Stage Two: ICD Implant: The Grim Details

Post-surgery round two -The ICD, where it's at...

I am currently five weeks out from my ICD implant and the thing still feels like an alien invader that somehow burrowed into my chest. There is much to talk about on the subject of the ICD -“Internal Cardioverter-Defibrillator”- and, I suppose; I have the rest of my life to do it. The alien in the chest is a permanent fixture. I’ll start with the surgery and the big question for those of you tuning in because you are about to receive your own alien: subdermal or subpectoral?

Thirty-six hours after my epicardial ablation I was carted back down to the electro-physiology lab for the surgery to implant my ICD. I received a Medtronic Virtuoso, a battery powered lozenge measuring approximately 3”x 2.5”x .75” and shaped like an asymmetrical lima bean. Its job is threefold: it paces the heart should it go too slow (this is not an issue for me), it attempts to pace the heart down if it goes into a fast, dangerous rhythm (i.e. ventricular tachycardia), and lastly it delivers a defibrillating shock should its pacing efforts fail.


The lima bean body mostly contains the latent energy needed to shock a heart back into action. Somewhere there is a small chip containing the device’s smarts, connected to a “lead”, which is a wire threaded along a vein and embedded into the heart muscle with a tiny screw. Depending on each individual’s heart condition one may need more than one lead. The whole thing is substantially larger than a conventional pacemaker, owing to the need to deliver big voltage to the heart (I’m not certain about the specific voltage, I think it is an ascending scale of shocks starting at 50 volts and going to 700, if anyone has more specific information please correct me).



Normally the ICD is placed in a pocket created under the dermal layer in a spot below the left collarbone. In my case I was given a sub-pectoral pocket, which sits under the dermis and the muscle and requires more cutting of flesh, more time in the operating room, and more recovery.

The subpectoral placement is an option I was not aware of until the day before the surgery. Through all of this I have been most concerned about the ICD restricting my lifestyle, specifically cycling, but also rock climbing back packing, etc. At one point I was planning to take a magic-marker to my chest and outline the location of the straps of my backpack with “do not put ICD here” instructions. That proved unnecessary.

The default positioning of an ICD is under the skin, beneath the collarbone. In this position the device is prominent, especially on smaller, skinnier people. In addition to the obvious aesthetic issues, a subdermal ICD is more easily jostled, tends to shift in its spot, and can be quite painful if accidentally whacked. There are also incidents of leads breaking or being pulled out. Basically a subdermal ICD is a constant reminder of one’s problem. It is also a liability for sporty types. It is less protected and therefore more easily damaged.


This image gives a good sense of just how much a subdermally positioned defibrillator sticks out. This is Gary Swain, an ICD recipient who climbs big mountains while waiting for a heart trasplant. His story here.

From perusing the ICDsupportgroup.org I discovered that many people are not even made aware that there is an option for ICD placement. My understanding is that electrophysiologists who do ICDs don’t like to do subpectoral implants because it involves more surgery and it is more time consuming. Electrophysiologists are not surgeons; their work rarely requires cutting people open, most of it is done via catheters and computers. So the bulk of ICDs are places subdermally.

Because all my work has been done at a large research hospital, the University of Pennsylvania, my electrophysiologist Dr. Marchlinski, does not do implants. They have specialists for these things. Mine was a Dr. Josh Cooper. There are benefits to having an ICD implant specialist. Dr. Cooper seemed almost anxious to do a subpectoral implant.

The surgery itself was a walk in the park compared to the epicardial ablation. It is done under conscious sedation. The operating room is similar to the EP lab, with almost as many nurses and technicians present as an ablation. I was given a local anesthetic and a heavy dose of sedative. Covered by a sticky blue sheet, including my face, I eventually fell asleep but I do remember feeling some painless poking around in my chest and something that I took to be cauterizing. There was some heat and a burning smell and I remember asking the doctor if they were making a crème bruleé. The whole thing took about three hours, the most time consuming part being the threading of the lead and screwing it into the heart. I imagine a one-inch wood screw.

Recovery was rough. I was dealing with both residual chest pain from the epicardial ablation, and this new source of discomfort: muscles that needed healing and an internal hardware that my body had to adapt to. That night my heart complained vigorously, in the form of PVCs and general ache. My left arm was restricted to minimal motion, not that I was able to move much anyway. I left the hospital the next day, but I didn’t feel very fixed.

Marco Villa Retires Due to Cardiac Arrhythmia

photo copyright Nick Rosenthal

Cyclingnews.com reported yesterday that Italian six-day specialist Marco Villa has retired at 39 years of age due to an unspecified arrythmia:

"Noted Six Day rider Marco Villa was forced to retire early when he learned that he had an irregular heart rhythm, UIV.dk reported this week. The 39-year-old Italian was intending to retire next February, but learned of his condition after a medical control for Olympic candidates earlier this year.

