Training: Getting into the Details

Let's get into the numbers. First, a few things to go over.

Hardware: I'm using my time trial bike (an Argon 18) on a Tacx Satori trainer (older model, not a smart trainer like the current model). I'm using a Garmin computer and heart rate strap, and a first-generation Stages power meter, left crankarm only. 

Software: I really wanted to like Training Peaks, but I've gone back to my old software (with many updates since the old days) at Cycling Analytics (CA). Cleaner more intuitive interface and great about all the metrics I'm interested in right now. I'm sure Training Peaks and especially their WKO4 software are more powerful, but I found it frustrating to use. One reason I tried Training Peaks first is because it automatically calculates aerobic decoupling (see below) on every ride, which CA didn't. But now CA does, so no problem there. 

Absolute power measurements: there are problems with a left-side-only crank. It's measuring power from my left leg and doubling it, so anything other than a completely balanced power output from the rider will throw off the measurement. Aside from that, I don't have other power meters to compare mine to, so I don't know how well calibrated it is. That said, the power number itself isn't of great importance to an amateur rider, only the meter's consistency and accuracy relative to itself. I'm not fussed about it, this meter has the latter qualities. 

Functional Threshold Power (FTP): this is an important metric. It is a number, in watts, that is your maximum power output for one hour, in ideally rested condition. The most standard FTP measurement protocol centres on doing a 20 minute maximum effort, and taking 95% of that power. It's an important number because it's used for setting training zones and calculating training stress score (TSS). The best FTP measurement I ever achieved in my racing days was 268 watts. Personal goal to beat that number in the coming years.

Aerobic Decoupling: here's a really useful metric for me now. In a steady-state aerobic effort (high zone 2), split that effort in half. Take the ratio of average power to average heart rate in each half, and compare the drift. Usually, less than a 5% drift is considered good aerobic fitness for that duration.

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Now, to business. Post surgery, things look very different than they used to. Most importantly, it's impossible to make apples-to-apples comparisons to any data I have from before because I'm on a beta blocker, which affects how fast my heart pumps, and generally makes exercise harder. Hopefully I'll be getting off this medication soon, as it's prescribed for atrial fibrillation prophylaxis, and that hasn't been a problem for me. Test at the end of the month, fingers crossed. When I eventually do get off the drug, I'm just dying to compare numbers. 

FTP is out the window. I have no data to set a power benchmark and doing a test would be far outside my doctor-imposed limits right now. The usual power based training load metric, the 'training stress score' (TSS) depends entirely on your FTP, and so is useless to me. Instead, I'm relying on a heart rate based metric that Cycling Analytics calls 'training impulse' (TRIMP), or Training Peaks calls hrTSS. 

As FTP is related to power and TSS is calculated from it, TRIMP is calculated based on threshold heart rate, which is an equivalent sort of metric to FTP. Obviously my heart is running differently than it used to, and I'm not in any position to run a threshold test for power or heart rate. What I've done is set my threshold HR to a point where the top of my target HR range, 140 bpm, is the top of zone 2, the aerobic endurance level where I should be training now. My TRIMP scores are based on that. It's not particularly accurate on an absolute scale, but that's not really important. It gives me a way to assess how rides compare to each other, which is the important thing at this point. 

Anyhow, my prescribed heart rate zone for exercise is 110-140 bpm, and boy I didn't expect to be able to get to such a high rate of perceived exertion (RPE) at what was previously quite a comfortable heart rate. I'm running two days a week at the cardiac rehab, and cycling three more days a week at home. I'm also going to stick with the periodization schedule from Joe Friel's seminal 'Cyclist's Training Bible' that I used in my racing days, which is three weeks of training followed by a light week to recover. 

When I'm on the bike I get data from my power meter, which is really useful and it's another reason why the bike is my favourite way to exercise. 

All my workouts have followed this formula: 5 minutes easy warmup, then the work interval at the top of that 110-140 zone, then a five minute cool down. Over the three weeks of exercise, I've increased weekly: 30, then 40, now 50 minute work intervals. Here's an example of the data chart from a typical ride, with heart rate 'zones', as described above, coloured:

example ride.png

My first rides were pretty exploratory, but I soon hit my stride, though the numbers were woefully low, by my old standards. I have to remind myself regularly that those old numbers are not applicable right now.

