Monday, August 27, 2012

Summer's end

My time in Homer has ended for this year. I wanted to post a few photos to show how things slow down as they get ready to pull back for the long winter to come. Alaska's growing season is fast and furious — plants have to grow fast to catch enough sun to flower and seed in the few short weeks of summer. Then almost as quickly they begin to fade away.


Alder leaf
Pushkii
Elderberry
I'm in Eugene now, where it is still summer I might add, and don't know exactly when I'll be able to return to Homer. I simply don't know how long it will take to recover from this huge surgery that feels far away at the moment but is in reality very close. For the time being I'll enjoy being here with my son Tuli and his son, Harper. And in a few short days I'll be back in Thailand with Nut.
Tanker on Kachemak Bay
Kachemak Bay panorama
In my last post I said the result of the angiogram felt like a reprieve. It still does. Even though I need heart surgery, I'm less concerned about having a sudden heart attack now that I know those pipes around my heart aren't clogged with cholesterol. Consequently, I've been happy as a clam and have very much enjoyed my last few weeks in Alaska. Working with my old friends at Alaska Boats & Permits all summer was really cool too as we completed a few big projects that should benefit the business greatly in the months and years to come. All things considered, I'm glad to say it's been a good summer.

Kirk's sauna — my quiet sylvan resort for the past 2 months

Monday, August 13, 2012

A matter of the heart

No, this isn't about a love affair. Nut and I are doing quite well, thank you. It is about a heart though, my heart.

I went to my doctor a few weeks ago for my annual physical before returning to Thailand. I like and trust my Homer docs, Randy and Bill, and we have a great relationship. Everything checked out fine and Randy and I exchanged the usual jokes about my heart murmur we've been tracking for the past eight or ten years, jokes about "valve jobs" and that maybe it's getting to be time for an overhaul. A heart murmur is a sound a doctor can hear with a stethoscope that is indicative of a malfunctioning heart valve. The heart has valves that open and close with the contractions of the heart muscle to force blood to go forward but not back, sort of like a one-way switch. When one of those valves isn't closing properly or is allowing a significant fraction of the blood that's supposed to be moving forward to leak back, it makes a characteristic sound we call a murmur.

Towards the end of the exam Randy suggested I go to South Peninsula Hospital to get an echo-cardiogram just to see if anything new or significant had developed in my heart valves. An echo-cardiogram provides a completely non invasive way to obtain an image of the heart using sound waves, sort of like a sonar depth finder on a fishing boat. But the technology has advanced to the point that measurements of flow rate (called ejection fraction), leak back (called regurgitation), valve diameters, and many other heart and blood flow characteristics can be not only visualized but accurately measured through the use of a 3D Echo-Cardiograph machine, a very cool and ultra high-tech device.

As I watched the pretty pictures on the computer screen I kept up a steady banter with the gal doing the examination. But when she started inspecting my aortic valve she got quiet. She said, hmmmm, that's not opening like it should, not exactly the words I wanted to hear at that time. Soon after that we finished up and I left the hospital. Later when I was at the tennis courts I got a call from my doctor. Deep down I had almost expected the call, just not so soon. He told me I should go to Anchorage as soon as possible to have my heart checked out by a specialist. Your aortic valve has severe stenosis and is only opening about one-third as much as it should, he told me. All of a sudden I realized why I've been avoiding those big bike rides of late. They tire me more than they used to — I had marked it up to the natural and inevitable decline in endurance as I approach 70 years of age. Now, it turns out, there is a more significant reason for my lack of stamina when climbing hills. I'm being shortchanged by a reduced flow of oxygenated blood to my body through this important valve at the top of my heart.

They don't know for sure what causes stenosis. It doesn't seem to have anything to do with high cholesterol or diet, exercise or lack of it. It might be because I had rheumatic fever as a child. Who knows? The problem is I have it and there is no cure nor is there any medication that can correct it. Aortic valve replacement surgery is the only option. This is no small thing, especially for one who has never had any surgery other than a tonsillectomy many years ago. It is open heart surgery, an operation during which they will stop my heart and put me on a heart-lung machine to keep me alive while the surgeon cuts out the old valve and sews in a new one. That's a tough remedy.

Naturally, I was alarmed. I was pretty sure the specialists would recommend immediate surgery. And hell's bells there I was, ready to return to Thailand in less than a month. I called Nut on Skype to explain the situation to her and told her I would be probably be coming to Thailand late, a month, maybe two, would have to pass before I would be well enough to travel. She was bummed but encouraged me to get it taken care of. She said, "I can wait. No problem. Take care of yourself, then come Thailand."

