PATIENT STORIES
David Malik
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Most recovering patients have important milestones. But rarely are they vertical.
In January 2002, David Malik, a man who had suffered for 30 years with a debilitating condition called atrial fibrillation, climbed to the 19,340 foot peak of Mount Kilamanjaro. His ascent was a personal triumph as well as testament to the power of catheter ablation, a medical procedure that has revolutionized the treatment of certain types of arrhythmias, or irregular heart rhythms. Malik’s journey to the top of Africa’s tallest mountain begins about 30 years ago.
Malik, at the time a college student, had been feeling exhausted and unwell. He ended up in the emergency room of the local hospital, and after an electrocardiogram, it was determined that he was suffering from atrial fibrillation. Atrial fibrillation is an abnormal heart rhythm in which the two small upper chambers of the heart — the atria — quiver instead of beating so blood isn’t pumped effectively. Patients who suffer from the condition are at increased risk for stroke. Malik, now a 51-year-old attorney living outside of Cleveland, said that he didn’t think much about the diagnosis at first, but as time went on, his condition became difficult to ignore.
Over the years, the episodes of atrial fibrillation grew more frequent. Some required Malik to undergo cardioversion, when a shock is delivered to the heart to restore its normal rhythm. Although Malik was treated with various medications, none seemed to work for very long. Day-to-day living was often a struggle and although Malik tried to stay physically active, it wasn’t easy.
“I was constantly exhausted and felt shortness of breath,” Malik told the Cleveland Jewish News. It was very “distracting, frightening and frustrating.” After a particularly bad bout with his condition in 1999, Malik heard about the relatively new procedure, catheter ablation, that was being done at the Cleveland Clinic where he was a patient. He was intrigued.
In the procedure, a catheter, which is simply a long, flexible probe, is used to locate the exact location of the arrhythmia’s source. Once the site is identified, the problematic heart muscle cells are eliminated with high frequency radio waves. Obliterating these cells stops the area from conducting the extra impulses that cause the irregular heart beat. The procedure has a high success rate and a relatively low risk of complications, according to the American Heart Association. When successful, ablation completely cures the patient.
Andrea Natale, M.D., a Cleveland Clinic cardiologist and a pioneer in the field of catheter-based treatment for atrial fibrillation, determined that Malik was a good candidate for ablation. In March 2000, he performed the procedure.
“I was told that I would begin to notice a difference in how I felt at the 90-day mark,” Malik recently recalled. “After the ablation, I was nervous because I kept having arrhythmias. On the 60th day, I went off my medication, Coumadin. But I still wasn’t feeling different. Then on the 90th day, I had a great day. And the next day I had a great day, and the day after that and those days turned into weeks and now those weeks are years. It was bizarre. The 90th day really was the turning point.” Malik has not even had to see a cardiologist for follow up.
After his recovery, Malik didn’t know what to do with all his extra energy. He began researching mountain climbing and decided this might be a good channel for his newfound vitality. He started working out regularly at a gym, biking and swimming, with the ultimate goal of climbing Mt. Kilimanjaro. It was slow going. At first, he could walk on the treadmill at the minimum speed for only 15 minutes at a time. Now he easily does 45-60 minutes, at the steepest elevation. His strength also increased exponentially. Malik eventually began doing practice climbs, scaling six of CoIorado’s so-called “Fourteeners,” peaks that are at least 14,000 feet high.
Then in January 2002, less than two years after his catheter ablation, Malik and his girlfriend Leah Dicker reached the summit of Mt. Kilimanjaro, after an arduous, seven-day climb.
“It turned out to be both a mental and physical challenge,” Malik told the Cleveland Jewish News last year. At 18,000 feet, he began suffering from altitude sickness and the strong wind and bitter temperatures made it difficult to sleep. But Malik woke up the next morning, determined to reach the summit. “There was a break in the clouds and the view was amazing. I was feeling great and I didn’t want to descend”. Malik’s next goal is to climb Washington state’s Mt. Rainer, a 14,000 foot high volcano known for its icy precipices and expansive snow fields.
Above all, Malik believes that with his recovery comes an obligation to act as an advocate for catheter ablation. “I have a responsibility to show others what technology and good medicine can do,” he told EP Lab Digest. “It is my personal challenge, and I get a lot of satisfaction talking to others about it.”
July 3rd, 2006 at 9:27 pm
Donald F. Seemann
Fate, God, simple coincidence? Donald and Dorthea Seemann are unsure what to make of the convergence of people and circumstances that prevented Donald’s December 2003 cardiac arrest from turning tragic.
Donald, 73, was driving the couple home to Huntley, Illinois, after visiting his brother, when Dorthea noticed the car beginning to slow down. She turned to her husband, asking him why he was slowing down, and saw that his eyes were closed. She touched his hand, and immediately knew something was wrong when she felt how cold it was. By this time, the car had come to a complete stop in the middle of the road.
