Echoes, Swedish Doctors, and Open Heart Surgery

Finally: I Get into The Echo Lab

Up to the end of October I had never met anyone at Stanford that focused on bridges. The cardiologists I was working with Dr. Mahaffey, Dr. Rodriguez, and Dr. Yeung (all excellent and fantastic) were not bridge experts. But, I had heard "whispers" of a "bridge team" and their leader.

Specifically, I had heard mention one or two times of a Dr. Schnittger. But, did not know much beyond the fact she studied bridges and was the head of the echo lab. So I was pretty happy when I managed to schedule the Stress Echo and an appointment with Dr. Schnittger less than 24 hours after the test. 

The test day, October 29th, rolled around and at 8:45 in the morning I was checking in at the cardiac clinic desk to get registered. 

Aside: I have always been totally supportive of gathering as much data about my bridges as possible. Both, because more data is good for choosing the best treatment for me; but, also I hope that with a better understanding of severe bridges they will be recognized as a real source of problems by the general medical community. I really am convinced that not all bridges are benign. So although this test was redundant for me at this point I would have volunteered for it anyway. However, I have do admit that I was really kinda psyched that the stress echo lab is part of Stanford's non-invasive (and non glow in the dark) imaging capability.

All of the other tests I had been given involved probes inserted into my heart and/or a really big dose of x-rays or other radiation. I was tracking my exposure using the great free exposure calculator located at this link and it was really starting to add up. I will have been exposed to to about 54 mSv of radiation, which is roughly equal to 1,080 chest x-rays, over the course of this journey. (For comparison: Fukushima towns where exposure is rated at  >50 mSv/yr are "difficulty of return" and require remediation.)  

Anyway, shortly after being registered I was lead back to the lab. This room was not freezing cold (hurray) nor did it have that "hospital organized" look. It reminded me very much of a working lab. Not saying it was messy, it was not, it just looked efficient, used, and highly functional. Upon walking in I met the awesome tech whom clearly was expecting me. She told me that Dr. Schnittger was pretty pissed that this was the earliest that I could have gotten into lab. And, apologized several times, for how busy they were. (I later found out that the usual bridge diagnosis flow at Stanford starts with the stress echo and then might include some of the other tests. But, because of schedule issues and just how my case presented I sort of did the whole thing in reverse. I did the most invasive and riskier tests first rather than waiting to see if they were really necessary. Oh well, I have never been great at doing things "the right way" anyway.) 

As she was getting set up I asked the tech what the purpose of this test was and why everyone had been so eager for me to have it. I told her that from everything I had read online this test did not have anything to do with bridges. She informed me that Dr. Schnittger (and team) had developed a new method of reading the results of the stress echo and could very accurately predict the presence of Myocardial Bridges. So it was important initially to help understand if I had bridges. But, now it was still valuable as it could further prove the validity of their screening algorithm.

I was glad to be of help even if the outcome was not really going to be directly relevant to me (after all I already knew I had bridges). But, it would be great if this test that anyone can take, involves no radiation, and no surgical procedures was universally accepted.

The test itself is very simple. 

1. Set up a 12 lead ECG. Lie still for a bit. 
2. Get ultrasound pictures of the heart while lying on my side. 
3. Run on treadmill (I pushed as hard as I could and was proud that I maxed the machine out).
4. Literally jump off treadmill and hop on table on my side for another ultrasound.

Done. Simple. Non-invasive with no risk of superpowers. 

Afterward I stopped in the cafeteria, which is on the first floor right under the lab, and had a banana and black coffee to celebrate finally getting into the bridge clinic and the opportunity to speak with a world class expert on my condition.

Meeting Dr. Schnittger:

The next morning I was at the clinic (which is really just a block of schedule carved out for bridge patients in the regular cardiac clinic) 20 mins early. I really did not want to be late because I wanted as much time as I could get with Dr. Schnittger.

