Fixed! Round 2: 12-hour light-sabre throw-down in my heart

heart catheterization (artist's rendering)

The human body objects to all puncture. After being opened and reopened for medical purposes with small, considerate needles and scalpels, it defies my imagination how a human could endure arrows, bullets, swords, or spears. What seems to be the end game in my battle with Ventricular Tachycardia began with a duel between my left arm and a nurse who managed to roll all the useful veins in it while trying to install an IV. It ended with my much-more-proficient Doctor Francis Marchlinski light-sabreing his way around my pericardial sac, routing out insurgent electrical circuits. It was his third visit to my heart; almost as if the epic quality of this adventure was deserving of a trilogy.

As I explained before, an epicardial ablation is not the walk-in-the-park an endocardial ablation is. The chest is entered with a large, hollow hook-shaped needle (the same one used for epidurals), the heart is reached through the pericardium and a catheter threaded in the opened channel; other catheters are passed through the femoral arteries reaching the heart from the inside. The heart is mapped, the dangerous circuits identified and eliminated internally and externally. Endocardial ablations are completely internal and thus less invasive.

Dr. Marchlinski found himself in a spot of trouble upon sitting down to work. Apparently I had been so drugged up the previous days that my heart would not produce any V-Tach on the table. The first step in ablation is to incite the heart into its bad behavior, find the locus and zap it. But my heart, despite all the previous drama, was behaving itself. I was sedated but awake when they discovered this, strapped to the table and fully cathetered. The epicardial catheter had not yet gone in -they knock you out for that- but I could sense some frustration in the room as I was loaded with adrenaline and electronically pulsed to high speed. All told, I was on the table for twelve hours; it seemed I was awake for the first three. Marchlinski took a bunch of educated guesses as to the locus of my circuits. As a consequence many of my PVCs were also eliminated by the end of the day. The main culprit, the original V-Tach-creating-scar, was already well-known and identified through prior mappings, and although it wasn't producing V-Tach now Marchlinski spent extra time going over it. In the end the diligence seemed to work. I was Dr. Marchlinski's first repeat customer for epicardial ablation for V-Tach, and, I'm sure, we both hope, his last.

I emerged from surgery in much better shape than my previous epicardial. I spent 24hrs on my back in a Dilaudid haze, unable to move because of the holes in my chest and groin. But I wasn't a paranoid mess like last time. It was all fine. My heart was utterly steady. I couldn't remember the last time it had been that way. The 12 hours on the table, the repeat surgeries, the cardiac breakdowns, were all worth it for this.

In a matter of days I could tell things were going to stay stable. While my body recovered from the surgery the soreness and sleepiness overshadowed the great feeling of a heart beating just like everyone else's. But after two weeks I was ready to declare myself victorious. I introduced a couple caffeinated beans to my morning brew. No worries. I had a sip of wine. No worries. A few days later 2 glasses of red wine. Nada. More caffeinated beans. Finally, three weeks out, I reintroduced exercise...

Fixed! Round 1: Drugs, drugs, drugs

welcome to the medical-industrial complex...


