Bicycling Blogger Restarts With An ICD: Part 1

My blog has been a little silent these past 3 years. But my life has not. It was almost completely silent. Metaphorically, my life took the cycling-equivalent of a sudden left turn through three lanes of oncoming traffic! Luckily I dodged all the cars... see: How CPR Saved My Life from June 2009. Exactly 3 years ago today, I started riding and racing down a slightly different road.

Here's a summary of how things have been for me, post-cardiac arrest.

A Change Of Gears

I spent the rest of the 2009 bike racing season wondering how to train. Should I be doing big miles, sending me far from home, away from immediate medical attention? Should I be doing any more training at all? I basically switched gears... to no gears, or rather a fixed gear, for the rest of 2009.

Besides road racing, I had been track racing for a few seasons too. For two reasons, I decided to focus the remainder of my 2009 racing season on the track. Reason 1: The workouts could be done either at a velodrome, or near home - both places relatively close to medical attention should I need it. Reason 2: The racing takes place, of course, at a velodrome, where there are lots of eyes about, meaning again, I'd be close to medical attention if needed. The result? Two Bronze medals (Power Omnium and Endurance Omnium) at the 2009 Canadian National Track Championships.

But What Happened To Me?

After much head-scratching with my primary cardiologist, Dr. Suhaib Alkurtass, in November 2009 he referred me to Dr. Evan Lockwood, a cardiac electrophysiologist (EP) - basically a cardiologist who specializes in the electrical wiring of the heart. Dr. Lockwood reviewed my case, and at first glance didn't think there was anything substantial, until he got a detailed look a my ECG.

There, he spied something called early repolarization; a very subtle condition that looks as if the heart is getting ready for its next beat ever-so-slightly early. In most people it is completely benign. However, Dr. Lockwood conveniently remembered reading (the phrase, "mind like a steel trap" came to mind) the May 2008 New England Journal of Medicine (NEJM) article "Sudden Cardiac Arrest Associated with Early Repolarization" (Haïssaguerre et al, NEJM May 8 2008 358:2016-2023). It described a study of the association between early repolarization and sudden cardiac arrest in fit, normal weight, middle-aged men.

All of the research subjects had had sudden cardiac arrests at rest. By the time they had been entered into the study, every subject already had an Implantable Cardioverter Defibrillator (ICD) implanted. And all had a median 8 +/-6 additional cardiac arrests during the 5 years they were followed during the study. Do the math: 8-6=2. Every subject had at least 2 more cardiac arrests in 5 years, and all were likely only alive at the end of the study because they had had an ICD implanted.

Then, within the same week that I saw Dr. Lockwood, I discovered that a new research paper was about to be published in the December 2009 issue of the NEJM: "Long-Term Outcome Associated with Early Repolarization on Electrocardiography" (Tikkanen et al, NEJM December 24 2009  361:2529-2537). This was a retrospective study of Finnish men. They had data for about 10,000 subjects over 30+/-11 years. It found a similar high correlation between early repolarization and sudden cardiac death.

Perhaps when something dreadful happens, the universe will speak to you - and sometimes quite loudly! One study within about a year of my incident and my EP happens to remember? And within the week that I see him I discover a new study is about to be published with a very similar finding?

Dr. Lockwood presented my case at Grand Rounds here in Edmonton, and his colleagues (I think there were about 10 of them) unanimously agreed that I should have an ICD. The choice was ultimately mine though, so I took a few days to weigh it all out.

Decision-Maker Time

Again I found out how the universe seems to work with serendipity more often than not. I had recently read Get Smarter: Life and Business Lessons by Canadian billionaire Seymour Schulich. It's a book he filled with little life lessons that helped him in big ways throughout his business career and life in general. In there he described a process of analysis he called The Decision-Maker. I applied it to the decision that lay before me: should I really have the ICD implanted?

Schulich's Decision-Maker process is like making a pro-con list, but with an added element to help minimize the emotions in the process, and get right down to the rationality of your decision. On one sheet of paper you list all the positive points, and give each one a 0 through 10 rating based on its importance to you - the higher the score, the more importance it holds. On a second sheet you do a similar process with all of the negative points, but here a score of 10 means it is a major drawback. Next, add the positives and then the negatives. If the positive total is at least twice the sum of the negatives, then you should do whatever you're analyzing. If you don't hit that two-to-one comparison, then either don't do it, or take a look again and see if you've really covered everything and have it scored correctly.

