Windsurfing, surfing, Maui, The Gorge, and random rants.

Wednesday, October 5, 2011


Exactly three weeks ago from today, as I'm writing this, I was just coming out of exceptionally complex heart surgery that essentially saved my life.  (The full story starts here, in case you haven't seen it) Right now my recovery is still going great. Hopefully in the not too distant future (months anyway) I'll be able to jump on a surf board and/or windsurf again. That's the possibility that I really wanted.  We also got the green light to return to Maui in about a week.  I'm thinking warm water and tropical skies should really help the rehab progress.  Yes!

For now I'm concentrating on gradually getting my strength back and following the rehab schedule.  One thing I was warned about on my discharge was a potential lack of appetite.  Which seems funny because I've had the exact opposite situation - I'm hungry all the time!  Which makes sense as I'm told the body can consume up to 3000 extra calories daily while repairing itself from such major surgery.  I've been eating the equivalent of five meals a day (I've been drinking high protein Ensure, but not as a meal replacement, as an addition).  The strategy seems to be working as my weight loss stopped around week two (low point 166.6) and has steadily inched up since (morning weight now 171.5).  Another thing that really helped is cutting way back on pain meds around week two. I had been taking Percocet, but no more.  I'm all ibuprofen now, about 4-6 (200mg each) a day.

The other warning concerned depression that supposedly hits around the first or second week after leaving the hospital.  I believe the cause is due to hormonal imbalances from the intensive repair process, plus perhaps being suddenly very physically limited.  And maybe the ongoing pain and lack of sleep.  Anyway, I seem to have side stepped much of that so far.  Actually sleep isn't perfect yet - I can't rest on my stomach which has always been my preferred snoozing position. But anyways, I feel nothing but encouragement to be recovering so quickly - and nada depression!

I hit a major rehab milestone by walking downtown to attend the Hood River Hop Fest last weekend.  There were over fifty taps on hand, many were unique fresh hop versions of old staples, such as Mirror Pond Pale Ale.  I sampled about seven or eight beers, consumed two Solstice pizza slices and a pulled BBQ chicken, told my story about twenty times to various friends over the course of a few hours, then did the long uphill walk home. And felt pretty good (especially after the beers). It was almost worth staying in HR a few extra weeks just to attend this.

We've also been taking progressively harder hikes, such as last weekend to Catherine Creek Arch. This is a pretty awesome hike just a few miles east of us on the Washington side, near Lyle.  Here the heavily wooded western gorge gives way to the very dry and desert like eastern gorge.  So it's got both trees and tumble weeds.  Also the occasional rattler though we didn't see any.  The coolest part of this hike is the famous arch, which you can hike right through if you're so inclined.  We hiked to the top of it and dangled our feet down toward the opening.  There are many other spectacular hikes around the Gorge, and if you need a guide book I highly recommend our friend Scott Cook's Curious Gorge (and Pokin Round the Gorge) offerings.  Great photos, historically educational, and highly entertaining!

One interesting tidbit I learned about my esteemed surgeon Dr Eric Kirker is that he is one of only five in North America capable of repairing a heart valve as he did for me.  And I'm not sure how many in the entire planet could do this as the technique is so new and very advanced. Again it seems amazing that I was in just the right place and time to have this done.  Fate?

I already mentioned that the company I work for, Kryptiq Corp, provides an application that allows doctors to send lab and medical information directly to patients via secure email.  In fact I'm one of the engineers developing this app. The really cool part is that I've been able to use this to get otherwise difficult to obtain information regarding my surgery.  Such as the complete operation report.  Now I might have said earlier that I didn't want to know the dirty details, but honestly it's pretty amazing to see what was actually done.  So in the spirit of sharing all this (some folks really wanted to see this) I'm including all below.  Skip this if you don't want the details.  Otherwise enjoy....

DATE OF ADMISSION: 09/12/2011.

CHIEF COMPLAINT: This is a 53-year-old white male seen at the request of Dr. Ali Rahimtoola for evaluation and treatment of aortic aneurysm with potential dissection.

HISTORY OF PRESENT ILLNESS: This is a 53-year-old physically active white male who presents with an essentially asymptomatic type 1 aortic dissection. The patient begins history by noting a typhus infection in Maui in 12/2010. From that time, the patient had intermittent episodes of palpitations and he noted increased pulsations of the abdominal area since that time. The patient denies inanition, abdominal pain, chest pain, shortness of breath at any time. He has not had syncope, headache or any physical disruption from his very active physical activities including ultimate frisbee, surface boarding, windsurfing and vigorous mountain biking. The patient biked to the emergency room for a followup echocardiogram on 09/12/2011 at which time the patient's aortic insufficiency and aortic aneurysm were noted. The patient on exam denies any neurologic symptoms, chest pain or shortness of breath. He has been very active up to the present time. He notes no previous episodes of chest pain. The patient has had no previous cardiac history. PAST

MEDICAL HISTORY: Significant for the absence of diabetes, stroke or hypertension. He has had previous ACL surgery and has had a duodenal hematoma from active trauma from an injury at ultimate Frisbee. He did not require operation.

