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Heartsick

How the Medical College of Virginia lost stature in the world of cardiac surgery.

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No one would patch the hole in Maria's heart. Nothing personal, just that surgery was too risky. The doctors in Mexico knew this. So did the surgeons in Phoenix.

The hole allowed years of pressure to build in Maria's lungs. Oxygenated blood mixed with deoxygenated blood, eventually creating what's known as pulmonary hypertension. At 32, she could drop dead at any moment.

In the fall of 2000, Maria Garcia, a native of Guadalajara who didn't speak a word of English, found herself in Richmond sitting in front of Dr. Richard Lower, who just so happened to be a retired heart surgeon volunteering as a family doctor at a local clinic.

Maria's lips were blue from the lack of oxygen in her blood. Lower (pronounced like “power”) immediately asked about her heart.

A towering, leathery man fond of the great outdoors, Lower pioneered the surgical techniques still used today in heart transplants. He not only taught the procedure, he invented it in the 1960s. For years he ran one of only two heart transplant centers in the world, at the Medical College of Virginia at 12th and Broad streets.

Maria was in luck. It's unclear exactly why she was in Richmond, but she somehow stumbled into the old surgeon at Cross Over Ministry's outreach clinic at Sherbourne United Methodist Church in Chesterfield County. It was like discovering Joe Torre coaching your son's Little League team. Lower, 75, pulled the woman's medical history and called one of his former students, Dr. Jim Zocco at CJW Medical Center, and asked him to take a look. She had an atrial septum defect.

“She was pretty high-risk, and she was really sick,” Zocco recalls. “Did I think she was inoperable? All of the preop tests pointed to that.”

Zocco probably would have concluded the same. Except his teacher was telling him otherwise.

Lower is the man who put MCV, and Richmond, at the forefront of clinical surgery for more than 20 years. MCV had been an A-list choice of the best and brightest medical students in the country, many of whom went on to start their own surgery programs at other hospitals. Zocco, who left MCV to practice at Chippenham in 1983, was one of them.

“Like everybody who has ever trained under him, he's my hero,” Zocco says. “He called me and said he thought (surgery) would work. You have to understand, he is the giant in the field. With his coaxing I felt pretty comfortable doing it.”

So he did. In February of 2001, Zocco and his team took Maria, who had no insurance, under the knife on the hospital's dime at the Chippenham medical campus of CJW. The hospital even paid for the $10,000-a-day medication that kept her alive during and after the operation.

As usual, the old man got it right. Maria survived, returning to a normal life in Mexico a few months later. “She did extremely well,” Zocco recalls, refusing to take credit for her successful operation and quick recovery. “The basic thing that saved this woman is she happened to show up in Dr. Lower's clinic.”



It was just like old times — another happy ending for Lower and the boys. Years ago, patients like Maria routinely flocked to Lower's heart program at MCV, looking for help when everyone else had given up. In the 1970s and early 1980s, the hospital did more heart transplants and open-heart surgeries than most institutions in the country. The high volume of heart patients allowed Lower and his fellow surgeons to track new methods for treating heart disease, to hone their skills in complicated surgeries such as valve repair, and to master the holy grail of cardiac procedures — heart transplants.

Sixteen years after his 1989 retirement, Lower's students are now running top-notch heart programs at Barnes-Jewish Hospital in St. Louis, Sentara Norfolk General Hospital and, locally, at CJW Medical Center, St. Mary's Hospital and Henrico Doctors' Hospital. His students are famous. One, Dr. Thomas M. Krummel, is now head of surgery at Stanford. Another, Dr. Benjamim L. Aaron, pulled John Hinckley's bullet out of President Ronald Reagan.

But none remain at MCV. (Technically, it's not MCV anymore. Last year officials at Virginia Commonwealth University renamed its medical arm VCU Health System for marketing purposes.)

The fact that Maria got her life-saving surgery outside the halls of the teaching hospital may be more luck than anything. But her story illustrates the shifting paradigm at the hospital, which built Richmond's storied reputation as a town of the heart.