Panicked, Dorthea jumped out of the car and began to wave down cars. Miraculously, a state police cruiser was traveling almost directly behind them and pulled to the side of the road. An EMT traveling back from vacation saw the state trooper lifting Donald out of the car and also stopped, as did a physician. Dorthea later learned that a second EMT joined the group as well.
The trooper had an automated cardiac defibrillator (AED) in his cruiser, a device that jolts the heart back to its normal rhythm, and with the help of one of the EMTs, began to administer the shocks. Within moments, an ambulance arrived.
“It seemed like they were working on him forever,” recalls Dorthea. “I could hear him gasping in the back of the ambulance. I was really nervous and upset. I couldn’t even call my daughter. The EMT who helped revive Donald called her for me.”
What had happened to Donald is his heart had gone into ventricular fibrillation, meaning its ventricles were quivering rather than contracting, and therefore inadequately pumping blood. This irregular heart rhythm, or arrhythmia, is life threatening.
Donald, however, has absolutely no memory of what happened. In fact, his last memory is of leaving the cemetery where he and his wife had stopped briefly to visit his parents’ graves — about an hour before his cardiac arrest. When he regained consciousness four days after the incident, Seemann said he really didn’t feel very bad, just tired. During those lost four days, he had been sedated, hooked up to a ventilator and fed intravenously.
Over the following days, hospital staff performed a series of tests, including electrophysiology tests that evaluated the electrical circuitry of Donald’s heart. His cardiologist determined that his heart rhythms could go awry again, and that he should have an implantable cardioverter defibrillator (ICD). A little more than a week after his cardiac arrest, the pager-sized device was implanted just below his left collar bone. Connected to his heart with wires, the ICD monitors Donald’s heart rhythms and when an irregular heart beat is detected, it delivers an electrical jolt that normalizes the rhythm.
A retired electrical engineer, Donald has more than a passing interest in the device that could save his life. “I’m intrigued with what this device can do. In my mind, I’m laying out its circuitry and how it can trigger the pulses of the heart,” says Donald. “It stores in its memory all of its activity and I’m fascinated by how the doctors can periodically ‘read’ that memory.”
Donald is still wrestling with the question of what triggered his cardiac arrest, and whether he should have seen it coming. Although he was in very good physical shape, thanks in part to his daily exercise regimen, there were a few troubling details in his medical history. In 1984, he had a portion of his colon removed. Immediately after the operation, he suffered a heart attack and he was told that a blood clot had lodged in his heart, causing the attack. However, he was unaware that there had been any lasting effect until a couple of years ago, when an echocardiogram and a thalium stress test revealed damage to a portion of heart muscle as well as a leaky valve. Donald said it’s possible that these earlier problems presaged what was to come.
Although the root cause of his cardiac arrest is still somewhat uncertain, what Donald does know is that his good physical shape had a big effect on how events played out. “The cardiologist said if I hadn’t been exercising the way I do, I wouldn’t have made it,” says Donald.
Donald has resumed exercising, slowly, limiting himself so far to short walks with Dorthea. But he plans to return soon to the fitness center where he used to work out regularly. His cardiologist tells him that eventually he should be able to do most everything he did before, with the exception of some upper body exercises that could dislodge the leads that connect the ICD to his heart.
So far, he says, the ICD has not fired and it’s had minimum impact on his life, although he’s conscious of the things that could interfere with its operation — cellular phones, heavy machinery, metal detectors, for example.*
“I feel it, it’s there, but not as much as I did in the beginning,” says Donald. “I imagine a couple of months down the road, I won’t even be conscious of it.”
July 3rd, 2006 at 9:28 pm
Syndicated Columnist Judy Foreman
I was very scared, shivering as much from fear as from the chilly room temperature. I was waiting on a gurney at Brigham and Women’s Hospital to be wheeled in for a catheter ablation, an invasive cardiac ‘’procedure.'’ (Ah, the euphemisms.)
In a totally bizarre twist of fate, I had interviewed Dr. Laurence Epstein, chief of the hospital’s cardiac arrhythmia service, several weeks earlier in preparation for a column I was working on about new treatments for arrhythmias.
He had shown me his very cool, animated PowerPoint presentations and explained the details of the procedure. As a medical writer, I was fascinated. The process involves inserting catheters through veins in the patient’s groin, snaking them up into the heart, then using the wires to record the heart’s electrical activity - from the inside. Once this activity is ‘’mapped,'’ the catheters deliver radio frequency waves to ablate (i.e., kill) the clusters of cardiac cells that trigger the abnormal rhythms.
As Epstein showed me his pictures and scholarly articles, I casually mentioned that, once a year or so, I got tachycardia - very rapid heart beat. He instantly drew me pictures of what he guessed was wrong - SVT, or supra-ventricular tachycardia, which affects an estimated 500,000 to a million people with varying severity.
