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)....