JIM LEHRER: Now, Vice President Cheney's heart trouble. Dr. David Pearle, director of the coronary care unit at director of the coronary care unit at Georgetown University Hospital here in Washington. First we need to say, Dr. Pearle, you're not directly involved in the treatment of the Vice President. You're here to add perspective, et cetera, so I'll save you from saying that.
DR. DAVID PEARLE: Thank you, Jim.
JIM LEHRER: All right, now, the catheterization procedure that is being done or was done, we don't know yet whether it's finished or not on the Vice President, what exactly is being done to him?
DR. DAVID PEARLE: A cardiac catheterization is a procedure whereby very thin flexible plastic catheters are inserted into an artery from the groin.
JIM LEHRER: We have a picture of it there.
DR. DAVID PEARLE: And tracked up to the heart, and pictures are taken of the coronary arteries. What you're seeing here is a stent being deployed in an area of blockage. The yellow material is an atherosporatic plaque that was blocking the artery. The stent is that silvery mesh-like device mounted on a balloon that was used three month ago to fix this coronary artery.
JIM LEHRER: We got ahead of ourselves there. I mean, we shouldn't have the stent up yet, because the basic angiogram, the basic catheterization is just to find out if there's a blockage.
DR. DAVID PEARLE: That's right. It's a diagnostic procedure; it takes about 25 minutes, the risk is very small.
JIM LEHRER: Right. Now, what happened in November, they did that and then they went to, on the Vice President, then they went to the second procedure and you were here, in fact, to discuss it that night. But that's when the stent came in. They did find a blockage and they decided to open it up with a stent. Now let's put the picture back up now. Now, we don't know if they're doing it this time, but this is what they did in November, right?
DR. DAVID PEARLE: Right.
JIM LEHRER: Yeah.
DR. DAVID PEARLE: This was the procedure done in November. They found an area of blockage, fixed it with a coronary artery stent, one of these little mesh-like metal devices to reopen the artery.
JIM LEHRER: Now, we don't know yet if there is a connection between what happened in November and, because there had been mild heart attack preceded that, and what happened today, do we?
DR. DAVID PEARLE: We do not. Usually in this time frame, though, well, the hope of course would be it's a false alarm; that certainly would be my hope and everybody else's. Or it may be a problem in an artery totally remote. But statistically the most likely thing three months after the event is that there has been a tightening up of the artery again at the same spot where the stent was placed.
JIM LEHRER: Now, why would that happen, the stent doesn't work?
DR. DAVID PEARLE: The stent works. In the early days when we used only balloons the artery would tighten up in the process of healing --.
JIM LEHRER: Can you explain that. Before you used the stent, just a balloon would go in there and the balloon would come out and the hope was it would stay up, but it didn't - that's why you started putting stents in there.
DR. DAVID PEARLE: Correct. In about 30 or 40 percent of the time when we used only a balloon, the artery would tighten down again. And one of the wonders of a stent is that it decreases the risk that the artery would tighten down again, down to about 10 to 20 percent, and if it's a very large artery even below 10 percent. But it's not zero percent. And statistically the most likely thing that's happened here is the area of the stent has tightened down again.
JIM LEHRER: Now, how could that happen? Why would the stent not prevent that from happening?
DR. DAVID PEARLE: Well, there are two processes of it. The first is the artery can just shrink from the damage caused by the balloon. And that doesn't happen with a stent. But in the normal healing process, tissue grows in, something like scar tissue, and covers the stent, so it's not bare metal, it covers the stent. And sometimes that natural healing process is sort of over exuberant, if you will, and instead of just forming a nice lining over the stent, it can actually block the artery again.
JIM LEHRER: All right, now, just for the record, a stent is about that long, a little over an inch long.
DR. DAVID PEARLE: Well, we have various sizes, we use the shortest possible, it can go anywhere from about five millimeters up to as long as 40 millimeters.
JIM LEHRER: And it's not very wide.
