About Recovery…

Ten Weeks Out & Doing Great:

Well as I write this tomorrow will be 10 weeks since surgery. On the whole I am feeling really pretty good. The biggest everyday win is that I have more energy than I think I have had in 10+ years. I genuinely feel much better than I did before the surgery. Enough that it is really noticeable. That would be great but the even bigger win is I have not had any symptoms! I have not really gotten my heart rate up too high yet (so I am holding off on declaring victory), but so far I have been totally symptom free.

The incision has healed completely and I am now a member of the "cool scar" club. All of the reading I did in advance said that 80% of the healing takes 6 - 8 weeks but you won't feel 100% for 6 - 12 months afterwards. So far I have to say that seems to be accurate in my case as well.  A big sneeze or cough is still probably the single biggest source of discomfort I have left. It sort of feels like when you have had a bad chest cold for a few weeks and it hurts to cough (plus a little bit more on top of that). Not as bad as it was back in the beginning but still quite unpleasant.

The only other significant challenge has been sleeping. I am a side sleeper (pretty much involuntary) so even if I go to sleep on my back I wake up on my side. Which meant I would wake up many times during the night uncomfortable / in pain. However, this too has been improving. In the past week (9 weeks post-op) it really has been getting better and I have even managed to sleep through the night once.

The only other data point to add is something that I did not read or hear much about before surgery and that is muscle pain. I have certainly been experiencing my share of just plain old aches and pains. Occasionally pretty severe but usually just on the "annoying" end of the scale. Best I can figure is that surgery and healing stretched and re-arranged many of the muscles on my chest and back. So that, plus all the awkward positions caused by the discomfort in my sternum are causing the pains. I do expect that they will get better. But, every so often it really is noticeable how stiff / uncomfortable to move it is.

So I feel that I can safely say, that while your milage may vary, myocardial bridge unroofing + bypass surgery is doable (although it is a big deal and not to be taken lightly). And, most importantly, things on "the other side" of the surgery are significantly better.

Bottom line for me at least: it absolutely was worth it.

Lessons Learned & Advice to Others:

I thought it might be good to remark on some of the bigger or more interesting things I learned during recovery. So here are a list of things I wish I knew before, stupid things I did that I recommend not doing, and some things that worked well. There is no "order" here and sorry if some of the pictures are a little "strong" but I am sharing them so other's will hopefully have fewer surprises than I did.

The Chair:

My home for the first month of recovery

Earlier I mentioned that a lot of people posted that they highly recommend having a recliner for the first weeks of recovery. I completely concur. Make sure you have a comfortable recliner if it all possible. Preferably one that you can sleep in easily. I did not have one but it was not too hard to find a medical supply company that would rent me a "lift chair" recliner. 

Turns out renting that chair was probably one of the best things I did as I pretty much lived in it for the first month of my recovery. It was great for me because for that first month it hurt to lie down on a bed, hurt to move once I was there, and hurt to get up again. A traditional bed (even with pillows) was just not going to work. The recliner was great because it was powered and that made it super simple to go from sitting normally to the closest to flat I could tolerate at any point (which in the beginning was not too much).

So, I hung out in it during the day and slept in it at night (narcotic painkillers helped with the sleeping). I got especially good at building a "nest" of sort with blankets and pillows for the night. 

The only extra piece of advice I have is make sure that if it has a built in head rest make sure that it is comfortable for you. Mine had one but it hit the top of my shoulders if I just reclined normally. This would cause back and shoulder pain in the morning if I did not slide down a bit first to make sure it correctly aligned with my neck. 

Medications:

I know I was just hopelessly naive but I did not realize how many medications I would have to take upon getting home and the schedule that would go with it. I came home from the hospital with something like 3 pages of drugs and instructions for how to take them. Girlfriend did an amazing job of figuring out the schedule that met all of the medical requirements but it really was a mess. I, of course, was no help at all as I was on painkillers for that first month and focusing was not really something I was particularly capable of. 

The good news is that the amount of medications I had to take tapered off pretty rapidly and right now I really am only taking a single pill as a result of the surgery. But, at the height of "the drug phase" there really were quite a few of them. The picture on the right is of the basket that we used to keep all the bottles, interaction slips, and instructions together. Not shown are the three daily pill boxes it took to keep a day organized. 

Complications:

I don't know if you can go through something as significant as open heart surgery and not have something not go perfectly to plan. To be clear all the stuff I really care about went significantly better than planned (zero problems during the surgery, no bypass machine, no transfusion, home after 3 days…) but there were a couple of things I want to mention so that others are aware. 

First, is constipation is the enemy. Narcotic painkillers, which for me at least were essential for the first weeks home, have a constipation as a very common side effect. I did not think too much about this and did drink water and took medication to combat it but was not "focused" on it. That was a big mistake. During my 5th or 6th day home my pain was getting bad, around a 5, and worst is that the pain killers were not working. That night was one of the worst I had experienced since surgery. Pain around a 7 or 8 and nothing was working. I could not sleep and was really really miserable. 

Turns out that when you have had open heart surgery your chest really hates pressure. Any pressure. And constipation starts pressure in your gut but it quickly pushes higher in the chest cavity and that is OW, big time. 

So my advice is drink more water than you think you need: 16 oz. whenever you think about it. And. eat carefully too. You will save yourself a whole lot of pain. 

Going into surgery I was a little bit worried about the Coronary Artery Bypass Graft (CABG) that they were going to do. A couple of the blogs I had read, and something that the surgical team and Dr. Schnittger mentioned as well, all said that the CABG site bothered patients more than the median sternotomy did. Apparently, the graft site (the leg in my case) really was supposed to be very uncomfortable for a good amount of time after surgery. This concerned me. 

So as I mentioned in earlier posts after the surgery I paid attention to how my leg felt. Honestly, it really did not hurt, rather it just felt a "bit off".  But, not really even that bothersome unless walking on it. Walking did hurt a bit (like a mild sprain) but was not anything super serious. So when I went home from the hospital I was not very concerned about it. 