Like many of those people, I probably was born with two electrical pathways through a key switching station in the heart, the atrial-ventricular, or AV, node, instead of just one. Electrical signals from the right atrium (one of the upper chambers of the heart) tell it when to beat. In people like me, the signals sometimes go down the wrong pathway and then back up the normal one, creating an electrical circuit that causes the heart to beat very rapidly.
‘’We can cure that with catheter ablation, you know,'’ he said.
‘’Great,'’ I said nervously. ‘’If it ever gets worse, I’ll be back.'’
Several weeks later, totally out of the blue, it did get worse, much worse. I’m pretty fit: I either swim a mile or do 10 miles on my exercise bike nearly every day. But, suddenly, I couldn’t walk a block without sending my heart rate up to 190 beats a minute. Even just washing my hair in the shower triggered it. I was fast becoming a cardiac cripple, afraid of climbing even one set of stairs, lest I become short of breath or pass out.
The whole thing was frightening, even though, rationally at least, I knew that SVT was not life-threatening. I decided to go back to Epstein.
But fear and discomfort weren’t the only things I had to cope with. Suddenly, I had a brand new, tricky role - patient. On the plus side, telling people about my unexpected medical problem meant that I got a huge amount of support from friends.
But becoming a patient also meant that I instantly became the target of masses of unsolicited advice from people. I was a Rorschach ink blot upon which people could now feel free to foist their pet theories.
Interestingly, the doctors I talked to - both friends who are doctors and doctors I consulted for this problem - were uniformly terrific listeners, contrary to the bad rap they often get. They listened calmly, respectfully, and took me seriously. When I asked, they offered advice, including one doctor-friend’s very useful mantra, ‘’Stay cool.'’
My close friends did all the right things, too. They called during the interminable weekend while I waited to have the procedure. They e-mailed. They hugged. They brought flowers, and excellent squash soup. But, most importantly, they neither pooh-poohed my problem nor rushed in to solve it. They had a way of simply listening, with attention and kindness, taking in what I was going through without trying to take over or tell me what to do.
On the other hand, I rapidly came to the conclusion that my friends are pretty special, because a number of other people were truly awful at listening and giving support. Their insensitivity ended up putting the burden of patience and diplomacy on me, as I tried to fend off unsolicited advice diplomatically - at a time when I had little patience to spare.
For instance, some people couldn’t stand to let me finish before interrupting with their own horror stories.
Others insisted, quite adamantly, that my problem must be ‘’stress.'’ This was especially annoying, first, because it seemed to imply that my arrhythmia was my own fault and, second, because it seemed to invalidate the reality of my symptoms, which had been confirmed by cardiac testing. As one friend put it, ‘’Telling someone they sound stressed blames them. Saying, `What a stressful situation you’re in’ doesn’t.'’
Sure, stress sometimes can boost the chances of getting some diseases, mostly notably, the common cold. But it shouldn’t be the explanation of first resort, partly because it blames people and partly because lots of people get very stressed and never get sick.
If some people were too eager to blame the victim, others were almost too kind - so eager to do something that they trampled a bit on my autonomy, not giving me the open space to decide what concrete help, if any, I really wanted.
Some people, I discovered, also seem programmed to pounce on someone else’s illness as an opportunity to promulgate their religious views.
Why are some people such naturally good listeners and others find listening so hard? I wondered aloud about this with my across-the-street neighbor, a psychiatrist, in the countdown days before my procedure. His conclusion makes sense: ‘’When you tell people how helpless you feel,'’ he said, ‘’they feel helpless. They can’t stand feeling helpless, so they jump in with advice.'’
Mercifully, the big day arrived and, scared though I was, the procedure was substantially less awful than I expected. The nice guys with the great drugs conked me out briefly while they inserted the catheters and, when I woke up (the type of anesthesia I had is called ‘’conscious sedation'’), the procedure was already underway. I could feel the arrhythmias as Epstein and his team intentionally triggered them. But none of these was anywhere near as disconcerting as the ones I’d been having spontaneously. I also knew that they could stop any arrhythmia at any time, a huge comfort.
The actual ablation felt a bit hot from my left hipbone to my left collarbone, but not uncomfortable. In fact, I found I was able to chat with the nurse through much of the procedure. I was also lucky. Sometimes, catheter ablations take three to four hours or longer, but mine was quick - an hour and a half.
Then it was over! I was ecstatic. I had to lie still for four hours so the puncture wounds in my leg veins could begin to heal, but that was easy.
I went home that same night, feeling terrific. No more tachycardia. No more worries about walking, or climbing stairs; not even a hangover from the drugs.
I had trusted Epstein and his team and they were magnificent. Thanks to them, I could trust my own heart again.
As for the creepiness of researching a medical problem, then actually getting it, that’s solved, too. I’m writing about hangnails and pimples from now on.
