Cardiologist helps athletes get back in the game

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When Will Kimble fainted during a 2002 basketball practice at Pepperdine University, it looked like the end of his career.

A scan of his heart showed Mr. Kimble suffers from hypertrophic cardiomyopathy, a heart defect that is the most common cause of sudden death in young athletes. A panel of medical experts recommends that basketball players with the condition, known as HCM, should be benched -- and Pepperdine administrators agreed. "I'm not willing to put his life on the line just for basketball," says John Watson, athletic director of the Malibu, Calif., school.

Then a Los Angeles cardiologist named David Cannom evaluated Mr. Kimble. Among cardiologists, Dr. Cannom, 66 years old, is known for giving the thumbs-up to athletes other physicians would bench. After a defibrillator was implanted in Mr. Kimble's left shoulder, Dr. Cannom cleared the young man to play.

In March, the 24-year-old Mr. Kimble finished his second and final season as a center at the University of Texas at El Paso. "I feel blessed to get another shot to participate in what I love," he says.

The debate over whether athletes with heart conditions should be allowed to play raises issues of free will, medical ethics and legal liability. Is the love of sports -- and the dream of a professional career -- worth risking death? Should doctors be in the position of prohibiting adults from playing? What's the difference between competing with a heart defect and pursuing risky adventures like climbing Mount Everest? Should fans be forced to watch a player risk his life?

Dr. Cannom's willingness to let athletes with heart disease compete makes him a renegade among his peers. Last year, a panel of experts sponsored by the American College of Cardiology reaffirmed its recommendation against competitive sports for those with certain heart conditions -- and emphasized people like Mr. Kimble with implanted defibrillators, tiny devices that jolt the heart if it starts beating too fast.

"Division One college basketball is a contact sport," says Barry Maron, head of the Hypertrophic Cardiomyopathy Center at the Minneapolis Heart Institute Foundation. He believes defibrillators don't eliminate the risks.

Research by Dr. Maron suggests that sudden death, usually from heart disease, strikes 200 to 300 young American athletes annually -- a number roughly 10 times as high as some previous estimates. He thinks athletes with heart defects are needlessly endangering themselves to pursue dreams of big-money professional contracts that few will achieve.

Most professional and college sports leagues don't have an outright ban on players with heart conditions; each team or school sets its own policies. But Dr. Maron says it's not unusual to bar people with health problems from some activities. The U.S. Armed Forces and most fire and police departments disqualify recruits for a variety of conditions, including heart ailments.

Dr. Cannom, medical director of cardiology at Good Samaritan Hospital in Los Angeles, has a different view, based on four decades of treating patients with heart disease. He believes many athletes with heart irregularities face little risk of sudden death. A pioneer in the use of defibrillators, he thinks the devices can permit athletes with some heart conditions to compete safely at the highest levels.

For 15 years, Dr. Cannom has been on the medical advisory board of Guidant Corp., a cardiac-implant maker. Since last year, Guidant has issued physician warnings involving more than 200,000 defibrillators and pacemakers because of reports of malfunctions. The warnings began shortly after a young man with HCM suffered sudden cardiac arrest while mountain biking, and died after his Guidant defibrillator malfunctioned. The company faces government investigations and lawsuits over whether it adequately warned physicians and patients about possible defects. Commenting on those lawsuits and investigations, a spokesman for Boston Scientific Corp., which acquired Guidant earlier this year, says "We believe any problems are manageable."

Dr. Cannom says the company should have been talking to physicians sooner about potential problems. But overall, he believes defibrillators are invaluable treatment tools, which have saved many lives, and the percentage of malfunctions is minor.

A former long-distance runner, Dr. Cannom wants athletes to be free to pursue their passion. He says people with heart disease should be evaluated individually. "A lot of this is trying to be a patient advocate," he says. Automatic bans are an easy out for doctors, he says: When saying no, "You're never wrong."

In the process, Dr. Cannom has become the go-to physician for players wanting to stay in the game. A decade ago, he was among cardiologists who cleared a college-bound basketball player who had passed out after suffering cardiac arrest. Last year, he helped persuade the National Basketball Association's New York Knicks to let Eddy Curry play. Mr. Curry's career was in jeopardy after his heart started beating abnormally quickly during a pregame workout in March 2005. Several cardiologists found no cause for the rapid heartbeat, although at least one couldn't rule out congenital heart disease. Mr. Curry, 23, continues to play.