Unexpectedly, 10 mins before my appointment was even scheduled Dr. Schnittger's nurse coordinator came out to get me and presently I was perched on butcher paper. And, after going over a bunch of questions with the coordinator Dr. Schnittger showed up. 

Now I was really hoping to get 20 mins of her time to go over my case. I figured 20 mins was going to be pushing it given what I expected her schedule to be. So I have to admit I was totally floored when she spent well over an hour with me. She started by covering my condition. But, since I had been studying it so much already we were able to jump right into the details rather than do the whole overview – which left even more time for questions. 

But, before specific questions about my condition I had a different objective. My priority was to ask if she would take over my case and thankfully she agreed. (Dr.  Mahaffey whom was my primary cardiologist up to this point had already intimated that he thought this would be a really good thing so no worries there.)

Here is what I learned from that initial appointment:

1. The conference of Stanford cardiologists could not really agree on a clear path for me. My plaque was serious but not severe enough to require addressing. (Mine was measured by angiogram at ~60% and ~70% is the threshold). And, of course, since there is no universal agreement on bridges even being a problem there was no agreement in conference about them either. 
2. Dr. Schnittger believes there is good evidence to show that plaques caused / influenced by bridges are more brittle than normal. Brittle is bad because a brittle plaque can break or crack and then form a clot. And, plaque + clot in the LAD is the reason that the LAD is called "The Widow Maker" it's a Very Bad Thing™
3. The bridge on my LAD is one of the most severe Dr. Schnittger has seen. Oh…Yay.
4. The bridge on my left circumflex is also "bad" but not as significant as the LAD. First, because the circumflex is not as critical as the LAD and second it does not fully close the artery. So it probably is not as much of an issue.

When I asked the $1,000,000 question: "What should I do?"  I was not exactly hoping for the answer I got. It basically bolis down to this I think: It turns out there is a sorta a rating scale for bridges and only those in the highest category are clearly recommended for surgery. I am still very functional with my bridges. The people that are in the highest category experience Sedona like attacks just walking from the car to the house. That is not me. Basically, neither my symptoms nor my plaque were severe enough to mandate surgery. (Update 2/5/16: After my 2nd Cath Lab trip this changed and I become a clear candidate for surgery based on new findings – 4 bridges rather than 2. And, a second bad plaque)

However, after that bombshell, things got a little better (or more nebulous depending on your point of view.) She told me that if I wanted to have unroofing surgery she would absolutely be with me every step of the way and would completely support my decision.

But - I was going to have to be the one to push for it.

I told her that I needed to think about the surgery a bit. I wanted to weigh all the data before making such a massive decision and at that moment was just "too close" to do so rationally. So we made a follow up appointment for a month later and I thanked her for taking the extra time with me and for the open and direct conversation.

That first meeting proved to me that Dr. Schnittger is kind and supportive but also direct and candid in her presentation of the medical facts and very clear about what is "known" and what is not. A super skilled, no nonsense, personable doctor and I am very lucky she is my primary cardiologist.

Open Heart Surgery:

I had a month but it only took me two weeks. 

We have come a long way from this!

Open heart surgery is a big deal but it is not as big of a deal as it used to be. Stanford is one of the best places in the world for getting it done. I am young (ish) and healthy but as time passes the first is guaranteed to be less true and the latter is unlikely to stay the same either. So, if you assume I must have the surgery at some point in my life now is better than later.

But, for me, the biggest reason to consider the surgery is the plaque. I really do think that mine is, at the very least, accelerated by the bridge on my LAD. With such a severe bridge it is only going to continue to grow but because of the bridge it can't be treated. That makes it effectively a ticking time-bomb. I firmly believe that at some point it is going to cause a very large problem – a problem that I probably would not survive.

And, I am just not ready to check out anytime soon. 

So two weeks later I contacted Dr. Schnittger and said I wanted the surgery and was ready to do what it took to make sure it happened. 