Judy Foreman is a freelance columnist.
She maintains a collection of her work online at www.myhealthsense.com
July 3rd, 2006 at 9:28 pm
Vice-President Richard Cheney
The day Vice President Richard Cheney received his ICD was a step forward in the care of people who have survived a prior heart attack. The ICD, which stands for “implantable cardioverter defibrillator,” is a pacemaker-like device. Doctors called it an “insurance policy” for the Vice President - it was there if he needed it. And, because of the type of heart disease Mr. Cheney has, it’s likely that someday he will need his ICD to protect him from dying suddenly from cardiac arrest (also called “sudden cardiac death” or SCD). SCD is almost always caused by ventricular fibrillation (VF), a dangerous heart rhythm disorder. In VF, the heart suddenly and without warning begins to beat too fast, quiver and spasm. When this happens, the heart no longer can pump blood to the body.
Mr. Cheney, like millions of other Americans, is a heart attack survivor. According to reports, he has a damaged heart, although it does not appear to interfere with his normal lifestyle.
This patient story may not be typical. Individual symptoms, situations and circumstances vary and response to therapy is not always the same. Please consult your physician or health care provider regarding your condition, treatment or any specific questions regarding your care.
Preventing Heart Attacks
Until the Vice President received his ICD, most of the information about his health focused on preventing further heart attacks. That meant a good exercise program, losing weight, watching his fat intake, and medications that control his cholesterol and, if necessary, his blood pressure. But his cardiologists were aware of a lingering problem that these treatments could not prevent - patients who suffer heart attacks may be at high risk for sudden death due to a heart rhythm disorder that leads to VF.
Physicians who are concerned with preventing heart attacks or caring for patients with heart failure or other disorders caused by a damaged heart, often do not give as much thought to the risk of sudden cardiac death.
Sudden cardiac death often is misunderstood by patients,and frequently even by physicians. It can occur in hearts that are literally “too good” to die. Often, the problem is an “electrical storm” coming from the scar of a previous heart attack. Like sticking your hand in a light socket, the electrical activity from this scar causes the heart to go into spasm, preventing it from pumping. When that happens, the heart stops and, unless emergency help is available within minutes, the patient dies.
It is important to know that this heart spasm can be converted back to a normal heartbeat with a controlled, electrical shock. Most Americans have seen a defibrillator on ER. Two large paddles are placed across the victim’s chest, everyone is told to stand clear, and the device discharges electrical energy that restores the patient’s heartbeat. Now it is possible to implant a similar device that is about the size of three, stacked silver dollars with wires leading into the heart. An ICD performs the same function as the large defibrillator.
Sudden cardiac death is a common problem for patients who have had heart attacks. In fact, it is responsible for at least half the deaths after a heart attack. The other deaths occur from another heart attack or from heart failure.
The impact of the defibrillator that Mr. Cheney has cuts his risk for sudden death from one in ten to one in a hundred.
The question patients and their families ask after a heart attack is, “Do I need one of those devices that Cheney had”? The answer is, “perhaps.” The question was addressed by several clinical trials on patients who survived a significant heart attack. These patients were monitored and those with abnormal heart rhythms underwent special testing to determine whether or not they were at risk for sudden death. If they were, they were either given medication or received an implantable defibrillator. At the end of five years of study, researchers determined that the group of patients with implantable defibrillators had nearly a 50 percent reduction in their death rate.
If you’ve had a heart attack and have a significant amount of damage, you may be at risk for sudden death. You need to find out how much damage you have. The way we measure that is with a number called the ejection fraction (EF). This number is the percentage of blood pumped with each beat. Normally, we should pump out 50 percent or more of the blood in our heart with each beat. In a damaged heart that is at risk for cardiac arrest, that number drops to 35 percent or below.
So you should ask your doctor how much damage you have and ask, “What is my ejection fraction?” If it is abnormally low, you may be referred to a heart rhythm specialist called an electrophysiologist who will monitor your heart to see if you show signs of an abnormal heart rhythm. Like Mr. Cheney, you may feel fine and carry on a vigorous lifestyle but still have a heart that is potentially at risk for ventricular fibrillation and sudden cardiac death.
If you don’t know your EF, check it out. It could save your life.
July 3rd, 2006 at 9:28 pm
Author Deborah Daw Heffernan
Nothing about Deborah Daw Heffernan even hinted at the massive heart attack that almost killed her five years ago. She was a healthy 44-year old with no family history of heart disease. Slender, with low blood pressure and cholesterol, she had never smoked a cigarette in her life. She ate well and exercised regularly. In fact, it was during a yoga class in Cambridge, Massachusetts, that she suffered the myocardial infarction that irreparably damaged her left ventricle, leaving her with — as she puts it — “half a heart.”