When Lower left — he retired to a 2,000-acre ranch in Montana — MCV's famous heart program took a dive. Many cardiac and general surgeons bolted to private practice. With new leadership — a renowned academic surgeon from Duke University, Dr. Andrew S. Wechsler, had been named chairman of the surgery department — the Richmond institution underwent a sea of changes.

The move away from MCV had started a few years earlier. Competition was brewing in the suburbs. Chippenham started an open-heart surgery program in 1979 under Drs. Harold L. Levinson and Lewis C. Bosher, who recruited surgeons such as Zocco away from MCV in the early 1980s. At the same time, open-heart surgery became more routine. Patients preferred receiving treatments closer to home. MCV was still the central institution, and the place to go for heart transplants and more serious conditions, but all that changed dramatically by the later part of the decade.

After Lower retired, the program fell into dire straits. After averaging about 90 transplants a year in the early 1980s, in 1989 the number fell to 18. At least one former surgeon recalls the number of open-heart surgeries — things such as coronary bypasses and valve replacements — dropped by half. At one point, the heart transplant center was forced to close because there were no surgeons left.

Few would suggest that VCU Health System is falling apart. The teaching hospital is gaining recognition for a plethora of good programs. The Massey Cancer Center is growing in prominence, the neurology department has for years been nationally recognized, and the hospital houses the only Level 1 trauma center in Central Virginia.

But the vacuum created by the heart program, especially the heart transplant center, has left the university without a national marquee. As a whole, MCV barely registers a blip on the coveted U.S. News & World Report hospital rankings, and last year administration officials buried the MCV moniker for good.

To many, MCV lost its identity when it lost its heart. The story behind the fall of MCV's storied heart program is one of changing demographics, strained leadership and a host of new forces facing the program and academic centers across the country.



At the Cross Over clinic in Richmond, Dr. Lower doesn't like discussing the demise of his heart program. But he fondly recalls roaming the linen-white halls at 12th and Broad, ruffling the world's feathers with Dr. David Hume, who performed the first kidney transplant, and the flamboyant Dr. Christiaan Barnard, who did the first heart transplant in South Africa in 1967.

Back in the 1960s and 1970s, MCV was not only one of the best-known hospitals in the country, but it was a bastion of clinical research and innovation. Dr. James Brooks, who worked with Lower in the late 1960s and still teaches clinical surgery at VCU Health System, says the atmosphere with Hume and Lower was electric. “Patients are sent to you worldwide,” Brooks recalls. “There was a tremendous amount of espirit de corps here.”

In fact, Lower remembers nearly doing the first heart transplant in 1966. They had a donor and a patient almost perfectly matched, except for blood type. Dr. Lower, who did the first heart transplant in a dog that lived years earlier, refused to go ahead with the human transplant, fearing it was still too risky.

At the time, heart transplants were considered by many to be ethically and morally wrong. “People were pretty sensitive about the heart in those days,” says Lower. “It wasn't just another organ that you could just switch around.”

In fact, Lower's first transplant at MCV resulted in a landmark lawsuit. The family of the heart donor sued Lower and MCV for taking a still-beating heart. The case — the lawyer for the family was former Gov. L. Douglas Wilder — was dismissed, but not before creating a new standard of death that changed surgery. Afterward, organs could be removed from donors once they were declared “brain dead,” which meant surgeons could snatch them up in prime condition.

Once, during a medical conference in the mid-1960s, he remembers speaking publicly in front of a large glass container that contained the heart of a cadaver. Amazingly, a human heart can be revived outside the body with an infusion of oxygenated blood. It was pure science fiction: A human heart, in a glass jar, pumping and gyrating by itself.

A dumbfounded photographer approached Dr. Lower and asked him about it. He assumed it was a dog heart. When Dr. Lower told him otherwise, the photographer walked away stunned. “He said, ‘God help us!'” Lower remembers.

