Before surgery, seventy percent of us will develop heart disease. If we’re lucky, we’ll survive long enough to reach the operating room and get help. This blog hopes to make you one of those lucky folks!
This is part 2 of a five-part blog about heart surgery:
1: Heart Surgery – Highly Likely for You or a Family Member
2: What Brings Us to the Operating Room Before Surgery
3: Valve Surgery Operation and the Intensive Care Unit
4: Life Beyond: Post Surgery Recovery
5: Heart Surgery Cost – Medicare Coverage and Hospital Staff
This part gives a brief chronology of the events that put me on the operating table. Many people who avoid a fatal heart attack will follow a similar path before surgery.
Before surgery there must be a diagnosis. Before a diagnosis, if you’re lucky, there’s a symptom that sends you to the doctor. This experience has taught me not to ignore any symptoms!
I have previously reported on my prostate surgery, which occurred May 10 of last year. Two weeks before that surgery I noticed that I had no appetite. I was only eating half my normal amount of food. I started tracking my weight, and from May to October it dropped from 180-ish to 160-ish pounds.
Surgery sometimes has a side effect of depressed appetite, and I thought that might be the cause. It was more difficult to explain the loss of appetite before surgery. I could only guess that subconscious worry about the surgery might have depressed my appetite.
After some months, however, I was no longer inclined to blame the surgery. Therefore, each time I happened to visit a doctor (primary care doctor, urologist, gastroenterologist, chiropractor) for some unrelated reason, I asked their advice about my weight-loss symptom. When I reached my cardiologist I was rewarded with an “aha!”
October 20: I had a routine appointment with my cardiologist Dr Sarine John-Rosman.
I mentioned my weight loss and its possible association with my prostate surgery. She consulted her record of my previous visits in October 2016 and April 2017. Dr John informed me that her office recorded a weight loss between those visits. Thus my drop in weight had begun long before my May surgery and likely had nothing to do with it.
As mentioned in the previous installment, Dr John noted that my heart murmur had become much louder since April. Although I did not have any additional symptoms, she suspected that my heart was infected with endocarditis. For that reason she immediately prescribed an echocardiogram (an acoustic image of the heart). I had that test on the next available date, October 26.
October 27: Dr John’s review of the echocardiogram revealed increased mitral regurgitation (backflow of blood). She directed me to go to the hospital right away for a blood culture.
October 28. The lab studied the blood culture for five days. However, even on the first day the culture showed a bacterial infection that confirmed Dr John’s diagnosis. She immediately checked me into the hospital.
The hospital started me on a daily intravenous infusion of the antibiotic Vancomycin. The blood culture eventually determined that my endocarditis infection was caused by staphylococcus epidermidis. This is a common bacterium that resides on the skin, and fortunately it is susceptible to Vancomycin.
October 30: Dr John came to the hospital for a more detailed study of my heart function. Her chosen test was a TEE (Trans-Esophageal Echocardiogram). Compared with the echocardiogram, the TEE gives an excellent view of the heart before surgery. However, it is more difficult to carry out. The doctors sedated me and then put an acoustic transducer down my throat, to view the heart from an informative angle. Dr John saw “vegetations” on my mitral valve, indicating that the infection was growing there and was eating away at the mitral valve’s tissue. This observation meant that I would need mitral valve replacement.
The valve replacement would have to be done quickly, since my valve could totally fail at any moment. Dr John’s insight and quick actions had literally saved my life.
A Critical Additional Test
October 31: Neither Dr John nor my local Beaumont Hospital performs mitral valve surgery. Dr John arranged for surgery by Dr Jeffrey Altshuler, a respected and experienced heart surgeon at Beaumont Hospital in Royal Oak, Michigan.
Before surgery, the doctors wanted one additional test to determine what kind of surgery was appropriate. Conventional open-heart surgery requires opening up the chest. That type of surgery typically requires six months of painful recovery and rehabilitation for the patient.
However, valve replacement can also be performed with a “mini” (“minimally invasive”) procedure. The mini requires only a small three-inch incision under a breast, and the patient’s recovery requires only weeks rather than months. (Another version of the mini uses small punctures through which robotic arms perform the surgery. However, surgeons have much more experience with the under-the-breast approach. Also, it has an excellent record of success.)
There’s a catch: the surgeon does not want to start a mini procedure to replace a valve and then discover that there are additional problems. That would disrupt the entire surgical plan and put the patient at risk. What kind of problems? Most probably, blocked coronary arteries that require bypass surgery. The doctors wanted more information before surgery.
The resolution of this question occurred at 6:30 am. Drs John and Altshuler conducted coronary angiography (“cardio cath”) of my heart in the hospital. This involved running catheters from my groin to my heart. (Naturally, this occurred while I was under anesthesia!) The medical team injected contrast dye into the arteries of the heart to visualize them clearly by x-ray imaging. If this test shows narrowing of the coronary arteries that requires surgery, that rules out mini forms of valve surgery.
World’s Fanciest Ambulance
Fortunately, the dye test showed that my coronary arteries were completely open. This cleared the way for me to have a mini valve replacement. I was scheduled for surgery and the hospital ordered transportation to transport me to their Royal Oak branch.
