Sunday, April 9, 2017

When a Heart Valve Fails

It is 27 years this month since my husband's own bicuspid aortic valve was replaced. It had completely failed him, causing his entire heart to fail too.

Since that time, we know now that his body has struggled with the artificial valves that have kept him alive, aortic valves made by man. First a mechanical valve. Then a bovine tissue vale. And now, it is almost 6 weeks since he received his third artificial aortic valve.

Why another surgery? He was, quite simply, on the brink of losing his life. The 11 year old bovine prosthetic valve in his heart was failing.

The 2 leaflets at the bottom were completely frozen,
only the 1 leaflet at the top was moving to let blood flow
Tissue Valve Deteriorating at Eight Years
At 8 years, we were told that one of the leaflets was not moving well. Only 8 years?

We had hoped that he would be like many in his age group, whose bovine pericardial valves still function at 20 years.

Inside his body, for whatever the reason, the valve is considered a foreign invader, something that needs to be attacked or healed!

I had read that tissue valves like this last about 6 years in children, and that was the case for one teenager we know.

He had a transesophageal echo, and those findings was more hopeful. The one leaflet in trouble was moving enough to close completely, it just could not open all the way. Maybe it wasn't too bad, and would still last quite a long time.

Another Leaflet in Trouble

Late in 2016, with the valve approaching 11 years old, a "regular" echocardiogram, through the chest wall, showed that two leaflets were in trouble now. We had to face that it wasn't just one leaflet, and that this valve continued to deteriorate.

Surgery the Only Hope

My husband was not a candidate for TAVI (TAVR), the procedure where another valve is threaded up and inserted inside the old, failing valve. One of the reasons for that was that his aortic valve diameter is too small, only 21 mm, to accept another valve inside it.

There was another reason also, that would have prevented TAVI from helping him. On the bottom, or "intake" side of the valve, my husband had grown scar tissue, called pannus all around the ring of the valve. It is pictured on the left. Most of the tissue was cut away and sent to pathology, so only a small part of the softer tissue remains attached.

This tissue was also blocking blood flow. In order to have full blood flow, those failing valve leaflets, and the scar tissue attached to the valve ring, had to come out. There was no other way.

Today, understanding these things, I am surprised that my husband's heart and body had coped as long as it had.

I found a paper from surgeons in Japan, Subvalvular Pannus Overgrowth after Mosaic Bioprosthesis Implantation in the Aortic Position, that discusses this happening in some of their patients. There is a picture, Figure 1, that shows the ring of scar tissue below the valve. In the conclusion, it mentions that preventing this scar tissue formation is unsolved.

My husband also grew pannus and strands of tissue on his first prosthetic valve, a mechanical valve. My personal feeling is that there is something about his body's reaction to these "foreign" valves that causes it to want to heal. However, in the body's attempts to heal, it has hurt him.

I do not know how many people form scar tissue on their artificial valves. Perhaps some of them do not live long enough.

In any case, this is why time was no longer our friend, and the surgery door was our door of hope. 

No Solutions?

And that, in this year 2017, remains the challenge. There is still far too little that is understood about the tissue in some of those who are apparently most complex, like my husband, who were born with a bicuspid aortic valve. For the sake of generations following us, we need answers to these mysteries.

I am glad that physicians such as those in Japan have seen and published about this. I refuse to believe that there are no solutions to these problems, if only someone will look for them! 

Monday, April 3, 2017

An Unplanned Door of Hope - Emergency!

An Unplanned Door of Hope
 The emergency entrance of the hospital
where my husband had his recent heart surgery.

As we passed the three week milestone after his surgery, there were some signs that my husband was not progressing as he should. Nothing, however, prepared us for his sudden decline. In the early hours of the morning, I was online and on the phone, searching for an ambulance to return him to the hospital where his surgery was performed. 

The Nearest Hospital

I could have called 911, the emergency telephone number here in the US. If I had done so, an ambulance and fire truck would have come quickly, from less than a mile away.

