Valve Job

I listen to Car Talk regularly, and any time the diagnosis suggests that a valve job is the cure, the Tappett Brothers apologize for the bad news and the associated high costs. I’ve been lucky so far, and haven’t ever needed a valve job on a car.

On my body…that’s a different story.

I’ve just returned home from having aortic valve replacement surgery at Sequoia Hospital. My surgeon was Vince Gaudiani (previously described as “Dr. G.” in Decisions on Incisions). He was assisted by colleagues from Pacific Coast Cardiac & Vascular Surgeons – I don’t know all their names, but one was a fellow RPI graduate, Adam Harmon, as we discovered while chatting as I was recovering in the ICU.

Diane and I drove up to Redwood City on Thursday, January 13th, for pre-operative testing and paperwork. The first step, of course, was the walletectomy; after that, they drew blood and took a chest X-Ray at the hospital, then I went up to the surgeon’s office. The first step there was a meeting with a volunteer from Mended Hearts; she’d had six open heart operations and four atrial valve replacements (both biological and mechanical) over her lifetime, starting at age 10! Then I had my legs examined (I’m not quite sure why at this point – I guess it was to look for places to harvest veins if need be) and met with one of the physician assistants. I was surprised when they asked me if I’d brought my angiogram CD with me – I hadn’t even thought of it. Fortunately, I’d saved a disk image of it on my MacBook Pro, so I was able to burn a new copy on the spot, but it could have been a problem.

By the time everything was done, it was 2pm, and we were very hungry – luckily, Redwood City has a lot of good restaurants, and we let Yelp steer us to Paradise Kebab House. After lunch, we returned to the hospital and checked in to the Sequoia Guest House. We spent a quiet afternoon, getting a quick walk in before the rains came. For dinner, we went to New Kapadokia – I’d been advised to eat lightly, so we split an entrée and skipped the wine, but probably made up for it with dessert!

Then it was back to the Guest House to shower, disinfect, and try to sleep; I’d asked for a prescription for Ambien, just in case, but I had no trouble falling asleep without help.

The alarm sounded at 0430; we walked over to the hospital and got to the “Short Stay Unit” just before our 0500 checkin. They were ready for us, and almost before I knew it, I was out of my clothes and on my back, being shaved from chest to ankles (though certain areas were skipped, somewhat to my surprise). Then another shower and disinfection, and it was time to meet the anesthesiologist (who I’ll have to call Dr. K., because I don’t remember her full name!), who gave a brief explanation of what she’d be doing for me. And then it was showtime. Diane and I said our good-byes, and I was wheeled to OR.

I’d watched Dr. Gaudiani’s videos on Valve Replacement Surgery (part 1 and part 2), so I knew what the OR would look like; there was a little chatter among the team as I was wheeled in and they said “hello” to me; then Dr. K. started doing her magic, and that’s all I know.

I woke up many hours later in the ICU; they had told me to expect to awaken with a breathing tube, but if I did, I’ve lost that memory – my first solid memory from ICU is seeing Diane and being able to talk with her. I was in some pain, but not much – perhaps a 4 on the 10-point scale they asked me to use throughout my stay. I was being given oxygen through a nasal tube, and there were lots of wires and tubes elsewhere on my body. They gave me ice chips and a little water; time passed in a blur. I even slept some, but at some time during the night, I felt a few pinpricks in my heart – I’d gone into atrial fillibration, and they used an external pacemaker to restore me to normal (sinus) rhythm. This happened twice that I know of.

I was pretty uncomfortable during the night – the nurse wanted to slow down my intake of fluids from the ice chips, and that made me even less happy. They kept medicating me, but it didn’t help much – I felt hungry, but they didn’t want me to eat yet. Eventually, they were ready for me to try a little food and gave me a breakfast tray; I surprised them by eating more than a slice of toast and a good bit of the eggs, as well as all of the liquids they let me have. And I surprised them even more by keeping it all down. My discomfort level dropped from 5+ to 2 as soon as I’d eaten, too.