The hospital ordered the vehicle for just after lunch. However, the transportation service could not confirm a specific time. I later learned that all the hospital’s vehicles were in use and never became free. Thus about 9:00 p.m. the transportation folks gave up and called an outside service – one 28 miles to the west in Livonia, Michigan – to send an ambulance.
The vehicle arrived at 10:30 p.m. and a staff member trundled me down to it on a gurney. I found that it was more than an ambulance. The hospital called it a “life-support ambulance,” effectively a mobile intensive care unit.
Why a mobile ICU? Well, since I was a heart patient, even before surgery I was wired up with continuous heart monitoring. I was on continuous IVs for saline, antibiotics and other medications. All the monitoring that I had in the hospital room had to continue all the way to the new hospital location. This mobile intensive-care-unit naturally included IVs and cardio monitoring. It also carried emergency drugs and resuscitation equipment in case I should have a stroke or heart attack while en route. Thus during the 45 minutes to Royal Oak I had full hospital support with both a driver and a nurse, trained and ready to lend help.
Waiting & Waiting
November 1 to 5: Once at Beaumont Royal Oak I learned that “hurry up and wait” also applies to hospitals. If I had entered as an emergency case, they would have popped me right into the operating room and then found any available hospital room for my recovery. However, since I was non-emergency, before surgery I would be on hold until a room in the cardiac ICU opened up.
This was not at all a negative. Almost a week of delay gave the hospital time to run detailed blood tests and a full respiratory evaluation before surgery. The more they learned about me, the better the surgery should go, because they would be ready for any special problems that might come up. They also conducted several more blood cultures, to verify that the antibiotic was already killing my bad bacteria before surgery.
The delay also gave me opportunities to talk with the cardio team and the infectious disease team. I wanted to learn as much as I could about the options, risks and likely outcomes before surgery. I discussed my obstructive sleep apnea with them, and they explained how they would keep my airway open during anesthesia.
Risks of Surgery
I learned that there was a 2% risk of death associated with major heart surgery. 1% relates to the surgery itself and 1% to the anesthetic. Incidentally, although mini surgery is much easier on the patient, its risk of death is no different than the corresponding open-chest operation.
There is also a 10% risk of “serious perioperative morbidity.” Although “morbidity” has a similar meaning to “disease,” it sounds like a deadly word, and in this case it can be. For this type of operation “morbidity” most frequently manifests as bleeding, infection, heart attack and stroke. To date, I have not had any of these, knock on wood.
Among the (Other) Geezers
My room was in the cardiac section of the hospital. Many of the other patients were obviously elderly and seemed to spend all day in bed. The nurses encouraged me to sit up rather than lie down, and to walk several times a day. I wanted to stay active so I was happy to do this. I logged several miles a day in the hospital corridors before surgery.
Unfortunately, the hospital’s monitoring required blood draws every few hours, both day and night. Each blood draw required sticking a needle into a vein. I have prominent veins so this was easy at first. However, after I had two blood draws within a centimeter of each other in my right arm, the vein “blew up.” That is, it swelled up, was sore and visibly bruised, and had to be given a long rest.
After that, I asked the phlebotomists to spread out their needle pokes. I wanted each poke to be at least an inch away from previous pokes. The arms have many veins, but after approximately 40 blood draws I was almost out of needle space. I don’t know how I could have handled it if my stay in the hospital had been extended.
It’s Show Time!
November 5 – 6 – 7: Prep before surgery was rather thorough. November 5, Sunday night, I showered and wiped my body all over with a special antiseptic liquid soap. Then I slept in a fresh hospital gown on fresh bedsheets.
Monday morning I repeated the disinfecting shower and donned a fresh gown. Thus I was about as clean as a person can get when they rolled me into the operating room.
Naturally I was completely knocked out with anesthetic during the surgery, which took six hours. Wow, that is a long time for a surgical team to stay alert and in coordination!
I was either unconscious or non-remembering for 36 hours in all. I know this because Nola visited me the next day, Tuesday, and found me perfectly coherent. However, on Wednesday I had no memory at all of her visit!
What Happened While I Slept
Although I was unconscious during surgery, I know a lot about it thanks to the detailed records kept by the hospital and thanks to my nurses. Here’s what I learned about what happened when I was (mentally) absent:
– I suffered “acute post op pain” and was given hydromorphone, an opioid. This was interesting and surprising to me. I have no memory of having felt pain, and I felt no pain after the effects of anesthesia wore off.
– The mitral valve they installed is a “33 St Jude Epic porcine prosthesis.” That type of valve is fabricated from the cusps (leaflets) of the aortic valves of pigs.
– The operating team found it difficult to install a Foley urinary catheter as planned. Instead, they used a coudé catheter. The coudé has a curved tip that makes it easier to thread through the curved urethra. Both types have a balloon tip that inflates to anchor the tip of the catheter inside the bladder.
– Following the surgery, the surgical team kept me on the mechanical ventilator overnight. This indicates that I was still so sedated that they did not trust me to breathe by myself.
– Several days later I spoke with a nurse who had assisted my surgery. She told me that during surgery she gave me a full unit of blood to make up for the amount I lost.
This blog installment illustrates that unless you’re at risk of imminent death, it can take a while to reach the operating room. But the delay before surgery is valuable because the extra testing reduces your surgical risk. The next installment describes the surgical process, step by step. It is “Valve Surgery Operation & the Intensive Care Unit.”
Image Credits: Photos by Art Chester