I did notice shortly after getting home on the first day that it was actually pretty numb. I had no real feeling in the skin on the front of the leg from just below the knee to just below the ankle. Basically, the leg felt like it was injected with Novocaine. It turns out that the vein that they harvested for the CABG is right next to the nerve that transmits feeling from the front of the leg. So when my vein came out it clearly made the nerve "unhappy". In the grand scheme this probably is a good thing as it meant that my CABG site has never really been a pain problem for me. Even today I still don't really have much feeling just below the knee and none around the ankle. 

So a numb leg was one aspect. But, what I was really not prepared for with the bruise. When the vein was harvested clearly there was something that was connected to it that did not get closed off too quickly. This was my leg on February 4th 5 days after surgery. 

I have been told that the swelling and bruising is atypical. And, I know this because, it unsettled me enough that I called the surgeon's office and sent them the picture. (you can faintly see a red line on my leg in the picture - I drew that when I was mapping out the area where I had no feeling.) 

Of course, this all healed just fine, as witnessed by this after picture I took today, but it was something I wish I knew about before hand because watching my num leg start to look like something from The Walking Dead was "disconcerting" without foreknowledge of what was going on. (Again, your milage almost certainly will vary). 

Summary:

During the time from October 2nd 2015 until today May 3rd, 2016 I have been on a journey unlike any other in my life. And, I know that it is not quite over yet…

There are still more things left to accomplish (cardiac rehab, lifting more than 2 lbs, sleeping consistently …). There are open questions: 

are the two untouched myocardial bridges going to be an issue? 

Was enough of the LAD unroofed to be successful in permanently eliminating my symptoms? 

Many more…

Yet, with all of that I really feel like the bulk of this journey is complete for me now. I feel better than I have in a long time. I can clearly see both the end of recovery road; and, the beginning of the post surgery one. 

Really, I feel just like any other guy (albeit one with a cool scar) whom has just learned a whole list of new things. The top of which is to appreciate today and focus on the things and people that matter most. (I know it is totally cliche, but, that does not make it any less true.)

I hope people out there reading this blog have found the information here-in useful (at least a little bit.)

Lastly, I want to offer to pay forward the immense favor that was offered to me early on in my journey. If you would like to talk to someone who knows what it feels like to be on a myocardial bridge journey: I would be honored to try and help.

Speed...

Day 1: Settling in and moving forward

After having to leave the ICU so quickly I guess I either got lucky or the staff took some pity on me (probably both) because I was wheeled from the ICU to a single bed room! It was such a relief to go from the ICU which I found to be quiet and somewhat restful (which is absolutely not what I know ICUs to be like – a difference probably explained by the fact that the only time I was really awake in the ICU was the middle of the night) to a room that was equally so. After getting into my new bed (no small effort) once again requiring some serious sweating, I managed to drift off and get some sleep all the way until 6:30am.

Now since, I got evicted from the ICU so early in the morning nobody had the chance to call girlfriend to let her know that I had left. So she arrived at the ICU right at the beginning of visiting hours which was unfortunately right in the middle of getting the new patient whom took my slot settled in. So she had to wait awhile before she was allowed back into the room I was assigned only to find that I was not there anymore. Minor SNAFU that was quickly remedied. 

Eventually girlfriend got directions to where I was. It was good to see her smiling face that morning for lots of reasons but, honestly, one of them was that she had my iPhone. (A really good thing as the withdrawal was starting to get bad.) So along with getting to see girlfriend, and get my phone back, the rest of the morning of the first day was spent with the usual hospital things: rounds, shift changes, morning work-ups, meds, etc… 

In fact the entirety of the rest of the day was equally predictable. I got out of bed for a wheelchair ride down to x-ray. Had more visitors – Dr. Schnittger, Dad, plus a bunch of friends. Sat in a "real" chair for a little while (which was supposed be a pretty big deal but was pretty anticlimactic since I had gotten myself into a chair twice already by that point). And, of course, finally got to eat again which was great. The food (despite a poor appetite) helped energy levels quite a bit.

Pain on this first day was certainly there but was pretty well managed between the block and some occasional narcotics. I guess the best summary of this first day was that it was about celebrating the successful surgery, visitors, and starting down recovery road.

Day 2: Pain and Unplugging

If the first day was about getting on recovery road the second was about disconnecting and dealing with pain.

Although no-where near the misery of the first night post-op the second night was still pretty rough. As day one became day two the pain at the surgery site just started increasing. I soon ran out of comfortable positions, spots, or anything I could find to get some relief. Everything just hurt. 

First post surgery selfie.

The pain management team was good about checking in and doing what they could. Their strategy was to give me regular boluses of meds on an interval. The goal was that the pain would just be starting to come back when it was time for the next bolus. Unfortunately, for me, this was not working as it was coming back well before the next bolus could be given. So I sort of found myself "losing ground" near the end of the cycle. All this meant that by morning of the second day I was not a very happy camper.

Narcotics would help with the pain before the next bolus but the block was far more effective. Clearly a new approach was called for. So the pain team, after talking with my caregivers, decided to switch from boluses to a constant drip which would keep the medication level consistent at the block site.

The switch took most of the day. The decision was made in the morning and it took about 10 hours plus one more smaller bolus (sorta to give it a final kick) to get everything to a good place. But, once I was over that hill the rest of the time with the blocks went perfectly. No real pain in my chest at all and no more pain cycles.

There were other major milestones that I managed to clear on that second day too. After open heart surgery they leave some tubes inside the chest cavity to drain fluids away from the surgery site. I had two of them and in the afternoon it was time for them to come out. Many of the blogs I have read talked about how the tubes "felt weird" or were uncomfortable. I don't know if it was because of the nerve block or some other reason but I was never really even aware of mine. I knew they were in there, because they were supposed to be, but I was not really "feeling" their presence.

Removal was straight forward and certainly felt strange but was not really all that painful. Sort of a burning sensation, with a quick sting, that went away in a few seconds. Once they were out it was much easier to take a deeper breath. I think the chest tubes being out gave me another 500cc worth of lung capacity before my chest would hurt.

