Staying Active While Aging Despite Life’s Curveballs- Heart Valve Replacement, Part II

Part II- surgery and immediate aftermath.

With good attitude in place, Karen and I showed up bright and early on August 11, 2017 at El Camino hospital for the surgery. Actually it wasn’t bright, it was still dark that early. But admission and prep for surgery went smoothly, and Karen’s beautiful smiling face was the last thing I saw before I was wheeled through the double doors. My doc got the complex procedure shown above done in just over 90 minutes. Karen had asked what the shortest time surgery could possibly take and was told two hours. So she went to the cafeteria to get some coffee, and when she got back she was bummed that she had already missed the surgeon. But she was pleased to hear I was out of surgery already, which was a good sign. I woke up an hour or so later, and again saw Karen’s smiling face. I figured it was good she was smiling, I must be ok.

I still had the tracheal tube that was used for the breathing machine during surgery so I couldn’t talk. They make sure everything is stable before taking it out. I could only communicate with Karen and my nurse via thumbs up, thumbs down, or writing. “How you doing Rich?” Thumbs up. “Are you in pain”? Thumbs down.

We did have one scare, I started bleeding internally. It seemed like 20 or so people were buzzing around me working on it (Karen said later it was more like 4). I thought, gee this must be serious. Oh well, they look like they’re pretty good at what they do, I’m sure they’ll figure it out. Drugs help a lot at a time like this- I was still half in LA-LA-land from the anesthesia. It was a lot harder on Karen, who had to stay out of the way and watch without benefit of drugs. She also overheard them discussing I might need to be wheeled back into surgery if they didn’t stop it soon. But they resolved it pretty quickly by injecting a clotting factor.

A while later I started having quite a bit of discomfort in my upper back. I figured it was just because I’d been laying on my back for so long, and maybe the nurse could rearrange me and fix it. I tried writing a note to Karen to explain this. I thought, she’s a wonderful wife, but I can’t believe how dense she’s being! Later she showed me the notes and they made no sense whatsoever. It turned out I could only communicate by carefully writing one letter at a time. Eventually I got through and my nurse did try to reposition me but it didn’t help. Shortly thereafter the breathing tube came out, which felt a bit weird but not particularly unpleasant. This was another ordeal people had warned about in my reading that turned out to be almost nothing in my case. Now I could talk (sort of, more like croak). But I didn’t bother mentioning I was still in discomfort, because I didn’t think we could do anything about it.

My back got worse by bedtime and I thought it was going to keep me awake. So my nurse gave me a narcotic in my IV and I slept fine. Next morning I woke with no pain. My surgeon’s assistant came by and he thought the back issue was probably from excess fluid around my lungs (pleural effusion), a common side effect from my surgery. I was receiving intravenous diuretic to get rid of it, so it probably had gone down a lot overnight. He also said my removed heart valve had indeed been bicuspid (a congenital condition described in part I), as well as calcified.

That was the last narcotic I needed. The sternum did not hurt AT ALL. The only pain reliever I needed in the hospital was Tylenol, and that was for mild headaches, maybe a side effect of drugs I’d received. Nurses kept checking with me “any pain? Are you sure?” but I was amazingly fine. The post-op care I got after this surgery was even more incredible than for my hips, because you have to be monitored closely. I was in ICU the first two nights (because of the internal bleeding scare above they kept me there two nights instead of the usual one).

I insisted Karen go to our friend’s house for a good night’s sleep because my nurse was taking care of me just fine. After ICU you go to a step-down ward but vital signs are still on telemetry. There was one exception to the no pain- my chest hurt if I coughed or sneezed. This violently expands the chest cavity, causing the ribs to jerk on the sternum. But it didn’t feel like bone pain, more like the soreness from a bad chest cold. The old-school way to alleviate this is to teach you to hug a pillow when you feel a cough or sneeze coming on. The hospital gave me a heart shaped pillow for this, which I got all my nurses to sign, and still have as a keepsake.

But for coughing and sneezing, there’s now a much better solution- the Heart Hugger! Believe it or not I’m not a paid spokesman but I loved this little gadget, which they issued me the first morning after my surgery.

It’s loose enough to let you breathe normally, but when a cough or sneeze comes on, you grab the straps and it supports you snugly, preventing pain. It was invented by a fellow engineer who himself had open heart surgery and thought there must be a better way than hugging a pillow. Clever, the design he came up with. If you are ever having this type of surgery I’d highly recommend checking with your surgeon to make sure they will be giving you this in the hospital. If not, you can buy it for yourself at the website- well worth it. What is pictured is the guy version, there’s also a women’s version that’s like a modified bra.