Here are the key metrics from my first rides. Note that all this data is just for the work interval, not including warmup and cool down. 

Duration Avg Power (W) Avg HR Decoupling (%) TRIMP
30:00 108 133 7.08 35
30:00 105 136 6.53 40
30:00 126 139 5.77 40
40:00 133 134 -0.79 45
40:00 136 135 0.31 48
40:00 138 133 1.83 44
50:00 135 135 3.48 58
50:00 139 138 3.68 61

What I see from that data is, after the first couple of rides, a steady and fast increase in power output at an approximately steady average heart rate, and a fast increase in endurance as measured by decoupling, taking a bit of a hit as I increased from 40 to 50 minutes (probably due to both the increased duration and accumulated fatigue as I finish my first three week block), but still staying within a range indicating good aerobic endurance. 

Seeing as I'm still limited in terms of my HR zone, the plan is to continue to increase duration and strive to have good decoupling numbers going into longer and longer durations at the same heart rate. We'll see how far I can get before restrictions come off at some point, which I would assume would be the end of the rehab programme. I should actually inquire about that, as it would be a big let down if that wasn't the case. I know for certain that I'll have no long-term restrictions, but I should solidify that timeline. 

Exercising at Home

I used to take bike riding quite seriously. Back when I was childless and unmarried, I put a lot of my time and energy into training and racing road bikes, and a bit of cyclocross. For most of my life I hadn't lived an active lifestyle at all, so when I got the bike bug a few years after I moved to Calgary I was as surprised as anyone. But I came to love riding, and I really dug in to the metrics and minutiae of training seriously. I loved racing time trials, though I'm not sure if I ever really liked the other races. But the racing was the tiniest fraction of the hobby, though an important motivator for training. 

When I found out about my heart valve problem it was stressful in many ways, but in one way it was a great relief: I had been training hard and working very seriously at improving my condition on the bike, but I kept falling short. It was endlessly frustrating to me that folks who were haphazard in their training and spending a lot less time on the bike were outperforming me. In fact at one point I wondered if I might be suffering from some sort of low-level chronic affliction (much like four-time Tour de France winner Chris Froome, who famously suffered from bilharzia for years, and upon discovery and treatment began his meteoric rise to the top of the sport). The leaky valve explained a lot. The diagnosis left my athletic pursuits rather deflated, and learning that the possibility of a mechanical valve and the anticoagulant that comes with it left me wondering if I'd ever be able to really get back at it. A minor crash, a bump of the head, things that would be a drag for a normal person could be extremely serious or deadly for someone on anticoagulants, like a subdural hematoma, for example. 

But here I am on the other side of the surgery, no anticoagulants necessary, and cleared to exercise. My fitness is really starting from scratch, but I can draw on my knowledge from my racing days and use the equipment I've got to get back in shape, and hopefully get ahead of where I was in my leaky-valve days!

As I wrote in a previous post, I'm fussy about bikes. I'm choosing to do all my workouts at the rehab running on the track, but at home I'm doing all my cardio so far on my time trial bike on the stationary trainer. I was curious if my sternum would be ready for the weight that is necessarily put on the arms in any sort of bike riding, but having gingerly tested things out at first I found that it was no problem at all. 

I've always preferred my TT bike on the trainer as the style of handlebar offers a wider range of hand and arm positions, which is useful during an indoor ride. I don't have a chance of getting down into the aero bars yet, but I look forward to that. Back in the day my position worked well out on the road, but I could never seem to hold it on the trainer and I never could figure out why. Anyway, I'm using a Tacx Satori magnetic trainer, which has always been great.

The other key piece of equipment I'm using is a power meter, in my case a first-generation Stages brand, left-crankarm only power meter. There's a lot better, newer, and fancier out there, but this is what I've got and I'm familiar with its quirks. Is it accurate on an absolute scale? Probably not 100%. But in my experience it's been good relative to itself, and all my pre-surgery benchmarks were measured on this unit. So left crankarm power it is.

