Episode 2? I had no idea that my original article was “Episode 1.”
Yes, I was delighted at how a stent to clear a coronary blockage instantly transformed my heart function and mostly restored my energy levels. What Episode 1 didn’t say was that there were a few other partial coronary blockages of my left anterior artery that didn’t get fixed, either because they were too minor to meet the threshold for stenting or were too awkwardly located to safely stent – for instance, a lesion at a 90-degree intersection.
The knowledge that I still had these unrepaired little time bombs – that‘s how I thought of them – proved to be a source of great anxiety. This resulted in my first full-on panic attacks, complete with my wife, at great urging, driving me to emergency in the middle of the night. I was annoyed at the behaviour of hospital staff who didn’t seem to understand the urgency of the situation – I was dying! Or so I thought. They knew better. But since I was a recent cardiac patient, I did get a fairly complete medical workup to confirm everything was OK. I’m embarrassed to say I put hospital staff through this routine several times. Guess I’m just a slow learner… although I did learn that anxiety issues are as tenacious as they are unwelcome.
An Issue Hiding in Plain Sight
One aspect of the extensive diagnostic testing that preceded my stent in March of 2021 was an echocardiogram. Virtually the same process as a prenatal ultrasound, except the technician was taking videos of my heart and valves rather than pictures of a baby in the womb. “Fascinating to see my heart valves flapping away” I wrote in Episode One. One of the things the technician noted was an atypical arrangement of my aortic valve. “You have a bicuspid valve,” she said. “Is that a problem?” I asked. “Not necessarily,” she replied. “It’s just something we need to keep an eye on with an annual check.”
And that’s what happened. My wife and I made a joyous return to our beloved Tucson for eight weeks at the beginning of 2022; a lot of cycling each week seemed to confirm I was OK, although the 2021 stent repair wasn’t exactly transformational: in my estimation I still “sucked on hills.” While I could almost keep up with the faster riders in the group, there was still that feeling in my chest that the engine just wasn’t putting out the power. It wasn’t the sort of feeling that would have me going to emergency; rather, it was just the familiar sensation that something was holding me back. With my heart having recently been repaired with the stent, I figured it was still a case of inadequate lung capacity. An unpleasant reality that I would just have to live with; after all, it had been my companion for decades.
With our return to Canada in March I was booked for the annual echocardiogram. Again, the assessment of the bicuspid valve was “moderate stenosis (narrowing). Continue to monitor.” Nothing to worry about. I happily Zwifted while waiting for better riding weather.
Riding Back Home
One of the problems with belonging to a cycling club with a core of long-time, dedicated members is that over time, everyone gets fitter and faster. It’s actually kind of annoying. And with a trend toward winter trail riding, a larger percentage of club members have started riding year-round. The obvious problem with that is you can’t rely on “winter hibernation fitness decline” for a lower Spring road ride pace. And of course there’s Zwift, so no matter how miserable the winter, people who rode B1 in the Fall and Zwift throughout the winter are still ready to rock in Spring with at least a B1 (or B1+) pace.
I had a fairly long history of hanging with the B1s, but the Spring and Summer of 2022 were tough. I attributed my inability to stay with the group to the factors listed above. While Tucson had been great, I also found myself performing there at a level below expectations. Perhaps my expectations needed some adjustment? That was hard to stomach, and it was mostly a matter of pride. And speaking of pride, my daughter had occasionally been Zwifting on my account (true confessions) which meant that my best recorded efforts on certain sprints and climbs were in fact her best efforts. She is a strong rider and was consistently kicking my butt with average watt outputs besting mine by 50 or more.
And then around the end of August 2022, it was a case of déjà vu all over again. Not only was my most energetic butt-busting effort on the trainer coming nowhere close to matching my daughter’s wattage on specific segments (the data-rich Zwift experience showed I was actually in decline), but I began to experience a familiar heaviness in the chest. Oh man, I thought – I’ve seen this movie before.
A Short Drive to the Cardiac Unit – Again
In the movie to which I refer (see Episode 1) the protagonist drives to the hospital in the middle of the night, thinking he has pneumonia, only to find he has something far more serious. Having learned that consulting with medical experts is a really good way of dealing with the unknown, it seemed a good idea to do that again.
The admission routine at Royal Jubilee Hospital was efficient and cordial – again, arriving in the middle of the night and having the status of a former cardiac patient helped grease the wheels. The familiar arterial hardware was inserted and the battery of tests began. While the ECG tracing was not definitive, it did suggest something going on, and I was discharged with an appointment for a follow-up echocardiogram. Knowing that my history revealed a bicuspid aortic valve, medical staff clearly thought that should be checked – even though the “echo” five months earlier had shown no cause for concern.
The echo in September of 2022 was a revelation – and not a happy one. As a cycling friend who was a cardiac surgery nurse in a past career explained, “bicuspid valves generally work fine until they don’t.” Meaning the transition from fine to seriously not fine can be a steep slope – and so it was in my case. In the few months since my last echo my condition had gone from “moderate stenosis – continue to monitor” to “severe stenosis – urgent surgery.” That got my full attention, and a place in the triage lineup for cardiac valve replacement.