On the subject of breathing, that is a big deal. You have to practice multiple times per hour with the “incentive spirometer”. You suck in on the white tube and try to drive the piston up high on the marker. I was probably only able get to about to level 2250 in the hospital, while 3250 is normal for someone my age, but that improved quickly over time. This exercise is vital to keep your lungs clear and drive out any fluid from the pleural cavity. I didn’t understand what the incentive was supposed to be, though. They didn’t give me anything if I got my score higher. A lollipop for 2300 or ice cream for 2400 would have been nice.

It’s in the step-down ward that you start doing PT, mostly short walks around the hallway that gradually get longer and longer. Under the circumstances, I was feeling pretty good about my progress. But then the physical therapist toome to a set of stairs. After going slowly up one flight, I was on the landing gasping for breath. She said“don’t worry, that’s normal”. It struck me: wow, what happened to climbing up steep hills fast on my bike or on hikes? This is going to be a long and challenging rehab. Oh, well, I’ve bounced back from square one before… Stairs remained my nemesis for several months, although I got slowly better at them. It turned out the severity was worse in the early days because of continued fluid around the lungs.

I really had to adjust my attitude about rehab. I’d actually made a schedule before I’d gone into the hospital which had me riding my bike full tilt within 2 months, based on average rehab results I’d read about, and the smug notion “I’m an athlete, it’ll go faster for me”. That went right out the window. Time for baby steps. Try to be able to walk a little further each day, try to get a little better at stairs each day. And be grateful you’re not in pain!

I am forever grateful to all the amazing nurses and other staff members who took care of me at El Camino. And I’m happy I expressed my gratitude to all of them at the time. This goes for the people cleaning my room (and helping to keep my safe from germs in the process), to those who brought my food and picked up my tray, to those who emptied my catheter bag or bed urinal, and those who ran the myriad tests on me (xrays, bloodwork, etc). I remember a phlebotomist that came in one morning, he was of Jamaican descent with a beautiful accent. They put a shunt in your wrist to make it easy to get blood for testing, because there are so manytests. But unfortunately it was clogged so he had to stick me to get my blood. He did a great job, a painless pinprick. I thanked him and he said “most people don’t thank me, they get mad at me if I have to stick them”. I don’t get that at all. He was there to help me get better after a lifesaving procedure.

After my third night all my vitals were stable enough to send me home. There had been no signs of afib in the hospital and I was considered a relatively low stroke risk, so the only blood thinner I was on was baby aspirin. They took me off the strong diuretic (Lasix) and switched me to a weaker one, because the last chest x-ray in the hospital showed no fluid around the lungs. I had a repeat of the systemic reaction to surgery that I mentioned above about my first hip surgery. I’d also had a similar reaction after my second hip. I guess this is how my body complains when you put it through major trauma. This time the weird “antsy” feeling that interfered with sleep unfortunately lasted a couple of weeks. My blood pressure was abnormally low at this time so I could not get prescribed sleeping pills. It felt great when this finally went away.

My at-home instructions were to start walking 5 minutes a couple of times a day and ramp it up about a minute a day, And no lifting over 5 pounds (one of my precautions until the sternum healed). And I had to be really careful about not falling for the first couple of months while my sternum was vulnerable. The sternal precautions can be summed up “Don’t lift anything heavy, if it hurts don’t do it, and don’t fall”. I was worried my upper body would atrophy by the time I was back to strength training, so after a couple of weeks I cobbled together a program of my own using the Heart-hugger. I’d put it on, grab the handle with my left hand, tense my back and chest muscles, triceps and biceps, and do a benchpress motion with my right arm for about 12 reps. Then I’d switch hands, and do the exercise with my left. Then do left and right with a vertical press, again no weight, just tensed muscles fighting themselves. This caused no chest twinges of any sort and seemed to work pretty well.

I quickly got into a routine. I didn’t work during this period. I read a lot and did my exercises and rehab, and we went on outings, like to restaurants or the store. It was great when I started walking outside (carefully, on nice flat sidewalks and paths). It was a bit amusing, though, when I ran into people I often had seen on my walks, usually brisk power walks with handweights. Now I was walking slowly and must have looked like I’d aged about 30 years. Don’t worry, it’s temporary, I’d assure them. Having the goal of increasing my walks a bit each day helped me feel I was making progress, rather than focusing on how pitiful it seemed compared to my previous level of fitness.

