A swim in the ocean off a beach in the Virgin Islands topped Thomas Nichols' bucket list.
When doctors told him he needed a risky surgery on his heart, he decided to first take the Caribbean detour with his wife and son.
"I knew if I lived, I'd never go swimming again," Nichols said. "So I wanted it one last time.
"I didn't know if I was going to make it back to the hospital; if I did, I didn't know if I'd leave the hospital alive.
He survived the trip back to Barnes-Jewish Hospital, and a week later awakened from a drug-induced coma feeling like new. Sore, but new.
"It hurt, but not as bad as congestive heart failure," he said. "I could breathe, I felt 1,000 percent better."
Surgeons had put a machine in his chest to do most of the work of his heart. That brought lots of changes.
He had no blood pressure, no pulse. "Just that whirring sound you can hear with a stethoscope," he said. He had a battery pack strapped to his side and a quarter-inch wire poking out of his stomach.
What he remembers most: He was alive.
That was fall 2007. He talks about the device now like a beloved pet always by his side.
Nichols was among the first people in St. Louis to receive the left ventricle assist device — or LVAD. The device, trade name, HeartMate II, pushes blood through the left ventricle. That's the heart chamber that sends blood into the aorta and to the body.
Dr. Gregory Ewald, medical director of the Cardiac Transplant Program at Barnes-Jewish Hospital, said the device was developed to keep people alive as they waited for heart transplants.
"Over the last 15 years, we've transplanted about 2,300 hearts a year in the United States, and that has remained steady; the donor pool is fixed," Ewald said. So people could die while waiting for a donor heart, he said.
But a second, not unexpected, use evolved for the machine. Some people with heart failure weren't eligible to get on a transplant list. The machine has saved a lot of them, Ewald said. About 85 people have the machines in St. Louis.
It's not a universal solution, said Ewald. It's for people with left ventricles that stop working. Still, it doesn't replace the transplant. "The heart transplant is still the best option for some, and there are other forms of heart disease," he said.
"But we have one guy (using an LVAD) we've urged to get on the transplant list and he keeps putting us off," Ewald said. "He's happy with (the machine).
"We have people now playing golf, dancing, having full lives."
Nichols' heart problems actually began with an intestinal disease. In 1996, Crohn's disease, ulcerative colitis and precancerous scars resulted in the removal of his large intestine and rectum. The therapies nearly destroyed his heart.
"That wrecked my body," he said. "It was a year before I could sit up in bed without help.
"The doctor told me I had about seven to 10 years of life remaining," Nichols said.
But he couldn't get on a heart transplant list because his health had deteriorated. He wouldn't survive the surgery or the anti-rejection therapy.
"I put on 50 pounds of water weight; my kidneys and liver failed."
Originally, he was slated to get a device called the HeartMate I, the dinosaur predecessor of the HeartMate II.
"But I read about it, the schematics; I said I wanted the HeartMate II," he recalled. "I'm a mechanical engineer, and I knew I wanted one moving part, a smaller machine; less to go wrong."
But that machine was experimental; he'd have to enter trials to get it.
"I fought for that," he said. "My surgeon fought for it."
He was accepted into the trials.
Still, he wanted one last fresh breath.
When the transplant staff wanted him to prepare for surgery, he instead announced that he was going swimming with his family.
Ewald said the device is far from being an artificial heart. The heart must be working for the device to do any good.
Nichols predicts, "Within the next 10 years, there won't be a need for transplants.
"Think about it. No need to wait for donors, no rejection, no steroids ..."
Ewald was more conservative. "I'm thinking in the future, the devices will be totally inside of the body, batteries, too — like pacemakers. But I'm not ready to say they're ready to replace the heart."
The U.S. Food and Drug Administration approved the HeartMate II for use 15 months ago, Ewald said.
For Nichols, the timing was right. "The thing is place and time: I'm glad I was at this place at this time. If this had been five years earlier, I'd have been hard-pressed to get this device," he said.
As long as he's walking upright, he feels ahead of the game.
"People say, 'It's good to see you," he said. "I say, It's good to be seen."