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Christine Alber's story: A team approach saves the day

08/04/2016

A cardiovascular center patient at Tufts Medical Center in Boston.In an instant, everything changed for Christine Alber. It was August 2015, and Christine, then 24, hadn’t been feeling well for a week. Three days of exhaustion, body aches, and feverishness sent her to her doctor’s office, yet resulted in no definitive diagnosis. Continuing symptoms progressed to a night of uncontrollable coughing and a near inability to breathe—prompting a 3am visit to a nearby ER two days later.

Though something was obviously off with Christine’s health, her array of symptoms didn’t clearly indicate any particular ailment, and she was sent home after a few hours. She barely had time to doze and shower before it happened. 

Standing in her apartment, Christine saw a sudden flash of light, screamed her boyfriend’s name, and passed out. In the ensuing moments, she would weave in and out of consciousness—robbed of the ability to speak—as EMTs whisked her back to the emergency room. The fall had chipped a few teeth, and (she would later learn) fractured her jaw. While taking her vitals, Christine recalls, they couldn’t get a heart rhythm read. “That’s the last thing I remember until waking up five days later.”

While She Was Sleeping

Over the course of those days, Christine was transferred to Rhode Island Hospital, where doctors diagnosed her with cardiogenic shock—a rare, life-threatening condition in which the heart suddenly can’t pump enough to meet the body’s needs—and stabilized her before rushing her to Tufts Medical Center’s critical Cardiac Care Unit (CCU).

“Rhode Island Hospital is one of our really close collaborating partners,” says Tufts MC Cardiologist Dr. Amanda Vest, overseer of Christine’s care for the past several months. “They started her on intravenous medication and placed an intra-aortic balloon pump, widely used at many hospitals to provide [short-term] support of blood circulation. Rhode Island Hospital expertly manages critical cardiac disease. However, if a patient is likely to require additional life support from a mechanical heart pump, he or she may be transferred to a hospital with a specialized team capable of performing this procedure.”

Though temporarily stable, Christine arrived “incredibly, incredibly sick,” says Vest, citing accompanying heart rhythm abnormalities, and a domino effect of diagnoses: lymphocytic myocarditis (heart inflammation which caused pumping functions to weaken), acute heart failure (due to the myocarditis-triggered cardiogenic shock), and acute kidney and liver failures (resulting from insufficient blood and oxygen flow).

Despite its overall rarity, cardiogenic shock is extremely serious—the leading cause of death in heart attack patients—and Vest estimates three to four cases arrive at Tufts MC each month. “So often, survival is dependent on that patient being able to quickly get to a quaternary center [a specialty hospital] where more advanced circulatory support is available,” continues Vest.

The CCU team medically induced a coma to keep Christine comfortable while interdisciplinary physicians worked in swift synchrony to allow organ recovery and investigate underlying causes of her illness. Infectious Disease ruled out an ongoing infection, Nephrology administered dialysis to reverse her kidney failure, Intensivists managed the ventilator and other life-supporting apparatus, Heart Failure Cardiology remained vigilant for signs of any emergent heart transplantation need (should recovery stall), and Interventional Cardiology stabilized and supported blood flow to vital organs thanks to a revolutionary technology: Impella heart pumps.

The Cutting Edge

According to The New York Times, Impella are the world’s smallest heart pumps, allowing placement via arterial and venous catheters—thereby side-stepping invasive heart surgery—and offering “the unique ability to enable native heart recovery, allowing patients to return home with their own hearts.”

In just four days on two Impella pumps, says Dr. Vest, “we were able to support and stabilize both the left and right sides of her heart without the need for surgery. Led in this effort by Dr. Navin Kapur, Director of Acute Mechanical Circulatory Support Program, Tufts MC is the first institution to successfully recover patients by employing both left and right pumps at the same time.”

“It’s known as the BiPella approach,” explains Dr. Kapur. “At present, the Impella series of pumps are the only devices approved by the FDA for use in cases of cardiogenic shock.”

