Fixing the Pump to Drink from the Well… (a primer)

I’ve always thought health stories are a bit of taboo, like an old lady telling you about her bunions or gall bladder – it’s not a necessary or a desired story that most want to hear. However, I have found other blogs that depict the situation I’m in and have been thankful that they shared the information. Ironically, this cyclist has such a similar path to my own that it’s a bit eerie (although his is much more involved and complicated than my situation thus far). At the very least, finding and correcting this issue will lead to much more activity on this blog… which as you probably know has recently sounded more like a field of cigales rather than a flurry of freewheels.

After going to the cardiologist, I was given an “Event Monitor” which you connect to 2 electrode stickers on your chest. When you feel a heart arrhythmia, you press the button and it records 30 seconds before you pressed the button (constant 30 second buffer on the SSD drive) and then another 30 seconds after. I headed out on a few bike rides and tried to catch a few episodes:
HeartrakSmart

Here is what a normal ECG should be with a normal heart rhythm:
NORMAL EKG
__________________________
When my doctor handed me my ECG I actually mistook it for an old Calculus 3 cheat sheet:
IMG3

There are not a lot of ECG images like this online so I’m happy to share if it helps someone.

The sensation is quite unsettling. It usually starts with a missed beat or breath while exercising and after that, it’s off to the races! You feel a bit annoyed or anxious and in my case, the heart pumps such that you can easily see it just by looking at my chest, even if I’m wearing several layers of clothing and a very thick ski sweater. If I’m riding the bike, my heart rate monitor immediately ignores the rhythm and dismisses it as noise or some other technical problem since a heart rate above 210 bpm isn’t possible under normal circumstances. Sometimes, I’ll feel a flutter and hope that it’s just a little cardiac bump in the road, but then I’ll look down at my Garmin and it simply displays ” – – ” confirming that my heart rate is now somewhere above 200bpm. At this point, my power output drops from comfortably spinning out 300 watts to suffering at 40 watts in a matter of 1-2 seconds. This phenomenon is called Ventricular Tachycardia (or “V-Tach” if you want to sound cool).

You might think that with the heart beating so fast, the blood and oxygen being circulated through your system would be impressive. However, V-Tach beats are so fast that the heart does not allow enough time to properly fill with blood, so it’s pumping away with abandon while hardly moving any blood at all. Some people become very dizzy at this point but in my case it just feels like you took a sip of wine. Probably something strong like a nice white from the village of Beaumes-de-Venise which was the start line for

The Start in Beaumes-de-Venise

The Start in Beaumes-de-Venise

this ride.

My V-Tach episodes can last anywhere from 10 seconds to 90 minutes. For me, the 10 second bouts are insignificant and the 2 minute episodes are the most typical. I’m usually very happy with a 2 minute V-Tach run because it just requires a quick stop and then I can resume riding (or whatever I was doing) after that. It’s the 20-90 minute V-Tach runs that are really no fun. Standing around that long at 200bpm in an agitated state while you get cold and your muscles bathe in an ocean of lactic acid isn’t intolerable, but I can think of better things I’d like to be doing.

So what really is going on here?

After visiting the cardiologist, my case looks very classical and surprisingly common for people in their late 20’s to late 30’s. I was diagnosed with RVOT-VT, a type of Ventricular Tachycardia (VT) which originates on the Right Ventricular Outflow Track (RVOT) of the heart. This leads to the question that just about everyone says to themselves after the doctor sits you down with any diagnosis:

“Geez, what is that?”
“All these acronyms can’t be good.”
“I wonder what I did wrong?
“I bet it was that apple I ate yesterday that I forgot to wash before eating it. Stupid, stupid.” (facepalm)
“… or what if I ate the sticker!”

Turns out, RVOT-VT has no known cause and is ideopathic. It’s not genetic. It’s nothing you did, or didn’t do. To understand what’s happening, you have remember that biology class you had in grade school that you actually spent gazing out the window and doodling pictures in your notebook. Normally, with each heartbeat, an electrical signal spreads from the top of your heart to the bottom. As it travels, the electrical signal causes your heart to contract and pump blood. The process repeats with each new heartbeat. The problem with Ventricular Tachycardia is that a small spot in the heart misbehaves. It thinks it should be running the show, telling the heart when to beat. So now the heart is getting TWO signals telling it when to beat. It’s the biological equivalent of the current situation in Washington. The end result is complete gridlock, nothing gets done, but it sure looks like it’s trying hard.


So How Does It Get Fixed? Do Nothing? A Filibuster?

The protocol for “fixing” RVOT-VT is actually proactive with a catheter ablation procedure. Since all blood vessels are basically roads to the heart, the doctor generally selects a large vessel such as one in your upper thigh or arm uses it like a highway to the heart with several flexible catheters being pushed through until they finally arrive inside the heart. One catheter has a special electromagnetic tip and is used to first create a 3D image of the side of the heart that it’s in (Right or Left). Here are some images I stole from a few different internets:

Ablation Mapping

Ablation Mapping

1-s2.0-S1547527108006231-gr2

Next, (I’m not 100% sure on the order here or if my info is correct) but as I understand it, you are pumped full of adrenaline to try and trigger a V-Tach episode. The sensor can then report back to the computer mapping system which spot in the heart was sending the bad signal… it’s like purposely sending the children outside unsupervised to see which kid is the bully. The image created is like a heat map, with red being the area where the little bugger is hiding out.

Once the red spot is found, the doctor uses another catheter with a special radiofrequency tip that can burn the heart tissue if it comes in contact with it. I’m not exactly sure how the doctor is able to position this flexible string-like catheter in the exact spot, but eventually he does and once in position with the right pressure, he burns the heart tissue in that area to kill it. On the 3D map, these show up as little pink spots. Here’s my map, you’ll notice the misbehaving red area and the pink polka-dots where the catheter burned the heart tissue:
3D Electroanatomical Heart Map

IMG-sm

Typically the surgery lasts 4-8 hours depending on the patient. After it’s done, you have to stay in the hospital overnight for monitoring. To keep a close eye on your heart rhythm, they place 6 electrodes or leads on your chest, connected to a big beige brick and stick it in the pocket of your fashionable hospital gown.
DSC_0844Meanwhile, down the hall there is what looks to be a computer lab with a few people gazing into several computer screens for 24 hours straight, watching real-time ECG output of every patient on the floor. And boy are they quick when something goes wrong! I’ll talk more about this when I get into the specifics of my experience.

So that is the general idea.
Catheter Ablation, however, is not 100% effective. Just about any overview of the procedure will say “some people who have the procedure may need to have it done again. This can happen if the first procedure doesn’t fully correct the problem.”

And that’s where we’ll pick up next time.

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One Response to Fixing the Pump to Drink from the Well… (a primer)

  1. Too Slow says:

    Wow, this is fascinating, just wish it weren’t happening to you! These days I feel like I’m in VTach whenever I even look at a climb. Not the same thing of course.

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