Villa said, "Originally it was my plan to stop after next winter, with the Six Days in Cremona in February 2009 as my definitively last race. But as a member of the group of Olympic candidates in Italy, I was called in for the normal health-control. That control showed some irregularities in my heart rhythm.

"They couldn't exactly tell me what was wrong, but the doctor's advice was that I should refrain from racing for at least a few months," he explained. "At my age it is not so easy to take a longer break, so I decided to stop now instead of taking any risks. I have had a wonderful career and I have a lot of good memories, and I want to let it be like that."

36 year-old Olympic Canoeist Gyorgy Kolonics Dies of Heart Failure

Part of the purpose of this blog is to provide a resource for endurance athletes with arrhythmias. To that end I will try to keep a running tab of athletes whose cardiac issues have made the news. This past week there was an especially tragic story.

For now it is unclear that a fatal arrhythmia killed Gyorgy Kolonics, a canoeing gold medalist at the 1996 and 2000 Olympics. The media has listed the cause of death as heart failure. Often cases of sudden cardiac death in young athletes -Kolonics was 36 years of age - are due to an electrical problem (i.e. an arrhythmia) rather than a structural one, but rarely is there a follow-up in a premature death like this. Below is an excerpt from an article by John Horvath on www.ohmynews.com which details the circumstances of his death and the fact that there was no defibrillator on site:

"Kolonics... had fainted while rowing and was immediately taken to shore where his coach and teammates desperately tried to resuscitate him. Kolonics died on the scene, however, soon after the ambulance arrived and despite the best efforts of paramedics. Although the precise cause of death is still unclear, what is known is that he died of a massive cardiac arrest.

As tragic as the death of Kolonics has been, there are still many questions left unanswered as to why the tragedy happened. As Kolonics was a professional athlete who participated in many world championships and took part in two Olympics, it is hard to imagine that someone in such great shape could suddenly and literally drop dead. Admittedly, Kolonics was in his mid-30s, which in the eyes of most sport professionals is retirement age. Kolonics himself admitted that he wasn't sure how he would be able to handle the training, but he nonetheless was looking forward to taking part in what he viewed would be his last Olympics as a professional athlete.

When it comes to sport, Hungary has some of the best training facilities and resources in Europe, if not the world. Unfortunately, because of budget constraints some of these facilities and resources are underutilized. Still, the general preparation for athletes is at a very high level. This includes a strict regime for the medical supervision of all athletes. Kolonics underwent his most recent medical tests in April of this year, and the results showed that he was in perfect health. Thus, his sudden death remains puzzling to many.

From the first time a call for help was made, it took about 40 minutes for the ambulance to arrive. To make matters worse, the ambulance that arrived on the scene was not fully equipped and the paramedics were not fully prepared for the task at hand. Later, it was revealed that another ambulance with more qualified personnel was closer at hand and could have made it to the scene much sooner. To make matters worse, a medical helicopter was also available that could have reached the area within 5 to 10 minutes.

Sadly, even during such tragedies politics in Hungary seem to go on as usual. Etele Barath, a member of the ruling Socialist Party and head of the Hungarian Canoe and Kayak Federation, appeared keen to sweep the issue immediately under the rug as he avoided critically appraising what had happened. Subsequently, it was determined that there was no need for an official enquiry. The authorities accepted the official version of the National Ambulance Service that the ambulance arrived 17 minutes after it had received the call. Yet this call was not the initial call; the first call got lost in the chaos of the dispatcher service."

Stage One: Epicardial Ablation, the grim details

Post-surgery-round-one. The orange blob on my chest is a sterile coating around the incision made under my sternum. There is a catheter in the pericardial sac to drain off excess fluid, which goes into the small, shiny pink bladder lying on my stomach. The contraption in the lower left corner is a PCA, the magic machine that lets me administer my own pain meds.

It is one week after the final assault on my ventricular tachycardia and the haze is starting to lift. I have two new holes in me. The first lives front and center on my chest, just below my sternum. My girlfriend Molly says it looks like the pouting lips of a blowfish. It is tiny, approximately a centimeter across. It is now, a week later, sealed up enough for me to shower with impunity. This remarkable little hole marks the passage created to gain access to my heart and destroy That Which Would Destroy Me.

The other hole was considerably larger, a one-and-a-half inch incision in my left pectoral which now holds a "Dick Cheney Signature" Medtronic Cardioverter-Defibrillator (now for liberals!!!) The defibrillator is its own story and gets its own forthcoming entry. For now we'll stick to the blowfish mouth.

The first stage of my two-part surgical voyage last week was an epicardial (exterior of the heart) ablation. You may recall that my initial endocardial (interior of the heart) ablation was unsuccessful. The site of scaring on my heart was large and deep, spanning a 3cm by 2 cm portion of the wall of my right ventricle. With scarring of this nature it is often the case that the less invasive endocardial ablation will not do the trick (I saw a 45-75% success rate somewhere). The day after that ablation I passed my stress test, and was sent home. But in the weeks that followed portions of the site returned to normal and the tissue that created the malevolent circuits responsible for V-tach came back online.