For non-cyclists, a power meter is a device that measures your body's output, that which you are putting into the bike, in watts. Power=work/time. Work=the scalar product of force, which is measured by the power meter, times displacement, which in cycling terms is measured as cadence, or revolutions per minute of the crank. What that means in practical terms is that the power meter tells you second to second how much energy you're putting into the bike. It's a great metric because it's instantaneous, unlike heart rate which takes some time to adjust to your level of exertion, and most importantly because it's unaffected by external conditions. Running is often measured by pace rather than power because running power meters are still in their infancy. But pace is a problematic metric because while running outside pace can be affected by many factors: wind, gradient, the surface you're running on. The same things affect someone on a bicycle. But with a power meter, I know that putting in 250 watts on a 3% uphill and a headwind is the same amount of effort as putting in 250 watts on a truly flat road with a tailwind. Simply, the power meter measures your input to the system (power), not the system's output (speed). And the relationship between power and heart rate is of paramount interest.

This is getting pretty technical. And it's going to get more technical as I dive in to my own (at this point very low) numbers in future posts. But it's a great way to measure progress, and I am indeed seeing progress at a rate much higher than I would have expected.

Cardiac Rehabilitation

I'm attending Calgary's cardiac rehabilitation programme which is sponsored by Alberta Health and run by Total Cardiology at the Repsol Sport Centre, formerly the Talisman Centre. I've been looking forward to returning to physical activity and getting back in decent shape for a long time. When I found out about my heart problem a couple of years ago it really took the wind out of my sails in terms of sport and fitness. 

Six weeks after my surgery I started the rehab programme. The first part is two classroom sessions that frankly seem like they were planned in a pre-internet time. That said, many of the people attending them might not have extensively researched all this stuff, but for a well-informed person these are long days presenting not a lot (but definitely some!) good new information. 

The first physical activity is a 'ramp test', at least that's the cycling term for this sort of thing. You're put on a treadmill that incrementally increases in speed and incline, and it's your job to keep up as long as you can. In this cardiac rehab context, you're wired up with lots of electrodes and your blood pressure is taken regularly mid-test. Tests like this get hard at the end, no way around that. Since this was the first physical effort over a brisk walk after my surgery I was very glad to be in a thoroughly supervised medical environment while I was doing it. 

The test is followed immediately by a visit to one of the programme's cardiologist, who reviews the data from the test. In my case he saw a couple of funny electrical blips, but nothing that raised any eyebrows. He said he was happy with my results and that it was basically what they hope to see at that point in recovery, so that was a relief. This was the appointment when I was sent for an x-ray about what turned out to be a pleural effusion, as I wrote about in an earlier post.

Also, they impose a hard systolic blood pressure limit of 160. At my maximal effort mine was under 150, so we're not worried about that number during exercise, and my medications are working well.

At the second classroom session I got two highly-anticipated pieces of information: first, my target heart rate zone for safe and effective exercise (110-140), and my rehab time slot (11:00 on Mondays and Wednesdays). 

At each session you check in and have a chat with a nurse or physiotherapist. Blood pressure is taken, and it's an opportunity to ask any questions. Then it's off to your exercise! I'm fussy about bikes, so I'm choosing to always run on the track for my activity there. The formula is always a 5-minute warmup, then your main work interval, then a 5-minute cool down. Sometimes someone form the programme will come exercise with you and check in about your work at rehab and at home. I'll detail how my own rehab is going in a later post.

Each session is ended with either a stretching routine or resistance training using bands. Pretty simple stuff, nothing fancy. I can go over those in detail if anyone's interested. 

All in all, I think it's a great programme. The level of personalization and one-on-one time is great, and it's so reassuring to be well-supervised while getting back to exercising.

Follow-up Appointments

I had my two-month follow-up appointments this last week with both my cardiologist and my surgeon, and they were both very happy. Here's a run-down of each appointment.

