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.

Myocardial Bridge 101

Got home from the scan had a light dinner and went to bed. As suggested by the doc the next day I hung at home and relaxed reading up on bridges. For those that don't know much about Myocardial Bridges here is my best attempt at creating…

Myocardial Bridge 101:

First, as I write this in 2016 I have to say up front that Myocardial Bridges are actually a controversial thing. Pretty much from the day they were first discovered in the late 1700s up to about 2006 they were considered totally benign. Even today there really only seem to be two or three medical centers that consider them anything other than benign. 

The bottom line seems to be that unless you get "needle in a haystack" lucky any cardiologists not directly affiliated with the bridge program at one of the afore mentioned medical centers is going to be very skeptical that your bridge is anything other than an anatomical curiosity. So I feel extraordinarily lucky that I am with Stanford (which probably is the most advanced with bridge research in the world). 

Okay so what is a M-Bridge anyway?

A Myocardial Bridge is basically a construction anomaly when your heart is forming in utero. The arteries that supply blood to our hearts (there are four major ones) run along the outside of the heart itself. They then send little runners down into the heart every so often to supply blood to the muscle. In about ~25% (big debate on this number) of the population some of the heart muscle, instead of being under the artery, grows over the top of it. Thus when the heart beats and that muscle contracts it squeezes some of the blood out of the section of the artery it covers. 

For 95%+ of the people with bridges this is never a big deal. Lots of reasons but basically they seem to boil down to:

• Not much of the artery is covered so what is has little effect.
• The muscle over the artery just does not squeeze it very hard for mechanical reasons.
• Most of the blood flow to the heart actually happens when the heart is relaxed (in diastole) after having finished a beat (in systole) so it really does not limit that much flow in the first place.

But, for the remaining 2 - 5% of people with more severe bridges they do cause problems. This probably is because they either cover a significant portion of the artery (3 cm or more), really squeeze hard on what they cover,  or have a slight delay after systole before the artery can pop-open again to let blood through.

A very important little LAD:

While there are four major arteries in the heart one, nicknamed "the widow maker", is pretty significant as far as bridges (and other things go). The Left Anterior Descending artery supplies blood to the left portion the heart but does more than just send runners along, and into, the surface muscle. It also dives deep into the heart supplying a disproportionate (as compared to it's partners) amount of oxygen rich blood to the ventricles. Wikipedia says it best: "…if the artery gets abruptly and completely occluded it will cause a massive heart attack that will likely lead to a sudden death." So a bridge on this artery is probably more significant / impactful than a bridge on other arteries given its critical role.

Congenital means since birth right?

I find it really interesting that bridge problems don't usually show up until sometime in the late 30s or early 40s. As we age our hearts, lungs, etc. become less efficient at getting O2 into and out of the blood stream. So as younger people we can deal with a bridge better because we are just better at getting O2 where it needs to go.

Aside: I have always gotten really altitude sick and I kinda wonder if the decreased O2 at altitude plus the bridges was enough to tip my heart into a lower O2 zone with altitude sickness as the result. Regardless, altitude clearly played a role in my initial "wake up" attack in Sedona as I was exercising at 4,500 feet rather than basically at sea level where I normally live. And that decreased O2 was enough to turn a "sports injury" (rollerblading really can be a sport) into a full on episode. 

Links in a chain:

Lastly, are related issues that severe bridges can cause (or at least influence). There is much research and discussion around what are the complications that bridges cause or influence. Candidates range from Endothelial dysfunction to coronary artery disease. But, frankly due to personal relevancy (see next post), I dove deeply into CAD. 

Coronary artery disease (CAD) is the big source of heart attacks we hear about. It is where a plaque builds up on the walls of an artery in the heart and eventually blocks blood from getting to the muscle downstream causing all sort of Very Bad Things™. This of course absolutely does not need a bridge to happen. But, having a severe bridge seems to add extra layers of fun to the problem. 

There are two issues. The first one has to do with the nature of fluids. An artery under a severe bridge is filled with blood. When the heart beats and the bridge squeezes the artery that blood is forced out of the bridged section. Some of it goes with the typical flow (out the bottom so to speak) but some of it also squirts out the top. This runs directly into the flow of blood that is normally coming into the artery. Now if you have ever had a garden hose fight where you and your sister spray one hose stream into another you know that causes water to shoot in all directions. When blood does this in the arteries of the heart it does a bit of hydrostatic damage to the walls of the artery. (It actually even causes changes in the DNA of the cells of the arterial wall). This damage can greatly increase the probability of a plaque forming at the place where the streams collide. And, in people with severe bridges, that seems to be just about 20 mm from the entrance of the bridge.

So not only do bridges contribute to a plaque the location of the plaque to the bridge makes doing something about it very difficult. If you accept the premise that the bridge probably contributed to the formation of the plaque then so long as the bridge remains anything you do to treat the plaque will fail, or not work well, because the bridge will keep doing what it did. So following the line of reasoning to ground: in order to do something about the plaque you need to do something about the bridge. 

Aside: If you found this blog because you have a plaque, and it is near a bridge (<20mm), there are a number of studies covering what happens if you stent the plaque without treating the bridge. This apparently (which is frightening to me) still is typically done. I would strongly encourage you to get a second opinion from someone whom has knowledge of bridges (or the studies) before agreeing to this. 

What can you do about them?

There currently seem to be four options for treating a bridge:

1. Do nothing. For 95%+ of the population with bridges (which is only ~25% of the general population) this is totally fine as the bridge is not causing any problems. 
2. Medication: Different hospitals / doctors are experimenting with beta blockers or calcium channel blockers. The basic goal seems to be by keeping the heart rate from spiking you prevent the cascade that triggers an attack. At issue is that with a severe bridge the faster your heart beats the less oxygenated blood gets through because the stupid bridge keeps squirting some back out the top out or at least delaying the time before it flows freely through the artery. 
3. Stenting the bridge: Some cardiologists have placed a stent in the bridge itself. From
   
   everything I understand, that is a really really bad idea. Stents are mechanical things. They are not designed to be squeezed 40 - 160 times a minute forever and if they fail mechanically (think flexing a credit card 20 or 50 times until it breaks) you really don't want that debris in a line that supplies blood to your heart. Even stenting a plaque too close to a severe bridge (< 20mm) can cause mechanical problems. Seriously, get a second opinion from a cardiologist that understands bridges before agreeing to this.
4. Unroofing surgery: This is open heart surgery where the surgeon exposes the heart and cuts the muscle that is covering the bridged artery therefore preventing it from squeezing it anymore. It has been described to me by a surgeon that does it as like a bypass – just without the bypass. 

Obviously the best place to be would be option 1 which, again, for the majority of people is just fine. (I say that here for anyone that hit this page via a google search)

If symptoms of a bridge are affecting your quality of life but, you have no other complications, and you can tolerate the drugs (they make many people tired and sleepy) then option 2 might be enough. 

In my opinion option 3 is a non-starter. Period.

Option 4, the surgery comes with all of the risks and long and painful recovery that open heart surgery is known for. But, if nothing else works or you have potential complications caused by your bridge. Well, at least you get to have a cool scar for halloween and (more importantly) have the best chance of getting some relief.