Mental Aspects of Rehab

My routine kept me from having a problem that is very common after heart surgery: cardiac depression. Both Tilda and Adam mentioned getting it badly in their books (discussed in part I). But they also both talked about laying around in the house in their bathrobes all day watching soap operas. I’d get depressed watching soap operas all day even without heart surgery. So- no moping around the house, get up, get dressed and get out every day, and move around as much as you can! But up to 40% of patients get depression post-op, so there must be more to it than just the soap operas. It is more prevalent among people who have had a heart attack or stroke because it can be hard to trust your body again. Bob Harper, the famous trainer from “the Biggest Loser”, had a near-fatal heart attack and described how psychologically challenging recovery was for him [1]. Everybody is different, and this might be just another area where I was lucky. The at-home instructions from my surgeon mentioned depression and definitely recommended “get out every day”, as well as how to get help if you’re hit with depression. The American Heart Association’s website has some tips also. One suggestion both sources give is to take advantage of a structured cardiac rehab program when available, which is usually paid for by insurance. People who go through these programs have a much lower incidence of depression, and are also much less likely to have future cardiac incidents.

I think it helped a lot with my mental state that I practice mindfulness and meditation. Mindfulness is also known as “being in the present moment”, something our society is unfortunately trending away from with everyone staring at their smartphones all day long. When you’re going for a slow walk during rehab because that’s all you can do right now, you can go along muttering “this sucks, I can’t believe how slow I am, I wonder if I’ll ever get better…” or you can pay attention to your surroundings and notice how nice the breeze on your face feels. For me, the latter is a lot more pleasant. Meditation is just sitting while focusing on something like your breath, which is great for stress relief and to avoid being fixated on negative trains of thought that can spiral into depression.

As I rehabbed, I enjoyed reading other people’s stories of recovery for inspiration. The Anna Meare’s Story was great. She bounced back from breaking her neck in a track cycling sprint race accident to later win gold for Australia on the velodrome at the London Olympics. Another was Iron Heart: The True Story of How I Came Back from the Dead, by Brian Boyle. This young man recovered from a horrific accident when he was hit by a car on his bike, with massive internal injuries. Eventually, after rehab, he finished the Ironman triathlon in Hawaii. These kind of stories illustrate that recovery is a long process requiring patience. It also does not always proceed on a predictable course of continued improvement, but is sometimes two steps forwards one step back, and you have to avoid getting discouraged by that. I tried to adopt that kind of mindset.

Another recommendation I’ve read about to avoid depression is to set a physical goal for yourself that would indicate you were fully “back”, like a marathon or ironman. Having a goal sounds reasonable, but those seemed a bit extreme to me. I thought about it and realized there was a local combination bike-hike workout I liked: bike to the trailhead in Coyote Valley Open Space, hike the Arrowhead trail, bike back. This used to take me just over 2 hours before I’d started to have the heart valve symptoms. The last I had tried it, though, I got the out-of-breath symptom going up a steep section of trail that was like my heart announcing “ok, turn around, I’m done. Time to limp home with your tail between your legs”. So I wrote down the goal that I would repeat this workout, in just over a couple of hours, as my goal after rehab.

Onward And Upward- Improvement Continues, Slow But Mostly Sure

After 10 days I had a follow-up with my surgeon’s P.A. An x-ray of my back showed the pleural effusion had returned. That explained why I had been starting to feel more out of breath. The facility where I had my exam had more than one building, and I had to go to a different one for the x-ray, probably a few hundred feet away up a slight hill, but it took me forever to walk there. Another comedown from my former athletic glory! The fluid retention was so bad I had “cankles”: there’s so much swelling in your lower legs you can’t see where your calves end and your ankles start. Also my feet were swelled. It felt weird to touch the flesh in this area, it was squishy. But the P.A. put me back on Lasix and the lungs quickly cleared up and the swelling went down. I lost 10 pounds of water weight in two days! That may sound like a great weight loss program but it only works once, and only if there’s so much water in your body it’s hard to breath and you think you’re going to slosh when you walk.

I had a second follow-up with the P.A. ten days later and everything looked ok. So they said they were done with me, wished me the best of luck, and said from now on I should follow up with my cardiologist. I did have one other remaining symptom, my resting heart rate was still abnormally high. It was less than 60 before my surgery because I’m in decent shape, normal for my age is low to mid 70’s. But mine was now in the 90s. This is common after my surgery, a likely cause is pericarditis: the pericardium (membrane around the heart) can get inflamed because of surgical trauma. I was assured it would eventually clear up but could take up to a year.

(Continued in part III)

References

1. Harper, R, The Super Carb Diet, St. Martin’s Press, 2017