I think the Decision-Maker is a process that helps to balance decision making, so that one particular point doesn't swing the whole decision.

No doubt, the ICD would make my chest look ugly, and turn me into a bit of a cyborg. You can't hide this thing in the chest of an athlete. It's about the size of a small cellphone, and is implanted just beneath the skin on the left side of the chest muscle, a little below the collar bone. From it a wire snakes into the sub-clavicle vein where it is made to slither its way down into the right ventricle of the heart and bury its head in there.

The wire (actually called a "lead" or "electrode" because it is more than a simple wire) senses the electrical rhythms of the heart, and also provides the pathway for the electrical shock to restart the heart if needed. It can even provide pacing stimulation, as the ICD can also be set to run like a pacemaker. It's really like having a small cardiac computer dedicated to monitoring your own heart. In the physician's lab, through a wireless interface, the device can be re-programmed and data downloaded from it.

The battery is not rechargeable though. Once it gets near the end of its service life, the whole device needs to be removed - a rather simple procedure compared to the initial implantation. A small slit is made in the skin to remove the ICD. The lead can be left in place and re-used, so long as it's still in fine condition. It has a simple set of terminal screws to re-attach it to the replacement ICD.

My Decision-Maker Analysis

Besides the aesthetics of the device in my chest, I'd have to start avoiding strong electromagnetic (EM) fields. This provided a bit of irony for me. I used to be a radar engineer. I spent many hours of my career working inside radar stations, surrounded by EM fields. Though I've never seriously considered returning to the field, having the ICD would forever rule that out. And in airport security lines I'd always be bypassing the screening machines and be subject to hand pat-downs.

But the way I looked at it, when it came to my beloved cycling the ICD shouldn't become a real concern. My physiological problem that we were dealing with happened at rest. Early repolarization actually disappears as heart rate increases. Under load, my heart should be fine, unlike most other arrhythmias that are either triggered by higher heart rates, or get worse as heart rates increase.

My only real concern might be getting caught up in a bike crash with the device receiving a direct blow, or something like that. I've been in many bike crashes, and have scars on all my pointy bits (elbows, shoulders, hips, knees) but none on my chest. The only way I could see that the ICD might get hit is if someone were to run me over while I lay on the pavement. That could happen, but it is one of the most least likely things to happen in a typical bike race. And if I really started to get anxious about that scenario, I could always stick to time trials and individual pursuits.

So my analysis of reasons not to have the ICD implanted was really going nowhere. Their Decision-Maker scores were all coming up really low. And certainly none of them scored a 10 on my Decision-Maker analysis. I seemed to be looking at issues around the little inconveniences the device would present or concerns I could mitigate through simple avoidance. So how about the case for the implant?

Being a man of science, I had to agree with the expert opinions, the research, and the simple math (median 8 - range 6 = 2, i.e., not 0). I needed an ICD to ensure I wouldn't wake up dead again within the next five years or so. It didn't appear I could do anything to avoid this. No mitigation. No guarantee that my wife would be handily beside me next time. No guarantee that she'd be able to execute absolutely perfect CPR again and bring me back with no brain damage (at least none that I know of, but I do see the occasional Man In Black watching me from afar now, but I assume they've always been watching me ;-) - they watch you too, no?).

My wife, my children, my parents - they could all sleep soundly at night without the worry I might be gone in the morning. Those are all high scoring Decision-Maker points in favour of the ICD.

It all seemed to come down to a matter of aesthetics (how I would look and feel living with the ICD) versus having a full-time device carefully monitoring me, ready to intervene when (not if) my heart stops again. The ICD had to be the most simple solution. I had my decision.

And thanks to my Canadian universal healthcare system, I did not once have to weigh the financial cost of the ICD or the implant procedure - somewhere in the neighbourhood of $30,000 for the device alone. And I don't care what people think about "universal" medical care leading to long waiting lists; in my experience they do not exist for medically emergent procedures. You see, within 11 days of my first visit with Dr. Lockwood I was under his knife in his Electrophysiology Lab in the Mazancowski Heart Institute at the University of Alberta Hospital.

Stay tuned for Part 2 coming next week. In the meantime, grab a subscription to BicyclingBlogger with one of the handy methods over on the right side of the blog so you don't miss publication of Part 2. Your email address is only ever used by me and the blog to stay in touch - never rented, sold or shared with anyone else. Also stick around here a little longer today and check out all the other useful content I've got published for you to use - Because You Can Go Faster!

Link to Part 2