My cardiologist sees me way down at the South Health Campus, where the bicuspid valve clinic is. I had an echocardiogram, a process I'm very familiar with by now, which was followed shortly after by seeing the doctor. She was excited to hear how well my whole recovery had been going since the very start, and gave my heart and lungs a good listen. I laid on my back and she put her hands on and around my incision several different ways while I breathed deeply and she was happy with how the bone was healing. Not 100% yet of course, but solid and healing well. 

Knowing about the pleural effusion that I had, she listened to my lungs and commented that it was much much better, almost negligible at this point. It will finish clearing up by itself, hooray! I was not relishing the thought of needing to have it drained.

I mentioned my lack of pain from start to present, and she was glad to hear it. She said that some people have experiences like mine and some folks do have pain and, but they can't predict where any given patient will fall on that spectrum. Slight advantage if you're otherwise healthy and fit, she said. 

We talked about my prescriptions and what the plan was for the beta blocker, bisoprolol. It's prescribed for atrial fibrillation prophylaxis, and I've never had a-fib, not even right after surgery. I had a junctional rhythm for a day or two (very common), but that resolved without any intervention (also very common). I'm being sent for a holter monitor test (tracks your heart's electrical activity for 24 hours), which is mercifully set for pickup and dropoff at Foothills hospital very close to me, rather than needing to make the long drive down south two days in a row, like I had to for my 24-hour blood pressure last year. If it looks good then we'll probably cut the beta blocker, which would be great for me as I look forward to riding my bicycle to the limits of my (now meagre) ability. Once I get back in good shape I'm not sure how my cycling performance would be affected by a drug that slows down your heart rate. I was warned though: sometimes the surgeon has reasons to keep you on a beta blocker, depending on the specific layout of the aortic graft and other technical considerations. More on that below.

The doctor confirmed my intention to return to work in January, and decided to schedule my next appointment in December to make sure that everything is still on track. Going forward from then, appointments should be once a year for a while, and if things continue to look good they might spread out even further than that. Excellent!

 

Surgeon

I saw my surgeon at Foothills. He too was pleased with my recovery (and with his work), saying that my murmur was fixed and the coaptation of the valve (the coming together of the cusps of the valve) was excellent. He poked around at my bones and was happy too. He said that at this point my bone was pretty strong, that I wasn't going to make a wrong movement and have it come apart. Time for me to be exploring towards full range of motion. He advised me to rebuild strength slowly, which is very sensible (more on that when I post about the rehabilitation programme later). 

We talked about the beta blocker situation, and he said that if the holter monitor test was good then he would have no problem with me coming off the beta blocker! Great news! He also thought that I'd probably be off my ramipril in a year, which would get me down to just my daily asthma inhaler and a baby aspirin, which I'd be on for the long haul. I'm all for taking drugs as prescribed, but if we can shrink that list I'm happy. 

The one part of my chest that is still a bit sore is the very top of my sternum, the area between my clavicle and the top of my incision. I had been thinking it was a symptom of the bone not being healed yet, which makes sense since the manubrium is a thick, marrow-filled bone that takes a while to heal. But the surgeon had a different idea: that flesh was put through the ringer during surgery. The top and bottom of the incision have called the most attention to themselves during my recovery, and it makes total sense considering that that part of my body was stretched way open. Up top, the bone underneath moved aside as well, so I shouldn't be surprised that it's sore. Chest wall pain, not bone pain. That reasoning hadn't occurred to me, and I feel much more comfortable with that than what I was thinking before.

I was reminded that there are no long-term restrictions on me in terms of physical activity, so the sky is the limit. I just have to get off the ground in these first months. I won't be saying goodbye to my surgeon for good though. Annual appointments for now, hopefully moving to longer spaces in between, assuming all is well with my heart. 

 

All in all, pretty much a perfect pair of appointments. I'm making lots of exercise progress too, more to come on that.

Two Months

Two months post surgery, and I think everything is going really well. 

I feel like my heart is doing great. I've started the local rehab programme (more to come on that), and while I'm out of shape my heart seems to be recovering well and working properly. I feel like my energy levels are at least at pre-surgery levels. 