Heffernan describes the incident in the opening pages of her poignant and funny memoir, An Arrow Through The Heart. She was in the middle of a reclining yoga pose on a May morning in 1997 when she suddenly felt a weight on her chest, a sensation that turned into the feeling of a vise, screwing her chest muscles tighter and tighter. She felt cold, and calmly observed her hands which had turned “marble white.” “I am having a heart attack,” she told her yoga teacher Zoe, who asked her what she wanted her to do.
“I want you to call 911,” Heffernan told her teacher. “Tell them I need a cardiac team. Tell them to take me to Mount Auburn Hospital, I need a cardiologist waiting for me. Something is terribly wrong.”
As it turned out, something was indeed terribly wrong. Heffernan’s left anterior descending (LAD) artery had dissected — in layperson’s terms: torn. No one is sure why. A blood clot had also been unleashed. It was unclear which had occurred first, but the result was that her left ventricle was dying, the chamber that distributes oxygen-rich blood to nourish the body. Although it was extremely risky to move her, her physician and family felt they had no choice but to transfer her to Massachusetts General Hospital, one of Boston’s finest teaching hospitals, to undergo an emergency double bypass. Her chances of surviving the operation? About 50-50.
Fortunately, the bypass went well, but during the surgery she developed ventricular tachycardia, or V-tach, as it is nicknamed, a potentially lethal condition in which the heart beats so quickly that it is unable to adequately pump blood throughout the body. Her only option was to have an automatic implantable cardiac defibrillator (an ICD) inserted beneath her skin and attached to her heart with wires. The matchbox-sized device would constantly monitor her heart rate. When it detected a minor arrhythmia — an irregular heart beat — it would deliver a small and imperceptible electrical current to her heart, to return it to its normal rhythm. If that didn’t work, it would deliver a far greater jolt, which could cause her to momentarily lose consciousness. The whole idea was terrifying to Heffernan, but she knew the device would save her life.
Jeremy Ruskin, M.D., director of Mass General’s cardiac arrhythmia service implanted the device between two layers of skin, above her left breast. He told her that she would most likely have to have another procedure to replace the batteries in about five years.
More than five years later, both Heffernan and her ICD are still ticking. Fortunately, her ICD has zapped her only twice, both times during her hospitalization. “It’s a Catch-22,” says Heffernan, when asked about her relationship with the ICD. “It’s my best friend and my constant reminder that I am not safe, that I am sick.” She’s always conscious of its presence beneath her skin, but finds ways to minimize that awareness, like propping up her left shoulder with a pillow, so there’s no pressure on the device as she sleeps. She is also ever vigilant about keeping her distance from the things that could inadvertently interfere with its operation, like cell phones, radio antennas, power lines and airport scanners.
Every year at first, and now every year and a half, Heffernan has to return to Mass General for what she facetiously calls her “date with death” — her NIPS (noninvasive programmed stimulation) test. That’s when her heart is artificially accelerated to determine whether her ICD functions correctly. So far, it has performed perfectly.
Heffernan went on to make a remarkable recovery, thanks to the superb medical care she received as well as the radical changes she made in her life. She and her husband Jack sold their apartment in Cambridge, Massachusetts, and moved full-time to their beloved weekend home in western Maine. She left behind her high-pressure job as a corporate trainer, and now lives what she describes as a stress-free life, which revolves around eating well, a daily 45-minute “power walk,” complementary therapies like yoga and acupuncture, and one thing you won’t find in a medical textbook.
“It’s terribly, terribly important for people to surround themselves with love every single day,” says Heffernan. “By love I mean kindness and consideration, generosity, humor, forgiveness.”
The alternative therapies have “kept my body unblocked, and energy flowing through it in the ways you want it to flow,” says Heffernan. “The body has considerable ability to heal itself, if you leave it open enough.”
“Jeremy ((Ruskin) cannot believe how stable I am and how much I’ve progressed,” she says. “I was one of the toughest cases Mass General has ever had. Now I’m working with the heart I have left. I have heart disease and working on that is my primary job.”
Heffernan acknowledges that her heart disease will always severely restrict her activities — she must sleep at least 12 hours a day to function — but her illness has brought her many gifts as well. In An Arrow Through The Heart, Heffernan writes:
This year of guilty languor; of slow, minute observations of nature; of quiet contemplation; of time to be angry and move through it; of receiving and expressing love — is required by anyone seriously ill to achieve physical strength and spiritual peace. I am living proof that you cannot separate matters of the heart from the muscle, as scientific research is finally agreeing.'’
Heffernan wrote the memoir as a way to help other heart patients along the difficult path to recovery, but also to sound the alarm about the prevalence of heart disease among women, and even young women. She is donating the book’s profits to several heart-related organizations.
“As women, we do not take enough care of our own hearts — both the muscle and the spirit,” says Heffernan. “It’s extremely hard for women engaged in the prime of their lives — with babies, husbands, and jobs — doing all of it — to say ‘no, I come first.’ But I think it’s important to say ‘I come first’ for at least half an hour a day.”
