to Carras.

“He’s right again,” Carras replied.

“He just wants to screw us.”

“Actually, he wants to screw me,” Carras said. “You’re just collateral damage.”

“Collateral or not, I’m still getting damaged here, Ath,” Mason said. “I think we’ve taken enough of this crap. If we put up a fight, the committee will split, but I’ll bet Bentham will rule in our favor.”

“But we’ll have won through politics. Auldfield would have the ethical high ground.”

“So what? We can get on with saving some lives,” Mason said. “Listen, Ath, what’s more important, launching a procedure that can save lives or beating that little prick at his own game?”

But Carras wouldn’t budge.

Carras knew that medical ethics had come a long way since the fifties, sixties and seventies, the heyday of creative innovations in cardiac surgery. In those days, the great cardiothoracic pioneers—Cooley, DeBakey and Lillehei—had wasted no time between preliminary testing of a new procedure and the first application to human patients. Many of those patients, even most of them, had died before the surgeons got it right.

Carras had lost patients. Sometimes all his skill and experience couldn’t let him undo the harm that disease or trauma can do to a human heart. He remembered every one of the failures, and every one of them hurt.

It was wrong to risk people’s lives, even the lives of those already on the lip of death, if there was a way to pretest the procedure on animals. He’d said it often enough in the debates that went on among those who were literally on the cutting edge of new medical techniques. Now James Bonar Auldfield was knowingly using Carras’s own standards against him.

“He wants to be able to call me a hypocrite,” he told Mason, their heads together and voices low. “I’m not going to give him the opportunity.”

“Sticks and fucking stones, Ath.”

“No, Craig, I’m going to agree to the extended trials.”

“But who’s going to say when enough time has passed?”

“Bentham’s a sound man. When it’s been a reasonable length of time, he’ll say it’s enough.”

Mason looked at Auldfield’s carefully composed face. “You never should’ve hung that nickname on the little asshole,” he said.

It had been two months and three days since the last series of operations on animals who’d been given boggy lungs. The three pig patients were coming along fine, the enhanced hearts pumping blood into resistant blood vessels that would have stymied normal transplanted organs. The pigs were thriving while human beings with similar problems were being denied heart transplants because of the risk of failure; or worse, they were receiving the transplants and dying.

Carras had decided to give the trials a few more days—that would make it ten weeks—before going back to the committee. Then Cory Goldenberg had collapsed in his office and the Boston teenager’s heart had been a good match.

*   *   *

CARRAS LOOKED INTO THE GAPING SPACE THAT WAS THE OPENED chest of Dr. Cory Goldenberg, at the grossly swollen mass that was the cardiologist’s diseased heart, its function assumed for now by the humming, gurgling heart-lung machine. Let me think, he had said to Mason. But what was there to think about? He knew he could save this useful man.

“Look, Ath,” Mason said, “so you gave your word to the committee. Do you think if Bentham was here, he’d tell you to plop that kid’s heart into Cory and if he died, tough shit?”

“It will be technically a breach of ethics,” Carras said.

“Then we’re doing it?”

“We’re doing it.”

“Damn straight,” Mason said, and Martini, the anesthesiologist, put in a “Roger that, Ath.”

“But this is on me, guys,” Carras said. “If we blow it, Auldfield will call out the dogs. But it’s me they’ll be chasing, because it’s me he wants.”

“And we all know why,” Mason said, with a wink to one of the nurses.

“Never mind the history,” Carras said. He held out his gloved hand to the circulating nurse and said, “Scalpel.”

CHAPTER 2

Even if the event that made them lifelong enemies had never happened, Athan Carras and James Bonar Auldfield would never have been friends. They were as different as two members of the same profession could be. Auldfield was an internist; he treat