He has a million stories. There was the time when Christaan Barnard — an international celebrity before he did the first heart transplant — observed Lower in his lab for a few months learning kidney transplants. Barnard didn't have the proper training to do a heart transplant, and Lower and Hume figured there was no way he'd try. “I thought that would be nuts,” Lower recalls thinking when Barnard's technician whispered that his boss was planning one. In retrospect, he's glad Barnard went ahead (although his patient died within a couple of weeks from pneumonia) considering all the bad press the breakthrough generated.

“He was a kind of a bad actor,” Lower says of Barnard, regularly seen around town with multiple women in tow. “He had young girls hanging all over him.”

After leaving Stanford in 1965, Lower and his teacher, Dr. Norman Shumway, had established a friendly rivalry. Hume had come to Stanford attempting to recruit Shumway first, but was turned back. As a consolation, Dr. Shumway offered up Dr. Lower. And the rest is history. “I had no pride in those days,” says Lower, adding that he made $18,000 a year. “I thought it was very exciting to have my own show.”



Upon his own arrival at MCV in 1988, Wechsler says he sensed change was afoot. With the hospital's heyday under Lower coming to a close, Wechsler decided the teaching hospital needed to ramp up its academic research. He says the focus on clinical surgery had overshadowed the department's research efforts.

“I think the fundamental science or research program was fairly minimal or nonexistent,” Wechsler recalls. “I wanted surgeons who had a strong emphasis in teaching and research and clinical surgery.”

With the shift of patients to suburban hospitals, MCV needed an edge. By focusing on new techniques and research, Wechsler wanted the heart program to regain its place at the forefront of cardiac science. But Wechsler's plans, and management style, rubbed some of Lower's surgeons the wrong way.

A little more than a year after Wechsler took over, MCV's top heart transplant surgeons — Drs. Lower, Marc R. Katz, Szabolcs Szentpetery and Glenn Barnhart — had left. The most devastating blow probably came when Katz resigned in August of 1989. As the last heart surgeon on staff, his departure to start a new heart program at Henrico Doctors' forced MCV to shut down the transplant center temporarily.

Katz says he left for a better opportunity. And he felt MCV was going in a new direction.

Over the next 10 years, Wechsler recruited several top surgeons from across the country, but had difficulty keeping them. With the newfound competition in the suburbs, he says it was difficult to maintain a strong referral system, a critical part of the program.

“The cardiology practice at MCV was very much a referral practice,” Wechsler says. “As the skill level was transferred from the medical center to community hospitals, patients tended to stay closer to home.”

In other words, Lower's surgeons took their business with them. By the time Wechsler left for Philadelphia in 1998, suburban doctors were doing considerably more open-heart surgeries than MCV. And that's precisely why Wechsler left.

“I personally wanted to operate at a higher-volume center,” Wechsler says. “Volume is important in academic medical centers because it allows you to have a critical mass of faculty. I don't know of any great academic programs in the country that are minimal-volume programs.” In 1997, the year before Wechsler departed, MCV did 419 open-heart surgeries; Drexel University's Hahnemann Medical College in Philadelphia was regularly doing 1,500 a year.

It got worse. MCV hit a low point in 1999 when the heart center did 175 open-heart surgeries, according to the Virginia Health Network, compared to 995 at CJW and Henrico Doctors'. That year, MCV did only one heart transplant.

Some say Wechsler was part of the problem. His autocratic management style, says Dr. Gerardo Mendez-Picon, who did kidney and liver transplants under Lower, pushed people out. Mendez was one of them. He left MCV to start a kidney and liver transplant program at Henrico Doctors' in November 1989.

“I would have never thought of leaving if it wasn't for the fact that Dr. Wechsler came to town,” Mendez says. “He had a way of doing things that was contrary to the traditions of MCV.” Mendez says it still hurts to talk about it. He loved MCV, where he spent more than 21 years, and thought he'd spend the rest of his career there.