The very notion of the small, minimally invasive Impella pumps is a great advancement, says Vest, but Christine’s application was “exciting and new” because the right-side Impella pump only became available within the last year, for which Vest gives major kudos to her colleague. “Dr. Kapur is involved in the development of these devices and has championed the concept that it’s not enough to think about the left side of the heart,” which receives oxygenated blood from the lungs and pumps it to the body.

Kapur insists “you also have to think about the right side of the heart,” which sends blood to the lungs to pick up oxygen. He points out that Tufts MC was among a handful of U.S. hospitals to participate in Impella’s Recover Right clinical trial for right-side heart failure.

 A team of Cardiologists discuss their patient at Tufts Medical Center in Boston, MA.

Coming Out of the Dark

Those four days on Impella pumps marked the turning point in Christine’s recovery, allowing her to begin weaning off her various supportive devices and return to consciousness.

“They woke me up Friday night,” she recalls. “Over the next few days, I had a lot of dialysis. I barely slept the first night—I was trying to fall asleep and was having really weird dreams. I was so bloated, I couldn’t move.” Her muscles already atrophied from a few days of non-use, “I couldn’t even touch my face. It baffles my mind.”

By Wednesday, she had made enough progress to transfer to the inpatient Cardiomyopathy Unit, where the Physical Therapy team started her walking right away. Those PT rounds, plus visits from Psychology, Occupational Therapy, and Social Work teams now supplemented Christine’s ongoing cross-disciplinary medical monitoring.

One day after Labor Day—just over two weeks from her admittance—Christine went home. All organ functions had returned to normal with the exception of her kidneys, for which she continued dialysis on an outpatient basis a few times per week for a month. Triweekly cardiac rehab visits at Newport Hospital rounded out her at-home recovery plan through February 2016.

“For the first few months, I was so tired…even to think was exhausting,” says Christine. Just watching TV, reading books, or playing cards was too draining. By mid-December, she returned to her job as a handbag designer part-time, and though today she is back to full-time, she works two days a week from home.

“I’m still really tired and get fatigued easily,” she explains, but realizes it’s part of her recovery, and “every day is different.” Though Dr. Vest feels any relapse is incredibly unlikely, Christine is careful to “watch out for signs and symptoms, stay active, and eat decently.”

Aside from one more planned check-up with Dr. Vest in October, Dr. Daniel Levine at Rhode Island Hospital is now overseeing her follow-up care, with several 2016 visits planned before she tapers down to just one or two a year.

“Dr. Dan Levine is an expert heart failure physician and a great partner in Rhode Island,” says Dr. Vest. “We collaborate very closely and try very hard to share care with our partners at other centers. We like to have the patient see the doctor closer to home,” while the Tufts MC team stays updated from Boston.

Reflections

As for what caused Christine’s cardiogenic shock, Dr. Vest and her colleagues believe a previous viral infection that somehow settled in the heart is to blame, though Vest points out it is “incredibly rare” and “often very hard to definitively make that diagnosis.”

It makes sense to Christine—she wasn’t feeling well for months prior to her hospitalization, complaining of fatigue, weight gain, skin issues and digestion problems. Though she went to doctors, she says, “no one had an answer.”

“Nobody’s expecting a healthy young lady to be going into heart failure,” explains Dr. Vest. “When she finally presented clearly, the Rhode Island team did exactly the right thing. Christine was on the extreme end of this illness. I’m incredibly happy that she came through this so well. It’s been an absolute pleasure taking care of her.”

The feeling is mutual. “I have a total new respect for everyone in that field,” having experienced premium medical attention at Tufts MC, says Christine. She cites “amazing” treatment from nurses to critical care to techs to physicians she encountered at every turn. “They weren’t fazed by anything—whatever came their way, they were calm and appropriate. My friends and family say the same thing.”

With her harrowing experience increasingly fading in her rearview, Christine is looking ahead to her summer—a Florida trip and plans to visit San Francisco during the anniversary week of when she got sick. “So much hiking, and water, and city life,” she muses. Thanks to Tufts MC, life goes on.