After breakfast, Dr. Harman was ready to remove my chest tube; the Mended Hearts volunteer had said that would be an uncomfortable experience and advised me to ask for more pain medicine. Dr. Harman said that I’d be fine as I was, and he was right; I felt a tiny bit of tugging, but that was about it. That was the last step before I was ready to leave ICU, but we had to wait for a room to become available in the Cardiac Surveillance Unit (CSU), which took a couple of hours.

I was transferred to CSU just before lunch – there was no nonsense about limiting my fluid or food intake in CSU, either, and I polished off most of what I was given (one note about Sequoia: the soups were uniformly tasty, usually the best part of the meal). Diane was even allowed to bring me fruit and candy from outside (I suspect they would have disapproved of salty foods).

I won’t go into great detail about my stay in CSU; it was mostly uneventful. I watched videos, read books, did a crossword puzzle, ate, slept (some), got awakened when necessary, learned how to get in and out of bed without using my hands, walked around the floor as much as I could, did breathing exercises, and, basically got better. The one complicating factor was that I was retaining some fluid, so my weight was up – they didn’t want to let me go until I was back to my pre-operative weight. They used diuretics to make that happen – it was pretty convenient until they took off the catheter; after that, I got lots of practice getting in and out of bed. My weight dropped back to the desired level by the Tuesday early morning weigh-in, and when the doctor visited, I asked if he was ready to discharge me. He was.

That started another flurry of activity; first, he had to remove the pacer wires from my heart (an interesting feeling – not painful, but very very odd) and put me back in bed for an hour of observation. While I was in bed, the patient educator visited to tell me a few things I needed to know before I left (probably not optimal timing, especially since I was also eating lunch and had a visitor!). Then a chest X-ray, followed by a return to the room for the removal of my central line, which required another hour or so in bed for observation.

And that was about it. Diane came and packed up my stuff; I put on real clothes for the first time in more than four days; they put me in a wheeled chair (not to be confused with the kind of wheelchair they used when I was taken to X-ray as a patient) and brought me to the car – and off we went, into the setting sun (and rush hour traffic).

I haven’t named everyone who helped me while I was in the hospital; in some cases, I don’t know their names. Everyone who worked with (or on) me was terrific and clearly interested in making my experience as painless as possible. The nurses were, of course, the people I interacted with the most; Erin, Kelly, Sev, Sharon, Melissa, Sonya, and Jin, you were all wonderful (I don’t remember the names of my first few ICU nurses). I got lots of help from Jenny in PT, Carlos and Carla in Respiratory Therapy, and many others who made my stay easier. Thank you all.

I’m very glad I chose Sequoia and Dr. Gaudiani and the PCCVS team.

In case you’re tuning in late, you can read all the postings about my Aortic Stenosis experience here.

Decisions on Incisions

A week after my angiogram, I visited my cardiologist to discuss the results and formulate an action plan. The main action was to start me on low-dose aspirin, in addition to the pravastatin she’d prescribed immediately after the angiogram; I’d already planned to interview two thoracic surgeons:

Dr. M., who would operate at Good Samaritan Hospital, a mile from home — he’d seen me right after my angiogram (though I don’t remember!)
Dr. G., who would operate at Sequoia Hospital in Redwood City, about 30 miles away — I’d found him through web research and talking with physician friends.

Our first appointment was with Dr. M. We sat in the office for about an hour after our appointed time, but once we started talking, I realized that was because he was willing to spend as much time as necessary with a patient rather than sticking to the scheduled slot (and I suspect we put the next person even farther behind). He proposed doing both the valve and bypassing my circumflex artery in one operation, which would require a full-length sternotomy. I asked if it would be reasonable to stent my artery instead, but he said that a bypass, especially since my mammary artery was available, was the gold standard for treatment. He leaned towards a mechanical valve, since it would probably last my lifetime, though it would require me to take a blood thinner forever.

A few days later, we drove to Redwood City to see Dr. G. He ran about 30 minutes late, but his staff kept us informed about what was going on, and we saw him pop out from the office between patients. Interestingly enough, he was dressed in scrubs (Dr. M. wore a jacket and tie), and he pushed one patient’s wheelchair himself. He introduced himself by first name, too, and then dove right into what was going on with me. He started by explaining why aortic stenosis is considered “critical” once the vessel narrows beyond 1cm — it’s because of Poiseuille’s Law, which states that the resistance to flow is inversely proportional to the fourth power of the radius of the vessel. This is not a trend which leads to a happy ending.