Wechsler's clashes with faculty even landed in court. When Dr. Gary K. Lofland attempted to move his pediatric heart surgery practice to Henrico Doctors' in 1994, Wechsler and MCV sued Lofland in a contract dispute. The lawsuit turned into a public battle that pitted parents of children needing life-and-death heart surgery with MCV, and, at one point, even involved the governor. Wechsler, in a letter to officials at Henrico Doctors', also called Lofland's character into question.

“Gary's time at MCV has been marked by difficult interpersonal relations, explosive behavioral patterns and other psychomotor oddities that we can discuss further, if you wish,” he wrote in the letter, dated March 2, 1994.

The suit was settled in arbitration that November. Wechsler says if Lofland really felt attacked, he wouldn't have settled. “The short answer is we won,” Wechsler says. “Obviously that was an attempt to move a program [at MCV] into the community … that would have been a bad move.”

But the damage had been already done. If the relations between MCV and the community hospitals had been a tad testy, they were now bitter.

Case in point: Shortly after Wechsler left, Zocco says MCV approached his surgical group — Cardiac & Thoracic Surgical Associates, which includes former Lower students Drs. Katz, Timothy Wolfgang and Richard Reynolds — about helping with the training of MCV residents while it attempted to rebuild its program. Those talks never progressed, Zocco says. When Dr. Robert S.D. Higgins stepped down as chief of cardiothoracic surgery at MCV in 2002, Zocco says his group again approached MCV and offered to help train the cardiac residents. He says it was turned away.

“They basically told us they didn't think they needed the resources of our practice,” Zocco says of the meeting.

Dr. Sheldon M. Retchin, chief executive officer at VCU Health System, remembers the meeting a little differently. He says he met with Zocco and other hospital officials about establishing a relationship, but didn't understand the purpose.

“It was unclear exactly what they wanted,” he says, “other than, perhaps, to take some of our surgical volume.” Still, Retchin didn't dismiss the inquiry out of hand. “I said, ‘Bring me a proposal.'”

He never received a proposal. Besides, Retchin remembers expressing to Zocco's group that MCV, under new cardiac chief Dr. Vigneshwar Kasirajan, didn't need any help. “I don't think there is anything they could offer that we don't have,” he says. “I have a superb team I didn't want to disrupt.”

The issue, Zocco says, concerned the lack of volume at MCV. Without enough open-heart surgeries, recruiting the best residents to Richmond is difficult. “We have an interest in good residents,” Zocco says, adding that now his group is discussing a possible partnership with the University of Virginia.

Making matters worse, the cardiothoracic surgery residency program at VCU recently lost its accreditation from the American Board of Thoracic Surgery. University officials say the program lost its status because of a “turnover in program leadership” and had nothing to do with a lack of volume or quality of care. An official with the surgery board wouldn't discuss why the program lost its status, other than to say that VCU's residency program was withdrawn. Pam Lepley, a VCU spokeswoman, says the university is reapplying for accreditation and plans to have it up and running by July 2005.

Great residents were critical to the program under Lower. The doctor says MCV, with its immense volume of patients, gained critical insights into postoperation care. With transplants, especially, controlling the immune system's natural rejection of a new organ is the difference between life and death.

“The second patient [to receive a heart transplant at MCV] lived for six years, and he was the longest living patient in the world,” Lower recalls. “That was the problem: Managing the patient's postop. That's why we thought it was better to have a large number of patients, so you could study the results.”

The high volume of surgeries also boosted university's bottom line. As a public hospital treating a disproportionate number of uninsured patients, MCV had cornered the market in the highly skilled, and profitable, arena of open-heart surgery. With 64 million Americans suffering from heart disease, cardiac care is one of the foundations of just about every hospital.



Dr. Kasirajan agrees that the hospital needs to increase its surgical volume, but says the quality of care and range of expertise at the teaching hospital is as strong as ever.

The program is breaking new ground in coronary heart disease — essentially blocked arteries — with advanced stents that prop open the arteries. There are artificial pumps inserted into the hearts of patients awaiting transplants. New advancements, of which Kasirajan is a pioneer, now suggest the tiny pumps provide a long-term alternative for patients who previously needed transplants.

