LOUISVILLE, Ky. -- On the worst nights, Kathy Ritvo would lie in bed and cry while her family rubbed her back.
Her feet and legs ached. She'd been coughing constantly for 18 months, to the point that normal conversation was a labor. Her heart was quitting. Her will was weakening.
On those haunting nights in 2008, she didn't want to fall asleep. She feared that she would never wake up.
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People would ask, 'How are you doing?' I didn't know how to answer that. You're either waiting to die or waiting to live.
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-- Trainer Kathy Ritvo
"People would ask, 'How are you doing?'" Ritvo recalled. "I didn't know how to answer that. You're either waiting to die or waiting to live."
Sleep will not come easily Friday night, either, for much happier reasons. A rejuvenated Ritvo is waiting to live out a thoroughbred trainer's wildest dream -- she will saddle a horse Saturday in the 137th Kentucky Derby. Mucho Macho Man, whose presence is a miracle in its own right, has brought her to Churchill Downs.
The horse's nickname as a foal was Lazarus, having risen from a seeming stillbirth three years ago at Rose Grove Farm in Ocala, Fla. It could apply to his trainer, too.
"I just have a really deep sense," said breeder Carole Rio, who helped coax Mucho Macho Man to life, "that he was meant for Kathy Ritvo."
* * *
She is curious by nature.
"I'm nosy," Kathy Ritvo said with a laugh, her sharp Massachusetts accent cutting the cold Kentucky morning air. "I'm nosier than anybody."
So, the pint-sized, 42-year-old mother of two wonders: Whose heart is this inside of me, keeping me alive? What was that person like? What happened to him or her?
Those thoughts have been there since she received the heart transplant that saved her life in Miami's Jackson Memorial Hospital in 2008. She wrote a letter that the hospital delivered to the family of the organ donor but has received no response. She no longer expects one, but she never stops wondering.
"I respect their privacy," she said. "But I just want to thank them. I got a good one."
She got a heart that gave her back everything.
It gave her back the chance to watch 18-year-old Dominique and 17-year-old Michael grow up. It gave her back the chance to share the love of horse racing with her husband, Tim, whom she's known since she was 16. And it gave her back the chance to do the only job she has ever wanted -- the up-before-dawn, no-days-off, dirt-under-the-fingernails life of a trainer.
"It's nothing short of amazing," Tim Ritvo said, "to see how sick she was three years ago, on the verge of death, to now."
Kathy began feeling an unusual amount of fatigue as far back as 1998. In 2000, she was diagnosed with dilated cardiomyopathy, a degenerative disease that weakens the heart muscle.
Prescribed large doses of medication and making lengthy hospital stays, Kathy already knew how deadly the disease could be. One of her three older brothers, Louis, died of it in 1996 at age 38.
And, for the longest time, it looked as if she would be next.
"Seeing it again, I couldn't believe it," said Kathy's mom, Mary Petro. "It was more than shocking. It'll take your whole peace right out of you."
Inner peace was impossible as Kathy's condition deteriorated. Drained of energy, she tried to persevere for her mother and her children. But at times even that wasn't enough.
"It just seemed like the days dragged," she said. "I was really sick. It was definitely mentally exhausting because it's hard to keep fighting. But I think you have to be a fighter to keep going. You have to be pretty tough."
On May 3, 2008, Kathy was in the critical care unit at Jackson Memorial. She asked that the television be tuned into the Kentucky Derby. Her cardiologist, Joseph Bauerlein, asked what she knew about thoroughbreds.
"I'm a trainer," she responded.
Then, without thinking about it, she said, "When I take a horse to the Derby, you have to come."
Bauerlein probably will not be able to make it to Louisville, but he and the entire transplant crew that worked on Kathy intend to watch the race together at Gulfstream Park in South Florida.
That statement from Kathy to her doctor, though sincere, had a whistling-past-the-graveyard quality to it. As she watched Big Brown win the '08 Derby, the odds seemed against her being alive for the race in 2009.
That changed abruptly on Nov. 13, 2008. At 7 p.m., she received a call -- a donor had been found. She returned to the hospital within hours, and a six-hour transplant surgery was performed by Dr. Si Pham.