As promised she was very supportive and we got the next required test set up. A CT scan of my heart. This would help give the surgeon a good map of where the bridge was. A map he needs to know what part of the heart to uncover and where to find the affected section of the LAD.

Bad news was this scanner (even Stanford only has a single scanner that can do such a complicated scan) was booked until December 17th which was just about a month away.

More waiting. (But, no complaining.)

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.

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.

It is NOT All In My Head!

Found it!

The trip to the heart catheterization lab was scheduled for October 19th on the preceding Monday the 12th. Now I know that compared to others whom have had to wait years to get some doctor, any doctor, to take them seriously I have nothing to complain about – and I am not complaining. But, that was still a very long week. I had never had any surgical procedure that was as serious as this and I spent the week doing what any good nerd would do in 2015. I curled up after work with my trusty iPad and señor Google.

I learned what the goals of the procedure were and was really happy to learn that if they discovered a plaque (which at that moment was the leading candidate for causing my problem) that they could treat it right then and there with a coronary artery stent. Not something you want to have happen to you at 46 but in the grand scheme of things it would have been okay. Señor convinced me that stents were pretty safe and if you took your meds like you were supposed to they came with really good outcomes.

Honestly, by now I was just ready to find something...anything to point to what was going on. I was not having episodes like Sedona but after that first episode I had was really tired – all the time. Even if I got a full nights sleep I still really needed a nap in the afternoon in order not to be a total zombie in the evening. And, there is nothing like the glint in the eyes of adolescents the moment they sense weakness, when you are on your own, to strike fear into a man's soul.

Moreover, now that I was paying really keen attention to it, my "sports injury" was bugging me two or three times a week. So I entered the cath - lab totally ready to accept that I had coronary artery disease and would need a stent.

Stanford Catheterization Lab #3

Arriving at the hospital on the 19th I was pretty psyched because I had been told that I had large veins and that meant they could go in through my wrist which was simpler, less embarrassing, and had a faster recovery time after the procedure. So I was a bit bummed when they still prepped all of the access options even though they planned on using only my arm. Oh well. After getting ready for bikini season plus my IV I was all set to go. They wheeled me into a room which resembled, and was as warm as, a large meat locker. But, had been turned into some really cool geek cave with lots of monitors and a big scanning machine positioned over a table.

I hopped up on the table and started shivering it was so cold. Fortunately a second later the nurse showed up with something like a porous air mattress that hooked up to a hot air supply plus a blanket. So once tucked into that I was completely comfortable and happy. (Honestly, they put a little something in the IV too - but I am going to take the credit for being "chill" on my own anyway.)

The cardiologist prepped the access site and the nurse moved a monitor so that I could see the feed from the scanner too. Once the doctor was all set he asked if I was ready for the dye to be injected and as soon as I said yep – we were off.

Not five seconds after the dye was inserted the cardiologist quite clearly and loudly said "you have a bridge." This was the very first time that I heard the word bridge so I did not know what it meant. But, I could see the feed of the scan on my monitor and saw something that resembled the video at the left.

This is not my scan. But, it does show a bridge. As I learned later, you can sometimes see the "milking" effect (in the video notice that after the dye is injected it is squeezed or "milked" out of the area that the video focuses on) of a bridge on the Angiogram. Although, this is not always the case because Angiograms are the lowest resolution of all the tests so it takes a severe bridge to show up. (Mine showed up just fine…uh…yay.)

At this point the doctor started looking around my heart so to speak. The monitor changed to different perspectives and there were a couple of more "shots" of dye looking at blood flow in the different arteries of my heart. After another 2 to 5 mins he remarked "there is another one." And, sure enough I saw the same milking pattern show up again on what was clearly a different artery.

At this point he stopped and a whole bunch of conversation started somewhere outside of my field of vision. The nurse came over and said that the doctors were discussing what they have found and deciding on what to do next. This went on for not more than 5 mins or so. At which point the cardiologist came over to me and said that he was done, things were fine, but he wanted to talk to some more of his colleagues.

