Tuesday, February 14, 2017

Mending a Broken Heart: Take Three

(Pre Ablation #2)
                In April 2016 I wrote the blog, A Healed Heart detailing Levi’s heart condition, Wolff Parkinson White (WPW). If you want more backstory on his heart condition and how an elite athlete like him even found out about his problem, see my previous blog. After reading that blog you would think everything was healed and fine. I didn’t write about it at the time but unfortunately the surgery was not successful.
                To cure WPW the electrophysiologist puts a catheter in the femoral vein and/or artery of each leg and runs multiple wires into his heart. They map the heart and find the unwanted accessory pathway, the “bad” spot, the pathway that shouldn’t be there that basically can let the heart conduct in a way it shouldn’t. When they find the pathway they either burn the spot or freeze it. Burning is the most effective method. Levi was not a candidate for burning as his accessory pathway is located right next to his normal pathway. If the Doctor were to bump the normal pathway this could cause his heart to stop. When working with burning, the results are pretty instant. When doing the freezing technique, there is a little leeway. If you accidentally touch the good pathway it may stop the heart but so long as you don’t continue to freeze, the tissue can “thaw” and the patient will be fine. If the Doctor touches the good pathway and stops the heart and it can’t recover, the only thing left is a pace maker.
                The Doctor Levi is working with has never caused heart block (where you have to put a pace maker in due to an unsuccessful ablation) in his 30+ years of practice. We feel in good hands. When the Doctor did the ablation the first time he froze the unwanted accessory pathway. His heart rhythm did not show WPW. The Doctor waited hours to make sure it didn’t come back. Upon leaving the hospital Levi was cured.  
Recovery after an ablation is very minimal and Levi was back at work a few days later. While on shift, he went on a fire call. The fire wasn’t huge and was easily contained. Levi didn’t end up in SVT (supra ventricular tachycardia) but after every fire the Firefighters go into rehab where they get fluids, food, and rest. In rehab the Medics come and check everyone out. With his WPW when Levi exerts himself he will go into SVT. His heart will start beating really fast and it will stay that way, sometimes for hours after. Since he didn’t have to exert himself his heart rate was fine. He asked the medics if they could do a 12 lead on him anyways. He was curious if he was cured from WPW. The Doctor had him scheduled for an appointment a month post operation but Levi figured why not check early to see? As soon as they ran the 12 lead EKG the words WPW appeared. His heart sunk. Apparently, he was not cured. He called to tell me the news. I was bummed. We knew there was a small chance of his heart healing itself and the bad pathway coming back and unfortunately for Levi he was one of the unfortunate few.
                 He told his Doctor and at his next appointment the Doctor had him wear a heart patch again to see what his heart was doing. There was a small chance that they damaged the unwanted accessory pathway enough that it wouldn’t allow Levi to go into SVT when he exercised. After two weeks Levi mailed in his monitor and awaited the results. They were as we expected, his heart was still conducting in a dangerous way. After talking with the Doctor, they scheduled another ablation.
                Upon operating on Levi, the first time, the Doctor discovered his accessory pathway is bumpable. That means if the pathway is even touched, it stops conducting, making it impossible to map/see. During the procedure, the heart is still beating. Imagine trying to zap an exact, tiny area with a small tool you are using through a vein, that you are looking at on a screen, all while your target is moving.  Saying it can be tricky is an understatement. This happened during the first ablation and the Doctor waited a couple hours and the accessory pathway eventually came back and he ablated again. During the second ablation, the pathway was bumped and it did not come back. Since the Doctor had mapped his heart out before he ablated the entire area and then some around where he knew the accessory pathway to be. He said he went as close as possible to his good pathway, even touching it which caused his heart to stop momentarily but quickly recovered since the freezing technique has more leeway in this regard.  They again waited for hours and it did not come back. Upon leaving it looked as though Levi was cured. The Doctor called me and told me how the procedure went, including bumping the good pathway, and that he felt confident they got the area. But Levi being a unique case, only time would tell.
(Levi finishing a 5km race or as he calls it, his marathon)
                Shortly after the second ablation Levi was scheduled for a yearly physical. He requested an EKG to see if he was cured. And for the second-time post ablation the screen read WPW. This was very disappointing. The routine was the same. Levi went in for his post op appointment and had a heart monitor strapped to his chest to see how things were conducting. Levi’s had WPW for as long as he can remember. He never knew anything was abnormal with his heart since he didn’t have major symptoms (like passing out) and thought the way his heart beat after exercise was normal. He now realizes what he thought was normal post exercise was in fact his heart going into SVT. He isn’t an endurance athlete so always thought he just didn’t recover as quickly after strenuous exercise due to being an anaerobic athlete.  I remember going on a hike with my family and Levi up the Grand Teton and my Dad hanging back with Levi as he was having a hard time recovering. We would take breaks and continue on our way feeling good but Levi would need more rest. My family and I are all endurance athletes so there was a little teasing on the part of Levi being a big muscular athlete who couldn’t keep up with the skinny distance runners. It was all in good fun but looking back we now realize he was suffering in SVT. I can’t imagine trying to exercise and having my heart rate stay well above its max for an extended period of time. No wonder endurance sports have not been his forte.