July 3rd, 2006 at 9:29 pm
Roger Blanchette
Because Roger Blanchette has no memory of what happened that day in June five years ago, it’s his wife Debra who tells the story. First off, she says, the story might have ended very differently if the family had spent the night before — a Saturday night– on their motor boat off the coast of Massachusetts as they had originally intended. But because their daughter Audrey was leaving for sleepover camp on Sunday, they decided it would be better to sleep at home.
On Sunday, after packing their van for the trip to camp, Roger was in the kitchen cooking chicken and Debra was upstairs taking a shower. After she got out of the shower, their then seven-year-old son Henry came into the bathroom to tell her that his father was lying on the floor. He also said something about their dog, which Debra didn’t understand, but she assumed Roger was simply playing with the dog on the floor. When Henry mentioned that his dad’s eyes were rolled back, Debra dashed downstairs.
She found her then 62-year-old husband lying flat on his back. “His face was blown up and he was purple and gurgling,” says Debra. Audrey, then 14, who by now had joined her mother, felt for a pulse and was unable to find one. Debra called 911 and began administering CPR, which she had learned years before when she had taught swimming to special needs children.
A neighbor who was an emergency medical technician (EMT) responded first and began to help with the CPR. Within moments a police officer arrived, who happened to be cruising the area. And in a stroke of luck, he had with him a newly purchased portable defibrillator, a device used to restore the rhythm of a patient in cardiac arrest. The defibrillator identified Roger’s irregular rhythm as ventricular fibrillation, a very rapid, uncoordinated and ineffective series of contractions throughout the lower chambers of the heart. Unless stopped, these chaotic impulses are fatal. On the second try, the defibrillator jolted Roger’s heart back to life. He was rushed to his local hospital and later transferred to New England Medical Center (NEMC) in Boston.
Fortunately, the brief time during which Roger’s heart had stopped beating did no damage to his brain or heart. But an extensive cardiac evaluation — including cardiac catheterization and electrophysiologic testing — revealed that his irregular heart rhythm could return. So at NEMC he had an implantable cardioverter-defibrillator (ICD) surgically inserted under the skin on the left side of his chest. Wires connect the device to his heart. When the ICD detects a minor arrhythmia — or irregular heart beat — it delivers an impreceptible electric current to the heart to restore its normal rhythm. If that doesn’t work, it delivers a far greater jolt.
“I’m never aware of it,” says Roger, who went on to make a rapid and thorough recovery, thanks in large part to the fact that he had been in such good shape prior to his cardiac arrest. “Maybe I think about it once a month. But it’s not part of my daily life.”
Except once. About a year after the ICD was implanted, he was in the check out line at a store with his son and his son’s friend. He had just paid the cashier, who was counting out his change. Suddenly, he began to lose consciousness. “All of a sudden, I felt nothing…I was blacking out, so to speak,” recalls Roger. “The only thing I remember thinking to myself was: ‘I’m in trouble.’ Then my mind shut down. Before I hit the floor, the defibrillator went off and sent the electric jolt to my heart and started it pumping again. I let out a bellow and scared everyone in line.”
Roger left the store feeling OK, but a little shaky. He sat in his car with the two boys for about 10 minutes, to make sure that he was collected enough to drive. Then they drove home without mishap.
Roger says that at 68, he feels great. His defibrillator hasn’t fired since, which he attributes partly to his consumption of supplements containing Omega-3 fatty acids. These compounds — found in oily fish like salmon and bluefish — have been shown to significantly reduce the incidence of deadly arrhythmias, which can lead to sudden cardiac death. He also visits his cardiologist every three months to have his device tested.
Before his cardiac event five years ago, Roger said that he had no idea that arrhythmias were the underlying cause of so many heart-related deaths. He now knows a lot more about the vagaries of the heart’s electric currents and about the devices which save people like him. And he brought that new knowledge to a bigger audience when he testified in favor of a bill that eventually became law in Massachusetts in 1999. The so-called Good Samaritan law extends liability protections to laypersons who use automatic external defibrillators in public places like offices or planes to save the life of someone going into cardiac arrest.
This patient story may not be typical. Individual symptoms, situations and circumstances vary and response to therapy is not always the same. Please consult your physician or health care provider regarding your condition, treatment or any specific questions regarding your care.
The Automatic External Defibrillator (AED)
Automatic External Defibrillator (AED) The Automatic External Defibrillator (AED) is a portable device that is used to restore the rhythm of the patient in cardiac arrest. It determines the patient’s rhythm and delivers a shock through pads placed on the chest wall to stop a life-threatening disturbance of the cardiac rhythm. It is automated so that it may be used by non-medical personnel wherever there are people. Its portability, reliability, and accessibility have made it one of the most important technological breakthroughs of our time.