I have to trust that bone healing continues apace. I continue to have no pain and have not experienced any "instability or clicking", the two things that I'm frequently told to look out for. The sternum has three parts, and I'm having somewhat different sensations from each. From top to bottom, they are the manubrium, the body, and the xiphoid.

The body of my sternum seems to be doing perfectly. No pain, no instability, no tenderness to the touch, and no unusual sensation no matter my movement. Ideal, by my reckoning. 

The manubrium is interesting. It's a thick bone filled with marrow, so I think it takes a lot longer to heal than the thinner body and xiphoid. Mine evidently cooperated with the surgical saw, as my incision only extends as high as the junction between the manubrium and body. Post surgery, the area between the top of my incision and my clavicle was quite swollen. Having seen various pictures of other patients post-op, this is definitely normal. My swelling is much less now, but the area is still tender to the touch. No pain, no instability, and no sensation when I move in any way, but if I poke at it it's sore. 

The xiphoid is the lowest part of the sternum, the little nub extending below the lowest point where the ribs connect to the sternum. Again, there's no pain, no instability, and no tenderness, but here there is a real feeling of stretching out whenever I extend the front of my body, especially after slouching at a desk or sitting with poor posture on a couch. A good reminder to focus on proper posture.

In broad strokes, I'm mostly back to normal. Having started rehab I'm cleared to exercise and I have good guidelines on how to do that safely. I'll post about all that in more detail than you're probably interested in, but it's good for me to walk myself through everything. I still can't do any real lifting and so I'm not capable of wrangling my toddler on my own, so I'm still leaning quite heavily on my dear wife for that. But I'm pleased with how things are going and I'm looking forward to progressing even further. I see my cardiologist and my surgeon this coming week.

Six Weeks

Well, it's been six weeks since my surgery and I'm doing pretty darned well. I had my exercise stress test, a progressively more difficult treadmill session under close medical monitoring, that marks the beginning of my cardiac rehab today, so it was interesting to see where I am. Of course I'm in objectively terrible shape, but that's to be expected. My stress test results were good, right where the doctor said he likes them to be at this stage. There's a hard limit on my blood pressure right now of 160 systolic, but even when I reached exhaustion in the test it was only up to 145. This gives me a very safe buffer, as I won't be exercising at that maximal exertion level, but rather in a specific heart rate zone based on my tests. I'll get that number next week at a classroom session that's part of the programme. 

This good blood pressure during exercise (and good blood pressure beforehand) means that my medications are working well. I'm also tolerating them well, which I'm very glad about. 

The only concern the doctor had was that the lower lobe of my left lung didn't sound great, so I've been sent for a chest x-ray. Might be something, might be nothing. But if it is something and it can be treated (or expected to clear up on its own), that's great low-hanging fruit in my quest to get back to 4.5L of lung capacity. I got home from the test and checked with my incentive spirometer, and lo and behold I was up from 3.6L to 3.9L, thanks to my first session of intense exercise.

The six week mark is where the precautions regarding your sternum officially come off. I think that's crazy, because the bone is definitely not fully healed. Getting to 100% bone integrity is my top priority, because any complications about that could really cause problems getting back to the trumpet (which is still a long way away). So I've decided to be operating under the same rules as I have been, but allow myself to gradually nudge those limits outward. One of the nurses who I was asking today about caring for my healing sternum said that at this point it's really about listening to what my body is telling me. If I can, for example, reach above my head with no pain or discomfort, then I'm probably fine to do it. I will carefully and judiciously test my self-imposed boundaries at this point, but I'll play it safe to focus on the long game. Most of what I've read suggests that from six weeks to three months is the time in which things get back towards being normal, at least for folks who don't play the trumpet.

Good news: Klaus is coming home tomorrow. I've missed my dog a lot, and now I feel safe to have him at home. We'll keep him out of the bedroom entirely, as I think the only way he could hurt me at this point would be to jump directly onto my chest when I'm lying in bed. Kathryn will take care of the walking for now, but I got myself a running leash that fits around my waist, so I should be able to get started walking him safely soon. After six weeks away he'll be shaggy (he missed a grooming) and his nails will be long (time to get back to his bi-weekly visits to the retired cop/doberman breeder who runs a slick dog nails operation), but it'll be a big step towards getting back to normal to have him home.