The scar itself can be imagined like a lattice, web or tic-tac-toe board. The spaces in between the lattice are unscarred tissue, but because these bits of tissue are separated from the rest of the heart by the scar, they create their own, independent rhythms. These rhythms can hijack the normal rhythm of the heart and create V-tach. In the ablation these areas of tissue are cauterized with radio-frequency waves, which cause them to scar as well. Ablation is a tic-tac-toe game; hatching the void areas in the lattice to create a harmless uber-scar.

The new approach was to attack from the outside a longer, more complicated and riskier procedure. After checking in the day before for overnight monitoring, I was wheeled into the U Penn electrophysiology lab at 7am. This is as much to pack the day with cases as it is a precaution in case more complicated surgeries run long. The first part of the procedure was done with conscious sedation. I was thoroughly catheterized; two cardiac catheters were placed on either side of my groin, one for the left chambers of the heart, one for the right. These were for purposes of monitoring the action that would take place on the outside of the heart, and to deliver pacing pulses when needed.

I was also given a Foley catheter, an incidental I had been dreading for weeks. This is basically a penile hose that goes up the urethra to the bladder, where it drains any urine produced during surgery. It would stay in for the next 24 hours, as I was unable to move during that period. I grew to love the Foley. It proved enormously useful. Imagine, you can drink with impunity and never have any pressing need to pee. It was not uncomfortable and I was so sedated I never noticed it going in. Thank you Mr. Foley. Of course I was never able to sit up and actually make eye contact with the thing, which might have been stressful...

There was an initial round of remote control V-tach as target sites were located and then the anesthesiologist stepped up and I was knocked out right and proper. The chest hole was opened up and a sheath inserted to guide other catheters into the "pericardial space" and through the pericardial sac . The pericardial sac is a protective layer surrounding the heart that reduces friction between neighboring organs and gives the heart its own space. Through this hole a catheter was maneuvered which probed the outside of my heart and mapped the areas in question. Another catheter applied the ablation, bursts of high-energy RF waves that cauterize the scar. Dr. Marchlinski concluded by running my heart through the gears, trying to induce V-tach. I was uninducable.

This process took 8 hours. I was wheeled out of the lab at 3pm. I awoke in agony. My chest felt crushed. It is a difficult sensation to express, but I suppose it must be something akin to getting stepped on by an elephant. I asked for my Mom, a nurse herself. I didn't want the rest of my family to see me moaning like this and I knew she would be a good advocate. There were nurses on hand to run me through a gamut of pain meds. Percocet, Fentanyl, Morphine, and finally Dilaudid. Only the Dilaudid had any impact. Dilaudid is, according to Wikipedia "about eight times stronger than morphine and about three times stronger than heroin". After that I was a giddy, pain-free mess.

I was hooked up to a PCA, "Patient Controlled Analgesia", a pump tapped into my IV that allowed me to administer my own dose of Dilaudid via a little button on a wire. It sounds a bit like a lab-rat experiment and it is; the PCA lets the patient administer only a prescribed dose per hour, after that limit is reached the rest is just the placebo affect of hitting the button. It works. I was mostly pain free that night.

But the drugs were making me anxious and paranoid. That night Molly stayed in my room in the ICU. I was having panic attacks. I kept my head tilted constantly to look at the ECG monitor overhead, checking my pulse, blood pressure and oxygen levels, and detailing any errant rhythms my heart was producing. And there were a lot. The days after surgery are filled with errant beats, PVCs, and small runs of V-tach that keep you on your toes. The heart is aggravated and enflamed, and it takes long days to calm it down. I knew this, but the Dilaudid made me think that every thump in my chest was going to kill me. It was a long night. Molly woke with every panic attack and reminded me of what reality was.

This continued into the next day. By the late afternoon I asked to be taken off the Dilaudid. The pain was down, and although there were occasional moments of drug-induced euphoria, mostly the stuff was making me freak out. I was taken off the PCA and the Dilaudid and put on Percocet, administered by my nurse. The second night was calmer; I was taken off the ICU and given a bed in a shared room next to, of all things, a cardiologist with Marfan's Syndrome. He heard one of my panic attacks and poked his head around the curtain to let me know that I was not, in fact, going to die, and if I needed any help he'd be there for me.

I slept poorly. The next day would be my second surgery, to implant my defibrillator. I was feeling unprepared. I hadn't been able to eat from Monday night until Wednesday afternoon, and when I finally had the catheter removed from my chest and was able to sit up and eat, I had no appetite. I consumed maybe 500 calories in 3 days. Hardly a robust candidate for a second surgery.