Moving Beyond Double Trouble

Patient overcomes major challenges with mechanical assistance

Anitra Kimble doesn’t remember much about the illness that nearly took her life. But then again, she really doesn’t want to know the details. Those are details her medical teams at the Texas Heart Institute at St. Luke’s will likely never forget. Anitra was in her last semester of undergraduate studies at Northwestern University when she became ill.

“It was January and I had a bad cough. I thought it was a cold but it seemed to last forever. Whenever I was doing regular activities, I became short of breath. I would take just a few steps and I couldn’t breathe,” she said.

Months of medical tests proved futile as doctors tried to find out what was wrong with Anitra. Her health continued to deteriorate. The last thing she remembers is the ambulance ride to Houston. Weeks later, Anitra woke up fully to find she had a new heart and lungs. What happened in between was a major battle to save her young life. The enemy was primary pulmonary hypertension.

“Primary pulmonary hypertension is not well understood. The exact cause is unknown. Small vessels inside the lungs gradually become thicker and thicker. As a result, the pressure across the lung bed keeps going up. This puts a tremendous strain on the right side of the heart, which becomes thicker as it tries to generate more force to put that blood across the lung tissues. Eventually it progresses rapidly and it’s a downhill course from then on,” said Biswajit Kar, M.D., a cardiologist in the division of heart failure and assist devices at the Texas Heart Institute at St. Luke’s Episcopal Hospital.

In Anitra’s case, doctors found that the lung pressures had been so high for such a lengthy period that the right ventricle of the heart had indeed become thick. She was in a rapid downward spiral when she arrived.

“Because both her heart and her lungs both were not functioning, the blood could not be pumped and it was not getting oxygenated. Her whole body was suffering because there was low oxygen saturation all over,” said Dr. Kar.

Anitra Kimble enjoys a visit with surgeon Igor Gregoric, M.D., during her annual check-up.

“We put the intraoperative Levitronix pump into the pulmonary artery in the right atrium just to help the right ventricle pump blood into the lungs. The pressures in the lungs were so high, the right ventricular assist device was not able to pump the blood across the pulmonary bed to be oxygenated. Her pressures in the pulmonary artery increased tremendously so we added an extracorporeal membrane oxygenator (ECMO) to oxygenate, replacing the heart and lungs,” said Igor Gregoric, M.D., Associate Director of Cardiovascular Surgical Research and Director of Mechanical Circulatory Support.

With the ECMO, Anitra had dramatic hemodynamic improvement. Oxygenation improved and her acidosis (abnormal acidity in the blood) was corrected. After the surgery, Anitra was heavily sedated and medically paralyzed to prevent unnecessary movement which would require oxygen. She required several other medications to improve her metabolic measurements.

“In addition, the challenge was to keep her blood thin because at that time her blood was going through two extra circuits because the natural filters were not working. Even the smallest of clots could go to her brain and cause irreversible damage while we were waiting for the definitive therapy – a heart and lung transplant – which is almost unheard of with this kind of mechanical support. We usually conduct transplants on patients who are more stable, not a patient who is in dire straits like this,” said Dr. Kar.

Anitra was supported with the dual devices for ten days while her medical teams assessed her for a transplant. Neurological function assessment was critical to be put on the transplant list. Doctors interrupted the sedation and paralyzation  just long enough for Anitra to wake up. Physicians were able to confirm her neurological function and she was immediately put on the transplant list. Anitra was put on the list on a Thursday morning and was fortunate enough to receive a heart and lungs by Saturday night.

“Recovery was a little prolonged due to the length of mechanical support. She had initial problems with respiratory infections but she made tremendous recovery within a week. Another week later, Anitra completely woke up. Her heart and lungs were functioning  properly and she was not rejecting her new organs,” said Dr. Kar.

“This situation demanded enormous effort from every single team involved in her care, day and night. Without this kind of extreme team effort, obviously something like this would not have been possible,” said Dr. Gregoric.

The six-week ordeal was a roller coaster ride for Anitra’s family. They had not realized she was so sick, and it threatened to become a terminal situation in a very short time.

“Her survival was hanging in the balance every day. For her parents to know there are very few cases in the world done like this, to hold out through the mechanical support and then wait for a transplant, to have the odds stacked up so much against her was a tremendous effort. Anitra has tremendous family support,” said Dr. Kar.

Organ rejection, infection, immunosuppression and use of steroids will be issues in Anitra’s long term outcome. PPH has a one-year mortality of 70 to 80 percent and she’s well beyond that milestone. Anitra has returned to college and is now pursuing a Master’s degree in social work at LSU. She looks forward to returning every year for her annual checkup because she enjoys seeing the doctors and staff who were instrumental in her care.

“I can’t say I’m back to normal. It’s a new normal. I’m more afraid of getting sick so I’m very careful about the things I do,” said Anitra. “In a way I’m glad it happened. It’s made me a better person and definitely changed my family for the better. We’re much closer now. I’m really grateful to my donor and the family.”

Updated March 2008