Sunday, May 12, 2013

Open Heart Surgery at the Cleveland Clinic

This a post about heart surgery. I wrote much of it when I was staying with my sister Sandy at her place in Olcott on Lake Ontario. Here's a view toward Toronto at sunset a few days ago. For those of you who prefer pictures over words, I'll include this photo and then get on with the wordy part of the post.

Lake Ontario Sunset
At this point, three weeks post-op, I'm happy to say that I'm back to blogging and back on track for continued good health thanks to aortic valve replacement surgery I recently underwent at the Cleveland Clinic. I can't say enough about the fantastic treatment I received from every single person in that organization, from greeters and housekeepers through nurses and physicians. I was so impressed with the employees' level of dedication and competence that I want to sing their praises to anybody who will listen. If you're not familiar with the circumstances that took me to the Clinic for heart surgery, you can read this blog post from last summer.

The Cleveland Clinic Guesthouse where we stayed
Sandy and I drove from Buffalo to Cleveland on Sunday the 21st of April for my aortic valve replacement (AVR) surgery scheduled for the 23rd. We stayed at the Cleveland Clinic Guesthouse which was reasonably priced and had a great restaurant downstairs, the Chicago Deli. The entire day of the 22nd was set aside for getting a chest x-ray, an EKG, echocardiogram, lung volume measurement, and blood tests. It culminated in a visit with Dr. Douglas Johnston, the surgeon who had picked up my case. I don't know how these cases are dealt out to the docs at the CC; all I know is that after I sent my records to the Clinic last summer a note came back by email telling me Dr. Johnston had offered to perform a minimally invasive AVR operation.

I quickly Googled both the technique and the doc's name. "Minimally invasive" sounded good because for it the breastbone is cut only about 4 inches to gain access to the aortic valve, which sits on top of the heart. The more common technique, the gold standard in open heart surgery, cuts through the entire breastbone from top to bottom. The rib cage is then hauled apart with clamps to allow unfettered access to the entire heart muscle. This is the sort of operation necessary for CABG (bypass) surgery or to operate on any of the other heart valves. As for Dr. Johnston -- his credentials were impressive and I learned he does over 100 AVRs every year. Most people who have OHS want to meet their surgeon and get to know him before trusting him with their lives. Considering I was to come to Cleveland more or less directly from Thailand, that wasn't possible in my case. I had to assume that he would turn out to be someone I could relate to.

Dr. Douglas Johnston
At the very end of the long day Monday I finally met Dr. Johnston. He was a friendly, soft spoken man, with the sort of haircut we would have called "collegiate" in the old days, and delicate looking hands, surgeon's hands I hoped. We had a chat and briefly discussed my options regarding whether to have surgery or not. Although we both knew the decision had already been made, this conversation was required along with my signed acknowledgment of the risks and details of the surgery ahead. I signed on the line and we continued our talk.

One measure of valvular stenosis, which is the stiffening of the valve that was affecting me, is obtained from echocardiogram tests.  It is called the mean pressure gradient and is expressed in mm of mercury (mm/Hg), a number directly proportional to the amount of energy it takes to push blood through the valve. Lower numbers are good, higher numbers bad. Coupled with the valve area, which is usually reduced because stenotic valves do not fully open, a qualitative measure of the severity of the stenosis can be derived. Normal gradients are in the range of 3-5 mm/Hg and normal aortic valve are roughly 3 sq. cm. in area. Mild stenosis is anything not exceeding 25 mm/Hg. Severe stenosis involves a mean gradient greater than 40 mm/Hg and a valve area of 1 sq. cm. or less. These last numbers characterize my valve situation when I entered the Clinic. My aortic valve was only opening 1 sq. cm., about 1/3 as much as it should, and my mean pressure gradient was just over 50 mm/Hg. This makes it very hard for the heart to deliver adequate oxygen to the rest of the body. The valve that controls the flow of freshly oxygenated blood is too constricted to be able to do its job properly.

In discussing my options Johnston told me that statistically people having my numbers eventually reach a point where mild physical exertion causes lightheadedness or even fainting and at that point I would have only a 50% chance of surviving another 3 years. I wasn't quite there yet but had already noted a reduction in endurance when playing tennis and riding my bike. Several friends upon hearing about my diagnosis last summer pooh-poohed the idea of heart surgery. They're just trying to drum up business, they claimed. In my mind, I never doubted I needed the surgery.

Next we discussed the type of valve I'd receive. Dr. Johnston recommended a newer model from St Jude Medical, the Trifecta valve, a combination porcine and bovine tissue valve that he's used extensively for the past year or so. The Trifecta  exhibited a high degree of reliability over a simulated 15 year test period (600 million cycles), has a high throughput rate and, because it's made from natural tissues, requires no blood thinners. I knew I would get some sort of tissue valve and I had no reason to prefer one over another so that's the one I ended up with.

Later that evening my daughter Carin arrived. She had driven up from North Carolina to be there during my surgery.  I was ready for the next day now that I had my support staff in place.

The big day started out in the nursing pre-op center on the first floor of the main cardiac center at the clinic. The aide who prepped me was very nice and after she learned I had come from Alaska via Thailand for my surgery, she started bringing her girlfriends in to visit the exotic guy in 2A. Who doesn't enjoy a little taste of celebrity whether deserved or not? I had some good fun talking with them about my travels and my life in Thailand. But reality soon intruded on our little gab fest.

