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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)....

Hey, I Was Only Following Directions

The Joy Of Nitroglycerine 

When I was discharged from the catheterization lab on Monday the 19th I was given a set of warning signs to watch out for and things to do if I saw them. Now given the fact that I had a probe inserted through my arm into my heart; most of the things to do were the same: "Call 9-1-1"

Heck, even I could remember that instruction.

The next day, Tuesday the 20th, went without incident as I chilled on the couch reading up on bridges and wondering how severe mine were? Where they were? Etc. I had an appointment the next day scheduled with the prescribing cardiologist so I knew I would get all the details soon.

The day was uneventful and by 5:00 pm I was bored and hungry. So I figured I could just walk to a great little restaurant near where I lived and grab some dinner. After dinner I came back home took care of some administrivia and went to bed.

That was when I started feeling a burning and uncomfortable pain in my chest. It was not severe at first but it was getting worse. So I lay there for a second sort of taking stock. It was not like the attack in Sedona. No "sports injury" starting point.

This was new and did not feel good at all.

Okay follow directions. In case of chest pain take a Nitroglycerine tablet (original instructions given by cardiologist on first visit). No problem. I got one tiny tiny pill out of the tiny tiny bottle and placed
it under my tongue and.....

BANG!! 

Some malevolent spirt or whatnot tackled me and placed my entire head in some invisible vise. Then, while I imagine it was cackling maniacally, started cranking the thing tight. On the tiny tiny bottle the tiny tiny warning label says "May cause headache" and that is like saying Donald Trump is "an atypical presidential candidate."

Understatement of the century.

I now understood why they prescribed these things for chest pain. The pain in my head was going to make me completely forget about the pain in my chest. Or at least completely stop caring if I was going to die as at least then the pain in my head would be gone.

But, I had to admit the pain in my chest was getting better. I thought: "Okay, trading chest pain for headache, probably not a bad thing…and then the chest pain started coming back…Damn."

Back to the directions again. They were pretty clear: in case of persistent chest pain – dial.

Does voice dialing work when your head is being squashed into a pancake? Let's see: "Hey Siri, call 9-1-1"…ring…ring…(+2 pts for the fruit company)

Conversation --> Sirens  (elapsed time ~5 mins)

The great paramedics (who were nice enough not to bust down the front door of the house waiting for me to open it instead) did a repeat of the Sedona EMS experience after which it was off to Stanford. It turns out when you say you are a cardiac patient with Stanford that pretty much ends the whole conversation and you are on your way to Stanford regardless of what they find.

I was admitted to the ER and they did the cardiac emergence: life in peril workup. Which was completely Myocardial Bridge like and thus totally normal. So once again there I was in an ER with all of the tests coming back completely normal. At least this time they had access to the Angiogram and the other data so there was proof that although I still felt like a gigantic idiot I was not completely crazy. There really was something not right.

Probably the best part of the ER experience was the nurse that was taking care of me was a post operative bridge patient! He had a severe bridge unroofed (without median sternotomy) a few years ago in his early 30s (although not at Stanford). He was thinking about becoming a patient of the Stanford bridge clinic because the unroofing was only partial (sternotomy required for full access) and he was becoming symptomatic again. He suggested if I ever was going to be looking at surgery to do the full thing if it was offered. "You don't want to go through it twice."

In the ER the attending physician gave me the official results from the Angiogram. They had identified two severe myocardial bridges. One was on my LAD which during systole completely closed the artery (100% occlusion). The other was on my left circumflex artery and during the heart beat the artery was 50% - 60% closed. As if that was not enough they also identified a plaque in the LAD that was blocking ~60% of the blood flow.

Well…Crap.

Given that it was now approximately 2:00 am and with my history they decided the best place for me to be was in storage. I was told they wanted to admit me and since I had no car, was in my pajamas,  was exhausted, and more than a bit worried about the results from the cath I was not going to argue. So I was admitted to the cardiac floor for observation and monitoring.

The Hospital:

Having spent months and months in hospitals with my kids when they were born I knew roughly how everything worked and what to expect. So although I had never been a hospital patient myself at least I was not totally unprepared. That having been said being a hospital patient really sucks. Stanford does an absolutely amazing job of making it as comfortable as possible. They have some really nice amenities and benefits but it still is a hospital. 