GENERAL: This is a tanned and healthy-appearing 53-year-old gentleman in no distress at rest.
VITAL SIGNS: BP 120/80, heart rate 64, respirations 14, O2 saturation 100 percent on room air.
CHEST: Well-developed.
HEART: Regular rate and rhythm. A brisk systolic and soft diastolic murmur heard in the aortic position. He has no heaves or lifts.
ABDOMEN: Soft and nontender. Soft palpation is noted at midpoint. He is definitely without surgical findings of the abdomen.
SKIN: Warm and dry, no lesions seen.
EXTREMITIES: No cyanosis or clubbing. He has equal pulses at the radial and posterior tibial bilaterally with the Corrigan's pulse.
NEUROLOGIC: Cranial nerves 2-12 grossly intact.
LABORATORY DATA: Echocardiogram from Hood River indicates preserved left ventricular function, dilated aortic root consistent with aneurysm and significant aortic insufficiency. A suggestion of dissection is also present. CT scan carried out at Providence Portland reveals type 1 aortic dissection with greater than 6.5 cm dilatation of the aortic root. The tear extends all the way down the descending aorta. Both kidneys have inflow with contrast filling the parenchyma of each kidney.

IMPRESSION AND PLAN: A 53-year-old gentleman with likely chronic aortic dissection. The extent of the dissection with aneurysmal dilatation mandates urgent reparative surgery. The patient is a candidate for aortic replacement with or without aortic root sparing. In addition, the patient may require a period of circulatory arrest for arch replacement, stent placement or elephant trunk type repair. The risks of surgery are high and include paraplegia, stroke, infection, MI, recurrent dissection and death. This has been discussed with the patient and his family. They are agreeable to proceed. PARQ was carried out by myself and also Dr. Eric Kirker who will attend his surgery. The patient is at extraordinary risk for both medical and surgical management. It is unusual in that he is largely asymptomatic from this extensive aortic pathology. Plans for the patient were discussed with Dr. Cynthia Ferrier who is covering for Dr. Malcolm Mcaninch today.

POSTOPERATIVE DIAGNOSIS: Severe aortic insufficiency, type A dissection, type 1, aortic root arch aneurysm, bicuspid aortic valve.

PROCEDURE: Intravascular ultrasound, thoracic endovascular stent with a Gore Tag 31 x 15 cm graft for frozen elephant trunk valve-sparing aortic root replacement (TD5), ascending arch and proximal descending replacement, also right axillary cannulation and transesophageal echocardiogram.

ANESTHESIA: General endotracheal anesthesia plus deep hypothermic circulatory arrest 27 minutes and cardiopulmonary bypass.

SURGEON: Eric Kirker, MD.

ASSISTANT: Kristy Khoury, PA.

INTRAVENOUS FLUID: Not applicable.


SPECIMENS: Ascending and root of aorta were sent.

DRAINS: Blake drain times 2.



DESCRIPTION OF PROCEDURE: The patient taken the operating room and placed on the table in the supine position. Placed under general endotracheal anesthesia, at which time a right internal jugular Swan-Ganz catheter and a left radial arterial line were placed. Transesophageal echocardiography was performed, revealing severe AI, moderate mitral regurgitation and severe dilatation of the aortic root with dissection flaps.

At this time, the patient was prepped and draped in the usual sterile fashion. A needlestick was performed in the right common femoral artery followed by a guidewire placed up this and, via Seldinger technique, changed out to an 8-French sheath. A Bentson wire was placed up through the aorta under fluoroscopy and intravascular ultrasound was used to visualize the wire. Clearly, the wire was in the false lumen. After some manipulation, we were unable to go into the true lumen and we did at that time turn our attention to the left leg. A needlestick was performed and this was switched over with Seldinger to an 8-French sheath followed by a Bentson wire and again intravascular ultrasound was performed, revealing we were, indeed, in the true lumen.

At this time, that being in place, we did secure the extra stiff Amplatzer wire in the true lumen and turned our attention back to the patient's chest. An incision was made in the infraclavicular fossa on the right-hand side. Dissection made with electrocautery down through layers of the chest, splitting the pectoralis major muscles and, indeed, opening the infraclavicular fossa and exposing the axillary artery. The axillary artery was looped proximal and distally with Vesseloops.