Greetings from the land of inconsiderate bloggers. The radio silence doesn't mean I died, in fact between now and my last post I've been completely fixed and too busy reveling in it. It may be temporary, it may be permanent, but for the moment my heart beats normally -so normally that three weeks after the miraculous third (3!) ablation I hefted myself atop my bicycle and started riding like I was 22-years-old and unemployed. That is to say, from November 4th (another miraculous day) to scant days ago, I rode or ran every day for six weeks straight, a minimum of 30 minutes on the feet or one hour on the wheels. That is how fixed I am.
Other amazing consequences of fixedness: I can drink coffee, red wine, or eat a large meal and copious chocolate without degenerating into mad PVCs. I can go up stairs without feeling like I just threw out my clutch, I can face a cranky final review jury (architecture school, remember) without massive deleterious RPMs. And, as of two weeks ago, I am doing all of this without any drugs. How did this happen? It wasn't easy. Here's a breakdown:
My last post detailed a cardiac freakout brought on by an ill-advised stoppage of my beta-blockers. There was a disastrous treadmill test, a day of intermittent VT and frantic reloading of beta blockers.
I went home the next day, heart calmed by the drugs. I returned a week later for another stress-test. All doped-up, I eeked through 15 minutes on the ERG barely putting my heart above 150. "He can make it to Christmas!" was the pronouncement. I went home again. Back on a much heavier beta dose I still continued to have bouts of PVCs, sometimes they were super strong and persistent, but generally I felt like I was back on track relative to where I was before my collapse. This happy state of affairs lasted about three weeks.
One fine Monday afternoon as I scurried about the architecture building preparing for a studio review, I went into V-Tach. No warning, no preamble, no reason. Totally unexpected. I didn’t believe it was real, I blamed myself: must be a nerves, pre-presentation panic. But the presentation was a minor thing; and here I was, after two ablations, an ICD implant, and months on beta-blockers, and I was more symptomatic than before.
I sat down, gave a couple coughs and vaso-vagaled my way out of the V-Tach. I gave my little presentation, felt much better, and decided that I maybe I was just over reacting to some PVC runs. But on my way home from school I went into V-Tach again. And for the first time in my life coughing wouldn’t clear it. I got home, put my heart rate monitor on but it wouldn’t read. I wandered around in a panic for ten minutes before deciding I needed some medical attention. As a neighbor drove me to the school infirmary the V-tach stopped. Later I found out my ICD recorded 20 minutes of V Tach in the 150-180bpm zone.
At the infirmary my heart was bubbly with PVCs, but there was no evident V-Tach. It wasn’t clear what precisely had happened. I was sure I had been in VT for at least ten minutes, but it was my word against my now (reasonably) stable heart rhythm. Then I remembered the FedEx box moldering on my front porch.
A few weeks prior I received said box from Medtronic, the manufacturer of my ICD. It was a “Carelink”; basically a modem for my heart that reads my ICD and sends the data to my doctors. Receiving this new “peripheral” annoyed me. The user’s manual cover image shows the “Carelink” sharing bed-side table space with family photos, and a lamp only your grandmother would love. The target population for this device was forty years my senior. The whole thing seemed to imply that with my new ICD I was going to need constant monitoring for the rest of my life.
I instantly had a problem with this. First, I don’t like the idea of being involuntarily networked into the medical-industrial complex that I have unwittingly become dependant on. Not that my heart function is particularly privileged information, but I have no desire to become mentally dependant on this essentially nonessential device (the instruction book recommends you take it with you on your travels and tells you how to troubleshoot a hotel room phone line).
The other issue is that I have no land line, and the Carelink needs a land line. When I moved back to the US in 2004 I went completely cellular. Now there was no way I was going to drop 50-odd bucks a month for a land line so that Medtronic could keep tabs on me. I’m sure there are ICD recipients who need constant monitoring but I didn’t consider myself one.
But sitting there in the infirmary, trying to figure out what was going on, the Carelink seemed an excellent tool. My roommate came by with it later that night and we got it to blink and make some chirping sounds. I spent the night at the infirmary while my ICD data dropped into some virtual box at the University of Pennsylvania by which time it was the next morning and I was back into V-Tach.
Again, it started innocently enough. Sitting in my "Property of Princeton" jammies, munching a bagel at 9 am, I suddenly realized I was in V-Tach. I wandered over to the nursing station and announced my predicament and immediately had the entire Princeton University Health Services staff in a panic. Gurneys and EKG's were rolled in, IVs administered, and ambulances called as my heart thumped away. This time it got pretty bad. I never passed 200bpm but I was feeling pretty faint and the inability to at least break the V-Tach periodically with a cough was discouraging. After a half-hour in persistent V-Tach I was ambulanced over to the local emergency room where things calmed down. The day passed at the local hospital while arrangements were made to ship me to U Penn, an hours drive.
That night, pumped with yet more beta blockers I was back in the U Penn CCU. This is when it all began to feel like Groundhog Day ( a trope in my life of recent). Again, I was back in the hospital for an unplanned stay. Again, the only reasonable thing to do was increase my beta dose. But the larger question: why was my condition degrading so persistently from week to week?
My electrophysiologist Frank Marchlinski stuck by his original assessment of my situation. My heart was healing from the previous ablation in a way that turned my errant circuits back on. And this time they were more persistent, but slower and less lethal.
Clearly I was not making it to Christmas. A repeat ablation was scheduled for the following tuesday. Loaded with enough beta blocker to knock out an elephant, I was sent home for the weekend to rest up for the third attack on my blown heart.