There are a number of advances in the AED design that have given AEDs widespread acceptance. AEDs have become more simplified, permitting their use by the general public. The AED has self-adhesive electrode pads that are placed on the patient after he or she has collapsed. The AED has a voice prompt that guides the user through the steps needed to defibrillate the patient. The AED has an automatic feature that interprets the rhythm to determine whether a shock should be given. Once a shock is given, the device immediately determines if the rhythm has been successfully converted.
The AED has been shown to be extremely accurate in determining whether a shock has been given. Its sophisticated computer algorithm prevents errors in classification of the rhythm. Its ability to make these determinations without human assistance has permitted its use by trained laypersons.
The AED is extremely effective in delivering a shock that successfully converts the rhythm. Important advances in optimizing the way the energy is released have results in a very high rate of conversion. In addition, the long lasting lithium batteries currently used in these devices require minimal maintenance.
As a result of the portability, ease of use, and reliability, the AED has placed in numerous locations, such as schools, offices, sports facilities, and airplanes. Numerous police and fire departments have adopted the AED for use in their emergency vehicles. Rapid access to the AED has markedly reduced the time to convert the rhythm and resuscitate the patient. Since time to intervention has been shown to be the major factor in patient survival, rapid interventions using the AED are saving lives.
The cost of the AED is now approximately $2000-$3000 and is expected to decline further as more units are placed throughout the country. Most states have adopted “Good Samaritan” laws protecting laypeople using an AED to resuscitate a patient in cardiac arrest. These important advances have led to the rapid spread of AED technology throughout our communities.
July 3rd, 2006 at 9:29 pm
Lawrence Beckmen
Lawrence Beckmen is a retired construction worker who has always led an active life. When he was in his sixties, he began to experience an alarming symptom. “Once or twice a year, for no apparent reason, I would just pass out,” he says. “It was frightening; once I fainted while I was standing in line with my wife at a picnic. I never knew when it would happen and it worried me — what if I passed out while I was driving?”
Mr. Beckmen was afraid that it might be his heart, “I had a heart valve replaced in 1982 and I thought it might be related to that,” he says. He decided to go to the Mayo Clinic in Rochester, Minn. There, he underwent a complete evaluation by electrophysiologist Win K. Shen, M.D. An electrophysiologist is a cardiologist with special training in the diagnosis and treatment of heart rhythm disorders. Fainting - doctors call it syncope (sin-ko-pea) - is sometimes a symptom of an abnormal rhythm of the heart, which shows itself in this unexpected and frightening way.
Doctors at the Mayo Clinic ordered a number of tests for Mr. Beckmen, including an electrocardiogram, and echocardiogram (ultrasound of the heart), a stress test and a tilt table test. None of these tests revealed what might be causing his bouts of fainting.
“When we applied slight pressure over the artery in his neck, however, we were able to reproduce the feeling of faintness and we could detect a slowing of the heart beat and a drop in blood pressure,” said Arshad Jahangir, another electrophysiologist at the Mayo Clinic.
Because of this special symptom, and the normal test results, the doctors were able to tell Mr. Beckmen that his problem was not related to the valve replacement surgery he’d had years before. Instead, the diagnosis was carotid sinus syndrome, a type of fainting known as neurocardiogenic syncope. “It’s caused by a nerve reflex in which the heart or vascular system overreacts to pressure over the carotid (neck) artery,” Dr. Jahangir said. Symptoms usually occur with neck movement, such as while shaving or turning the head while reversing a car, or from wearing a too-tight collar. “When this happens, the heart rate and blood pressure can decrease dramatically. The result is severe lightheadedness and fainting and, often, the patient falls.” The elderly are particularly vulnerable to this type of fainting because of age-related conditions that may limit blood flow to the brain or medications or other factors that may cause them to become dehydrated.
Fortunately, carotid sinus syndrome can be treated. In Mr. Beckmen’s case, the doctors implanted a pacemaker that detects when his heart rate slows down - one of the effects of the exaggerated nerve reflex that precedes a fainting episode. When this happens, the device paces the heart at a faster rate to prevent or minimize his symptoms. It worked for him, and allowed him to continue to maintain the lifestyle he enjoyed before, without the fear and worry that had disrupted his daily routines.
Several months ago, Mr. Beckmen suffered a heart attack that was not related to his carotid sinus syndrome. “While I was in the hospital, they tested my pacemaker and said it was still working fine after all these years.”
Today, Mr. Beckmen is 78 years old. Despite his medical problems, he continues to be physically active. “I mow my own lawn, trim the bushes and do work outside. We also have an active family life - my wife and I have four children and many grandchildren who all live within 30 miles of us.”
“It’s been nearly 10 years since I had my pacemaker implanted,” he says, “and I’ve never had another fainting episode.”
This is a story that ends on a happy note; like many others who have experienced this problem, Mr. Beckman’s active lifestyle has been restored through the use of technology.
