TheBanyanTree: Heart Chronicles - A New Development

[Jim Miller]

My disclaimer: I am about to discuss anatomy and surgical procedures. I
am speaking from my research and knowledge. Nothing has been verified
and may be technically incorrect. This is as I know and understand it.

I didn't think that I would have anything of interest to report today.
And then . . . . . out of the east . . . . . like a bolt of lightening,
IT struck. 

Enter Dr. Sandler. "Dr Icenogle has something to tell us". Zip -  he's
gone, as if, dust in the wind. My curiosity is peaked, but I'm happy to
wait for when-ever to learn what Dr. Ice learned at the conference in
Montana this past few days.

3:30 PM, comes Dr. Icenogle to the floor . . . . . followed by
transplant coordinator Pam . . . . . followed by VAD tech mark. Whoops,
one too many people here for the ideal scenario. Dr. I is abuzz; not his
typical demeanor. I overhear him talking to the monitor tech about
Miller's A-fib . . . . . maybe talking to the group in general. Soon, Dr
and Pam enter the room. Pam closes the door. (Monitor tech later tells
me, ("no, don't close the door,") my heart rate zipped to 150+bpm).
Possible apprehension, or simple intuition on my part.

Dr. Icenogle invites me to sit. Then he sits. Pam sits. Who's missing?
Mark walks in and leans silently against the counter to the front of the
room. Dr. begins by telling me that the Montana conference is possibly
the best in the country. Montana allows practice by credentialed
surgeons without a state license. This allows live surgical
demonstrations by noted national and international participants. 

He tells me that one key noter is a surgeon from the Mayo clinic, who
presented a paper on his case histories with 11 patients who had rapid
A-fib with cadiomyopathy similar to my own. The MAZE procedure was
performed on each of these. The Maze surgery has proved 90+ percent
successful in curing A-fib. It is an old and established procedure,
which we discussed several years ago. For a weak heart, it is radical
and was severely discouraged by my cardiologist. I could tell that he
likely thought the suggestion to be reckless advice. 

The cases at the Mayo Clinic prove quite the opposite. The 11 patients
had severely weakened hearts. As I understand they also suffered dilated
left ventricle like me. The results were substantial ejection fraction
increase, with some returning to completely normal output and function.

This we know about me. In the two months that I have been in the
hospital, my heart function has declined rapidly. At first, I could walk
as long as I wanted at a reasonable pace without increasing my heart
rate beyond 120-130 bpm. Now I can only walk a few hundred feet, and
that must be very slowly. At this rate, without a transplant I may
require a VAD within 30 days. While VAD implant surgery is very
successful in this hospital, at best it is high risk. Dr. Icenogle
considers the Maze procedure lower risk than the VAD.

Let me describe the Maze procedure. It is occasionally referred to as
'slice and dice, or cut and stitch'. But first, a rudimentary
explanation of the hearts electrical system. The top two chambers of the
heart are called the Atria. There is a right and left. They act as a pre
pump to the right and left ventricles. In a normal sinus rhythm, the
pace pulse begins at the SA node in the atrium. The pulse begins at the
top of the atria, and follows a prescribed path, creating an even
contraction of the atria to pump blood into the ventricles. The pulse
arrives at the AV node, and begins it path across the ventricle chambers
to affect a squeeze action, pumping blood to the lungs from the right
ventricle and the full body from the left ventricle. When the pulse and
contractions follow their prescribed paths, you hear a very even 'lub
dub' beat. When the pulse leaves the SA node and does not follow the
path, the compression is uneven and out of sync with the ventricle
chambers. Essentially, the atria are useless to the output and can
counter the work of the ventricle chambers. There is question as to
whether the dilation is a result of the inefficient pumping action. If
caught early enough, the fibrillation can be stopped by burning the node
with radio waves. This is known as radio frequency ablation. With this
procedure, a pacemaker is required to regulate the beat. Some function
is lost.

The Maze procedure involved opening the chest to the heart. Placing the
heart on bypass and slicing the atrial chambers into ribbons. Each
ribbon is cut so as to create a pathway around the upper heart. When
these ribbons are sewn together, the resulting scar is a barrier to the
electrical path, causing the pulse to follow the prescribed course. This
has the affect of containing the beat and placing the heart into a
normal sinus rhythm.

Dr. Icenogle is recommending a modification to the procedure. The longer
I remain on the bypass machine, the greater the risk, and the more
likely my heart will fail. He is suggesting that he burn the channels
instead of creating scaring by cut and sew. The effect of redirecting
the electrical pulse will be similar, but the time to accomplish will be
faster, thus lowering the risk. The burn method has a slightly lower
success rate.

Should the heart fail to recover from the procedure, our parachute will
be a VAD implant. And that explains why Mark was also in the room. I
imagine they were prepared should I have VAD questions. Those can come
next week. While the VAD has been a successful bridge to transplant, it
is a difficult way to live, and there are no guarantees.

While the risk is great, a successful surgery will result in many
benefits. Sinus rhythm will almost surely increase the heart function
substantially. If I can attain the results experience by the Mayo
Clinic, I may no longer require a transplant. Even if I require a
transplant later, great leaps in knowledge and technology are
continuously occurring. Mechanical devices are more sophisticated and
reliable. A lifetime mechanical replacement may not be far into the
future. Stem Cell research also shows great promise for heart
regeneration. Today, the most significant benefit is that there will be
no need to suppress the immune system. Immunosuppression is required
with a transplant in order to prevent rejection. Without an immune
system, even a slight infection, undetected, could be fatal.

Surgery is scheduled for next Wednesday. I can change my mind and wait.
Earlier surgery is always best when heart failure is imminent. Tomorrow,
I'm scheduled for a MUGA test. This will measure the current function.
We also want to know what my valve condition is. Earlier indication is
that the mitral valve is leaky. This surgery will be the appropriate
time to repair or replace the valve. The decision has been made to
proceed. I don't think that is has yet registered with me that my life
is at risk. Perhaps I've failed to accept the risk I freely discuss
daily. Logically, I should be frightened. As of now, I am not
frightened. 

This is life; one day at a time.


Jim Miller
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See this article and my photo gallery at
http://www.maze.cc