Saturday, July 21, 2012

Endocarditis and Heart Attack

A Rough Start to 2012
A new year begins with many good wishes for happiness and good health. However, as January 2012 began to unfold, it brought a crisis to my friend, John.

It was in January just five years earlier that John's bicuspid aortic valve and ascending aortic aneurysm had both been replaced. All had been well since, and he had no particular reason to imagine that just a few days into this new year would find him not only hospitalized twice but undergoing emergency surgery to save his life.

One evening John began to run a fever. Remembering the warnings he had been given about the dangers of infection for someone with a prosthetic aortic valve, he went to a hospital ER the next day. By the time he was checked there, he was no longer feverish and was sent home without further investigation. Two nights later, he was back in the same ER, this time with a soaring temperature of 105. He was admitted, a transesophageal echocardiogram (TEE) confirmed endocarditis, and he remained in the hospital on IV antibiotics for about a week.

What is Endocarditis?
In this video, after discussing infections more generally, beginning at 4:08 there is a TEE image followed by the actual surgical tissue from someone who developed infection on his bicuspid aortic valve.

Released Home - Crushing Chest Pain!
John was allowed to return home from the hospital with a pic line, through which he would continue to receive IV antibiotics. What a wonderful feeling to come home! But suddenly, just two hours after he got there, John felt horrendous chest pain and nausea. Something was terribly wrong. The call to 911 brought EMTs quickly. John had all the signs of a major heart attack, and his only chance of survival was to get to the nearest cardiac hospital. Now!

What Was Going On? Heart Attack?
Heart muscle needs blood in order to remain healthy. It will die without it. This is the searing pain of a heart attack. But how could John be having a heart attack? It was clear his heart was not getting the blood supply it needed, and nitroglycerin was not helping open up the blood flow. What was blocking the blood flow to his heart muscle?

At a nearby hospital, the villain was exposed - some of the infected tissue, called vegetation, had broken off and blocked his coronary artery, preventing blood from flowing to his heart muscle. John was indeed having a heart attack and needed surgery immediately.

It was already late in the day as the cardiac surgical team assembled. It would be a long night. After many hours of surgery that included carefully cleaning out the infectious debris and giving him a new prosthetic aortic valve, John was alive! Fragile, with injured heart muscle, but alive! 

There are some cases that heart surgeons particularly talk about and remember. These are the times when without warning they are called to wage tremendous fights, to save life against the odds. John became one of those cases. He eventually was transferred to the original treating hospital, where he continued his recovery.

Teeth Cleaning, a Cut on the Hand?
Looking back, John has tried to identify where the infection might have begun. There are two things that happened prior to his fever that are suspicious to him. He had a deep cleaning of his teeth performed, and although he did pre-medicate with antibiotics, was that sufficient? Around the same time, he also received a cut on his hand when he fell from his bike.

Always on Guard
Over twenty years ago now, when my husband received his first prosthetic aortic valve, we were warned to take any fever seriously. Although we knew he had a heart murmur, we did not realize he was at risk of infection before then. Over the years with his prosthetic valves, any hint of fever has always been taken seriously by his physicians. Invasive procedures have been accompanied by intravenous antibiotics.

What happened to John is a reminder of the special dangers of infection for those born with BAV.  In addition to damage to heart valves, endocarditis is associated with stroke. A shower of vegetation particles can be sent to the brain, damaging multiple areas. And as John's experience shows us, heart attack can also result.

Knowing About Yourself and Your Loved Ones
John was well informed about BAV and TAD, and he had shared that information with those close to him. In critical condition, arriving by ambulance in a hospital where no one knew him, precious time was saved because they could tell the EMTs and ER physicians John's story. 

John survived against tremendous odds. As someone who knows John said to me, "I'm just glad he's still here."

Thank you, John, for letting me share your story,
telling others of the danger of infection,
and helping create a climate of hope.

Arlys Velebir
Bicuspid Aortic Foundation

Sunday, July 15, 2012

Aortic Aneurysms, Bicuspid Aortic Valves, and The Sword of Damocles

Sword of Damocles, Richard Westall, Ackland Art Museum
"...the presence of a bicuspid aortic valve appears to indicate, at least in a portion of the cases in which it occurs, a tendency to spontaneous rupture of the aorta, which hangs always, like a Sword of Damocles, above the unsuspecting subjects of this type of coarctation, for this anomaly occurred in quite half the cases so terminating." M.E. Abbott, Coarctation of the Aorta, The American Heart Journal, 1928.

Among those born with bicuspid aortic valves are a group of individuals that are athletically gifted, with tremendous focus and stamina. They pursue amazing athletic goals with exceptional physical strength, endurance, and intelligence. They appear the picture of health, and in many ways their bodies are in excellent condition. However, life-threatening danger may hang over them, sometimes undetected. I recognized those traits in John Marschall, known as Coach Jay, who is interviewed below.

I was struck again by Dr. Abbott's wisdom, published over eighty years ago, as I read about this man's experience:  Go Hard or Go Home: Determination Despite Cardiovascular Disease .  However much others might admire his extraordinary athletic ability, no one would wish to walk in his shoes between 2008 and 2010, years when he first had his bicuspid aortic valve replaced, later contracted endocarditis, and then went under the knife again when a large aortic aneurysm was discovered. Coach Jay tells about his last race, and new beginning, in this post, Monday, June 27, 2011, The end and the Beginning . 

In Dr. Abbott's day, surgery and antibiotics did not exist. The sword, hanging by only the thinnest of threads, was out of reach and would eventually fall. Today surgery and antibiotics do exist, but the sword still hangs there, the dangers remain for those with BAV and TAD. There is still a great deal that is not understood. Controversies exist about the timing and methods of treatment and surgery. Individuals, families, and physicians have a great deal to ponder as they make decisions about first finding the sword, and then deciding when and how to remove it. 

Seemingly healthy, 
extraordinarily gifted people
 with BAV and TAD
 may be under life-threatening risks.

As we share their stories, 
we expose those risks 
and raise awareness,
creating a climate of hope.

Arlys Velebir
President and Chairman
Bicuspid Aortic Foundation