What exactly is a bicuspid valve?
The aortic valve is THE valve regulating the flow of oxygenated blood from the heart to the rest of the body, including the heart itself. A proper functioning valve has three triangular cusps, or flaps, which when closed resemble the Mercedes 3-pointed star (see the diagram below). The “bi” in bicuspid indicates (bicyclists are likely to guess the answer to this) two flaps, typically the result of congenital malformation. Those with an engineering bent will instantly see that the bicuspid arrangement results in less than complete opening of the arterial channel, meaning less blood flow, and importantly, less ability to hang with the group in situations requiring high cardiac output, such as sprints and climbs.
FUN FACT: 1 to 2% of the population are born with some variation of a bicuspid valve. That’s 100 to 200 riders on a weekend morning with 10,000 Zwifters online! Do I have your attention now?
The Main Event
After a couple of false starts, typically a result of being bumped due to genuine life-and-death emergencies taking precedence, I was finally prepped and wheeled into the operating theatre on November 28, 2022. Just as it was with my stent procedure, I was more fascinated than frightened.
While every medical system has its merits and faults (the Canadian/American system debate continues, as it will for a long time to come), what is indisputable is the effectiveness of the Canadian triage-based system for allocating priority care to those with serious conditions. As my deteriorating valve had allowed me to rise to the top of the triage ladder, I now got to enjoy the focused attention of an open-heart surgical team at the top of their game. At least that’s the memory that was seared into my last moments of consciousness before it was “lights out” with the general anaesthetic. A brief glimpse of gloved and caped superheroes playing their roles with practised precision amid gleaming towers of equipment. Waiting off to the side was the new piece of kit ordered just for me: an Inspiris bio-synthetic aortic valve replacement with plates crafted from bovine (yes, cow – hopefully specially-raised cows) pericardium. For good measure I also got a single bypass arterial graft to ensure unrestricted flow to the left anterior artery where I had that potentially troublesome non-stentable restriction.
Minutes later (that’s how it seemed), I woke up in the cardiac recovery unit where, for at least the first 24 hours, it was one-on-one, round-the-clock attention from a team of highly experienced cardiac care nurses. Again, it was fascinating to observe the system at work, and to watch close-knit professionals devoted to their craft handle every conceivable challenge with panache. I learned that the staff turnover in this most demanding wing was almost zero; they love what they do. As for me, I was pretty much a gratefully helpless recipient of their attention and had to admit the drugs they administered were great. I gained new insight into the inspiration for some of the Beatles’ tunes from their Strawberry Fields Forever period.
While the Cardiac Patient Manual – a comprehensive tome – said that I could resume all my normal activities without restriction after three months, a wise doc buddy said that was optimistic, especially for high-output sports like group road rides. My wife and I did return happily to Tucson after three months, only for me to confront the reality that even though I had a new high-efficiency, full-flow valve, my heart muscle had still sustained a surgical trauma and would take time to heal back to its old self. A cycling buddy who had been an elite-level competitive runner added some additional wisdom: don’t push it. “Train Zone 2” for long hours was the mantra – both for cardiac recovery and for building base endurance capacity. There are a ton of YouTube videos on the subject, and the GCN guys do as good a job as you could hope for. It’s surprisingly hard to do as it requires solid, patient discipline and is almost impossible on group rides.
Here’s where Zwift came to the fore once again. With the re-engineering of the user interface I found Zwift more fun and more useful than ever before. The must-have feature for me was the 24/7 Group Rides (RoboPacers) organized by watts/kg. Now I could truly do Zone 2 for hours without having to constantly adjust or restrain myself – all I had to do was hang with robo-leader Taylor. (I wonder if any of my friends knew I was riding with Taylor Zwift! DAD JOKE)
And my doc buddy was right: it takes at least a year. As I write this, it’s one week after the 1st anniversary of my valve replacement, and I’m starting to feel the results of a healing heart. I’m back in Tucson, riding mostly with the “bigger dogs” and truly enjoying the occasional full-on climb. I’m confident (and grateful) that with consistent training my cardiac output will be what I’ve always hoped for. We’ll see…
- Pay attention when someone notes an anomaly in your physiology, such as “You have a bicuspid valve.” While it may not be a big deal today, it could be one tomorrow – learn about it. Bicuspid valves can also be genetically inherited, so if you have one, and have children, it’s a good idea to have your kids “echoed.”
- If you have any cardiac symptoms at all (see Episode One!), keep your diagnostics up to date. Have you had an echocardiogram? It’s easy, painless, non-invasive, and (I’m guessing here, you’ll have to do your own research) reasonably priced, the biggest cost element being the interpretation of the videos by a cardiologist.
Huge life-saving thanks to cardiac surgeon Dr. Kenny Kumar and his team at Royal Jubilee, and the terrific cardiac care nurses who manage the patient’s post-surgical entry into the real world. And big thanks to all the people who responded to Episode One with detailed accounts of their own, validating the importance of listening to your body and not “pushing through the pain” as many athletes do either on command or instinctively. The response I enjoyed most came from a fellow with an email address @zwift.com who said, “Your article is saving lives – probably mine! It would look really bad if I died on the job…