Why didn't I just do that - call 911? From previous experience, I knew that our local service would take him to the nearest hospital that in their judgment had the expertise he needed. If you search online, you will find articles that describe how this works, in my area as well as most of the US. 

Continuity of Care

Quite simply, I didn't call them because I felt strongly that my husband needed to be back under the care of the same team that had so recently cared for him during and following his heart surgery. They were not the physicians nearest to us, but they were best equipped to understand and help him.

In the medical world, they call this continuity of care.

Finding an Ambulance

Some companies would only transport him to the nearest facility. I found one service that would not do it, because it had to be a distance of at least 300 miles, and we only needed to go about 75! 

Who would do it? I found an "inter facility transportation" service. Yes, they would take him from our home to the Emergency Room of the hospital where he had surgery. 

I am forever grateful to this company.

Decision in My Hands

My husband was too sick by this time to know anything except that he was very sick, but I was confident that I knew what he would want.

We were taking a risk to do this, rather than go to a local hospital. 

Each person and their loved ones must make
 what they believe is the right decision,
and be prepared to accept the consequences, whatever happens. 

I rode in the ambulance with him, seated at his head, steadfast in the conviction that he needed to return to these specific doctors. I did  not know what was at the root of this. However, especially if he had succumbed to an infection, I wanted him in the hands of his surgeon, who has a stellar track record at conquering post operative infections.

Mercifully, his vital signs remained stable, and what seemed an endless ride at last brought us to the Door of Hope pictured above. He remembers almost nothing of any of this - the ambulance ride, the experience in the Emergency Department itself, and some of the time in Intensive Care. I am so glad. It is enough that I must remember it. 

In the Doctors' Hands 

I stayed in the Emergency area to answer questions and sign any permissions needed to treat him. I can never express my gratitude to the Emergency doctor, in my memory a lovely woman with dark hair, and the two nurses that worked on him. It was not long before the Pulmonary specialist who had cared for him appeared. I am sure he was shocked to see the change in a man who had looked so well when discharged. I know I was crying as I told him that my husband was just "a mess"! Later his surgeon arrived, and no doubt others.

It was up to these doctors now, to do what they could. And they did!

Acute Renal Failure

The Mayo Clinic website states that this can happen rapidly, can be deadly, and requires intense treatment. I certainly saw the reality of those words! 

In that cubicle in the Emergency Department, and then in Intensive Care and through out his hospitalization, the treatment was indeed intense.

I have not counted the number of doctors who cared for him.  There were many.


Today we are grateful for many things, especially the expert and compassionate treatment and care. His doctors and nurses gave him the best possible treatment and recovery. We are home together again, no dialysis was ever needed!

Surgery Far From Home

Out of four heart surgeries, only one was done nearby our home. From past experience, I knew that it might be necessary to return to his doctors and hospital if there were complications. In 2006, we had signed out of our local hospital, who wanted to admit him, and I drove him back to the hospital where he had surgery myself. He was stable enough and well enough to ride in the car that time.

However, this time, he was too ill, too quickly, for me to drive him there. What I discovered is that, even if paid privately, cash up front, many ambulance services will not transport someone from their home to the hospital they request. 

If it should be necessary again, I will always have the phone number of that inter facility transport service in my area at hand and be prepared to call them. 
The 911 service responds to everyone, and takes them to the nearest hospital equipped to help them. For example, in the case of a stroke, to the nearest stroke designated hospital. Generally this makes sense.

However, in a case such as this, wishing to return after a major heart surgery to his doctors was a challenge. It was necessary to pay the full ambulance fee up front in order to make it happen. I understand that may be beyond what many people could do. In that case, the next best thing is to get to the local hospital via 911.

Let Others Help You

Normally, when we are well, we are used to being independent. Going through this crisis, there were so many who were so thoughtful and helped so much. We can never adequately thank those who were there in our hour of need.

I think now of my dear friend and her husband, who drove my car to the hospital that day while I rode in the ambulance, and stayed with me in those first terrible hours at the hospital. Others came later to be with me. A very dear friend of the heart, on the other side of the world, spoke to me by phone at midnight that night. A very brave young woman came daily to support and cheer us. There were so many messages of love and encouragement.

