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A physician recounts the story of a beloved patient who survived cancer but later developed heart disease.
For JoJo, to sing was to breathe. It was his lifeline. But he had lost his breath a long time ago.
As a young vocalist, JoJo had been diagnosed with lymphoma. Immediately preceding his diagnosis, he noted progressive shortness of breath and was found to have a mass in his mediastinum. He received chemotherapy including anthracyclines, radiation therapy, and an autologous bone marrow transplant, which cured his disease. He was a cancer “survivor.”
Approximately 10 years after his therapy, his heart's function began to decline slowly at first and then more rapidly. His chemotherapy had led to irreversible changes of the myocardium that finally manifested as heart failure. By the time we met, not only the muscle but also the valves had begun to fail, the effects compounded by concurrent radiation.
He began to accumulate fluid in his abdomen, his legs, and his lungs that became harder and harder to remove. His trips to the hospital became more and more frequent.
I met JoJo as a second‐year resident on our advanced heart failure service. By that time, I was no stranger to terms like “chemotherapy‐induced cardiomyopathy” and “radiation‐induced heart disease,” having seen various patients with these words plastered on their medical records. Years after cancer treatment, they became plagued by congestive heart failure and crossed paths with me.
JoJo was a patient beloved by all—physicians and nurses alike. He had been admitted to the hospital many times before. On prior occasions, he could have been spotted, still attached to his intravenous diuretics, whizzing around the nursing station while the telemetry continuously alarmed from artifact resembling ventricular arrhythmias.
This time, he walked slower. The prior harmony of his heart and lungs was now a cacophony. To breathe was a chore, let alone to sing.
First, we thought it was a simple pneumonia. Then, we decided he just needed diuretics to remove the fluid that was hiding in the wrong places. But things got more complicated as the fickle homeostasis between his heart and his kidneys was lost. His electrolytes became deranged to dangerous levels.
Every day, JoJo remained upbeat. He knew his daily lab values from start to finish. He asked sharp, insightful questions about his care but always with a smile on his face. He wanted to share in our vision, our difficult decisions, and our musings.
Despite his optimism, his clinical course became more tenuous. He was “sliding on inotropes,” a designation used for advanced heart failure patients. I imagined his diuretic molecules on a slip‐and‐slide or at the water park, a more optimistic vision than the reality. His heart was walking a tight rope.
Our options were limited, the best of which involved a new, chemo‐free heart.
We had hoped that we could buy JoJo more time, especially time out of the hospital with his wife and daughter, before he needed a new heart. He was on the transplant list, but we no longer had the luxury of waiting for a potential donor. We decided JoJo needed a ventricular assist device, a pump to help his heart squeeze, as a potential bridge to transplant in the future.
JoJo's chest was a corn maze, an obstacle course from his prior thoracic procedures. The implantation operation was long and hard, made more difficult by the dense fibrosis gluing the structures of his mediastinum together secondary to his radiation therapy.
His course remained rocky from the second his chest was closed. Catheters and cannulae arose from an increasing number of orifices. I watched him slide further and further away from his goal of getting home.
One evening following his surgery, I meandered down to the intensive care unit to visit JoJo, his doting family at his bedside. He remained intubated and sedated but opened his eyes wide to my voice.
“We are all thinking about you, JoJo.”
He tried to mouth what I imagined was “Thank you,” but no words escaped. He had lost his breath yet again. Instead, tears began to stream steadily down his face. Even crying was hard for his breathing to bear.
“Hang in there,” I said, fighting back tears of my own. My words were wholly inadequate but there was nothing more to say.
With each day, JoJo became less responsive. On some days, all I could do was watch the rise of his chest from the door—too afraid to look into his eyes and see his pain and suffering.
He and his family had already managed the ups and downs of his initial cancer diagnosis—the fear, the uncertainty, and the relief when he achieved remission.
And yet here he was, his body being asked to overcome another challenge, another insult, the final chapter in his long journey that had evolved over the previous two decades.
Although JoJo had been cured of his lymphoma, it was as if cancer was still invading his heart 20 years later. It lost its ability to relax and squeeze, to pump blood to the organs of his body. His shortness of breath that had once signaled his initial diagnosis of lymphoma remained, but now for other reasons.
We knew we were fighting against incredible odds, hopeful that the mechanical support would alleviate some of the burden, but JoJo was too powerful a spirit; no ventricular assist device pump could spin fast enough to match the heart and soul he brought to each day.
His heart was strong and weak all at the same time.
With each day, I waited for JoJo to regain his strength of voice, to share with us the beautiful melodies of which his wife spoke.
JoJo died peacefully fighting a battle that had started 20 years ago.
I imagine him now—unencumbered, at peace, and singing his song.
I would like to thank the patient's wife for reading this piece and allowing me to share this story. She requested that I use the patient's real first name in print.
The author indicated no financial relationships.