There's little solid medical evidence to guide doctors in assessing this risk. Studies show that barely one out of 100,000 athletes suffers sudden cardiac death. Yet as many as one in 500 people suffer from HCM. That suggests that dozens of athletes would need to be sidelined to save a single life. The risk of playing sports with a heart defect and a defibrillator has barely been studied. The number of people with defibrillators who want to play competitively is small. Dr. Cannom is now pursuing a study with a Yale University cardiologist.

The difficult choice between passion and protection makes some cardiologists yearn for a middle ground. Michael Ackerman, a Mayo Clinic cardiologist who has worked with Drs. Maron and Cannom, says, "I wish we could have a detailed discussion with the families instead of the default -- you have a defibrillator, you're kicked off the team."

Dr. Cannom has specialized in cardiac electrophysiology -- the electrical rhythm of the heart -- for 40 years. Raised in Missouri and Minnesota, he attended Yale Divinity School before enrolling in 1963 at the University of Minnesota's medical school. He worked briefly at Stanford University at the same time as Norman Shumway, who performed the first U.S. heart transplant in 1968.

Settling in Southern California, he helped implant early defibrillators in 1984 while they were still being tested. The electrical device, approved in 1985 by the U.S. Food and Drug Administration, sends shocks through a wire to the heart if it begins beating irregularly. The shocks jolt the heart into beating properly, a sensation akin to the kick of a horse.

Since then, Dr. Cannom and his partners have implanted roughly 4,000 defibrillators. In the early days, the large, clunky devices were placed in the abdomen, mostly in older patients. Over time, defibrillators shrank and were approved as a treatment for more types of heart disease. Today, some 600,000 people world-wide have defibrillators.

Dr. Cannom and others saw the smaller devices as a means to help young patients lead more normal lives. Then, he was faced with young patients who wanted to compete in sports. Among the first was Nick Knapp.

As an Illinois high-school senior in 1994, Mr. Knapp suffered cardiac arrest shortly after agreeing to attend Northwestern University on a basketball scholarship. Soon after, he had a defibrillator implanted. When he arrived at Northwestern in 1995, university officials wouldn't let him play. Mr. Knapp and his father sued Northwestern to let him compete.

Dr. Cannom was one of four cardiologists who recommended Mr. Knapp be allowed to play. Dr. Cannom says he made the decision, in part, because Mr. Knapp had the defibrillator, and had no structural heart damage.

The lawsuit pitted Dr. Cannom against Dr. Maron, who argued on Northwestern's behalf that playing basketball would increase Mr. Knapp's risk of sudden death. Northwestern won the lawsuit, but that didn't stop Mr. Knapp. Backed by Dr. Cannom and the others, Mr. Knapp played two years at Ashland University, a smaller school in Ohio. He quit during his third year after the defibrillator malfunctioned.

Mr. Knapp later had the device removed, and says he has had no further heart problems. He's thankful he had another chance to play. "I was very lucky to have people like David (Cannom) on my side," says Mr. Knapp, now 29 and working in finance.

Dr. Cannom doesn't believe all athletes with heart disease can play competitively. He rules out football for those with defibrillators, for example, because heavy contact could damage the devices. He says he has held a Beverly Hills high-school soccer star out of action for two years because of the nature of her heart disease. He's currently caring for about 15 competitive athletes, he says, primarily water-polo and basketball players.

Other cardiologists wrestle with similar decisions. As a sports-medicine specialist, Paul Thompson has diagnosed dozens of athletes with cardiac conditions too dangerous to let them compete. But as a marathon runner who once qualified for the Olympic trials, Dr. Thompson knows how painful that message can be. He says he has cleared for play athletes whom other cardiologists had benched. "When you tell an athlete he can't compete anymore, a part of him dies," says Dr. Thompson, chief of cardiology at Hartford Hospital in Connecticut.

That's the prospect that Pepperdine's Mr. Kimble faced after he collapsed in November 2002. Physicians who initially treated him ruled out future basketball.

But Mr. Kimble wanted other opinions. He was referred to Dr. Cannom. The two met on Dec. 17, and the following day, one of Dr. Cannom's partners implanted a defibrillator in Mr. Kimble's left shoulder.

Before Mr. Kimble left the hospital, Dr. Cannom set the defibrillator to shock the athlete's heart if it exceeded 250 beats per minute, indicating that his heart was going into cardiac arrest. Even during intense competition, Mr. Kimble's heart would not normally beat that fast.

