Safe Landing for a Troubled Heart
A space-travel scientist’s golden years are rejuvenated by a small, parachute-like device.
At 1:17 p.m. Pacific Daylight Time on July 20, 1969, 47-year-old thermodynamics scientist and Iranian immigrant Galen Etemad, along with a half-billion people around planet Earth, was looking at a television screen. He watched intently as the Apollo 11 lunar module approached the rugged, pocked surface of the moon. And then he heard the reassuring words he had been waiting for: “The Eagle has landed.”
Unlike most of those half-billion people, Galen can claim Apollo 11 as the highlight of his professional life. Thanks to his work, the spacecraft would ferry the astronauts safely home and not burst into flames upon re-entry into the Earth’s atmosphere. Today, if really pressed, Galen might admit to a sense of pride for the part he played in space exploration. But humility is a default setting for this 90-year-old retired scientist and, when it comes to the moon launch, he is deceptively matter-of-fact. “I was glad it went up,” he says, adding with a smile, “I was glad it came back!” If his heart fluttered with ominous foreshadowing during the landing in the Sea of Tranquility, he certainly did not notice.
Galen could not have known it then, but his heart had a problem—something to do with a thumb-sized pouch off the left atrial chamber called the left atrial appendage. We all have one, but the body seems able to manage without it, like an appendix or spleen. Even experts who study the heart’s structure are not sure what the appendage is for, although various theories exist. “Nature must have given it to us for a reason, but I don’t know what the reason is!” says Galen’s interventional cardiologist, Saibal Kar, MD, director of Interventional Cardiac Research at Cedars-Sinai.
For people with an irregular heartbeat, or atrial fibrillation, the appendage is troublesome. Blood can pool there and form clots that travel to the heart or brain, triggering a heart attack or stroke. Atrial fibrillation (AFib) is responsible for up to 20 percent of the most common type of stroke.
Until recently, the only remedies were blood thinners that prevent clotting. But those medications cause severe bleeding in certain people, especially the elderly. And therein lies the predicament, as Dr. Kar explains: “If a drug prevents a clot, it also causes bleeding. If it doesn’t cause bleeding, it doesn’t prevent a clot. There is no free lunch.”
Until recently, the only way to close off the appendage was with open-heart surgery—a solution potentially more dangerous than the problem itself. “We needed to fix this, and we needed to do it in a way that is simple and safe for patients,” says Dr. Kar.
Enter the WATCHMAN® Left Atrial Appendage Closure Technology, manufactured by the medical technology company Boston Scientific. The pea-sized investigational device is designed to liberate AFib patients from the catch-22 between bleeding and stroke. Admittedly, the left atrial appendage is one of the body’s more obscure pockets, and the WATCHMAN is not the kind of medical device that usually makes headline news. But for Galen, the device is a technical marvel that rejuvenated his golden years.
Atrial fibrillation is responsible for up to 20 percent of the most common type of stroke. Until recently, the only remedies were blood thinners to prevent clotting.
Today, Galen shows off his home with a spryness that belies his age. Tiburon, the California Bay Area town of his retirement, has graced itself with the tagline “Near. Perfect.” Life seems that way in this house, a mélange of Persian elegance and contemporary artwork curated—and in many cases crafted— by his wife, Jaleh, artist laureate of Tiburon. Her studio is out back, installed there by her husband so they need not be apart while she creates. Theirs is an enduring love story: He proposed within three days of their first meeting and they were married less than two weeks after that. Forty-four years later, they take daily vigorous walks together to sustain the longevity that runs in Galen’s family; more than one sibling has lived to see age 90.
“You have to tend to your mind as well as your body,” says Galen. He would know. His entire career represents a rigorous application of mental energy and, sure enough, the conversation soon drifts to the ever-intriguing topic of Apollo 11. Galen explains that, when it comes to space travel, getting off the planet is not the tricky part. That comes down to propulsion, pure and simple. The real challenge lies in the return trip. The astronauts are sealed in a capsule plummeting through the Earth’s atmosphere at 18,000 mph. Heat builds up rapidly, with flames licking the vessel. “We have to protect the vehicle and occupants from extreme heat of up to 5,000 degrees Fahrenheit,” he says.