And, with that, I was disconnected from everything and wheeled into recovery.

I was actually pretty happy at this point. They had found something. I had no idea what a myocardial bridge (the nurses gave me the full name) was or why it would be causing me issues but at least they found something. Unfortunately, they did not "do" anything about it so I still had whatever was wrong, wrong. But, I had proof I was not crazy – or at least I was not crazier than I had been before Sedona anyway.

This was progress and by now I was all about progress.

So after hanging in recovery for a little over an hour and a half (much better than the 4 - 6 hours the other approach requires) I was on my way home with an appointment to follow up with the original cardiologist that prescribed the catheterization.

Most importantly to me at the time: I knew something I did not going in. I had not one, but two Myocardial Bridges, and my iPhone, señor Google, and I were already busy diving into what in the hell those were.

Of NICUs and Silver Linings

A Bit of NICU Influenced Luck:

Almost 14 years ago now one of the greatest things in my life happened: I became a father. And, while I could not wait at the time to meet my son I would have been happy to wait a little longer than I actually did. My son was born 2.5 months early and so I was thrust into fatherhood, and the NICU, at the same time. I was not fully ready for the first and definitely not ready for the latter. Fortunately, after nearly 4 months in the hospital he came home healthy and today is an awesome…teenager.

My son also has a younger sister.

Now, like any good younger sister ("anything you can do I can do too") when she was born two years later she just had to do the NICU thing also. And, again, like a younger sister, she was more efficient (only in the hospital for 2-ish months) while being significantly "louder" (much scarier path) than her brother. Today, she too is doing fantastic and getting even better at scaring the pants off her dad.


I learned so much from these experiences about modern medicine, hospital life, appreciating what is, love...the list goes on and on. But, the one thing that I learned all those years ago that really came back to provide incalculable benefits for me now is an appreciation for Stanford Hospital & Clinics. Both of the kids NICU visits were under the care of Stanford's Lucile Salter Packard Children's Hospital and I really valued the depth that organization brought to their care. So when I had to choose a "regular" doctor for myself a year later I choose Stanford's Family Medicine practice. I figured that if anything weird happened to me that would be one of the best places to help me sort it out; and, if I was a "regular" patient of theirs it would make things that much easier / faster.

So having two preemies in the NICU (something I do not recommend) actually had a silver lining – 13 years later.

First Doctor's Appointment:

My plane landed at 9:30PM on October 5th and by 10:30AM the next day I was sitting on the oh so comfortable doctor's office butcher paper. As usual my pulse, BP and everything else was normal. I was not able to see my regular doctor as she was off that day but it was not an issue. The appointment only took 10 mins and I left with a referral to Stanford Cardiology and an appointment scheduled for the next day. The on call doctor I saw was just awesome and there was no debate about what to do next.

So October 7th I met with a cardiologist and his fellow. They listened carefully to my detailed recounting of what happened (assisted by thorough notes and data compiled by the afore mentioned great girlfriend and myself) as read off my iPhone – have I mentioned I am a bit of a nerd? And, they agreed that I did not have a heart attack but that whatever did happen was not just "dehydration" or "hunger." They recommended getting a stress ECG to see if we could get a better picture of what was going on.

So that Thursday (October 8th, 2015) I got to play hamster on a wheel and run on a treadmill while trying not to strangle myself, trip, or other wise short circuit many thousands of dollars of equipment. The results from this ECG were normal of course but I got lucky once again. During the test as I was running my left arm once again started going into "annoyance mode". It was nothing like Sedona but I did mention it to the tech and she noted it on the log of the test. I decided to keep going as I had exercised with this thing before and really was not sure that it was not all in my head anyway.

Honestly, I was worried the pain in my arm was my brain playing tricks on me. Kinda like if you say "don't think of pink elephants" that is all you can think of. So if I was thinking "my arm hurts when I get my pulse up" then presto my arm hurt. (My brain and I don't get along very well sometimes.)