The other "big" removal of the day was the dressing on my incision. I could see the surgical site for the first time. It actually was not as bad as I was prepared for. Five inches long with no staples or external sutures. In many ways it just looked like a big cut and it was a cut that was healing nicely to boot.

The rest of the second day was filled with the same events and happenings as the first; plus, some other stuff. Lots of great friends visiting, tests, meds, and just generally monitoring my condition. But, I also was able to get out of bed and walk around the floor a bit. And, both Dr. Schnittger and Dr. Boyd dropped in to check on me and gave me a chance to ask questions again. (Which was great since I was not as drugged and had a much easier time remembering their answers).

On the whole day two was another day of solid progress. And, just as I was sort of reflecting on all this the nursing shift changed and my new night nurse, after introducing himself, mentioned that I might be going home tomorrow…

Day 3: Done

I know there is a big concern that hospitals in the US are pushing patients out the door too quickly. Rushing them home before they are ready and thus adding some risk to their recovery or their health. And, honestly, the first time I heard that I might be discharged only three days after undergoing open heart surgery that was where my head went. It made no sense: I was supposed to be in the hospital for five to seven days not three.

I thought about it that night. On the plus side I basically was not really hooked up to anything anymore. I had an IV that was not being used, two catheters for the blocks, and heart telemetry. I could get into and out of bed, get into and out of a chair, and walk around. (200 - 400 feet anyway). From a functional perspective I had to agree I could go home. 

But, I was really concerned about pain management. Up to this point I was relying pretty much entirely on my blocks for management of the pain. Early on the morning of the third day the pain team had been by and had removed the catheters for the blocks. I was pretty nervous about this since I was basically relying 100% on them for management of the chest pain. And, after my experiences the first night in the ICU I knew how badly it could hurt and really did not want to go through that again. But, the catheters can't stay in very long because of infection concerns and it was time for them to come out. So with the block lines gone (a completely painless event) I was both able to have my back scratched again (the tape used to secure the catheters really itched) plus I started taking pain pills for the first time.

That morning of the third day was the first time I had even tried any pain pills. The first pills were strong stuff and worked pretty well for the most part but they still were not quite "enough" for lack of a better phrase. With pain levels of ≤ 3 I could relax and sleep. With just the initial pills the pain was usually in a range of 3 to 6 averaging around 5. Too much to really be able to relax.

So later in the morning, after consulting with girlfriend, I pushed back and said that I was just not comfortable going home until we had a better pain management strategy. I really wanted to go home (very much) but was just not comfortable that it would work out yet. 

The doctors were great and listened to my concerns and agreed that going home would wait until we had a better, and proven, pain strategy. Plus, they also wanted me to have successfully climbed some stairs (I live in a 3 story townhouse so negotiating stairs was a must for me).

With new, and clearly defined goals, it was pretty easy to develop solutions. My morning nurse suggested another drug to "stack" on with the original pain pills. This worked really well. By 11am it took the pain that was ranging from 3 - 6 down to a 1 - 4 with the majority of the time hovering around 2. Certainly something I could sleep and rest with. 

And, around 2:00pm physical therapy showed up and gave me techniques and the "do's and don'ts" of climbing stairs with a broken sternum. A practice session later and the last hurdle was cleared. 

By 3:00pm it was clear I was going home!

The rest of the day was discharge instructions, prescriptions (almost 10 of them), and a heroic level of effort by girlfriend to secure all of the medications before the only pharmacy my insurance would cover closed. (Weekend hours as it was Saturday).

So at 5:00pm on Saturday February 20th, 75 hours after being wheeled out of surgery, I was being
wheeled out of the hospital to go home!

That car ride home, holding tightly to my "sternal precaution pillow", was one of the best car rides I have had in a long long time.

It's Party Time!

Twas the night before…

Well, I don't think it is hard to imagine how difficult it is to sleep the night before open heart surgery. And, I am proud to report that after conducting extensive research in the area (one night) the hypothesis is confirmed. Before they crack your chest open with a overpriced skill saw it is damn near impossible to sleep. But, beyond the "normal" amount of worry I was also dealing with some pain from the installation of the catheters for the block from the day before.

In the last post I mentioned that they had been bugging me all day; and, that pretty much was the way it was until I got prepped the morning of surgery. Best I can figure is that inserting the two catheters (plus the saline and x-Ray contrast injections to confirm placement) through the muscle into a tiny space where the nerves from the chest connect to the spine irritates those nerves. And, since these are the nerves that communicate pain from the front of the chest, it felt just like my chest hurt. (for comparison: it is not as intense as the actual pain from the procedure – maybe 30%)

To be clear, despite hurting for over 12 hours and really not being able to sleep / be comfortable, I am a huge fan of paravertebral blocks. I can personally attest that when they work (and are managed effectively) I was significantly more comfortable than with the oral meds or IV narcotics. All without any of the downsides of the narcotics to 'boot' (and the 1980s definition of 'boot' is the most appropriate here.)

So, I would take the night of discomfort I had in an instant vs. not having the blocks and their relief post-op. (The real upside is that the discomfort made me very glad to get to the hospital at 5:15am because it meant that I finally could get something to stop it.)

So when it was time to get up and "wash" I hit the surgical pre-wipes quickly and was ready to go well before we needed to leave. 

Pre-Op:

The pre-operative experience went totally as expected. I showed up at 5:10am registered with the desk (same great crew as the day before for catheters insertion) and was shortly camped out on butcher paper. Everything was the same as before except I did notice one difference: my prep-bay had a little blue "surgical shave" handwritten sign. (As soon as I saw it I immediately started itching for some reason.)

Turns out a "surgical shave" is as aggressive as it sounds. Below my neck I have one tuft of hair left on my kneecaps plus some mottled patches on the arms. But, that is about it. (Respect level for my female friends has been appropriately increased.) 

After the shave came the relief from the catheter placement I was hoping for. The pain team arrived and graciously gave me a full bolus dose of Bupivacaine. Within 15 mins all of the discomfort was gone. Along with it went much of the sensitivity in the center of my chest. Huzzah! This gave me real hope for pain management after surgery which was great to have going in. 