By spring of 2003, Mr. Kimble says he was ready to play basketball again. He reviewed the risks with his father, also named William, and his mother, who is a physician. Mr. Kimble and his parents offered to sign a waiver relieving Pepperdine of liability if he suffered another heart problem. "We had no qualms about William playing again," says his mother, Irene Donley-Kimble.

But after having Mr. Kimble undergo additional cardiac evaluation, Pepperdine officials refused to let him play. Mr. Kimble traveled with the team and sat on the bench until he graduated in 2004. Athletes are eligible to play basketball for a total four years, in either undergraduate or graduate school. Since Mr. Kimble had only played two years, he was interested in continuing to play when he went to graduate school.

That summer, he played in a recreational league at the University of California, Riverside, where he caught the eye of coaches from that school and the University of California, Los Angeles. Officials at both schools spoke with Dr. Cannom but decided against allowing Mr. Kimble to play, unwilling to assume the potential liability and not wanting to risk having an athlete die on their courts.

"A lot of schools were worried about the publicity if something happened," or a lawsuit, says Dr. Donley-Kimble. "We were real disappointed."

The risks are real. After 22-year-old Antwoine Key died of undiagnosed HCM during an Eastern Connecticut State University basketball game last year, his father obtained medical records that showed Mr. Key had previously been diagnosed with a heart murmur. Medical experts recommend young athletes with heart murmurs undergo a scan, like the one that detected Mr. Kimble's HCM. Yet the medical records Mr. Key obtained showed no evidence that either the doctor who found that murmur or representatives of two college teams that received his records ever sent him for a scan. "He would never have kept playing if he knew he had this problem," says his father, Anthony Key.

Eastern Connecticut State University declined to comment.

It's not clear that defibrillators reduce the risk of sudden death for athletes. Doctors worry a defibrillator won't withstand the rigors of competition, or that a blow to the chest or shoulder could damage the tiny wire that delivers the shocks to the heart.

When Mr. Kimble decided to go on to graduate school in education, he was still looking for a school where he could play. By August 2004, through a coaches' pipeline, his name made its way to the University of Texas at El Paso.

At least once before, the school had let back onto the court a player diagnosed with a heart condition. In 1966, Willie Cager was sidelined because of a heart murmur. He later returned, playing four minutes at a time, to help the team become the first with an all-black lineup to win the National Collegiate Athletic Association championship.

Nearly 40 years later, the university's athletic director, Bob Stull, initially opposed letting Mr. Kimble play. But he and his staff consulted with cardiologists, including Dr. Cannom, as university officials tested Mr. Kimble's fitness. During one test, "he almost broke the treadmill," Mr. Stull says.

Mr. Stull also consulted with Kenneth Shine, executive vice chancellor for health affairs for the University of Texas system, who previously worked at UCLA and knew Dr. Cannom. After reviewing the case and speaking with Dr. Cannom, Dr. Shine gave the go-ahead. "It makes perfectly good sense to allow people to engage in sports" if tests show they can withstand the stress, and other safeguards are in place, says Dr. Shine.

The family signed a waiver relieving the school of liability. Dr. Cannom didn't ask them to sign one with him.

Dr. Cannom acknowledges that an athlete or his family could still file a lawsuit against him. But he says, "giving opinions is what we do and you have to believe in yourself that you are correct." He feels he shares responsibility for an athlete's health with the family and the collegiate staff. "It's a communal risk," he says. "You can't be a cowboy."

By October 2004, the school's trainers and a local cardiologist formed a game plan so Mr. Kimble could start practice. It included testing his defibrillator at least once a week during practice and after every game. Mr. Kimble had a special shirt made with a foam patch that covered his upper chest and shoulder where the defibrillator was implanted, to reduce impacts. If he passed out on court, medical staffers were prepared to swiftly move him out of sight for treatment.

Mr. Kimble played two seasons at the University of Texas El Paso without needing a shock from the defibrillator. "I love being out there," he says. "I wouldn't have done it if I had a doubt in my mind." But basketball team trainer Michael Gutierrez says he was nervous during each practice, and each time Mr. Kimble fell.

After playing 18 minutes in his second-to-last collegiate game in March, Mr. Kimble sat with the team trainer and a sales representative for Medtronic Inc., the maker of his defibrillator. The school required a company representative to be at every game, to test the device.

As he has done dozens of times, Mr. Kimble slid a round wand over his T-shirt and the defibrillator implanted in his left shoulder. A minute later, a Medtronic representative printed out a beat-by-beat report on Mr. Kimble's device and his post-game heart. There were no irregularities.



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