When the Dr. got the test results back, although the ECG showed no problems, that note helped him decide that doing something more invasive like an Angiogram was a good idea. I really do think if it was not for that note I would still not know what the hell was wrong with me and would actually be in a good deal of danger. Note to self #2: if something seems wrong to you, even if you are convinced it is not real, say something anyway.

So I now had an Angiogram scheduled for October 19th.

How To Fail while Still Passing Tests

Not all people suck:

The kindness of strangers as I lay on the seat of that golf cart that day shows that not everyone in the world is callous and unwilling to get involved.

While waiting the 5 - 10 mins for the EMS team to arrive the driver of the cart monitored my vitals and a doctor that was on vacation with his kids stopped and hung out with me. The general consensus was that I was not having a heart attack (always good to have confirmation) and given my strong vitals I was probably just dehydrated (the vacationing doc even gave me a Coke he had as I had finished the water we packed for the hike) or hungry.  I did not believe that explanation, but did not really care either, as I was busy playing "not a heart attack" over and over in my brain.

EMS showed up and they were very polite, thorough, and efficient. They had me wired for sound (12 lead ECG) within minutes. The readings from the ECG were all clean and showed that everything was fine which was nice but frustrating.

Aside: Now I want to take a quick moment here to interject something out of chronological sequence.

As I have been learning about Myocardial bridges I have come to realize just how lucky I have been with mine. Reading on the net, and talking with my doctors, I have learned that many people who become symptomatic with bridges go for a long time, often years, with debilitating attacks like the one I had and no diagnosis of the actual problem. They will have symptoms just like I did (or worse even) but when hooked up to ECGs and given the typical battery of cardiac diagnostic tests they come back as normal (or nearly normal). As a result they are often told things, just like I was told in the beginning, that their issue was dehydration, indigestion, stress, a panic attack, or worst of all "it is all in their head."

In the beginning I knew something was wrong; but, I could not prove something was wrong. So I fell into the trap of thinking it might actually all have been in my head. That maybe the episode was not as severe as I was remembering / thinking it was. At this point I was feeling really relieved, confused, frustrated, scared and pissed off all at once.

This is what, I learned later, is pretty much the universal patient's introduction to Myocardial bridges: "OW OW!…Oh Crap!!…Whew, thank God! … Wait a second …WHAT!?!?"

Passing yet Failing…

Regardless of the clean ECG and the solid vitals the EMS team wanted to take me down the hill to the local ER for a full evaluation and I was not going to argue. Next stop:

In the ER everyone was super nice and very efficient just like the EMS guys. When I mentioned that to the Doctor he told me that cardiac issues were bread and butter to the Sedona emergency community. (Note to self: next time I plan to have a "cardiac event" do so where snowbirds roost). So in the ER (as previously mentioned is normal for bridges) all the blood work, X-rays, ECGs and other tests were clean. They showed nothing amiss. Which was great for calming immediate fears but not so great for not making me feel like some ginormous hypochondriac / fraud. But, hey at least I was not in immediate danger. 

They discharged me but not before one really great nurse there thoroughly impressed upon me that I must follow up with my regular doctor as soon as I got home. This was another big lucky break for me because, honestly, I was sorely tempted at that point to just chalk it up to "eh....maybe I am a big crazy dummy" and do nothing more. (I was definitely rocking an awesome Ostrich vibe)

So we finished a much lower key vacation in Sedona than we expected and headed home. Where immediately upon walking in my front door I scheduled a visit with my regular physician group for the next morning.

Red Rocks, Red Lines and Magic Number 92

Just a simple little getaway: 

Skip forward to the summer of 2015. By then I have managed to find 30 pounds of the ~50 that I lost way back in the mid 2000s. I am not feeling that great with all the extra weight and my 46th birthday is rapidly approaching. So...