(At the top of Mailbox Peak, most likely in SVT, doing hand stands. 
If this is him with a heart condition,  
it's scary to think what healthy will look like!)
                After his second ablation Levi did hard track workouts, a track meet, and had a commercial fire that pushed his body to the max. He didn’t need to wait for what he already knew. The WPW wasn’t cured. He now knew what SVT felt like and he was definitely still having it. While on shift, he went on call for a commercial fire. Levi was working hard during this call. He sweated so much, the heart monitor patch came off. When he went into rehab the medics came over and took his pulse. His heart rate was high. Levi explained his situation and even showed them the heart patch the Doctor had put on his chest. The Medics said they still had to evaluate him per protocol so strapped a 12 lead to him. They saw WPW, which was expected, and that he was in SVT. The Medics told Levi to bear down. They wanted him to flex and hold his breath as sometimes this can get your heart out of SVT. Unfortunately for Levi his heart rate went higher, soaring to 217 bpm.
(Being evaluated by Medics post fire in SVT)
                The Medics put him in their rig and called the hospital for medical direction to see if converting him with adenosine would be acceptable to do. The drug is designed to stop your heart. Since Levi was already working with a heart doctor and this is what they would do to convert a regular patient the hospital said it would be acceptable to do. The Medics put an IV in Levi’s arm and administered one does of adenosine. It didn’t work. They doubled the dose and did it again. They told him to stay calm and take deep breaths as it can freak people out when their heart stops. When his heart stopped, Levi said he felt heat and pressure all over his body. It stopped his heart for 5-6 seconds. It worked. His heart restarted and immediately dropped from 140bpm to 90bpm in an instant. He said he felt amazing. He later recognized the feeling when his heart stopped as suffocation. Like if you dove deep under water and struggled to get to the surface before running out of air.
                The elctrophysiologist had a lot of good data after the heart monitoring and just as expected he was still in SVT. At his next appointment, the Doctor discussed the option of medication. The reason they hadn’t gone that route is because Levi’s heart rate gets very low at night. During monitoring, it would drop as low as 21 bpm. Since the medicines can slow your heartrate they would not be an ideal option. Levi wondered what would happen if the drugs made his heart rate go too low at night? How would he know? The Doctor said they would keep him over night in the hospital for a night or two in case his heart rate got dangerously low. He talked with me about the options and neither of us liked the drug option. He emailed his Doctor with questions about doing another ablation and was relieved to find out the Doctor was completely fine with doing another ablation. Sometimes patients want to see results and don’t want to continue doing surgical options without result. Since Levi was fine with going in as many times as the Doctor saw fit they went ahead and scheduled another ablation.
Levi’s Doctor brought up his case with his other colleagues and after discussion, he decided he is going to try and go in from the left side of Levi’s heart. Ablations are typically done going in via the right side. The left side is a different approach for his condition. There is a slightly higher risk of a blood clot traveling to the brain since the left side of the heart has arteries that lead to the brain. The Doctor will give Levi a blood thinner to lessen the risk.  Levi’s accessory pathway is in the wall that separates the two sides of the heart so the Doctor may be able to access it from the left side of the heart. The Doctor will go in and first map the area to see if there is a window of opportunity to get to the area. If there is they will ablate, if not, he will pull out and we will go from there and see what options we have. 
For some inspiring and uplifting thoughts, I’m resharing a video of Levi vaulting. I love this video. It was taken while Levi was wearing his heart monitor after his second ablation. After his doctor reviewed the data he saw that Levi was in SVT during his vaults and there was a marker where a button on the monitor was pushed. The button is used to mark when you feel something weird. It got pushed when Levi’s friend tackled him onto the pit in celebration. The video shows the clutch vault that Levi took that qualified him for the 2016 Olympic Trials. Levi took a risk, on his opening height he put the bar at a PR (it is very rare for anyone in pole vault to open at a PR), and on his third attempt made it. Let’s hope the third ablation attempt will yield the same result. I have faith.

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