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Update, July 6

I went for my chest x-ray this morning. They're walk-in only at the local diagnostic imaging place, so I crossed my fingers and went around 9:00. I literally had zero wait, a very pleasant surprise. Not long ago, around 1:30, I got a call from the cardiac rehab where a cardiologist had already reviewed the x-ray, and it turns out that I do have a small pleural effusion.

A pleural effusion is a buildup of fluid in the pleura, which is the membrane that surrounds the lungs. It prevents the lungs from expanding fully into the space that is holding the fluid. This is a common issue after surgery like mine. There isn't that much fluid built up for me, so the doctor said that it should clear up on its own and that there's nothing to be concerned about. I'm to go back in a month for a follow-up x-ray to make sure things have resolved themselves.

While of course this isn't ideal, the bright side is that I now know that the bottom of my left lung will open up more and get me back some air capacity. I'm still lacking a little over half a litre and I had previously thought that it was all way up high in my lungs, the area that I'm still hesitant to really work to expand due to my still-delicate ribcage, but now I know that that is not entirely the case.

Five Weeks

I haven't posted in a little while because there's really been nothing to post about. It's slow and steady, low drama and low stress. My drain holes are completely healed, and only two little knobs of scab remain at the top and bottom of my main incision. My lung capacity has inched up to 3.7L or so. 

My mobility is a bit better, so I'm able to shower and dry myself without assistance and I can get out of bed by sitting straight up from lying down on my back, not using my hands at all. I've been going for long walks, up to two hours, without perceiving any particular cardio stress. 

I'm still unable to cook properly, which is the main way that I'm still leaning on my wife for help. Slinging pots and pans around, and the force required to chop vegetables are still too much for me. 

The only moderately frustrating thing is that I occasionally find myself with some muscle soreness that I can't really do much about. For example, right now my back is a bit sore, probably from my limited ability to adjust my position when I'm in bed. I know this feeling, and all I want is to do some yoga, I know I'd feel fine after. But alas, I'm not recovered to a point where that is possible, so I've got to grin and bear it. 

And I miss my dog. Klaus is a standard schnauzer, an irrepressible and inquisitive medium sized dog. He gets all up in your business and would, without a doubt, have jumped on my chest and sent me back to the hospital. He's staying with my in-laws in Lethbridge, and he always has a grand old time there, but I miss him and I'm looking forward to having him back here. I start my cardiac rehab program at the Repsol centre next week, which is supervised by physiotherapists, a cardiologist, and cardiac nurses, so hopefully I'll be able to get some more clarity about what is and is not safe for me to do, and maybe that'll give me some clarity about when it's smart to have Klaus come home. 

A Free Half Litre!

Somehow between going to bed last night and waking up this morning I gained half a litre of air capacity. Same quantity as when my left lung seemed to 'unpeel', and I feel less resistance in my right lung now. That's 3.5L now, and getting back to my original 4.5L doesn't seem so unattainable anymore.

Three Weeks

 

Well, three weeks ago yesterday was the day of my surgery. I feel fine, though not back to my old self yet, of course. At this point my recovery basically looks like I'm lazing around the house and not contributing much. I'm spending easily more than an hour a day walking around the neighbourhood, I'm sleeping 8-9 hours a night plus a nap or two, and I'm not feeling bad. Here's a bit of an inventory of the different aspects of my recovery.

Breathing - I've been holding steady at about three litres for several days now. I had been at 2.5, but then I was reading in bed when I suddenly felt what I can only describe as a sensation of unpeeling in my left lung, and all of a sudden I found I had an extra half litre. Still waiting for my right lung to do the same, I can feel it trying to pull open when I take a big inhalation, but no luck yet. Patience!