A midline sternotomy was then performed. Dissection made with electrocautery down through the layers of the chest, exposing the sternum, which was divided with a sternal saw, treated with Gelfoam, and the pericardium was cleaned off of its fat. The patient was fully heparinized. After the heparin had a chance to circulate, the axillary artery was clamped proximal and distally, opened with an 11 blade, extended with scissors, and matched to the proximal end of a 10 Hemashield graft, which was sewn with 5-0 Prolene. After this was accomplished, Bioglue was placed on it. It was cannulated with a 7 Sarns Soft-Flow cannula, hooked up to the cardiopulmonary bypass circuit without air. It is important to mention that even though we were heparinized now, prior to heparinization, 2 whole units of the patient's blood were drawn off to be given back to the patient at the end of the case.

The pericardium was opened and there was an inflammatory aneurysm in the ascending aorta, at least 8 cm in diameter, going down into the root. Extensive dissection was performed around the aorta. A pursestring was placed into the right atrium. This was cannulated with a 3-stage venous cannula, hooked up to the cardiopulmonary bypass circuit without air. Another pursestring was placed in the right atrium, which was cannulated with a retrograde cardioplegia circuit. Another pursestring was placed in the right superior pulmonary vein, which was cannulated with an LV vent.

At this time, we did proceed with cardiopulmonary bypass and began cooling the patient intensely. The patient was cooled all the way down to 18 degrees centigrade as a goal. At this time, we did turn our attention to the ascending aorta. With the great size of the ascending aorta, a large cross-clamp was placed around the aorta as well as the pulmonary artery and clamped and we did arrest with retrograde cold blood cardioplegia. The ascending aorta was opened widely and we could clearly visualize very large destroyed dissection flaps. Hand-held cardioplegia was used to give antegrade cold blood cardioplegia down the right coronary ostia. However, a total of 1200 was given at the beginning. For the remainder of the case, an additional 300 mL was given retrograde every 20-25 minutes. This was done with the patient having clear blood coming back from the right and left coronary ostia. Extensive dissection was performed, dissecting out the entire root and the ascending aorta below the clamp. The root was dissected down to the annulus exteriorly.

The valve appeared to have good valvular tissue, but be a bicuspid valve. Therefore, I chose to spare it at this time. Fourteen interrupted subvalvular sutures were placed with pledgets. After this was accomplished, a 34 graft was brought onto the field. The outflow tract was sized to a 25. Therefore, a 34 graft was chosen. The 14 sutures were brought up through the bottom of the graft, the graft was dropped into position. The Hagar dilator was placed down the left outflow tract again and all the sutures were tied, starting with the commissures and then running around.

At this time, the patient reached 18 degrees centigrade. We did tip in steep Trendelenburg position and proceeded with deep hypothermic circulatory arrest. It is important to mention the patient had already received a gram of Solu-Medrol and high dose of propofol to provide burst suppression. Once on deep hypothermic circulatory arrest, the ascending aorta was completely resected as well as the lesser curvature of the arch and the ascending aorta was resected all the way up to the innominate artery. The proximal transverse arch was also removed completely. The true lumen clearly had the guidewire in, which I had left. The true and false lumen were reapproximated with Teflon felt provided as a neomedia. Running Vicryl was used to reapproximate those 2 layers. Bioglue was placed on the 2 layers. After that was accomplished, the guidewire was pulled forth. A 15 cm x 31 mm Gore Tag graft was placed over the guidewire and put down the descending aorta in an antegrade fashion. After this was accomplished, it was found to be past the subclavian. It was deployed. After it was deployed, multiple tacking sutures were used to secure it to the aorta so that it would not slide or "bird's beak." After this was accomplished, the 28 sidearm Hemashield graft was cut to size, brought onto the field and sewn to the arch. After that was accomplished, the graft on the axillary artery was clamped and the cannula was removed, cannulated into the side arm and secured of the ascending graft. We had to de-air the patient at that time, replace the crossclamp and proceed with cardiopulmonary bypass and rewarming. The total deep hypothermic circulatory arrest time from 18 degrees centigrade was 27 minutes and the patient's cranial saturations never dropped below 57 percent.

That being the case, I did turn my attention back to the root. The commissures were secured to the graft with pledgeted RB Prolenes. The valve was truly bicuspidized. Trussler stitches were placed in the edges of the fused right and left cusps to shorten it and make it the same length as the noncoronary cusp. There was good approximation at this time and the valve was tested for competency with cold saline and was found to be competent. At this time, I did proceed to take a stitch and run it along the inside of the graft, securing the edges of the aorta with the valve back to the Hemashield graft. After this was accomplished, 2 coronary ostia holes were cut in the Hemashield graft and the coronary buttons were cut out circumferentially and sewn to the graft with 5-0 Prolene. This was all reinforced with Bioglue. After that was accomplished, the 34 graft was cut off at the level of the sinotubular junction, just above the commissures, the distal graft was cut to length and the distal and proximal grafts were anastomosed with running 4-0 Prolene. After this was accomplished, ophthalmic cautery was used to make a small hole in the ascending graft and an ascending vent was placed.