I was one of the first patients lead back into pre-op and by 6:15am the whole bay was really jumping. There were patients getting prepped, patients waiting with their families, and the hustle and bustle of the surgical teams collecting their charges to wheel back to an OR.

By 7:00 the pace really had slowed down and the room was nearly empty: but, I will still there. Turns out that my procedure had been pushed back behind an emergency case that came in the night before which was just finishing up in the main OR. So I had to wait until around 9:15 or so before they were ready for me. Of course it increased anxiety having to wait longer but, honestly, I was okay with it. I was comfortable and was enjoying passing the time with girlfriend and catching up with my dad.

So when the anesthesiologist showed up to give me something to "get ready" to go back I did not think about it much at the time. I asked what I should expect to feel and he mentioned it would feel like a few drinks. Sounded interesting to me....He injected my IV line and I remember feeling a slight rush followed shortly by a much bigger fuzzy wave. 

I distinctly remember saying as the wave arrived something like: "Yeah, that really does feel like a few beers!" after which point I have got nothing…

Surgery:

I have been told that after the drugs kicked in I got really smiley, happy, and clearly "out-to-lunch" while we said goodbyes. All I can say is that either:

1. My dad and girlfriend are the best kind of people in the world because they did not video this …or…
2. They are really good liars and I just have not seen said video yet.

(I am really hoping for option 1. Although, dad is an attorney…)

After getting wheeled back there was around another hour of preparation. Where I had a bunch more lines inserted. Lines that I am actually very glad not to be able to remember getting.  I gained an arterial line in my left wrist and an IV in the back of my left hand. I also an got IV inserted in my neck. All, told I had 3 IVs (both hands and neck) and one arterial line.

The surgeons got to work around 10:00 that morning. And, first up was the unroofing of the LAD. This apparently went very well and they were unable to uncover much of the artery. As expected, not the whole 8cm, but enough that hopefully it won't be causing more issues. The LAD bridge really was very deep and at one point while unroofing a section of it that section expanded significantly
– having been freed from 46 years of encasement. (Given the way it was explained to me the best analogy I have is: think about a sleeping bag rolled up in it's sack. Then cut the sack the long way along one side. It does not unroll but it does expand without the sack to hold it tighter. I think it was sorta like that but more uniform of course.) 

Next was to apply the graft from my leg (that was the final choice: preserving the radial and LIMA for use later if necessary) to the Ramus. The goal was to do that after unroofing the Ramus but apparently after actually seeing my heart the Ramus bridge was determined to be just too physically hard (plus risky) to attempt to unroof. So because that bridge was very short anyway, and very close to the plaque it was influencing, they just bypassed them both.

All of these procedures required me to be on the table for about three and a half hours. But, what is even better than the shorter surgical time is that it was all accomplished without heart / lung bypass or even any extra blood! (A major heart surgery without a single drop of extra blood performed on a 100% beating the whole time heart certainly was not the expectation – and I am very grateful that it was not required.) 

So around 2:30pm or so in the afternoon I was wheeled into the ICU.

Waking in the ICU:

I remember "dreaming" a little before "waking up". Apparently, before I think I was awake,  I asked the same set of questions over and over for a little while. Things like: "what are my O2 sats?" or "how did it go?" (Honestly, I think girlfriend and dad are just making this up. **I** remember everything from the ICU clearly – and I don't remember asking those questions at all.) 

As the haze of the anesthesia wore off, and after family had to leave, I do remember thinking: "Hey, I made it…I wonder if everything works?" So I conducted some experiments: I remember moving my arms a little with no issues. I moved my left leg with no pain. But, moving my right leg really did not feel quite right. Did not hurt, but did not feel great either. Okay. No serious problems there.

Then I went for broke and focused on my breathing. First off, just breathing did not hurt. I felt like I was breathing fine and since I was not intubated was able to control the pace a bit. I did notice I was taking multiple, and rapid, shallow breaths. So I tried to slow down the pace and breath deeper. I succeed in slowing the pace but not in breathing deeper. The reward for this combination of success & failure was a rather serious alarm from my O2 monitor. Okay, got it: I was balanced right on the edge of normal / caution oxygen saturation. 

Last, it was time to try and take a deep breath. Now, I have to assume that a "deep breath" to me back then is not even close to a "deep breath" even now (1.5 wks post op). But, regardless I did accomplish what I felt was a reasonably deep breath. The reward this time was predictable – OW!  Okay, so they really did do the surgery.

But, that pain was not as severe or as "Oh CRAP" as I had expected, or prepared, myself for.  And, that was the first moment I started to believe that it was really going to all be okay. I could do this. Everything serious seemed to be working and, at the very least, the pain could be managed – I just had to avoid doing stupid things (more examples of stupid things in later posts).

I think all of this would have taken place around 6:00 pm or so. 

As the evening went on the pain started to grow. The bolus of Bupivacaine I had earlier was wearing off. I mentioned to my nurse that I was starting to hurt and she told me that the pain team delt with the blocks so she could not help there. But, there also were orders for IV pain medications too. So we decided on paging the pain team and trying the narcotics as a bridge until they could arrive. 

I will spare everyone the specific details of the next sequence of events and rather just summarize them here:

1. After surgery I was still "nothing by mouth" so no water or food.
2. Pain medication, especially strong narcotics, can make you vomit.
1. This is worse if your stomach is empty.
3. Anti-nausea drugs work really well but there is a delay between giving them and when they start working. Plus variability in how long they last and their overall effectiveness.
4. Hospitals have you rate pain on a 1 - 10 scale. With 1 being very mild and 10 being the worst pain of your life. During my previous 46 yrs on this planet I never really had a solid clear winner for a level 10 pain experience: I do now.

By 1:30 in the morning everything settled down. The block had been re-bolused and was working well enough that previous few hours' "narcotic --> vomit  --> anti-nausea --> repeat" dance party was done. I was finally feeling pretty good…

…and that is when the nurse came in and told me that I would be moving soon. With a value of soon measured in hours not days. Wait…what…moving soon! I was just admitted to the ICU sometime around 13 hours ago. I was supposed to be in here for one or two days not 13 hours.