I began doing research on the Internet. There are several types of open heart surgery in use these days. The "gold standard" is the one where they split the sternum down the middle and pry it open to give the surgeon easy access to the heart. But there are less invasive types too. One requires a much smaller opening, only a couple of inches, near the top of the sternum. There are also several kinds of replacement valves available: ones made from human tissue, others that use pig tissue, or that from a cow or a horse. There are also purely artificial, mechanical valves on the market. These have the benefit of a long service life but because they tend to cause blood clots anyone receiving such a valve must use blood thinners like Wayfarin for the rest of their lives. All but the mechanical valves will last for about fifteen years while the horse tissue valve may last twenty. After that they must be replaced again. Depending on a person's age and condition, one type of valve or another may be recommended. A youngster will likely get a mechanical valve so that she doesn't face repeated valve surgeries as she ages. An older person would likely get a tissue valve. The implications of that are all too obvious.

Anyway, last Sunday I set off for Anchorage and the Alaska Heart Institute.  The ride to Anchorage from Homer is world class. The scenery is beautiful and regardless of the fact that the reason for my travel was quite serious, I always look forward to it. I include these photos to brighten up this gloomy post.....

Watson Lake - Sterling Highway
20 Mile River near Portage - Seward Highway
A sunken forest - trees killed in the '64 Earthquake - Seward Highway
Bottenintnin Lake - Skilak Lake Road

At the Alaska Heart Institute I underwent a procedure known as a heart catheterization or angiogram. During it the doctor inserts a narrow tube with a small attached probe, called a catheter, into the femoral artery in the area of my groin and with the aid of x-ray imaging guides it through the twists and turns of the artery until it's near the heart. Once in place a small quantity of iodine solution (about 8 cc) is injected into the bloodstream. Iodine is opaque to x-rays and thus shows up the arteries well. The images one obtains are as good a picture of the arteries supplying blood to the heart as can be had.

The main reason for this test was to determine whether any other part of my heart was compromised before embarking on a valve replacement. Seeing as they're eventually going to go inside my chest they wanted to know if I would need a coronary artery bypass at the same time. No sense in going through all that trauma twice. During our initial interview my cardiologist told me that in consideration of the fact that I have no symptoms of heart stress other than the stenosis it might be fine for me to travel to Thailand as planned but that if  the test showed I had significant blockage of any of those coronary arteries he would recommend immediate surgery. Consequently, it was with great apprehension that I found myself looking up from my gurney at Providence Hospital's million dollar, multi-armed, multi-screened, computer controlled heart cath x-ray machine last Wednesday.

The nurse prepped me with some Versed (could I have a bit more of that, please?) to get me relaxed. My doc came in and began the procedure. I swear I could feel a faint flutter inside as he guided the catheter toward my heart. When he started the dye injection I literally hung on his every comment.
"They look pretty good," he said.
After a few moments he said, "No serious occlusions."
And then, "A couple of the smaller arteries have maybe a 20-30% occlusion but all in all, not too bad."

My relief in  hearing those words was enormous. I've been concerned for years that my high cholesterol would eventually block one of those arteries and cause a heart attack. The angiogram has all but removed those worries.  It felt like a huge reprieve even if only a temporary one. I decided right then and there that I was going to Thailand on schedule and would defer the surgery until next spring.

Part of that decision was because my readings in various forums on the Internet and a few helpful library books, told me that recovery from open heart surgery can take from 3 weeks to 3 months, maybe longer. I knew that if I had the surgery I'd be chafing at the bit to get back to Thailand and my sweetheart and might be tempted to do that prematurely. And then if I did experience  any complications I'd be forced to deal with them with entirely unknown doctors and hospitals. Thailand has some excellent medical care available — indeed many people come to Thailand for medical procedures that they cannot afford in the U.S. — but I have Medicare and, until the Republicans have their way and somehow eliminate it, I can get my operation paid for in the U.S.

Plus, in my research I discovered that the best cardiac hospital in the U.S. happens to be in Cleveland, Ohio. The Cleveland Clinic is top rated, surpassing Johns Hopkins, the Mayo Clinic and the Harvard teaching hospitals in Boston, and has been ranked #1 for the past few years. Why? For starters, the overall mortality rate for these operations, some 250,000 per year, is about 2.5%. At the Cleveland Clinic it is 0%.

If that's not enough, my lovely sister Sandy lives only four hours away in Buffalo. She is willing to  accompany me to the clinic and help me through recovery. She might not be so available if I did it now as she's scheduled for hip replacement next week.

Then yesterday my cardiologist telephoned to discuss more fully the implications of my decision to postpone. I had asked to have a conversation because we hadn't had time to talk after the exam. I was half expecting him to cautiously advise me that were I to proceed I would be risking serious problems. Instead he said he didn't see any reason for immediate surgery. And that I should be just fine waiting until spring. Needless to say, I was overjoyed to have him enthusiastically sanction my plans.

So it appears that I'll be able to go to Thailand to rejoin my darling girlfriend in Chiang Mai. I'll plan my surgery and look at options from there. When I return I'll go to Cleveland and get a "valve job" at the Cleveland Clinic.

That's the plan, Stan. Wish me luck....