In 1969, Galen was special team leader of thermodynamics for the group working on spacecraft re-entry at North American Rockwell, a major contractor for the National Aeronautics and Space Administration (NASA). His team was tasked with protecting the Apollo 11 command module when it returned to Earth. It was a new problem for thermodynamics but, fortunately for the spacemen whose lives were at stake, Galen is a very determined person. “I get that from my father,” he says. His determination helped solve NASA’s re-entry problem for early manned space missions and the Space Shuttle program.
In a major engineering breakthrough, Galen’s lab used the X-15 rocket plane to mimic spacecraft re-entry conditions. Neil Armstrong piloted the X-15 in test flights. “The astronauts always came to see the vehicles we designed,” Galen recalls. His team used data from the X-15 tests to develop an innovative design for the Apollo 11 command module, including a novel protective material for the exterior. On July 24, 1969, the capsule safely splashed down 900 miles southwest of Hawaii, human cargo intact, aided by three red-and-white-striped parachutes.
The WATCHMAN device now housed in Galen Etemad’s heart resembles a tiny parachute. It was inserted by catheter, a long flexible tube threaded through an artery in his leg up into his heart. Little barbs on the device grip the tissue at the opening of the atrial appendage, then the parachute deploys, forming a sieve that filters out clots. The entire procedure takes less than an hour. In a matter of weeks, patients can stop taking their warfarin or Coumadin® medication and carry on with only the mildest of blood thinners: aspirin. In time, tissue seals over the parachute, permanently separating the appendage from the rest of the heart.
Dr. Kar notes that the WATCHMAN is one of many such devices under study, but it provided the proof of concept for the others and has the most data behind it. He has enrolled patients in three clinical trials for the device. The first study showed that the implant is as effective as medication in reducing the risk of stroke and that it eliminates the need for blood thinners about one and a half months after implantation, he explains. During the two subsequent trials, Dr. Kar would become one of the world’s leading experts on the procedure. He had not yet heard the name Galen Etemad.
In 1974, Galen developed diverticulitis, an infection in his intestine. It put him in the hospital for more than a month and required major surgery. Years later, the catch-22 of clotting versus bleeding caught up with him. In 2009, Galen’s AFib sent a clot into a blood vessel in his brain, causing a stroke. “It knocked out almost all my faculties,” he says, refusing to dwell on the aftermath. Slowly he healed, but to prevent another stroke, he needed blood thinners. That old enemy diverticulitis meant blood thinners might send him right back to the hospital, bleeding. With his precise and disciplined mind, this was exactly the kind of paradoxical problem Galen detested. Dr. Kar would help him solve it. As it turned out, these two men, born one generation and three countries apart, shared two important traits: tenacious determination and uncommon talent.
Galen narrowly escaped a career in what he considers the messiest science, Dr. Kar’s chosen profession: medicine. Mathematics was Galen’s first love and engineering an early passion. “When I was a child, we had a phonograph and a radio. Every time something went wrong, I fixed it. I loved to fix these things.” But his father advised him to go to medical school. He followed his father’s counsel, but soon felt he had betrayed his true calling.
“I was like Dr. Etemad. I loved mathematics!” says Dr. Kar, who once thought he might become an engineer. “I like doing things with my hands; I used to paint and draw.” But genes and childhood experience destined him to become an interventional cardiologist: a kind of sophisticated heart mechanic who performs procedures, but not surgery.
The child of two physicians, Dr. Kar was raised in Kolkata, India. His father was president of the Cardiological Society of India and is known as the pioneer of pacemakers in his country. “My dad took me to conferences when I was very young,” Dr. Kar remembers. “I wanted to work with heart patients like he did—but I also wanted to do procedures, so at first I thought I would be a surgeon.”
Another factor greatly influenced Dr. Kar’s career. As a teenager, he watched his cousin die from an infection following open-heart surgery. “I never forgot that,” he says. “He was a kid. I saw how morbid open-heart surgery was back then, and I knew there had to be something less invasive and safer.” Today, the boy could be saved with an interventional procedure that takes 40 minutes. “Now I am doing what my father dreamt for me to do and what I dreamt to do—which is to fix heart defects.”
After the initial WATCHMAN trial, the FDA required another study, and then another, to make absolutely certain the device could be placed safely in patients’ hearts. Dr. Kar’s prowess led Cedars-Sinai to become the second-largest enrolling site for the two follow-up studies, with a total of 123 patients, and the medical center with the best safety profile. His record helped demonstrate the potential of the device while elevating Cedars-Sinai to a Center of Excellence for the procedure: a home for teaching the practice nationwide. As one of the studies’ most accomplished operators, Dr. Kar is one of two principal investigators for a national registry that allows qualified patients to receive the investigational device before the FDA approves it. He shares that esteemed position with Shephal Doshi, MD, of the Pacific Heart Institute.