Turns out there was another emergency surgery underway and that patient was going to need to an  ICU bed. And, since the ICU was full that meant the healthiest patient in there had to go; and, that patient was me. 

I was not thrilled since after my "dance party" I just now felt the ICU staff / pain team had just figured out how to make me comfortable. But, I trusted the IICU (cardiac care wing) would be able to do the same thing. The only other added wrinkle was that the ICU did not want to give up it's bed (other patient arriving too soon I think) to transport me so they were going to put me into a wheelchair to move me.

So approximately 13hrs after surgery I was sitting up, getting out of bed, standing, turning, and sitting down again in a wheel chair. It does not seem like much…but, I have raced crew at the university level before so I know a little about exertion. Crew taught me what it was like to go 120% all out in every race, pass out crossing the finish line, loose 3 lbs in just sweat during a race, and work out 5 hours a day. Crew takes real effort but...

…I think that was easier than just getting up and moving myself to the chair was that night. I was exhausted, sweating profusely, dizzy, hot, and nauseous after just that simple activity. But, I did it!

This was only the first of many "accelerations" my post-surgical hospital course was going to take. More on those in the next posts.

An Im-port-ant day

Ready Set…

Home stretch now. With less that 24hrs left I am as ready as I can be. Another bridge patient that I had connected with early on, "swissdots," mentioned that today was going to be a busy day of tests and information and she was so very right.  

The morning started off with my 6:45am weigh in. I had set a goal for myself to lose 20 lbs by the date of surgery to help reduce risk and speed recovery. I hit the goal last week and have been managing to hold the line since. Still have about another ~10 lbs to go to get to my perfect weight but still pleased with the progress. (Especially, since I pulled it off without any exercise at all – thanks to the symptomatic bridges.)

Eating Paleo, with extra cardiac modifications, works well for me at least.

Then came the "surgical scrub" shower. After which I had absolutely no doubt that I was the cleanest that I had ever been.  (I still have an extra sponge. hmmm…wonder if I can get the teenager to use it after practice…)

A quick Uber after scrubbing and I made it to the 8:30am check-in at the oh so glamorously named E25: Surgery Reception for my paravertebral block procedure – with time to spare. The first step was full on hospital registration complete with double wrist bands, allergy warning bracelet (I am allergic to tetanus vaccine), and of course double confirmation of insurance and billing information. This was more like the cath-lab visits than the other procedures.

After a short wait in reception it was time to head back to the general surgery pre-op area to get my high fashion hospital gown and warm socks. The most unexpected part of the visit was that while I was answering registration questions my surgeon stopped by and updated me on the latest plan for tomorrow's procedure: 

1. Unroof as much of the LAD as possible.
2. Unroof the Ramus bridge. (which I found out is about 1cm - 2cm long.)
3. Bypass the plaque in the Ramus.
1. Final bypass plan, is to go with my initial understanding, and use a vein from my leg.
2. Thus saving both the LIMA and the radial arteries for future needs (just in case since I do have a calcium score of 217. Stupid genes.)
4. But, best of all, is that the above should be possible without Heart & Lung bypass. Hurray!

So surgery is set.

…Block

After my surgeon left the anesthesiologist fellow dropped by to chat about the paravertebral block.

Short summary: This procedure was used much more frequently in the 1970's but then went out of favor. However, it has been making a comeback recently.  Today, it is most often used for mastectomies and thoracotomies but Stanford has been experimenting with it for median sternotomy patients, specifically Myocardial Bridge patients. Apparently, bridge patients have more post-operative discomfort than others whom undergo median sternotomies.  Possibly because of age (we tend to be younger than other cardiac patients) or just due to other strange aspects of bridges. (An example: I really can't sleep on my left side anymore as it hurts; which is totally strange to me, but also is apparently pretty common for bridge patients.)

Okay, this is where I would usually recount the procedure and my experience of what happened: but not this time. Honestly, I just plain don't remember anything.

All I do remember is: I was wheeled to a different part of the pre-op room where there was some more space for the team to work. They inserted an IV and asked me to roll onto my stomach. After which they started mapping my spine assisted by ultrasound. Simultaneously, they told me they were going to place some sedation in my IV.

I remarked that my head felt fuzzy…      and…       that is the last thing I remember – until the doctor was asking me to roll back over onto my back because they were done.

Better living through chemistry.

Things do become clearer after that point: they injected some contrast dye and shot an x-ray to double check placement. Then flushed the dye with more saline.

Now, remember that the targeted paravertebal space is where the nerves from the front of the chest join to the spinal column? I learned (the hard way) the additional fun fact that if that space is smaller than normal and you compress the nerves, say by injecting a bunch of fluids, they activate. The contrast made my chest uncomfortable and the saline flush elevated "uncomfortable" to "very painful."

I must say it really was a strange experience: the pain "told me" that my chest hurt – something was wrong there. Yet, I "knew", that there was nothing wrong at all: it was just that the nerves that signaled "chest pain" were being directly manipulated; but, I still had a real strong urge to tap my chest to find the source anyway.

The good news: this proved (as also confirmed by the X-ray) is that the blocks are perfectly placed. The bad news: it hurt.

That was solved easily enough by running in a little of the medication that will be used tomorrow. It quickly dulled the pain for awhile. 

As I write this entry, about four hours after the procedure, my chest still hurts plus my back hurts too from the installation of the ports through the muscle.  However, I am confident that this really is going to be a valuable pain management tool tomorrow (and for 2 - 3 days after that) even if it is not very comfortable now. (Update: 2/17 night before surgery 2:45am – this discomfort still is around. So, not that it was going to really happen anyway, but sleeping tonight is pretty much over. My little malevolent lizard brain is busy: so his senseless ramblings, plus the discomfort, woke me for good after about 2 hrs of sleep.) 

A fellow journeyer:

Lastly, if you have been following this blog since the beginning, you might remember the E.R. nurse I mentioned in an earlier post that also had a partially unroofed bridge that was becoming symptomatic again? Well, it turns out he did decided to join the Stanford bridge clinic. And, in fact is scheduled for surgery tomorrow as well. He was in the bay next to me getting his block set up. (His surgery is scheduled immediately after mine is finished.)