Drain holes - The two holes below my sternum from the drain tubes are not a worry at all. The first couple of days home the scab would crack and bleed, so I decided to put some polysporin and a tegaderm on to keep them moist. That worked great for a few days, then I found that the surrounding skin was getting irritated by the moisture, so I thought I'd take a little break from the bandages. But things sealed up just fine, and I haven't gone back to putting any sort of dressing on. I found that the scabs would pull a bit (being on soft tissue only), and the scab would thicken from below as it bled or oozed imperceptibly. Not a problem, but the scabs got so thick they were catching on my shirt, and I was worried they would pull off. So I used a nail clipper and just trimmed those things down nice and thin, and there's been no problem at all since.

Numbness - A big incision always comes with some numbness after, at least in my experience. I had hernia surgery when I was younger, and there was an area of numbness around one end of the incision that gradually regained feeling over the following year or two. I have some reduced sensation near the bottom of my incision from this surgery, but I'm used to it now and I'm sure it'll creep back towards normal over the next couple of years.

Energy - I definitely feel more like myself now than I have since the surgery. I have no problems going for two 40-minute walks a day, though I do usually feel like a good sit-down or nap afterwards. I've never felt like walking or stairs or anything has been too much for me. I tend to settle into bed around 8:00, a while after my two-year-old goes to bed, and read for a good while before getting to sleep at 9:30 or 10:00. The little guy is always up before 7:00, so the whole house is. 

Incision - A little less than half of the incision scab has peeled away, and I was shocked at how little scarring there is underneath. I'm sure it'll be visible if not prominent when all is said and done, but it's certainly not the badass looking memento mori that I was expecting. 

Appetite - I have always been hungry at every moment of my life, and now is no exception. I've been craving protein very strongly, so we went out for sushi. There is nothing more delicious than eating the food that your body is desperately craving, and boy oh boy was that a good meal. I can't cook because I can't handle the hardware without hurting myself, so my wife has been taking over what is usually something I do most of, and she has been very accommodating of my cravings.

And honestly I'm at a loss for what else to recap at this point. Feel free to make requests. 

Oh, I had been waiting to watch 'The Expanse' until my convalescence, and now that I'm well and truly into it I can say boy oh boy is it ever good! Highly recommended. 

More when there's anything new.

 

Pain

Pain is notoriously unquantifiable, and difficult to describe. So when I was getting ready to go in for my surgery I wasn't sure what to expect, which was tough for a planning-type person like me. I'm sure different folks have very different experiences, but I feel like my pain management at the hospital was so good as to be completely invisible to me. I knew at all times that I could ask for more pain relief, but I never once considered it, there was no hint of a need. 

I recall regularly taking two extra-strength tylenol while in hospital. I’m sure that heavier drugs were used on me, but I don’t recall (perhaps due to the effects of those very drugs). Certainly, by the last day or two in the hospital I felt pretty lucid, and it was just tylenol for me. 

In my first couple of days at home I quickly tapered down to no painkillers at all: not to be a hero (that’s dumb), but because I simply didn’t have any pain. Now, I’ve taken a regular strength tylenol once or twice because of muscle soreness in my upper back (can’t stretch it out, of course), but that has been it.

This has been pleasant surprise overall, as what had been a matter of some dread pre-op has turned out to be a complete non-issue. Hooray!

All that said, I know that some people use strong painkillers and chemical drugs for off-label purposes. That's problematic for lots of reasons, but the one to be highlighted here is that when (not that farfetched!) you have a major medical event you definitely, definitely want those drugs to work as intended. 

Sleep

UPDATE June 6: Before I settled on sleeping in the chair I went ahead and ordered a big wedge pillow, which arrived yesterday. And boy oh boy, it is way better than sleeping in a chair! The comfort of actually being under the covers in a bed is so welcome. And the wedge is tall enough that I can easily sit straight up and get out of bed myself, a miracle! 

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Sleep is the most important part of recovery, I think. You never sleep great in the hospital with so much going on all around you at all times, not to mention being so early in the process that your body is still figuring out what is going on. When you get home and into your own routine, then it's super important to find the best way you can to get the most high-quality sleep.

First, remember: I cannot use my arms to adjust myself in bed or get out of bed. 

