Who Knows What Secrets Lurk in the Hearts of Men? The ICD Knows...

(Back-written)
Five weeks after my ablation and ICD implant, and four days after what I thought was a night of V-Tach runs, I trucked down to Philadelphia to get the secrets of my heart read by a woman with a large computer. My Medtronic Concerto ICD in addition to its life-saving functions, gathers certain data about my heart function. Specifically it monitors, EKG-style, dangerous arrhythmias of a speed above a pre-set limit, it notes any prolonged but less dangerous arrhythmias, and it records the heart’s overall bpm trends: how much time as a percentage of the given period did I spend at X, Y, and Z heart rates. It also tells what percentage of total beats are PVCs.

I was surprised to find out that, since my implant, I had no record-worthy V-tach, and only 1% of my total heartbeats were PVCs. This was a relief, but also disconcerting. I had been having, with seemingly descending frequency, what I thought were crazy bouts of PVCs since my surgery, and the occasional V-Tach.

The latter number, 1% of total beats being PVCs, is actually larger than it sounds. If an average person has 60 beats a minute x 60 minutes x 24 hrs, that equals 86400 beats per day, 1% of which is 864 errant beats a day. If those 864 beats come in bouts of, say, 20 beats a minute (a pretty noticeable amount of PVCs) then that is a 40 minute stretch of PVCs. Add to that equation the fact that I had some days where I had almost no PVCs and other days where I had many, and my “bouts” weren’t complete fabrications.

Well, all that made me feel a bit better about my recovery from surgery, but also convinced me that I was being hypersensitive, and should try to ignore the PVCs and get on with life. Dr. Marchlinski’s assistant said as much, recommending I start exercising again. Exercise, she thought might aid in recovery at this point, and reduce the number of PVCs.

Things were looking up for a few weeks. The day after the ICD “interrogation” I went for a two-mile run. I was advised to keep my heart rate from getting too high and I set a 135bpm speed limit for myself. Higher than last time, because we fancied me fixed and almost ready for prime time.

That weekend I went for my first bike ride, 14 miles in Central Park, at a very pedestrian pace. By the following weekend I had ridden 3 more times, each a 100% improvement, each faster, and farther. The next weekend I went out for a 3hr ride with my girlfriend Molly, who was gentle on me, although there was no question of me keeping up on the hills or if she decided to scoot. At 135bpm my out-of-shape body could manage a pretty paltry speed.

Riding with an ICD took some getting used to. First, I still didn’t trust the thing, and any weird sensation from my chest had me in a panic. Gradually I came to grips with the fact that the thing wasn’t going to go off accidentally if I rode over some washboard surface and sent pseudo-V-Tach vibrations up my arms. Then there was the worry that I might have some stupid accident that would wrench the thing from its tenuous lodging in my chest. All these fears dissipated over time, as did the feeling of heaviness and soreness in the pectoral zone.

What didn’t go away, however, were the PVCs. When I rode I’d always have at least a few that were quite strong and would make me pause for a moment. Often I’d feel unduly light-headed, but I chose to ignore that, chalking it up to being out of shape, riding in the August heat, and the fact that I was still not completely recovered and didn’t have all of my heart function.

The next, and hopefully final step in confirming my complete return to normal and victory over the giant scar on my heart, would be a final test, known as a “NIPS” test. NIPS stands for Non-Invasive Programmed Stimulation. Using a combination of the ICD and drugs the heart is stimulated to try to induce V-Tach. This is basically a final test of the success of the ablations. If V-Tach is induced, it means either more ablation, or more drugs, or both. If there is no V-Tach, then life is good again.
In the two weeks before the NIPS I exercised as much as I could, hoping that the return of fitness would help me ace this new test. In the final week I was told to stop taking my beta-blockers in order to have a pure, unadulterated heart. That’s when it all went pear-shaped...

PVC Hell

an amusing explanation of PVCs and other arrhythmias, be patient there is no audio


By the second week in July, two weeks after my epicardial ablation and ICD implant, I was starting to feel functional. I went home from the hospital with specific, doctor advised “dos” and “don’ts” and some self-created “cants” “and won’ts”, mostly to prevent the ICD from shifting around in its chest pocket and the lead from pulling out or breaking inside the heart. These scenarios can keep you up at night, especially when you have a ghost sensation of the lead poking into your heart as I did.

I was told not to raise my left arm above my head, extend it behind my back or too far to one side, and lift nothing more than a few pounds. I was told not to drive for two weeks. The arm-moving moratorium lasted for six weeks and I was given a sling to wear at will if I felt I was going to forget. The sling wearing lasted a day or two, and after that mostly at night in bed to keep me from flailing around. When I felt good enough to go out I took it with me in case I was feeling nervous about being bumped into in the subway or on the street. The sling was a little sign that said “injured dude approaching.”

The sling also helps deal with the initial discomfort of the ICD. The whole arm/shoulder/pectoral area throbbed for many days and I enjoyed many Percocet. After a week I voluntarily kicked the painkiller, I was worried about getting too familiar with it and the pain had become tolerable. The ablation also left a residual pain in the chest like heartburn. It came and went randomly and seemed to be connected with the continuation of errant heartbeats. On leaving the hospital I was told to expect lots of PVCs for some time. Premature Ventricular Contractions are explained elsewhere on this blog, but basically the phenomenon -in addition to existing as a relatively benign cardiac anomaly- is a temporary byproduct of most kinds of cardiac surgery or other intervention. PVCs are the heart’s way of being cranky.

My heart was pretty damn cranky for many weeks. I had been given the same beta-blocker I was on pre-surgery, Metatoporol, to calm the heart down and lessen the PVC’s. But most days and seemingly every night I was plagued by bouts of PVCs. Often every 2nd or 3rd beat was a PVC; when translated into dance beats this equates to a kind of reggae-samba.

As I recovered the PVCs lessened, but when they were around they were loud and proud. At their worst they feel like a small caged animal thumping on your ribs, sometime the thump extends up the neck and throat. Other times PVCs are barely noticeable. In the right patient (i.e. me) a run of PVCs can deteriorate into V-tach and sometimes enough PVCs will actually feel like V-tach, particularly to a new ICD recipient who is paranoid about being shocked by the bloody device. All this makes for sleepless nights and panicked moments. I didn’t dare do anything too sprightly, no running up stairs, or for a train, no lifting heavy objects, and definitely no bike riding. On several occasions my girlfriend would lie awake at night, her head on my chest and remark “I don’t think you are fixed.”

Four weeks post-surgery and my arm was suddenly better. My range of motion was returning and my PVCs started to quiet down. That Friday I was in New York City and had run out of my beta-blocker and didn’t have my prescription. I was feeling good all the same and we went out to dinner and a movie. Some combination of heavy French food and Cote de Rhone and slacking on the beta-blocker suddenly made me light-headed. I slumped over onto my girlfriend and fully expected a shock from the ICD. Then as quickly as the feeling came it was gone. We left the restaurant and went to the movie where I slipped into a nasty run of PVCs that I thought was V-tach. It was enough to make me leave the movie, take a cab to the nearest CVS and down some beta-blocker. ( I now owe my girl friend two tickets to Man on a Wire and a coffee with Philippe Petit, who was in the theatre for a post-showing Q&A).

The experience shook me up, I assumed I had at least one run of V-tach that night. Monday I got an appointment with my electrophysiologist for a reading of my ICD. The cool thing about the ICD: memory. It records basic information about your heart function 24/7 as well as any events that might be shockable, or almost shockable. I was sure my ICD was going to tell lots of stories about the depravity of my heart....