Bring it!

Tomorrow morning at 5:15am I report to registration for surgery. I think I am feeling the appropriate amount of apprehension. But, more importantly, I feel good: I have done everything that I can to get ready, I am calm, and I am really at peace with what lies ahead.

T minus 5…

Short Update:

I know it is really inconceivable for this blog to have a short update; but, hope springs eternal…

Surgery is definitely getting closer now and I have been working diligently on getting prepared. My ultimate goal is to remove as much stress from surgery and recovery as I possibly can. I figure recovery itself is going to be enough stress and I don't need "life" providing more. So I have been working down a long checklist of things to get done before Wednesday. Really deep things like: "get a haircut that requires minimal arm use to maintain" (It really is amazing the amount of administrivia that makes up life once you write it all down.)

Another item from that list was renting a lift chair which came this week. I did not have any recliners, and with all the raves from others who had a median sternotomy, I figured it would be a good idea to have one. I have to admit this thing is seriously comfortable. So at least from a pre-operative evaluation it seems great. I can get into it, recline fully flat, return to sitting, and get-out without using anything other than 10% of my legs. No arms, no core, no chest, no nothing. Seems like this is going to be great.  (Yes, it is true, I have sunk to the point where I am psyched about a motorized chair. I think my hair actually got 15% grayer just writing that paragraph. Seriously, I need to have my head checked…)

Surprise Evaluation:

I also had an unexpected (by me anyway) vascular ultrasound this morning . They were looking at the arteries in my arms. I knew that the most popular source of an arterial graft was the left internal mammary artery (LIMA) but my team did not want to harvest mine preferring to save it for later in case I needed it. The ultrasound surprised me because I was behind on my studying and had not read up on grafts. So, I just thought they would harvest a vein from my leg and that would be it. Pipes are pipes right? 

Wrong. Turns out the body really LOVES to specialize. 

Accordingly there is a much better approach than getting veins from the legs. For coronary artery bypass grafting (CABG) arteries are much preferred over veins. The reason was kinda obvious when I actually thought about the "plumbing" of the system for a second: coronary artery grafts carry arterial blood vs. venous blood. Arterial blood is "close to the pump supply" vs. veinous which is "end of the line return." So arterial blood is higher pressure than veinous. And, like any good plumbing system, the body only uses hoses rated for the specific pressure they are going to be carrying. So a high pressure rated artery is better at carrying high pressure arterial blood. (As mentioned in another post: even the DNA of the cells in the walls of the arteries changes in response to pressure. So arteries really are customized to their job. Cool system.)

So, when I spent the time to actually think, it makes sense that they would want to check the inventory of available parts and make sure it suited. I guess the arms are the best choice as the sizes of the arteries there are going to be closer to the coronary arteries as opposed to the ones in the legs or elsewhere.

I think I passed the inspection. No blockages. And, unlike my heart, no construction weirdness.  Both the superior and inferior arterial loops in my forearms and hands supplied blood to all my fingers; so I could do okay with one loop not working or not working 100%. 

Bottom line: looks like the graft(s) for the bypass will come from my arms, not legs. Which I guess means I am going to be able to walk without ouch. (+1 pt) But, probably at the expense of typing.  (-1 pt) 

Next…

The other useful event of the week was getting my paravertebral block scheduled at set up for the morning of Tuesday 2/16. I have to admit this one has me a bit nervous. Of course, none of the concern is due to anything rational. It is all "lizard brain" reaction stuff. (I keep trying to have a rational conversation with that little fear monger in the back of my head; but, he is listening to me with the same focus and attention that my adolescent kids exhibit when they are "staring at the abyss" – aka their iPhone screens.)

I guess just the thought of inserting catheters into my back and kinda interweaving them with my vertebra is…well…unsettling. You are not supposed to insert things into your spine. You are supposed to be careful and protect it. I am pretty sure I remember my mom being rather specific, and clear on, the topic. 

Of course the other aspect is that going to this appointment will mean that the surgery is less than 24 hours away. I will be glad for the relief the surgery will offer and the weight off my shoulders once the plaque(s) are addressed but… still…

Anyway, while talking to the nurse as we were setting up the appointment I learned that Stanford's approach to pain management is multi-modal. They really attempt to address pain from as many angles as possible. So the paravertebral block is only one dimension. They also use good old narcotics (hopefully less though thanks to the block) administered both after surgery and before. Even vitamins apparently play a role in pain management. I have instructions to take 500mg of vitamin C twice daily starting the day before the procedure – for pain. 

I guess I failed at keeping this post short.…not really surprised.

Next up holes in my back…

Buy One, Get One for Free - Only 15.99 mSv!

Deja Vu:

Eventually February 4th rolled around and it was time to have my second heart catheterization done at Stanford. But, this time it was going to be intravascular ultrasound + angiography.

IVUS Probe & Plaque.

Intravascular ultrasound (IVUS) allows direct "visualization" of the plaque as opposed to angiography which studies the flow of blood through the plaque. IVUS was key as it is the highest resolution test for plaques available. Much higher than CT scan or regular angiography (both of which had already been done and both producing different estimates of the plaque's obstruction - probably due to the effects of the severe bridge of the LAD.) So I was glad to be doing it as it would provide the final answer if I needed a unroofing + bypass or just unroofing. 

IVUS image of Plaque (green).

And, since they were already going to be in looking at the plaque I also consented to an experimental IVUS bridge study procedure. The goal of the procedure is to use IVUS to attempt to detect, measure, and quantify the effects of a bridge. Thereby helping not only differentiate severe bridges from benign ones but also help outline their effects on other complications surrounding the bridge. More data for the general bridge pool that, hopefully, would benefit me too. 

So at 6:45 am I found myself once again on butcher paper getting ready for a procedure. The ultrasonic transducer and sensor for the IVUS is tethered on the end of a long wire so that meant that this time they had to use the femoral artery in my leg for access rather than the wrist. So once again I had to get prepped for bikini season – but, this time they meant it. (I actually could probably even pull off a mini-skirt given how much they shaved.) 