Arshia Noori, MD, an attending cardiac electrophysiologist at Cedars-Sinai, applauds his colleague’s career on the cutting edge of multiple clinical trials. “Dr. Kar has been a pivotal cardiologist and scientist in keeping this institution’s top reputation in the country and around the world,”
Dr. Noori says. Dr. Noori also happens to be related to Jaleh, and describes his cousin’s husband as “the wise uncle who’s incredibly well-respected and admired in the family.” After his stroke, Galen sought the counsel of Dr. Noori, who recommended he have the WATCHMAN device implanted without delay. “But as any meticulous engineer would,” says Dr. Noori, “he wanted to do his own research first.”
“I am doing what my father dreamt for me to do and what I dreamt to do—which is to fix heart defects.” –Saibal Kar, MD
For a full year after the stroke, Galen and Jaleh performed a finely tuned balancing act: They kept his blood thin, but not that thin. Using a home test for blood viscosity, they tweaked his medication day by day. “For most people, this wouldn’t have been doable,” says Dr. Noori. “But they are very sophisticated and they had it down to a fine science.” Ultimately, science wasn’t enough. Galen experienced a bout of bleeding that put him back in the hospital for five days.
Soon after, Dr. Noori called his cousin and told her about the WATCHMAN trial’s great progress. The following day Galen was introduced to Dr. Kar.
By this time, Dr. Kar was a global leader in conducting this investigational procedure. In demand internationally, he logged 400,000 air miles in 2012, teaching doctors around the world a variety of interventional procedures. He introduced the WATCHMAN device in Australia, New Zealand, Korea, India, Singapore, and Israel. If one comments on his tenacity, he bursts out laughing. “I’m just exhausted!” But despite his resistance to flattery, Dr. Kar believes fervently in the importance of spreading knowledge. “It’s no use saying I can do the atrial appendage procedure. It’s more important to see 50 other people who can do it well, too.”
Galen was one of Dr. Kar’s final patients in the WATCHMAN trial. The implantation went so smoothly that Jaleh felt it took no more than 10 minutes, although in reality it was a 45-minute procedure. Galen was soon able to eliminate prescription blood thinners, and he found himself enjoying terrific health.
Then, this past April, Galen was once again admitted to the hospital for heavy bleeding. There was a leak where he received surgery for diverticulitis 39 years ago. “They had to take me off all blood thinners—including aspirin—for six weeks after this incident,” he says. “Before the WATCHMAN, I would have had a stroke. There is no question that the device just saved my life.”
Today, other than a pacemaker, Galen’s heart is perfectly healthy. “The reason I survived is that I wanted to live,” he says passionately. “In every episode of my life, I have been determined to conquer the challenges before me.”
Initial data that Dr. Kar and his co-investigators have gathered with patients they’ve been following for as long as five years suggest a distinct survival advantage. Compared to blood thinners, the WATCHMAN shows a significant reduction in cardiovascular death. Quite simply, Dr. Kar says: “This means the device doesn’t just make life more convenient for patients like Dr. Etemad. It could add years to his life.”
Dr. Kar is hopeful that the WATCHMAN will be FDA-approved by the end of the year. Manufacturer Boston Scientific has appointed an advisory committee of 10 expert physicians, of whom Dr. Kar is one. The group will provide crucial counsel regarding physician training, patient qualifications for receiving the device, and the establishment of new centers for implantation. “This is an amazing opportunity to deliver life-enhancing technology to an entire nation,” says Dr. Kar.
The first Saturday of each month, Galen gets together with a group of Iranian expats, former dignitaries, and other “big shots who escaped.” Anyone with exciting news presents the information to the group. Galen has talked about his groundbreaking work in the space program to his circle of compatriots. And after his procedure, he spoke to them about the WATCHMAN device.
As he looks toward completing a century on planet Earth, Galen says, “I owe my longevity to the WATCHMAN, and I am extremely grateful to Dr. Kar and Dr. Noori. At 90, I have my heart and I have my brain.” Near. Perfect. Indeed.