For all those who sent thoughts and prayers on our behalf, we are forever grateful.

Plan for the Worst, Hope for the Best!

Thinking about it now, I could have identified the ambulance company ahead of time. I just did not realize many would not choose to be hired privately. And so, in the future for us, when our doctors are not nearby, I will plan for the worst case, and hope for the best!

And that worst case would include knowing ahead of time how to request an ambulance to take us back to the doctors and hospital we need.

Above all, especially in emergencies,
keep hope in your heart!
There is a Door of Hope waiting to receive you,
a door with big red letters that say

Best wishes to all who follow us on this journey,
~ Arlys Velebir

Thursday, March 16, 2017

Surgery Number Four - The Longest Day

The heart is a Red Jasper stone,
 known as the "warrior stone"

 We had been asked to come to the hospital early, and we were right on time. The clock said 5 AM sharp as we signed in at the front desk. It was the beginning of the longest day, his fourth surgery. . . .

I was prepared for this day to be a long one, especially from that moment when we parted at the "Kissing Door". 

After 27 years, some memories of his first surgery day have faded, but some never will. I remember the shock I felt, going in to see him in "recovery" in the afternoon. Later, I was there when  he awakened from the anesthesia with a great commotion of alarms blaring at 6 pm that evening. As soon as he opened his eyes, we connected again, although he could not speak yet. This is the most wonderful moment for me, when I feel we communicate again - we don't need words!

Until this recent surgery, that first one had been the longest - the longest period of time when I felt separated from him. The elapsed time of the two surgeries that followed (aneurysm in 2001, replacement of mechanical aortic valve in 2006) were shorter, and he woke from anesthesia quickly.

Why so long?

Why was this this surgery going to take so long? There are two main reasons: 1) scar tissue and 2) the delicacy of my husband's own tissue. I have been convinced for some time that in our family as well as many others, BAV is a sign of something that involves the body's tissue more broadly, not just the aortic valve and aorta.

1) Scar Tissue
After a first heart surgery (and he had 3 prior!), the body forms scar tissue, not just on the outside of the chest where we can see it, but on the inside. This scarring has to be gently and carefully navigated.  "Rise of the Redo" , an article from Royal Brompton and Harefield hospitals in the UK, describes the challenges.

2) Delicate Tissue
It was the next morning, in ICU, before my husband was even allowed to wake up and breathe on his own, that the surgeon told me about how very delicate his tissue is inside now. It had been 11 years since these same hands had last operated on my husband.  Now, his tissue generally is so much more fragile, only the gentlest touch would not damage him! In the wrong hands, this surgery would have been a disaster. 

Many BAVers, including my family members, have delicate tissue that manifests in various ways, and it seems to become more so with time.

A few weeks ago now, I heard Professor Mona Nemer describe her work with BAV mice families. I was thrilled to hear her say that the genetic defects in these mice, so like their human counter parts, are defects of the tissue. BAV has not been called a "connective" or other kind of tissue defect historically. Professor Nemer's work is vital to looking beyond a malformed aortic valve alone, and accurately characterizing those with BAV.

Progress, One Step at a Time 
The most lovely liaison nurse went into surgery periodically and then updated me on the progress through out the day. It was just after noon when she told me that there was lots of scar tissue, but the old valve was out! 

It was great progress, and I felt relief flow through me for a moment. Then I realized that he had no aortic valve at all now, until a new one was safely anchored in place! 

It took the remainder of the day to place a new valve, slowly rewarm him, and close the chest. The surgeon came out to tell me about the surgery around 6 pm.

I will write separately about what the surgeon said about the old valve. What was it really like? How well had the echocardiograms and CTA tests prior to surgery portrayed what was happening inside my husband's chest? Learning from this is extremely important, given that these tests, along with symptoms, help guide the decision to have surgery or to wait longer. I will just say now, the tests and symptoms were accurate enough for us understand that waiting was not an option for my husband, if he was to have this surgery at all. 