Around 8:00 it was time to head into the main catheterization lab. They had redecorated since the last time I was in there; but, otherwise it was the same. This time, because I knew about it, I immediately asked for a "bear hugger" up front (the semi permeable air based warming mattress) and they managed to find one for me. Hurray for not freezing and being embarrassed at the same time. 

After they got me a good view of a monitor to watch the feed from the probe, ensured I was all "plugged in", and dimmed the lights – it was showtime. This round was much longer than the last due to lots of different explorations of arteries via detailed IVUS assisted mapping expeditions. From my vantage point it was interesting as I could see the arteries when they shot dye into them just like last time. But, unlike last time, there was this 2 cm long worm looking thing dancing around in there too. Of course, that was the IVUS sensor but I swear it really looked like a worm the way it "crawled' and "wiggled." (An impression I am sure was "assisted" by the much greater selection of drugs used this time. Drugs that included Acetylcholine to get the heart rate up and cause the bridge to be "unpleasant." And, some general sedative to back things off again.)

Also, of note, is that like last time I caught snippets of conversations happening outside of my field of vision and heard things like "another one" and "significant?" 

After, the procedure was over, but before being wheeled out, Dr. Schnittger came over to me on the table and reviewed what they had found so far. (The full report had to wait until recovery because they wanted to talk with Dr. Boyd (my surgeon) and some others about the findings.)

So next, from there it was off to the recovery room where I had to lie flat on my back not moving for four hours. It was not as boring as it could have been thanks to girlfriend's excellent company plus an iPad (definitely better than bleeding from my femoral artery) but still not a recommended way to spend an early afternoon.

Around 12:30 pm Dr. Schnittger dropped by with the skinny on the findings. 

Bridge B.O.G.O. …

Results from the Angiogram & IVUS:

• (Update) They did not do a full study of the bridge on the LAD because it is so severe as to actually be atypical enough that the results are not relevant and not really safe to explore either. Dr. Schnittger summed it up best by pointing out: "you can see that thing from across the room." But, to help with my surgery, they did precisely locate the entrance. They confirmed that it is 99%+ closed during systole and learned some useful other facts (see later on in this post).

So, according to Dr. Schnittger the priority for this surgery is:

1. Fix this bridge!
2. Fix this bridge!
3. Fix this bridge!

(It was also confirmed, that because of the length of the bridge on the LAD, it will not be possible to unroof the whole thing as the artery under the bridge becomes too small, <1 mm, at some point (maybe about ~6.5 cm down) to be safely unroofed. My hope is to clear about 6 cm.

• (Update) The IVUS study of the plaque in my LAD (the primary reason for doing this procedure) showed that the plaque, in both Dr. Schnittger's & Dr. Tremmel's opinions was not significant enough to warrant treatment. My surgeon Dr. Boyd disagreed and was going to continue to have "conversations" with Dr. Tremmel on the topic. But, regardless of who wins these "conversations" I feel better that this plaque is not as bad as originally thought. (Hurray!)

Of course right after she said this I started thinking "hey, since this plaque was the reason for considering the surgery then maybe I don't need the surgery…" (That ended quickly…)

• (New) They found a third, previously unknown, bridge on my Posterior Descending Artery (PDA). This bridge is basically like the one on the Left Circumflex (LCX) and interesting in that it exists but not really causing problems. It was just sort of "winking at them" on the scans.

• (New) The left main coronary artery usually divides into two branches, known as the left anterior descending (LAD) and the circumflex coronary arteries. In some patients, a third branch arises in between the LAD and the Circ. This is known as the ramus (pronounced ray-muss), intermediate, or optional diagonal coronary artery. Only about 15 - 30% of the population has this and, of course, with my "heart luck" I am a member of that group. 

The point where my ramus branches off happens to be under a section of a bridge which makes getting images or scans of that area using the other tests I have gone through difficult. But, not for the IVUS probe, so when they explored down the ramus with that probe they discovered, a previously unknown, second plaque. This plaque is in a section of artery that has a natural "hook" or "kink" and is obstructing 85% of the blood flow. A Bad Thing.™

That makes this a significant enough blockage to mandate treatment. So although the plaque on my LAD probably does not need bypass this one does. 

• (New) When trying to understand why this plaque was so severe Dr. Schnittger went back to the CT scans and consulted with some radiologists about them. When they looked more purposefully at the scans they found the culprit: there is a fourth, and previously unknown, bridge on my ramus. (I don't suggest reading the last part of that sentence aloud – at least not with anyone aged 12 - 16 around.) Creating a situation where you have the main, and most severe, bridge on the LAD back flowing blood into the blood that the bridge on the ramus is shooting "out the top." Basically, to borrow and build upon the analogy from a previous post, I have three (normal flow, LAD bridge, Ramus bridge) hoses squirting directly at one another. Thus creating a more damaging situation and thus bigger plaque. 

And, of course to treat this plaque, both of the bridges causing / contributing to it have to be fixed. So the bridge on the ramus must be unroofed as well. 

Bottom Line & Path Forward:

Summing up: An additional plaque, beyond the one that was already known, was discovered. This new plaque, in Ramus, is dangerous and requires intervention (bypass).

Also, during this procedure they discovered an additional two bridges beyond the two (LAD & LCX) that were already identified. One of these is likely not significant (PDA) and one of them is (Ramus). The one on the Ramus requires unroofing due to plaque if for no other reason. 

I was originally not supposed to require the heart & lung bypass machine during my surgery. However, due to the recently discovered additional surgical needs, this is no longer the case. So the surgery will be longer, slightly more risky, and the recovery a bit more involved than was originally anticipated. 

One last thing…the date of the surgery was moved up by two days too. So it is now scheduled for the 17th of February rather than the 19th. 

I know that I am, once again, super lucky. If Drs. Tremmel and Schnittger did not do this study, and it was not as thorough as it was, I never would have known about the second (and dangerous) plaque or the severe bridge that caused it until Very Bad Things™ had happened.

So don't get me wrong; I am happy and genuinely grateful. Especially to all the bridge patients at Stanford who came before me and from whom's experiences I am now directly benefiting…

…but…seriously four myocardial bridges…Four?!? Even Dr. Schnittger has never seen anyone with four bridges. (…uh…Yay…another "really don't want to win these things" record.)

