For Gov. Casey, the stakes can go no higher.
So rare is the operation he faces that it never has been tried in any of the innovative medical centers in Philadelphia.
So high are the risks that not one survivor remains in the entire country to tell Casey what he'll go through.
The 61-year-old governor's upcoming heart-liver transplant is a desperation move born of a desperate medical condition.
He may die with it - but without it, the shadow of death is capricious and always near.
Weekend medical tests showed that Casey's heart is "dramatically abnormal," said Dr. William Follansbee, chief cardiologist at the University of Pittsburgh Medical Center, where Casey awaits surgery.
Follansbee said that electrical impulses were causing quick and slow rhythms at different times and that Casey was at high risk of a sudden, fatal heart attack.
That's why Casey - inviting the public's prayers - said yesterday he had opted for an operation so rare that only a handful have been performed in the United States.
And Pitt physicians said they knew of only one heart-liver transplant in the world - in London - that ever had been performed for a patient with amyloidosis, the hereditary liver disease that has damaged Casey's heart.
"To have a liver transplant to cure amyloidosis would be novel enough," said Dr. Susan Brozena, a transplant cardiologist at Hahnemann University in Philadelphia. "But obviously his heart couldn't sustain him through that kind of complicated procedure."
And to protect the transplanted heart, Casey needs a new and properly functioning liver.
"If you just did a heart transplant and did not cure the underlying disease, that would come back," Brozena said.
It's the excess protein caused by the liver disease that has severely damaged Casey's heart. That's why he'll remain in the Pittsburgh hospital, instead of leaving - as earlier announced - to await only a liver transplant after the weekend tests.
He could undergo the operation within four to six weeks, doctors said.
"The essential testing has been completed and my doctors have informed me that my cardiac condition is much worse than I would have expected," said
Casey, who underwent a quadruple bypass in 1987 after a heart attack.
Although Hahnemann has done heart-kidney transplants, that doesn't rank with a heart-liver transplant for rarity or difficulty, Brozena said.
Three of Pitt's four heart-liver transplant patients - all half as old as
Casey - died within months of the operation.
The other - 7-year-old Stormie Jones, of White Settlement, Tex., the world's first heart-liver transplant - lived a record six years before dying after her body rejected the new heart in 1990.
The roll of the dice to a heart-liver transplant does raise Casey's standing among patients awaiting transplants.
Howard Nathan, director of the Delaware Valley Transplant Program, said combined transplant patients get priority - unless a single-organ transplant candidate is critical - because it's more difficult to find a donor with both a healthy heart and a healthy liver.
Doctors prefer to transplant both organs from a single donor to cut the odds of organ rejection.
But the donor must not only match Casey's "O" blood type and approximate build (6-foot-2 and a large build, before his illness), but must have undamaged organs.
For example, a car accident victim may have cardiac arrest and be given electric shock. That often damages the heart so it's not usable for a transplant.
"Finding a donor is a problem," said Dr. David Campbell, a heart- transplant surgeon at the Penn State Medical Center in Hershey. A heart-liver candidate, he said, "is likely to die waiting."
The donor must be declared legally brain-dead and the transplant teams have only a limited number of hours to transplant the organs once they're severed
from the donor - up to 24 hours for the liver, but only three or four hours for the heart.
So Casey's heart transplant would come first. Then, once the heart stabilized, another transplant team would begin the tedious process of joining numerous blood vessels and ducts to attach the new liver.
While neither transplant operation alone is particularly dangerous, Casey's risk of death increases when the two organs are transplanted together.
During the surgery, Casey will be put on a heart-lung bypass machine to provide oxygen to his blood. But the bypass machine escalates the risk - ''it's huge," Campbell said - of dangerous bleeding during the liver transplant.
The medical center said 15 patients with amyloidosis have received liver transplants in the world, and 14 survived. But only the one in London also received a heart, said Dr. Thomas Starzl, head of Pitt's Transplantation Institute.
Information on the fate of that patient was not available last night.
Casey, who has 1 1/2 years remaining in his term, announced Friday he intended to undergo a liver transplant to cure amyloidosis, which doctors diagnosed after discovering the protein buildup in his heart in 1991.
Casey is receiving a drug to thin his blood to reduce the risk of a stroke and fluids to replace minerals such as potassium, which he lost as he lost weight, doctors said.
Last year about 650 organs - hearts, kidneys, livers, pancreases and lungs - were transplanted in eastern Pennsylvania, South Jersey and Delaware, the area handled by Nathan's transplant program.