Dr. G. said that he didn’t think my circumflex artery was a serious problem, so he suggested only replacing my aortic valve, leaving the circumflex to be stented later if it caused me any problems; he said I should have my cardiologist give me a full-on treadmill test after I’d recovered from the surgery and use those results to decide whether or not to stent the vessel; he also quoted the COURAGE study, which would suggest that medical therapy might well suffice. Since he only wanted to deal with the valve, he would do a mini-sternotomy — he said that was faster than going through the ribs and required less time on the heart-lung machine, both of which sounded good to me.

Dr. G. leaned towards using a biologic valve, even though it would probably require replacement in 15 years or so. He said his results operating on patients at the age I’d be then are good, and no worse for a second operation than for a first one. And, of course, techniques are improving. He also pointed out that using warfarin has its own risks, and over the fifteen-year period, they’re about as severe as the risks of a second operation. He explained how warfarin works (it’s a vitamin K analogue) and why it’s critical to keep the level of warfarin steady (they now are starting to let patients monitor their own warfarin level, which generally results in smaller deviations than if the only monitoring happens during doctor visits).

When I was reviewing my notes, I realized I needed some clarifications to be sure I understood everything Dr. G. had said, so I called his office. They told me to email my questions to him, and he called me back the same evening and we talked for 10 minutes. After that call, I was sure I wanted to have him operate, but I thought I should run it past my cardiologist, since she’d be taking care of me after the operation.

She and I talked yesterday, and while it was obvious that she’d prefer I went with Dr. M. (if I were to be operated on at Good Sam, she could stay in the loop while I was in the hospital), she said that Dr. G.’s plan was “not unreasonable”, especially if I chose a biologic valve. (Stenting, if it’s necessary, would mean taking Plavix, which is not a good combination with the warfarin required for a mechanical valve.) She also said there wasn’t a clear choice from her perspective.

After talking about it with Diane, I called Dr. G.’s office and scheduled the surgery for mid-January, and I plan on a biologic valve.

By the way, I spoke with patients who’d been operated on by each surgeon — both patients praised their doctors, but, as Dr. G. had said, “our unhappy patients can’t tell their stories”.

Dr. M. gave me one very good piece of advice about the decision: “make your decision, then be at peace with yourself. Don’t second-guess.” He was mostly talking about the choice of valve, but I think it applies to the whole process.

The next step is in the hands of the Postal Service — I have papers to sign. And then I wait for mid-January. In the meantime, it’s lots of walking and careful eating for me, though I do plan to have half a slice of chocolate peppermint pecan pie on Thanksgiving!

The inside scoop

Today, I had an angiogram done to determine the next steps in my quest to regain heart health.

My procedure was scheduled for 8am, so they told me to arrive at the hospital at 6 — the nurse’s workday, however, didn’t officially start until 6:30! Fortunately for me, he arrived early, so I only had to cool my heels for a few minutes (and that was in a waiting room, not the hallway). Once he arrived, things got started fairly quickly; I don’t know exactly when they put the IV in (about 7:30, I think — I don’t know how to get a precise time from a Facebook update, so I can’t be sure…no, wait…I just found the “My Status” app, and it tells me that I had the IV in before 7:13am), and very soon after that, they were wheeling me down the hall to the Cath Lab itself, while someone from the Business Office was collecting my co-pay from Diane (there was a discount offered for same-day payment). I remember the nurse shaving some hair in the area of my femoral artery; further, deponent remembereth not.

After being returned to the “short stay” area, Diane tells me I spoke with both my cardiologist and the thoracic surgeon she recommends (who, I now have discovered, doesn’t appear to be on my insurance! [update: I called his office, and he is on my plan. Glad to know that the “provider search” site is unreliable as well as being hard to use!]). They told us (well, mostly Diane) that, in addition to my stenosis, I also have a constricted circumflex artery (90% narrowed), and that it would be a good idea to have the surgery done soon.

My memories pick up, for the most part, after that conversation (though I must have been tracking to some extent, because I posted the name of the artery to Facebook!); I had a belated breakfast, a sketchy lunch, and then was cleared to go home. Someone, possibly the nurse, said that I should be started on statins soon, but I can’t find that in my discharge papers.