When Kathy awoke from surgery, the effect was immediate. She felt better than she had in 10 years.
For months after surgery, she had to stay away from the horses. Working in a horse barn remains a slight risk for infection, but it's an acceptable one now, according to her doctors. And she has shown no adverse effects in the past three years.
"I've felt really healthy," she said. "I've never had a bad day."
Beyond a positive attitude, all it takes to keep Kathy going is some 30 pills a day -- 15 of them at 7:30 a.m., 15 more at 7:30 p.m. After what she's been through, that's a minor inconvenience.
Really, any daily problem is a minor inconvenience now.
"I don't worry," she said. "My daughter smashed up one side of our truck not long ago, then smashed up the other side. It doesn't matter."
A remarkable triumph of medicine and will got Kathy to this point. But really, this is a moment she has spent her whole life working toward.
As a girl growing up outside of Boston, she had five dogs. She got her training start with them.
"She would line them up," her mother said. "She would make them sit, make them stand, make them do this and do that."
When Kathy wasn't in school or playing with the dogs, she was at the racetrack with the rest of her family. After working as a barber and owning laundromats, her father, Peter, followed his heart and bought a racetrack. It became the family business.
Brother Michael helped train the horses. Brothers Nick and Louis were jockeys. And little Kathy tagged along and worked around the barn, doing anything and everything.
"We came to the barn together in the mornings," Kathy said. "We stayed in the barn and worked, then we got in the car and went home."
It surprised no one, then, when Kathy got her training license on her 18th birthday. After marrying Tim Ritvo, she trained a division out of his stable and won 149 races in 1990-98, before her health forced her to abandon full-time training.
For the next decade, every day was a progressively more difficult struggle. All the hopes of watching her kids grow up and watching her horses run were jeopardized.
"All you have to do to make God laugh," Tim Ritvo said, "is to tell Him you have a plan."
* * *
At the same time Kathy Ritvo was close to death in Miami, a foal was stillborn in Ocala.
At midafternoon on June 15, 2008, Carole Rio of Oak Grove Farm got a call from her farm manager. Three weeks past the due date, their mare, Ponche de Leona, had delivered.
"I think he's a dead foal," the manager said.
"Just hang on," Rio said, rushing back to the farm.
The foal had been birthed in a field instead of the barn, and it lay motionless. There was no heartbeat.
Rio, her husband, J.D., and daughter all rubbed the foal's body while others said prayers. Several minutes passed.
"It seemed like an eternity," Rio said.
Suddenly, without warning, the foal stood up and ran off, none of the usual wobbly, halting steps, just a straight and stunning run.
"It was unbelievable," Rio said. "When I remember it now, it's still unbelievable. He just popped up and ran off. It was just that quick. He probably took six or seven strides."
She laughed, thinking back to the day Lazarus got his nickname.
"I don't know where he thought he was going. But he must have known he's going somewhere."
Now, he's gone to the ultimate thoroughbred destination. Churchill Downs.
* * *
Lazarus shipped to Louisville on April 26. At 2:30 that night, Kathy Ritvo and owner Dean Reeves went to the barn to check on him.
"He came to the window [of his stall] at the sound of her voice," Reeves said. "That horse knows her."
In the days since then, Churchill Downs Barn 41 has become an increasingly popular stop for fans, media and others. Ritvo has found herself a sudden celebrity and spokeswoman.
She filmed a public service ad for the Kentucky Circuit Court Clerk Trust for Life organ donation program. She met with a group of young people interested in becoming trainers or jockeys. And, at one of the many parties this week, Kathy met a woman whose 10-year-old daughter was killed in a house fire -- but her donated organs have helped five other people to live.
"She said that's how she gets through every day, thinking of those five people," Tim Ritvo said.
Kentucky Derby nerves will set in eventually and inevitably. No trainer has ever walked a horse from the backside barns to beneath the Twin Spires without feeling them. Yet few trainers, if any, have ever made that emotional walk with as much appreciation and perspective as Kathy Ritvo.
"I'm so proud to be in the Derby," she said. "But just to get up in the morning is amazing."
Pat Forde is a senior writer for ESPN.com.