More Waiting 
Yes, surgery was over, but my husband would not be allowed to wake up as quickly as he had with his past surgeries. Before surgery, his right heart had been overworked by the failing bovine valve, and the long surgery time had also been hard on it. He was to remain sedated while his right heart recovered. Thankfully, his left heart, the main pumping chamber, was strong! 

It was a long night, thinking about that right heart. By 8 the next morning, I was told that his right heart had completely recovered during the night. Soon, he was awake and then breathing all on his own once again!

Family Friendly Care 
I was allowed to remain with my husband in ICU from that very first night, which was wonderful! This is generally not the case in ICU's. We would spend a total of four nights there. I remember that first night, looking at all the technology surrounding his bed, lights glowing in the darkened room. It had a surreal quality, the feeling of another world, another universe.

Not everyone may find that they can do this. All the machines, the tubes, and the sight of their loved one can be more than they can bear. This hospital is new, 'state of the art", and the nurses so supportive, that I was indeed comfortable there. I remember the warm blankets brought for me to  rest under, and the hot tea given to me at 3 am that first morning. These are beautiful touches of care, not to be forgotten, in the midst of all that technology. A century ago, those kind of comforts were all that could be done for the patients themselves - none of the drugs, the surgical and intensive care expertise and equipment, existed.

The Heart of a Warrior,
Healing Once Again,
27 Years after His First Battle
Post Surgery Day 16 - Recovery at Home

Today is the 16th day following the day of surgery. With the attentive care of his surgeon and a home health nurse coming in, I am comfortable caring for him as he recovers. We just need to stay vigilant lest any complications should develop. From our own family and others, we know how nasty some of these complications can be! 

Overall the hospital was a great place to be as long as he needed that level of care, but there is just no place like home for recovery! 

I am not a nurse, and I admired many of the things nurses did for him in the hospital. However, I do tell my dear husband that no one else could ever put so much love into his care!

Friday, March 10, 2017

The 11th Day - Reflections on BAV and the Fight for Life

 ICU at daybreak, on the first morning after surgery.
My husband was still sedated and on the respirator.
I was allowed to be with him,
resting on a padded bench beneath the window,
 all through the night.

Today, March 10th, is the 11th day since my husband's fourth heart surgery.

Bill Paxton died on the 11th day after his first heart surgery, on February 25th.

Based on press reports, Bill Paxton was born with BAV and had an aneurysm. He also had rheumatic fever in his youth. 

My husband was born with BAV, had an aneurysm, and had rheumatic fever as a child.

We made the decision to fight one more time, have one more surgery, on February 21st. It had seemed unthinkable, that roughly 27 years after the first surgery, no longer young or even middle aged, my husband would have surgery again. We decided to fight this, one more time. This was a very personal decision, made with his surgeon, who knew his own skill as well as his patient, and above all, with the help of God.

Today, my husband's body fights to heal, one step at a time. All is going well, one step at a time. I am so blessed to be with him, every step of this fight. We are in a different kind of fight, but the words of a Navy SEAL come to mind:

 "There's a storm inside of us, a burning river, a drive.
You push yourself further than anyone could think possible.
 You are never out of the fight." 
- Marcus Luttrell

Our deepest sympathy, beyond words to express,
 to all those who mourn the loss of Bill Paxton.

 Our deepest sympathy also, to those we may not know about,
 who mourn the loss of their loved ones,
in the BAV battle for life.

~ Arlys Velebir

Saturday, March 4, 2017

Making Progress in Our "Three Foot World"

I took this picture years ago. Looking at it today, I feel my husband and I were in that place on the water where the sun shines through the clouds.  There has been just enough light and hope to guide us and help us once again.

In May 2016 I wrote about our challenges with prosthetic aortic valves. (See "Imperfect Heart Valves" post, May 10, 2016).  Today, less than a year later, the concept of the three foot world shared by Navy SEAL Mark Owen is very helpful once again.

