If major heart surgery is necessary, it helps to have good timing. That was the case with William Shoenberger, 59, of Dunbar Township, Fayette County, whose cardiologist now calls him Pioneer Man.
Initial health concerns arose in 2006 when Mr. Shoenberger had trouble walking his 14-acre farm with a logger. Further testing after an initial diagnosis of pneumonia revealed his heart to be nearly three times normal size and pumping at less than 10-percent efficiency.
After years of heart drugs, followed by implantation of a defibrillator and pacemaker, he was listed in April for a heart transplant. By October, UPMC cardiologist Jay K. Bhama recommended the implantation of a left ventricular assist device, or LVAD, sooner rather than later, to bolster heart function while he awaited a new heart.
Then Mr. Shoenberger received especially good news as the time approached for surgery for someone whose love of the outdoors equals his distaste for hospital stays. Dr. Bhama offered him the opportunity to be the first Pennsylvanian -- one of a few dozen patients nationwide -- to undergo minimally invasive surgery to implant the LVAD. That would mean the typical three- to four-week hospital stay would be cut by half or even more. He'd also have much smaller scars.
"I wasn't nervous," Mr. Shoenberger said. "I was just glad I wouldn't be in the hospital too long,"
So it happened. On Nov. 30, Mr. Shoenberger was summoned to UPMC Presbyterian only three days after Dr. Bhama returned from Germany, where he was trained to perform the minimally invasive LVAD surgery.
"I heard they had a training program in Germany for minimally invasive LVAD, which I thought might be a great option for some of our patients," Dr. Bhama said, describing those needing the procedure as "the sickest of the sick." "If you can do the surgery with smaller incisions and quicker recovery, you might really help them in an important way, given that they are so sick when they come to see us."
After more than 10 hours of surgery on Dec. 3, Mr. Shoenberger awakened to the name of Pioneer Man.
The LVAD replaces the heart's most important function, with the left ventricle responsible for pumping oxygenated blood throughout the body after it arrives from the lungs. Traditional LVAD implantation required the surgeon to saw open the sternum from collarbone to just above the stomach to gain access to the heart.
The golf-ball-sized HeartWare device, resembling a small yo-yo with a smokestack rising from its center, is implanted into the left ventricle so blood entering the heart flows into the smokestack-like port. The rotor inside the device uses hydrodynamic and passive magnetic force to send a steady blood flow through a tubular graft to the aorta for transports body-wide. A thin electrical cord exits the skin to a control pack, powered by ion lithium batteries, that hangs from the belt or over the shoulder.
Mr. Shoenberger's surgery required only two small incisions, one in the upper sternum and another in the left side of the chest. Through these incisions, Dr. Bhama separated the smaller portion of ribs and upper sternum with a retractor to gain access to the heart. Each of the two incisions are one-third the length of the incision to open the entire chest.
Heart pumps exist to help the right, left or both ventricles. Some are temporary while the person awaits a transplant. Others are permanently implanted when a heart transplant isn't feasible. Minimally invasive procedures already are used for heart-valve repair, heart-pump replacement procedures and heart-bypass surgeries.
Lee Goldberg, a cardiologist with the University of Pennsylvania, speaking on behalf of the American College of Cardiology, said minimally invasive procedures offer many advantages but also have a few negatives of which surgeons must be aware.
"The advantage is not only a quicker recovery but also the lower risk of infections, strokes and other complications associated with being on a bypass machine during surgery, which also can disrupt kidney function," he said. "If you can avoid those problems, then it can improve outcomes."
But risks increase for patients with scar tissue in and around the heart from previous surgeries. In those cases, traditional surgery may be necessary, Dr. Goldberg said.
Less invasive methods of boosting heart function are being designed and tested, including devices inserted into blood vessels via catheters. They can boost blood flow by a few liters per minute, which can be sufficient to help some patients.
"The newer devices are designed to be implanted through minimally invasive surgeries. Existing devices, including HeartWare, which Mr. Shoenberger received, were designed to be implanted in traditional fashion, with "clever surgeons figuring out ways" to implant them less invasively, Dr. Goldberg said
The newer methods are designed to be implanted more efficiently, with less bleeding, fewer transfusions, and quicker recovery time to increase chances of survival, he said.
Since Mr. Shoenberger's surgery, Dr. Bhama has performed a second successful minimally invasive LVAD surgery. "Both patients have had the shortest hospital stays than ever happened at Presby -- 10 days versus three or four weeks, with a minimum of two weeks," he said.
The LVAD surgery boosts Mr. Shoenberger's chances of survival.
"It means he doesn't die from heart failure," Dr. Bhama said. "Twenty years ago people were dying because of this. Now not only do you live, but you have five liters of blood pumping per minute, which allows him to live to do things he wants to do with a higher energy level and better quality of life as he waits for his transplant."
The transplant likely will occur in coming months, but only after Mr. Shoenberger recovers enough to return to the transplant list. While his heart function still is low, he said he's feeling better by the day. Soon he said he hopes to venture outside for more physical activities, including riding a Harley-Davidson motorcycle -- activities he couldn't do prior to surgery.
"Dr. Bhama calls me 'Pioneer Man,' " Mr. Shoenberger said. "Everyone calls me a pioneer because I'm the first person in Pennsylvania." He's seeking donations through PNC Bank to help pay for the transplant.
"My new life? It will involve getting back to my old life."
Correction (Jan. 20, 2014): William Shoenberger's residence has been corrected. Also, the name of the HeartWare implant device was corrected.
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