The next day my cardiologist dropped by. He went over the results with me again with a little more detail than the ER doctor. The bottom line was that I officially was a "complex case" and when your cardiologist, at one of the top heart clinics in the US, calls you a complex case you know it is not good. So due to the complexity of my case he, and all of the other doctors in cardiology, wanted to discuss my case in their weekly conference (Oh…Joy™).

The core of the complexity was that the plaque might be causing problems but they did not want to treat the plaque because of the bridge. Also, the bridge might be causing problems – but there was debate amongst the medical community at large about what role the bridge played as bridges are often thought to be benign things. 

But, he assured me, that there were some great doctors here at Stanford that were studying bridges. One of them was a Dr. Schnittger and she was going to be at the conference. They would come up with a plan of action and for me not to worry.

The bad news was that the conference was not until Friday and today was Wednesday. So between now and then they wanted to try and get some more tests run. Specifically, they wanted to do a test called a stress echo but the lab was booked solid into next week with no openings. So while they continued to try and somehow get me into the stress echo lab they would do a nuclear stress test. The nuclear stress test was set for next day and by keeping me as a hospital patient hopefully that would improve chances of getting the stress echo too.

Okay a plan to get more data. Data is good. I guess I could hang under the microscope a bit longer. 

So I spent the rest of the day in my room getting ECG-ed, poked (every hour on the hour), watching movies, reading, and looking online for anyone else whom had a bridge and was talking about their experience. (My difficulties finding the experiences of anyone with bridges is part of the reason why I am writing this blog)

Glow in the dark:

The nuclear stress echo test the next day was pretty interesting. It was a much smaller room than the catheterization lab but was just as cold. To start, I was wheeled in and hopped up on a table where they did the now all too familiar 12 lead ECG setup. Then a baseline scan by the imager and then it was time for the "fun stuff."

Specifically, the "nuclear" and the "stress" part of the deal. The "nuclear" is that they inject you with a radioactive dye that has a ~10 min half life and watch it flow through your heart on a scanner. Because the half life is so short they make the dye right in the building in a device they call a reactor. They then bring it to your room in a syringe transported inside a solid lead thermos which is mounted to a massive cart. The whole thing looked like it had been around since the 1950s.

So although it was not a "nuclear reactor" in the way people would expect I still can honestly say I was injected with 15ccs of radioactive stuff taken directly out of a reactor that was delivered in a 60 pound lead container.  

Take that spiderman. 

The "stress" part is a chemically induced 2 mile sprint. Basically, a full 45 min workout in a syringe. Aside from the whole possibly killing someone aspect of the deal it seems like a great idea. I bet you really could make a fortune in Beverly Hills with the 10 min - sitting in a chair sipping a smoothie - full workout.

Anyway, the tech quickly set up the two syringes (stress drug first) in a robotic injection machine and then got the hell out of the room fast. That nuclear stuff is clearly serious. I think it even glowed a bit. 

Over the intercom the tech asks if I am ready and I let him know that I am. "This is going to feel strange" but try and hold still I am told – and we are off. 

All I can say is that the stress drug really did make me feel like I ran 2 miles in about 10 mins. I felt my heart race, became short of breath, and that was followed by a sort of hollow pit in my stomach – just like the one that you get if you really crank an exercise hard.

Sometime while that was going on the reactor gravy was added to the mix – but I have no idea when. All I do know is that I can't shoot webs from my wrists, lift cars, or climb up buildings – I know…I tried. 

Another scan, 12 lead, and that was that. Simple. (I am really bummed about the superpowers though)

Back to the room:

Once back in my room that was pretty much the end of my adventures. I hung out in the hospital doing blood draws, ECGs, and other fun things until the morning of Thursday October 22nd when I was discharged. I had an outpatient appointment for the important stress echo set for the following Thursday October 29th plus an appointment with Stanford's lead on bridge studies Dr. Schnittger the day afterwards. 

Never officially figured out what set off this little adventure but my guess is indigestion. Next time I am taking 2 Tums before I start following directions. Certainly, before I take another Nitroglycerine tablet anyway. 

Now I just had to wait a week for the conference to happen and for the stress echo.