The ride down the corridor to the open-heart surgery suite is the patient's equivalent of the long mile into an unknown forest.
The hall radiates with smiles of assurance and confidence, earnest but not totally convincing.Moments earlier, a nurse had come into my room with some relaxing medicine to ease me into a cozy twilight zone before the anesthesiologist produced some serious oblivion.
The corridor clock at Abbott Northwestern Hospital in Minneapolis showed 9:30 a.m. Four days before, I played tennis. Just 21/2 days before, I walked into the emergency room at Abbott Northwestern on the advice of an internist. I expected to leave in four hours and to make my three appointments the next day.
I missed them all. It seemed to be a reasonable choice in view of the verdict by one of the hospital's cardiac experts. "The common term for the procedure," he said, "is quadruple bypass."
"And I need it?"
"Offhand," he said, "I haven't met anybody today who needs it more."
So here you are, I told myself on the way to bypass heart surgery at age 64.
Well, why?
I was one of those people who in midlife rediscovered the gift of the human body. At 38 I weighed 200 pounds and smoked two packs of cigarettes a day. What happened then was not a sudden vision but an accumulating feeling of disgust. So I stopped smoking. I lost 40 pounds. I ran and ran and dieted and felt omnipotent and in the next 25 years raced through a time of physical and professional activity I couldn't have imagined.
I wrote books, ran talk shows, wrote newspaper columns, rode a bike around Lake Superior in seven days and led treks in the Himalayas and Africa. When ache and fatigue intruded, I decided these were temporary inconveniences that could be overcome with one more mile.
I tried not to abuse my body, I conditioned it and I respected it, and I also believed it could more or less run unencumbered into the next century.
On two consecutive days several months ago, I felt a stab in my chest while chasing down some ground strokes by my tennis partners. Late in the week something else happened in my chest as I sat at my desk.
Some soft and invisible fist was gripping it. The sensation was painless, but the tightening pressure was abnormal and unsettling. I called a friend on the staff of Abbott Northwestern.
In a few hours an internist, Dr. Parin Winter, asked me about symp-toms. She was emphatic.
"You should go to emergency right about now or in the next hour. You want to be looked at."
About 22 hours later, a doctor handed me a diagram of my heart's arterial system. It showed blockages of 90 percent, 75 percent, 95 percent and 100 percent.
It didn't matter that all of my external signs showed five stars on the honor roll. My heartbeat was strong and regular. Blood pressure low. Lungs clear. They did the questionnaire. "Have you ever had allergies, major sickness," etc.? I answered no to all of the above.
"But you still feel this tightness in your chest," Dr. James Daniel, a cardiac specialist, said.
"It comes and goes, but it's not painful except for those tennis games last week."
"We're going to give you a stress test," Daniel said. "That doesn't tell everything, but it's a step in the discovery process."
Good. Bring it on. They wired me and turned on the scopes. After six minutes on the treadmill, the pain was back, spearing my chest.
They stopped the test and looked at their scopes. The an-gio-gram followed.
To do their investigation, the doctors and specialists inject catheters into the heart chambers and
FAMILY EXTRA
the coronary arteries that supply the heart with blood. They anesthetize the groin area and launch the catheter through a vein there.
It moved quickly through the blood canals until it was positioned in my heart chambers and coronary vessels. I felt a tingling and then some heat. By that time the catheter had ejected dye that created a cardiac road map for the viewing sleuths. The head sleuth was Dr. John Lesser, who gave me a pleasantly calm and clinical description of what he was seeing, like a highway engineer explaining a road construction mess.
I watched it myself.
The blockage in the heart arteries was widespread and massive, from 75 percent to 100 percent. Miraculously, I had not suffered a heart attack. The heart muscle was still healthy and strong. But I was a ticking bomb.
Medication can treat some coronary congestion effectively, but not this. Another remedy is angioplasty, in which a tube is passed into the blocked artery and a balloon device used to dilate or open the vessel.
Daniel laid out the options. His implied vote for bypass surgery was obvious.
"You'll be far better than you were before. All that crud in your arteries is a fatty substance that stifles the blood flow. The pain at tennis was your heart screaming for more blood, even when you thought you were fit and indestructible. The surgery will reroute the blood around those dams of plaque to restore adequate blood flow to that heart muscle. There are a few things you have a right to know."
He handed me a card the size of a recipe card. It read: "Coronary Artery Bypass Surgery. Risk of dying during surgery: 3 percent. Chance of heart muscle damage: 15 percent. Chance of bypass graft closing: 15 percent. Chance of stroke: 1 percent to 2 percent."
Daniel was comforting, though. "With the way you've taken care of the rest of your body, you can bring that risk down to 1 or 11/2."
But wait. If I'd taken care of my body that zealously, why was I signing this waiver two days before surgery and why was I climbing the Matterhorn just five months ago?
"Sometimes the trouble announces itself clearly," the doctor said, "but in your case maybe not. A lot of things can make you susceptible to heart trouble, and some of them you can't control, such as age, being male and family history of heart disease."