Time to put more energy on getting back into shape. 

So my girlfriend and I decide we need to go on a little hiking / nature get-away. The question is where? On a total and absolute whim I suggest going to Sedona AZ (my first lucky break - more later). I have NO idea why that place popped into my head other than I used to live (many moons ago) in Phoenix. 

So it is all set up and we leave shortly after my birthday in September.  Now if you have never been to Sedona I strongly recommend it. It is absolutely beautiful.

On the first day we plan a not too severe hike. A little 5 mile trail that only gains a couple of hundred feet of elevation and goes up a beautiful canyon. I was feeling pretty charged about getting out and doing stuff again.

We made it to the top of the trail head without any issues or problem and in fact I was feeling pretty good and my arm was fine (I had completely forgotten about my "sports" injury). We sat for a quick rest at the "Don't go past this sign or really bad things will happen" sign and then headed back down. 

About 15 mins after getting moving again, going downhill none the less, my arm started it's old nuisance routine. My bicep hurt a little but not severely or anything. So I stopped for a second (which usually made things better) and even decided to take a picture:

But, things did not really improve so I just figured this was just going to be another one of the "lingering" times. I do distinctly remember thinking "geeze ('80s remember) I must be in really bad shape if just the movement of going downhill bugs my rotator cuff."

I mentioned to my girlfriend that my arm hurt. And, pretty much as soon as I finished speaking my life took a totally new direction…

The pain in my left arm became much worse: like someone was squeezing my left bicep in a vice while stretching it lengthwise. A couple of seconds after that the same type of pain materialized in my right bicep – at the same intensity. I decided this was not at all good but still did not really think heart. I was just really confused as to what the hell was going wrong. 

Which is precisely when I felt a crushing / squeezing pain in the center of my chest and breathing went from being simple to a serious effort. Now I figured it out, ah this must be a heart attack. 

That instant going through my head was: "Of course. Radiating pain down the arms. Chest pain. Breathing....... okay dummy, you know what this is: it is a heart attack."

……Wait!……Oh crap (lets just say that was the word I choose okay)…I am having a heart attack!?"

So I explained what was going on to my girlfriend and we took stock of the situation. We were approximately 2-ish miles from the trailhead. We had no cell service. I was becoming very cold, sweating, and my skin on the back of my neck was apparently very white with blue veins showing up clearly through it. A quick check of my watch showed that my pulse rate was around 130 yet I was standing still. 

The best we could come up with was walk very slowly down the hill for as long as I was able to do so breathing as deeply and as slowly as possible. Stopping did not help and this slow movement coupled with the breathing seemed as good as anything. (at least it was not getting worse) 

So we were off. Me watching my heart rate on my watch and she watching me. Over the next 20 mins or so things got a little better. My pulse rate came down with the breathing; and, as it did my chest hurt less and my arms were slightly better. I quickly figured out that a pulse of 92 was sort of the magic line. Keeping my pulse below that number was "good" where a pulse rate above that number became "bad" … fast.

Carefully we worked our way down until we were about a quarter mile from the trail head. By this point (say 50 mins after the episode started) I was doing okay. Chest was good, stomach hurt a bit, and arms were better. Pulse was in the 80s and staying pretty much put. So we discussed options and decided that it would be best if my girlfriend took off for the trailhead and went looking for a land line to call EMS. 

So she did, and I just kept plodding along glued to my Apple watch and it's heart rate readout. I reached the trailhead with a pulse of 88. 

I was completely confused as to what the hell just happened. I was no longer convinced I was having a heart attack. After all, you don't walk off a heart attack and that was basically what I just did; so not a heart attack. But, I was at a complete loss as to what the hell actually was the problem. Because, I was convinced there was a problem. 

At this point a resort golf cart came rocketing into the parking lot I was standing in and a guy jumped out asking if I was the one with the heart problem. 

Yay girlfriend!