I’m not supposed to do anything more strenuous than walking for the next couple of days, and someone “suggested” that I skip golf class on Thursday, too, so it’s going to be a quiet week here at home.

I go back to the cardiologist on Monday to formulate the plan for the operation.

The beat goes on

It’s been about a month since I found out I have aortic stenosis. I’ve spent that time doing many things, including an Alaska cruise, from which I’ve posted a few photos on Facebook — the rest will get edited and posted RealSoonNow.

Despite the cardiologist’s clearance, I haven’t tried yoga yet. But golf class continues apace at West Valley (and I’ve even played nine holes with a friend and not lost by too much). However, I have had to make some modifications to what I do; for example, I can’t be one of the Stunt Doubles when we play that game at ComedySportz San Jose Rec League. And I’ve had to consider what this means to my job search; it’s clear that it’s not the time to look for an immediate full-time gig, though I am continuing to meet with people (I hate using “network” as a verb) and go to classes.

On the medical front itself, nothing much has happened. I don’t feel any different than I did before; I’ve had one consultation with the cardiologist, and am planning to meet with another one for a second opinion. Yesterday,I had my first call with my nurse from Empire Blue Cross (the insurance company), which was very helpful; I haven’t made it through all the material she sent! I’ve also been researching thoractic surgeons and hospitals — the best hospitals in the area are at least 30 minutes from home, so it would be nice to be able to use Good Sam (5 minutes from home), but having a successful outcome is far more important than anything else. More research looms.

The next active step is an angiogram, sometime in October; that’ll let us know whether the surgeons have to do anything else for sure while they’ve got the hood open, and I guess that will also let us know if we can wait until early next year, which would be my preference at this point.

I’ve had a lot of support from friends and family, which I greatly appreciate; having knowledgable friends is a real boon!

Getting to the heart of the matter

A few years ago, I happened to have completed a vigorous workout at the JCC just before visiting my doctor for a routine checkup. When he listened to my heartbeat, he heard a murmur, and referred me to a cardiologist. She had me do a stress echocardiogram, decided that there was nothing to worry about, and asked me to come back in a year. I did; that time, she only did a stress EKG, and sent me on my merry way.

A few weeks ago, I was at the JCC for Body Sculpting class, where we had a new instructor, who added quite a bit of cardio to the mix. One of the additions was a quick run around the room; I was surprised to feel some tightness in my chest while I was running. But if I slowed down a bit, all was well. And it didn’t happen every time. But I did make a point of mentioning it to my doctor at this year’s routine checkup. He decided that it needed to be investigated; a chest X-ray showed nothing (whew!), but something about my EKG didn’t look quite right, so he sent me back to the cardiologist for another stress echocardiogram, which happened yesterday.

They started by wiring me up, then doing some baseline measurements and getting a baseline echocardiogram before putting me on the treadmill. It seemed like the process took longer than it did on my first visit, so I wondered what was going on. When the cardiologist came in, she and the tech conferred for a bit, and then she told me that she wasn’t sure I should take even the test — that my aortic valve was clearly not opening fully. But then she decided she’d get more data by putting me on the treadmill, so away I went.

Taking the stress test is a lot like playing a coin-operated video game — the machine is going to win, it’s just a question of how long you’ll last. This time around, I made it to the fourth level (16% grade, about 4 mph) before the doctor stopped the test; my heart rate was up around 150, and I was starting to feel a little tightness in my chest. Right after the test, they took another echocardiogram, and that confirmed the diagnosis: I have symptomatic aortic valve stenosis, which means I have surgery in my future. Not, fortunately, the immediate future, but probably within a year or two.

In the meantime, I’m excused from the classes I’ve been taking at the JCC and from giving blood; I also need antibiotics before I visit the dentist. But I can continue to do aerobic exercise (as long as I stay below the point of discomfort), and I’m cleared to try yoga (but not pilates) and to continue to frustrate myself with golf. What could be better?

Needless to say, I have lots of research to do before making any decisions, including where I want to be treated (and making sure that my insurance plan offers choices). I am very glad to have time to make decisions on this one!