And the gem, perhaps, may be the advanced electrophysiology lab. The new state of the art facility includes what's known as a bi-plane X-ray machine that limits patient exposure to radiation in the treatment of irregular heartbeats and coronary disease.

Retchin couldn't be happier with the program. A thin, long-faced man with dark-brown hair, he grabs several textbooks from his office bookshelf and spreads them across a coffee table. “See what I'm doing here?” he says, pointing to the titles, one of which is the newest text in electrophysiology, co-authored by VCU's Dr. Kenneth A. Ellenbogen.

“I view it in terms of how it's viewed nationally. Who writes the textbooks?” Retchin says. “In this business, perception is reality. Nationally, our cardiac program has gained in recognition.”

Not everyone agrees.

VCU Health System is specializing in everything but the cr‹¨«me de la cr‹¨«me — major heart surgery and transplants. While it remains busy, some argue, the real breakthroughs in heart surgery are taking place at places like Henrico Doctors', where Dr. Katz performed the first FDA-approved robotic-assisted thoracic surgery in the country in March 2001.

Katz, one of the pioneers in the growing field of “closed-chest” coronary bypass surgery, says it's time his alma mater took off the blinders.

“The reality is there has been more innovation in the community in recent years than at MCV,” says Katz, who met with VCU President Eugene Trani about establishing a relationship with the university a couple years ago. “We were told, ‘No thanks.'”

Even Wechsler concurs with his former colleague on this point. The university has always restricted its doctors from practicing at the community hospitals, and that's left the program on an island, he says. It started when Dr. Lower first resisted overtures to start a sister program at Chippenham in the late 1970s. That mindset hasn't changed. Now, to regain its stature as a nationally prominent heart program, Wechsler says volume will have to increase. But it may be too late.

“I don't think cardiac surgery will change appreciatively until cardiology changes,” he says.

Recapturing the glory days when MCV built its reputation on heart transplants now seems next to impossible.

During the 1980s, hundreds of new heart programs, many specializing in transplants, opened to capture a piece of the cardiac surgery market as advancements with the procedures matured, creating less need for academic centers. As for transplants, the number of hearts available leveled off — it's hovered around 1,800 to 2,000 for the last two decades. Meanwhile, the number of hospitals doing transplants has exploded.

When MCV lost its surgeons in the late 1980s, there were plenty of other programs across the country to pick up the slack. Nobody knows this better than Dr. Irving L. Kron, chairman of the Department of Surgery and Cardiovascular Surgery at the University of Virginia Medical Center in Charlottesville.

In 1989, U.Va. performed three heart transplants. But in the next three years, as MCV's transplant center tapered off, it did 70. Kron says the new leadership at VCU Health System, under Dr. Kasirajan, is capable of returning the program to national prominence. But it takes time. “They haven't been around that long,” he says. “I think they have a real chance to recapture the market.”

Still, recapturing the market and becoming a major transplant center means something entirely different in 2004. The days of 90 transplants a year are long gone. “Today, statistics show that centers that do 30 or more heart transplants a year are in the top 10 percent,” Wechsler explains.



Like MCV, Lower is now out of the spotlight. After retiring, he spent seven years running a ranch in Montana before returning to Richmond. A friend had asked if he'd volunteer at Cross Over from time to time. No problem, except that his license had lapsed. He passed the test on the first try.

And now, he says with a wry smile, he's back where he started. “I really wanted to be a [general practitioner] when I was in medical school,” he says.

Now he is. When the old cowboy enters the tiny kitchen at Cross Over Ministry's clinic on Cowardin Avenue, one can feel something like divinity. The nurses and other doctors, all milling about in other rooms, are energized by his presence. Lower works hard not to notice how the staff beams with pride because of him. Perhaps the greatest doctor Richmond has ever known works in a free clinic on South Side.

“It's no big deal,” he says. “I guess now I'm doing what I always wanted.” S

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