July 3rd, 2006 at 9:29 pm
Sebastian Hitzig
Sebastian Hitzig’s story begins with an event that seemed insignificant at the time: he stepped on a toothpick that punctured his foot. The ensuing infection was treated by a physician and once the pain and swelling went away, 24-year-old Sebastian forgot about the incident.
What Sebastian hadn’t realized is that the infection lingered in his system. Several months later, on October 14, 1995, his father, Rupert, found him unconscious on his bed, bleeding from his nose. The right side of his body was paralyzed. Rupert rushed his son to the emergency room at Harbor UCLA Medical Center in Los Angeles. The news was grim: he had suffered two strokes, his lungs had collapsed and his kidneys were failing. The emergency room physicians told Rupert his son was dying. “He was the sickest patient I’ve ever seen,” remarked one of the physicians who treated him.
Sebastian was diagnosed with bacterial endocarditis, an inflammation of the tissues around the heart. His foot infection had traveled to the valve that connects his heart to his aorta — the main artery pumping blood through the body. And as Sebastian’s heart beat, blood clots carrying the deadly infection circulated to other vital organs, including his brain, kidney, spleen and lungs. Blood clots had also caused bleeding in his brain and surgeons feared an operation would trigger a massive stroke from which Sebastian would not recover.
Sebastian Hitzig (center) with his parents, Rupert and Karen Hitzig, at their home in Los Angeles, 2002.
The infection had also reached the sac surrounding his heart, and cardiac surgeons decided they had to operate. When they opened Sebastian’s chest, they found far more damage than they had anticipated. “It was as if the heart and aorta were plastered against the sternum. There was a hole where the aortic valve should be,” one doctor said. The infection had destroyed the sinoatrial (SA) node — the heart’s natural pacemaker that produces steady electrical signals stimulating it to contract and pump blood. A pacemaker was implanted to replace the SA node.
“Because of the damage done by the infection, my heart beats too slowly on its own, about 30 to 40 beats per minute,” says Sebastian. A man his age could expect to have a resting heartbeat of 60-100 beats per minute. “The pacemaker compensates for the damage,” continues Sebastian. “Without it, I wouldn’t have survived, or I would be living the life of an invalid.”
Sebastian stayed in the hospital for more than three months and went on to make a remarkable recovery, building up his strength by working out regularly. He vowed to complete a marathon with his pacemaker.
But several months later, in October of 1996, Sebastian was working out at a gym when his heart went into ventricular fibrillation (a heart rhythm disorder in which the pumping action of the lower chambers of the heart — the ventricles — becomes rapid and chaotic) and he fell to the floor unconscious. He had suffered sudden cardiac death (SCD) an abrupt loss of heart function caused by the dangerously unstable heart rhythm. Death can occur within minutes if emergency treatment is not performed. An emergency team arrived within minutes with an external cardiac defibrillator, a device that shocks the heart back to its normal rhythm. SCD is the most common cause of death in the U.S., killing 350,000 people every year. Sebastian was one of the lucky 10 percent of victims who survive.
An electrophysiologist, a cardiologist with expertise in diagnosing and treating heart rhythm disorders, determined that Sebastian had a type of Long QT Syndrome (LQTS), a heart rhythm disorder. Patients with the syndrome are vulnerable to very fast heart rhythms known as torsade de pointes. When these rhythms occur, no blood is pumped out of the heart and the brain is quickly deprived of oxygen. In many cases the person faints and then suffers sudden cardiac arrest, which is exactly what happened in the gym. Sebastian may have had LQTS since birth or it may have been caused by his heart surgery.
LQTS can be treated effectively. Sebastian’s electrophysiologist inserted an implantable cardioverter-defibrillator (ICD) in his abdomen, a pager-sized device that connects to his heart with wires. The ICD monitors his heart rhythms and when it detects a dangerously rapid heart beat, stimulates his heart with electrical impulses to restore its normal rhythm.
Today, Sebastian is a healthy, active young man, splitting his time between acting and public speaking. He has become very involved in heart-related causes, serving as a board member of the American Heart Association and a councilor and fundraiser for a camp for kids with heart disease, Camp Del Corazon. He also did a stint as the patient ambassador and spokesperson for a manufacturer of cardiac devices.
When he speaks publicly, he often talks about the theme of conquering fear, drawing on his two near-death experiences. He also volunteers to speak with patients who are candidates for ICD therapy. “Sometimes, patients who have just been diagnosed with LQTS or other heart rhythm problems have not yet experienced a sudden cardiac arrest like I have,” says Sebastian. “They may not understand why they need this device. I talk with them about the security I feel knowing that the ICD is there. I go to the gym five days a week. I play basketball with my brothers. I’m very active. I want to feel the ICD in my abdomen, to know it’s there and will save my life if I need it.”