I had no such history that I knew of. But 64 is practically the optimum age for heart trouble. Being male makes your chances a little worse. Still, I wasn't fat. I didn't smoke. My blood pressure was low.
"You kept your weight down," the doctor said, "but your cholesterol was up around 217 to 224, not spectacularly high but high. Stress, Type A personality, all of that can figure."
THE NEXT afternoon, a doctor walked into the patients' lounge with a nimble step and terse optimism. Comforting qualities in a surgeon whose announced intentions are to save your life.
At age 45, Dr. Bob Emery had performed more than 1,000 of these bypass operations.
Later, a nurse walked into my room. "The patient scheduled ahead of you needed some extra time," she said. "You've been moved up. You go in an hour."
("That's right," Emery said deadpan later. "The guy was an attorney. We take newspapermen ahead of lawyers.")
Suddenly I was getting shaved across the chest, down my leg and above the crotch and feeling like a defeathered chicken. They scrubbed me with antiseptic soap, dosed me with antibiotics and a sedative, and into the surgery room we rolled.
I remember overhead lights and smocks and surgical masks, and the rest is a wipeout. Emery gave me the picture the next day.
It was his second of three open-heart operations that day, beginning at 7:30 a.m. and running into the night. On the table a patient lies wide open, his heart stopped for more than an hour.
"You had disease or blockage in all main vessels of the heart," he said. "To compensate, your system had created a network of smaller vessels, like a tree developing branches to bring in more nourishment. But yours wasn't going to be able to do that much longer."
From just below the neck to 4 inches above the navel, he cut through the sternum, exposing the protective sac around the heart. They came with retractors to bend the sternum halves in opposite directions for 10 inches of working space. From the left leg Emery removed the saphenous vein, the one often used in the treatment of varicose veins. Remarkably, it's a spare part. It almost seemed to have been put there for open-heart surgery, Emery said.
From the left side of my chest, they took the internal mammary artery and diverted it to provide more new channels for the blood, completing the bypasses in front, behind and beside the heart.
While they were doing this, they cooled the body temperature to 70 degrees and then chilled the heart even further by packing the cavities with an ice-slush solution.
"You looked like a large frozen daiquiri," the surgeon said.
The condition was temporary. The heart was reunited with its blood supply. The machine that had been oxygenating my blood could be turned off once the heart began to pump again. The sternum halves were folded back together and spliced with stainless steel wire, which will stay there for the rest of my life.
It took about three hours.
MY FIRST serious glimpse of the new world after bypass heart surgery was the sight of a nurse doing the cha-cha using a couple of gallon urine jugs for castanets.
It was 6 a.m. and I was slept out. The seam ached where they had fused the halves of my sternum. My left leg had ballooned under the thigh-high white hosiery you are required to wear for six weeks to reduce swelling. To ease the stress on my bladder, the nurse had inserted a catheter.
Thus pierced and trussed, I wandered into the corridor outside my recovery room, rolling the IV post ahead of me. It was then that I saw the nurse swinging the urine jugs overhead and twisting her hips to an imaginary Latin rhythm. I liked it, but I had a question for one of her colleagues at the desk.
"Are those jugs full or empty?"
Finishing my patrol feeling better, I returned to my bed. Since no complications were foreseen, my postoperative career was limited to 51/2 days, meaning eight days from the day I walked into emergency.
But random pain after a bypass surgery is inescapable. Your breastbone has been separated, bent apart almost a foot and laced back together. Your heart was stopped, chilled and revived. Veins were uprooted. In my case, the left lung was partly deflated and quickly took in fluid, a relatively common aftermath of the surgery. The patient aches in the expected places and in some unpredictable ones for several weeks. You relearn how to breathe deeply. When you cough, grab a pillow and slap it on your chest. When you laugh hard, don't.
Bypass surgery is a critical business. Yet it is also a liberation. A hidden hazard has been discovered, but life is enhanced. Alongside this, the residual pain and discomfort are nothing, and the months of daily rebuilding therapy ahead can be exhilarating. I had new channels for the flow of blood and energy - that and the strong probability of being able to resume a normal, active life within three months of surgery.
That is a gift beyond sum and imagination. A person who experiences bypass surgery ought to be a little smarter as well as grateful.
He ought to know that even in one who follows the stars and wind of an active life, and presumes to be healthy, the truth of body health can be skewed by ignorance or complacency.
For three decades I watched my weight and held onto my muscle and passed all the superficial tests.
But someplace in my head it was decided that if all the other lights of body health were green, I could afford one that occasionally blinked red. That one was the cholesterol level. Somehow I figured I could afford higher-than-average there if the others were lower-than-average.
And the gunk in my vessels built and built. Other hazards were at work, hard to define. Some of these you can control, some not, especially if heart disease is in the family, which in my case didn't apply. Stress? Yes. Hyperactivity? Yes. How much?