If our next rainstorm is a thunderstorm: I am going to go out and stand in the middle of an open field while holding onto a flag pole…you can't get hit by lightening twice – right?  (Playing in the field will be more "successful" than buying lottery tickets. I tried that last month. Nada.)

Anyway, this was the best 16 mSv I ever spent. 

New Year: Time To Fix This

It is 2016: Time to get moving.

Aside: Up to this point I have been writing "in-arrears" so to speak with several posts yet to get done after any specific one I was working on. This however is my last catch-up post. From here on out I intend to keep this blog more current so expect the occasional future post to contradict previous ones. 

The new year started off with an appointment with Dr. Schnittger on January 8th to review the scans and confirm that I am still a candidate for surgery.

It is amazing what tricks the brain will play on you when you're waiting for results from medical tests. It reminds me of an electrical circuit with an ungrounded input. Just all kinds of random off the wall noise and "static" gets played through. Even with both Christmas and New Years Eve to keep me distracted I somehow managed to get myself tied into some knot that I might not be a candidate for surgery.

Of course it was all completely unfounded. (As I said a few posts ago sometimes my brain and I don't get along very well.)

Open Heart Surgery: "There is an app for that" 

After the appointment with Dr. Schnittger, and the accompanying green light, on January 20th I met with my surgeon and got the surgery scheduled. I go under the knife February 19th, 2016.

So to understand what is involved with this surgery I have been using Visual Body – Atlas on my iPad to learn the anatomy and steps. So when I met with my surgeon for the first time there was not too much to review. We could therefore spend the majority of the appointment covering the specifics of my presentation. Of particular note was that my surgeon lead off by mentioning that my bridges at 8+ cm each, and >90% occlusion on the LAD, are the most severe he has seen. (Not a "record" I exactly wanted to hold.) 

Not Me

Here is the plan we came up with: The day before surgery, the 18th, I am going to go into the Stanford Hospital pain clinic for a paravertebral nerve block for pain management. This procedure is typically used for mastectomies but Stanford has been experimenting with it for open heart surgery patients as well. Basically, it involves very carefully placing two catheters on either side of the upper part of the spinal column where the nerve endings from the chest join to the spinal cord. After surgery lidocaine is inserted into the catheters and, if it all works, blocks most of the chest pain while still giving full muscle control of the lower body. The end result will hopefully be better pain management in the hospital with significantly lower amounts of narcotics. 

The surgery itself, is on February 19th, involves a median sternotomy (the cool scar type) with myotomy (unroofing) of the bridge on my LAD. My surgeon has done about 30 of these and Dr. Schnittger will be in the OR too. She has been present at every one done at Stanford - nearly 60 (the most unroofing surgeries in the US). Unroofings used to be done on full heart - lung bypass but my surgeon started doing them without the heart - lung machine about a year ago and hopes to be able to do so without the machine in my case. (Yay - hopefully no risk of pump head.)

Immediately after surgery I will be transferred to the ICU and listed as critical (this is standard procedure for all post operative cardiac patients at Stanford). I should be out of the ICU in a day or two and moved to the cardiac care wing in the main hospital where I will stay for an additional 5 to 7 days. From there I go home to recover for the next 6 - 8 weeks. 

I have rented a "lift recliner" for the first month or so at home because I understand that getting up from sitting / lying down is going to be difficult. Plus, I am not going to want to lie flat for awhile so a comfortable chair to sleep in sounds like a really good plan. I got this idea by reading many cardiac surgery patient blogs. The opinion seems to be unanimous that having a chair is key so I am going to follow the crowd on this one. 

Also, stairs will be a problem as I am not supposed to be climbing but I live in a 3 story townhouse so I guess I will just have to take my time. 

One last little detail to nail down:

Recapping my condition: I have four Myocardial Bridges on my heart. The first one is on my LAD starting approximately 3cm from the origin and extending over at least 8cm. During systole that bridge results in a 90%+ closure of the affected area. Also, in the LAD, between the origin of the artery and the head of the bridge, there is a plaque that obstructs ~<55% of the blood flow.

The second bridge is on my left circumflex artery. It begins about 2 cm away from the origin of the artery and extends over 8 cm. It obstructs ~60% of the blood flow during systole.

(Updated 2/5/16):)  The third bridge is on my posterior descending artery. It is most likely benign. 

The fourth, and final, bridge is on my ramus artery. It is as deep as the bridge on the LAD but shorter. It is problematic because it is contributing to a plaque in the ramus. This plaque in the ramus is obstructing ~80%+ of the blood flow to the ramus.  This plaque does require bypass. 

Arteries affected by bridges show scattered calcification. With the other arteries show mild calcification. 

So the remaining question is what do to about the plaque on my LAD?

As I mentioned previously the plaque is my primary motivator for opting for surgery in the first place. The Angiogram placed it at 60% obstruction and the CT scan placed it at 50% (Updated 2/5/16: and IVUS placed it even lower than CT or Angiogram I think).  So the question really is: that since I am going to be undergoing open heart surgery to unroof the bridges should the surgeon do a "drive by bypass" while he is in there to nullify the plaque.

The reason why he just can't "do it anyway" has to do with blood flow. The plaque has to be severe enough that enough blood will flow around the plaque and through the bypass it to keep the graft alive and healing. If there is not enough blood flow through the bypass it will fail and close off.

So another angiogram is necessary to determine if the plaque is severe enough to bypass. And, since they have to go in to attempt to measure the plaque (I say attempt because it might not be possible due to of the severity of the bridge) Dr. Schnittger's colleague, and fellow bridge researcher, Dr Tremmel is also going to try an experimental procedure to map the bridge with even more detail than the CT scan did. 

Bottom line: I am definitely having myotomy (unroofing) of the bridge and may / or may not have a bypass of the LAD done at the same time. If the bypass is not done then the doctors and I will monitor the plaque and if it becomes a problem, because the bridge will be gone, I can have it stented. 

Next up: Deja Vu (eg another Angiogram)....