DR. DAVID PEARLE: No. It depends on how big the artery we're working in is. The chance that it will stay open is much greater if it's a large artery. A large artery would be three or 3.5 or 4 millimeters in diameter. Anything under 3 millimeters starting with a small artery the risk is higher, that the artery will restenose, is the medical term, block again.
JIM LEHRER: Now, I know everybody is different, whatever symptoms they have and what the impact of those symptoms could be. But is it consistent with what you just explained, the possibility that this is in the same artery, with having mild chest pains that the Vice President apparently had yesterday, and then apparently on Saturday -- he had his first one on Saturday and then another one yesterday?
DR. DAVID PEARLE: That would be consistent. Some people don't get any pain at all, some get more severe pain. But statistically in this time frame, three months out the kind of chest pain he has, it's restenosis or reblockage.
JIM LEHRER: Now, what's the -- are there percentages, or are there any kinds of information you can give us about the adequacy of when you go back in a second time and have to do it again?
DR. DAVID PEARLE: Sometimes it's a very small artery that closes slowly and all have you to do is readjust medicines. The problem is if you just use a balloon or even the laser device or a little cutting device, the chance that the artery will tighten up a second time, tighten up yet again, is unusually high -- 50 percent or higher. And so there are some newer techniques now we use, in this specific situation, when a patient with a stent has had a restenosis, there are some newer procedures that can be used to drop that risk down.
JIM LEHRER: Is there a scale, a gravity or concern that goes with this second time around?
DR. DAVID PEARLE: Well, usually the risk of the procedure is even lower, because the stent is there. The chance the artery will totally collapse while you're working is small. So the risk of the procedure is small. The real worry when you open it again is that it will tighten down yet again. And that's where some of these newer techniques come in.
JIM LEHRER: Now an overview here, Dr. Pearle. He has quite a history now, the Vice President does, he's had four heart attacks, including the one in November -- during the transition period. He had a quadruple bypass in 1988 and then of course what's happening today. Is there a pattern to this, what can you tell us about this?
DR. DAVID PEARLE: Well, with the caveat that I'm not involved in his care, it's not good that he's had recurrent heart attacks and it's not good that his heart muscle is a little bit damaged. Now, if this specific problem is restenosis within the stent, the area tightening up within the stent, that does not carry the same kind of implications, that's really due to an exaggerated healing process, and is not part of the same spectrum of disease.
JIM LEHRER: But if it's in another artery, then that's a whole different game.
DR. DAVID PEARLE: That would be very worrisome.
JIM LEHRER: The Vice President has made it clear to people he's talked to in the last several weeks, he's been exercising, watching his diet more, et cetera. Is this the kind of thing that can be helped by that kind of activity in and of themselves?
DR. DAVID PEARLE: The overall amount of blockage throughout the coronary arteries is tremendously benefited by all those things: The proper medicines and diet to keep the cholesterol down, the blood pressure and so on. Those things do not impact restenosis within stents to any important degree. It's sort of a different disease process -- if you will -- that's treated differently, but certainly anyone who has coronary disease at all is encouraged to keep the cholesterol down, proper diet, exercise, and a number of different medicines that we know are protective.
JIM LEHRER: This, I'm not asking you to speculate or anything, just as a matter of fact, that if an additional procedure is needed, is it common or uncommon for a person to have another bypass, say? I mean, where do you go from here with all the things he's already had and all the things he's been through?
DR. DAVID PEARLE: Sometimes if you have an important artery that keeps tightening down at the same spot, you do have to do bypass. But there's an option now, very recently improved by the FDA, using very local radiation therapy right at the spot where the stent is. And that's been shown to decrease the risk that that spot within the stent will tighten down again, and I'm sure that's a consideration of what's going on this afternoon, if in fact it is a restenosis that's caused this chest pain.
JIM LEHRER: Dr. Pearle, good to see you again, thanks very much.
DR. DAVID PEARLE: My pleasure, Jim, thank you.