Who knows? Everyone faces stress. Not everyone, though, realizes that it can be linked with other potential causes of heart disease, dealing with genetics and body abuse. Not everyone has the sense to be examined frequently. I didn't. And not everyone has the money or the insurance to do it. Which simply means that the poor, once more, are more vulnerable.
Annual exams? Yes, please. Stress tests, certainly. But you can't walk in off the street and ask for an angiogram, and for many people, that is the only true evidence. Yet from this comes some leavening and wisdom in unaccountable ways. You tend to look at the world more generously and, the Mike Ditkas excepted, maybe a little more patiently. Two days after surgery I received a call from a stranger who expressed a genuine hope for speedy recovery. "Thank you," I said. "That's very thoughtful of you."
"I thought you'd also be interested in knowing that I had a relative who underwent the same operation six months ago."
"How is he doing?" I asked.
"The operation went well," he said, "but he had a reaction to the blood thinner, and they had to amputate one of his legs."
I refitted my catheter and considered this news. You can escape IVs and swinging urine jugs, but there's no escaping the information age. I thanked the man, replaced the phone and retightened my white hosiery. Life in the new world is going to need some re-ad-just-ment.
*****
(Information from color illustration)
A heart attack occurs when the coronary arteries are suddenly sealed off by a blood clot.
Heart Facts
-Blood vessels form a banching network of more than 60,000 miles.
-A man's heart weighs about 11 ounces.
-A woman's heart weighs about 9 ounces.
-Your heart is about the size of your fist.
-Your heart beats about 70 times per minute and more than 100,000 time a day.
-Your heart pumps five quarts of blood throught its chambers every 60 seconds. -Your coronary arteries are about the size of a pencil lead.
-High blood cholesterol: 200 over age 40....180 if under age 40.
Arteries: Carry blood from the heart
Veins: Carry blood to the heart Capillaries: Connect veins and arteries
What is coronary artery disease?
Coronary artery disease causes the blood vessels that bring oxygen and nutrients to the heart to harden. This happens when fat, cholesterol and mineral are deposited on the inner surface of the coronary arteries causing plaque. The results are restricted blood flow to the heart and possible closure of the arteries.
Artery Cross Section
Plaque may change the surface of any artery from smooth to rough. Rough surfaces stimulate the formation of blood clots that may further restrict blood flow or abruptly close off arteries.
Myocardial infarction: Lack of blood actually causes the tissue to die from lack of blood. The muscle is replaced by scar tissue that cannot contract.
Warning Symptoms
-Fatigue, tightness in the chest or a peculiar chest pain (Angina pectoris). Symptoms usually associated with emotional stress or exercise can be relieved by rest.
Diagnosis
EKG: (Electrocardiograph) Records electrical changes that occure as the heart beats.
Stress test: Determines how the heart functions while performing strenuous activities. patient is connected to EKG while walking a treadmill.
Coronary catheterization: Patients heart is examined with a fluoroscope (X-ray) to determine blood flow to the heart.
Treatment
Treatment for coronary artery disease must be very individualized and can consist of:
-Bood nutrition (low cholesterol, low salt)
-Exercise
-Taking various medications
-PTCA (percutaneous transluminal coronary angioplasty)
-Coronary artery bypass surgery
PTCA: When the disease is localized in one or tow arteries the blockage can sometimes be opened by stretching or dilating.
The surgery: Bypass surgery enables blood to flow around blocked coronary arteries.
The heart is stopped by injecting cooled blood (10 degrees centigrade) with a high potassium content into the heart.
Arteries and veins used in the operation are expendable and removing them does not significantly affect blood flow where they're taken.
Bypass facts
Surgery lasts an average of 4 hours.
Bypass can last as long as 20 years.
Cost of surgery: $20,000-$30,000
Surgeon requires nine years of training before being qualified to perform bypass operation.
Bypass surgery has a 2% mortality within 30 days.*
*LDS Hospital figures
The Incision
After incision is made ribs are pried apart, with rib separators.
Surgeon cuts through pericardium to expose heart. The patient is then connected to the heart-lung machine.
Saphenous Vein
Average Length of vein removed 2 feet
Bypass surgery requires a vein or artery to be taken from another part of the body. Typically it comes from the sapehnous vein.
Recovery
After surgery catheters are placed (usually in the arm) to administer drugs and fluids and to withdraw blood samples.
Patients are taken to a recovery area until the effects of the anesthesia wear off. Soon afterword, they are tranferred to intensive care.
Average time in intensive care: 2 days
In intensive care patients are monitored 24 hours a day for any complications that might result after surgery.
Average patient is up and walking about the room withing a day or two.
Average hospital stay: 6 to 7 days
Patient usually feels weakness for about three to four weeks after surgery.
Average time away from work:
4 to 6 weeks sedentary work
6 weeks or longer heavy work
Patients are urged to watch their diet, stop smoking, keep their weight down and start a regular exercise program.
After bypass surgery, patient should be able to return to their normal routine, including physical exercise.