What is it like in our three foot world today? I marvel at all that is within our reach. Specially trained cardiac nurses, medicines and monitors, tests of all sorts.... Things I don't begin to truly appreciate. There is no place more detail oriented, more proactive. All are here to help my husband recover.

Even in this very special place, my husband is rather unusual. As one of the doctors said this morning, most people don't have even one heart surgery and now he has had four!

He is making good progress here, and all signs are that the clouds are being banished, many things being discontinued and taken away. They are no longer needed as he progresses toward moving to a "normal" hospital room soon!

The picture below, clear blue skies and calm seas, symbolizes our goal as we think of returning to our life again, a priceless gift of more time together.

Wednesday, March 1, 2017

Recovering in Intensive Care

My husband was very brave as he went through the door to the operating room. This was as far as I could go with him. Heart warriors and their surgeons know this is their battle, and it is for  loved ones to stand by as bravely as they can, waiting to welcome them again when surgery is over.

It was a long, complicated surgery, as we understood it would be. It is no small thing just to safely open the chest in someone who has had three prior heart surgeries, let alone deal with the issues once inside.

It was also a marvelously successful surgery. Full blood flow was restored with a new valve in place, and as night turned to morning, his heart recovered beautifully from the surgery. As I write he is breathing on his own, awake and alert. There are more milestones of recovery to achieve, but this is everything we hoped for at this point.

Once removed, it was clear that the failing bovine valve only had one leaflet still functioning. In addition,  some kind of scar tissue had grown around the intake side of the valve. This also obstructed the flow. Clearly his heart had valiantly coped with this restricted blood flow, but had reached its limit, making surgery urgent if it was to be at all.

Today, on the other side of that Door of Hope, we are together once more, still in intensive care, but we dare to dream of futures days together once more.

Monday, February 27, 2017

The Door of Hope - Surgery Once Again

Beautiful Pacific Coastline, Southern California

There are always memories, whenever we have reason to visit our local hospital. This hospital happens to have a beautiful natural setting, overlooking the sparkling waters of the Pacific.  My husband's heart experience began there so long ago now, in 1990. His first ever echocardiogram was done there at that time. 

Last Monday, February 20th, was such a day of memories, as once again we drove there and parked. It was time for another echocardiogram (ultrasound) of his heart. We are so grateful for a very special sonographer there, who over the years has so carefully taken the images of his heart. Once again she did her excellent work that afternoon and coordinated getting the results read and the doctors connected.

On Tuesday evening, the 21st, the results were explained to us, and it was clear that it is time to intervene once again. After 11 years, the artificial tissue aortic valve is severely narrowed and also leaking. The heart, especially the right side, is working very hard, there is back pressure affecting the lungs, and there may be some risk of another stroke if we wait! The good news is that his heart muscle remains strong and vigorous, and placing a new aortic valve will allow blood to flow properly again and address all these issues. If the mitral valve needs any attention, it will be addressed as well.

And so it is time for surgery once again. Having done this three times previously, we know what this means, but of course each time the body may respond somewhat differently. We look forward with hope that he will soon feel better with his heart and blood flow working properly again.

We understand that it is wise to do this soon and eliminate the threat of further injury. The arrangements are all in place for his surgery, 24 hours from now. All that is left is just to get to the hospital on time!

Without intervention, in 1990 my husband would have lost his life to heart failure. He was incredibly sick, with critical BAV stenosis at that time. We had never even heard of BAV until then, although we knew he had a heart murmur! 
Keep Hope in Your Heart!

Since then there have been 27 precious years, thanks to his heart surgeries. It is a great comfort that once again when he needs it so much, this surgical door of hope is open to him. 

This is why I write so often about hope. As my dear friend BJ shared with me once again with the picture here, always "Keep Hope in Your Heart".  I know there are so many in BAV families like ours, some just newly diagnosed, others facing another surgery. On the threshhold of my husband's surgery, his Door of Hope, may all who need it find their door of hope and receive the help they need.

Keep Hope in Your Heart,

~ Arlys Velebir