It was a surreal journey to the operating room. I said goodbye to my daughter and sister and was wheeled away through stainless steel corridors and a stainless steel elevator to the operating room, a brightly lit and chilly room full of people and equipment. There I lay supine on my little gurney, the person for whom this technology and effort was being marshaled and the focus of all the energy in that room. It was a weird feeling. My mind was racing through various scenarios and outcomes until someone placed an oxygen mask over my mouth and asked me to take some deep breaths.

I woke up 5 hours later in the ICU. A nurse whose name tag read Cheryl said hello and asked how I felt. I signaled okay with a thumbs-up and then slipped back into semi-consciousness. Something was stuck in my throat and it felt awful. Try as I might I simply could not swallow. And I was stuck like a pin cushion with IVs, electrical leads, a drain tube in my chest and a catheter in my you-know-what. I couldn't swallow and I couldn't move. It was the most uncomfortable moment of the whole deal -- I felt so constrained and claustrophobic I wanted to scream. The feeling passed but it was never far away until those tubes came out. After a while my sister and daughter were allowed to come in to see me and soon after that the breathing tube was removed. If I never have to use one of those things again it will be just fine, thank you.

Later I scanned the surgeon’s report where I read that after I was fully anesthetized  “the upper sternum was opened and the thymus divided; the pericardium was opened and the heart and great vessels exposed …” And, “the aorta was cross-clamped and the heart arrested with a single dose of cold blood Del Nido cardioplegia antegrade. After adequate diastolic arrest the aorta was opened and a heavily calcified bicuspid valve excised … after debriding the annulus, a 27 mm Trifecta sizer was a snug fit. The valve seated well. The aortotomy was closed.”

Phew! A lot of big words having big implications. That was my heart being "arrested", my aorta he's talking about and my valve that was being "excised". I'm very glad to say I made it through all that.

After an overnight stay in the ICU I was wheeled upstairs to a very modern private room where I spent the next few days getting my strength back. My diet of drugs was extensive and included aspirin (blood thinner), acetaminophen (pain), colace (stool softener), Pacerone (heart rhythm regulator), Lasix (diuretic), heparin (blood thinner), lidocaine (pain), Lopressor (beta blocker), Protonix (proton pump inhibitor to prevent acid reflux), potassium chloride, tramodol (pain), and last but not least, a patient controlled device to administer Fentanyl to control pain and help me sleep. Fentanyl is about 100x more potent than morphine according to Wikipedia and I used 36 cc of it while I was there. Pretty good stuff!

A room at the Cleveland Clinic
Spotless corridor at Cleveland Clinic

I knew the mini-sternotomy would be less severe than the standard op, as I've said, but it was apparently a whole lot less severe judging by the folks I saw on my floor who had got the full treatment. They were walking gingerly as though their incisions still hurt quite a bit. In my case, the pain was never serious and after a couple of days the Fentanyl pump was removed along with the catheter and I was encouraged to get up and walk about. I took some of the tramodol a couple of times the third day post-op and then quit the pain meds entirely. My chest was tender but not enough to keep me awake. I slept a ton while in the hospital.

I had one minor complication that I've been told is quite common. Atrial fibrillation is an irregular heartbeat that can cause serious problems if left untreated. Fortunately, mine was corrected in a few hours though the use of the drugs Lopressor and Pacerone which help regulate and control heart arrhythmia and fibrillation. Of the drugs I was getting just after surgery, those are the only ones I'm still taking.

I'm in Eugene now and will be back in Alaska next week. I can't play tennis for a few more weeks to allow my chest to heal fully but the doctor told me to feel free to do any sort of exercise I want as soon as I was up to it, aerobic, whatever. He said, "Once we re-start a heart it either works or it doesn't. There's no in between."


Cleveland Clinic Rooftop Patient Lounge
The Cleveland Clinic opened its doors on Feb. 28, 1921. It was a new kind of medical center for the times: a not-for-profit group practice, dedicated to patient care enhanced by research and education.

Cleveland Clinic pioneered the world's first cine-coronary angiography, first published coronary artery bypass (CABG) surgery (1967), and the first successful larynx transplant and first near-total face transplant took place there. In addition to many other achievements  the first minimally invasive AVR, the kind I got, was performed there. In other words, the Clinic pioneered the very surgical technique I had the other day.

The main campus of the Cleveland Clinic consists of 41 buildings situated on a campus of more than 140 acres in downtown Cleveland, Ohio. It was ranked as the fourth best hospital in America for complex and demanding situations according to recent U.S. News & World Report's America's Best Hospitals report and has been ranked number one for cardiac care for 16 years in a row.  This is the primary reason I chose Cleveland Clinic for my surgery. The Clinic is the largest private employer in northeast Ohio, and the third largest in the state of Ohio, with over 36,000 employees all over the United States and revenues exceeding $4.4 billion annually. It has over 1200 beds and admits about 50,000 patients every year, patients from all 50 states and all around the world.

It is an awesome hospital. Of course, I'm biased.

My room is in there somewhere

Note (August 2013): The full cost of my surgery and 6-day hospital stay was a mind boggling $220,000! I count myself fortunate to have Medicare, which paid 80% of that, and supplemental insurance from the State of Alaska that I received when I worked for the City of Homer back in the 90s, which paid the rest.