After this was accomplished, we did give the patient warm blood cardioplegia. During 2 minutes of warm blood cardioplegia, 2 right ventricular and 2 right atrial pacing wires were placed. The patient began beating. Once the patient began beating, the patient was put into steep Trendelenburg position again. The vents were turned on high, the cross-clamp was removed in a low flow state and the flow state was brought back up. After this was accomplished, we began ventilating. After ventilating some time, we did load the patient's ventricle and check the function of the aortic valve. The aortic valve was completely competent with no evidence of regurgitation or stenosis. At this time, also the mitral valve improved greatly with its very trivial mitral regurgitation. At this time, we did remove the LV vent, tie down its pursestring, and again view the valves, finding them in good condition, just as described earlier. With the patient completely de-aired, we removed the ascending vent, tied down its hole with a pursestring and another pledgeted Prolene. With the vent out, the patient ventilating, warm and in normal sinus rhythm, we were able to wean from cardiopulmonary bypass.

At this time, we weaned from cardiopulmonary bypass, removed the retrograde cardioplegic cannula, tied down its pursestring, removed the venous cannula, tied down its pursestring. The patient still hemodynamically stable, we reversed the patient's heparinization with protamine. At this time, we gave the patient back all his blood from the pump. The patient still hemodynamically stable, we did tie off the sidearm grafts and then cut them off. After this was accomplished, with the patient hemodynamically stable, we did use multiple topical hemostatic agents, including Gelfoam thrombin and Arista. With good surgical hemostasis and the patient hemodynamically stable, we also gave DDAVP. That being completed, with a good thromboelastogram, we gave the patient back his own blood. The patient was hemostatic and hemodynamically stable.

We did proceed with closure. Two Blake drains were placed, one behind the heart and one in front of the heart. The pericardium was closed with running Vicryl. Four interrupted figure-of-eight Pioneer cables were placed across the sternum. The underside of the sternum was reinspected and found to be hemostatic. The sternum was treated with vancomycin, Gelfoam, and thrombin paste. The sternum was reapproximated. The cables were tightened, clipped, and cut. The patient was washed out with antibiotic saline. We did at that time close the fascia with running Vicryl. We washed him out again. The subcutaneous tissue was closed with running Vicryl. Skin was closed with running Vicryl subcuticular stitch followed by LiquiBand. Attention turned to the axilla. The graft was tied off and cut low. With good surgical hemostasis, the pectoralis was reapproximated with running Vicryl. Subcutaneous tissue was reapproximated with running Vicryl. Skin was closed with running Vicryl subcuticular stitch followed by LiquiBand. The right groin line was removed. Pressure was held for 15 minutes and the groin was stable with good pulses in the feet. At this time, we did have instrument, sponge, and needle counts correct, did return the patient to the CCU, intubated, in stable condition, on no drips and having received no blood products.

HOSPITAL COURSE: Mr. Jones is a 53-year-old gentleman with likely chronic aortic dissection. The extent of the dissection with aneurysmal dilatation was determined to mandate urgent reparative surgery. The patient underwent the aforementioned procedure without complication on 09/13/2011.

By postoperative day #1, the patient was doing very well. Tubes and wires were discontinued, and he is looking great and transferred to 2G.

By postoperative day #2, he had no major issues. Pain was controlled. Insulin drip was discontinued. He was started on sliding scale insulin, and clonidine as needed was added for elevated blood pressures.

By postoperative day #3, the patient had no complaints. JP and pacing wires were discontinued. Lasix was initiated for weight being up and for volume overload.

By postoperative day 4, the patient did have an episode of atrial fibrillation the prior day and was started on the amiodarone protocol and quickly converted back into normal sinus rhythm. The patient was asymptomatic throughout the episode. He will be discharged on prophylactic amiodarone and metoprolol.

The patient feels very well. He has no major complaints.


Tatiana said...

Have you ever had Alaskan Pale Ale?
: )

(Ben) Jamin Jones said...

For sure, and Alaskan Brewing might have been here at the fest with some taps. But most of the brewers here are much smaller and more local than AB - you won't find many of these beers outside of the local pubs.

rebecca said...

I like how you went from a 'white male' to a 'gentleman'. see you two soon! xx r

(Ben) Jamin Jones said...

I kept telling them to call me dude!

Natbr said...

New definition for living Aloha: "This is a tanned and healthy-appearing 53-year-old gentleman in no distress at rest."

Thanks for sharing the details ... incredibly complex and invasive. Yikes !! But your experience is clearly improving the right side of the odds !!

Adu ...

-- Nat

Copyright © 2011 Jamin Jones, All rights reserved.