My first couple of nights at home were not great. I slept relatively well in the hospital bed, which had an automatic top half tilt adjustment. I found it best to lie mostly flat, but waking up in the middle of the night I would tilt myself up and have a drink of water, or whatever. Here at home, no such fancy bed. I thought that a similar flat position would probably be fine, or wedging myself up with some pillows. I found that if I started sitting up mostly, I was able to wiggle my way down to flat, but not the other way around. Well, this turned out to really not work for me. I would inevitably find myself flat on my back, super sore, and unable to make any kind of adjustment to my position by myself. 

One other odd thing: night sweats. Apparently this is a common aftereffect of anaesthesia, but it's super super gross to wake up in cold, wet sheets and have no way of moving yourself. 

But after a couple of nights of this, I reconsidered a chair that I had previously ruled out of my recovery plans: the classic Ikea poang chair. I've always found it incredibly comfortable, it's got a bit of spring to it, but it's too deep and reclined for me to get out of without using my arms, properties which also make it very comfortable to sleep in. And so it proved, as my sleep in that chair has been excellent, and the night sweats immediately stopped, either by coincidence or not. Getting out of the chair requires a helper, but it's as simple as tipping the chair forwards until I'm able to just stand right up. Easy!

It also has the happy consequence of freeing up the bed, so my wife can sleep there now. Quality of life for the person looking after you is a very important consideration. I'm relying on Kathryn for pretty much everything, so anything that makes things easier for her is good for everyone.

Post-op days 1-4

Day 1 post-op

I remember my wife Kathryn being there when I was being moved from the ICU to a regular recovery ward, along with my various tubes and attached gadgets. When I got there I was baffled by the other folks in my room just talking and talking. On the phone, to visiting family who hung around for a long time, and to any nurse they could lasso into a conversation. How were they doing more than the bare minimum of speaking only when necessary and just enduring? Didn't make sense to me. Presumably they were all at a similar point in the process as I was? I don't remember much from this day, other than the general impression that there were still a lot of drugs in my system and that this was a harder day to get through than operation day.

 

Day 2 post-op

This started off as a tough day. While the fog of the surgery-day drugs was still quite strong, I was more aware than previous days. This was the first day I saw the physiotherapist, who got me on the incentive spirometer, and I realized that my maximum inhalation was about half a litre. Yikes. We did a series of exercises, after which I could immediately get a full litre, so that was great motivation to get on those exercises every chance I got. 

During surgery your lungs just get all smooshed up, compressed by the business that's happening adjacent to them. The alveoli collapse and stick closed, so no air will get into them. Of course you lose flexibility and mobility of your ribcage from the operation, but that's a long-term project. The immediate goal is to literally open up your lungs again so they can fill what space they have available to them.

The main breathing exercise to achieve this is a simple series of three stacked breaths: a full inhalation, hold for a count of three, sip in as much air as you can, hold for three, then sip and hold again before releasing. The first time I did this I literally felt the pressure in my lungs decreasing as the little sacs inflated again during each of the three holds. I asked the physio specifically how far I should push into pain, and she said as far as I could. This exercise won't do damage. Each day since, I've set a new best inhalation. As I write this on day 5 post-op, I'm at about 2.6 litres of my pre-op capacity of 4.5 litres. I can tell that my ribcage still is barely moving when I take a deep breath, so I think I'm getting into diminishing returns until my bone is healed and I can really start going for it up high. 

The big event of day 2 was the removal of my chest drain tubes, the pair of which sucked fluid from the surgery site out into a little suction machine that came everywhere I did. Aside from the main incision, one or both of the exit holes of these will be the only other long-term scarring from this procedure, just below the bottom of my sternum. 

Now, this whole recovery procedure is a long parade of tubes being removed from your body, and they all felt very different from one another. They all felt uniquely uncomfortable, and various degrees of unpleasant, but never painful. The drain tube was a weird one, but the strangeness of its extraction was immediately overshadowed by an incredible feeling of physical liberation. Almost in a blink, I felt human again. This, the extraction of the drain tubes, is the the goalpost for in-hospital recovery. After this, everything came easily and felt so darned great relative to what was before. Beyond this, it has been just fine. 

A blood draw was taken each night around midnight, and while I slept really well on the first night without the drain tubes, your sleep rhythms are so thrown off by the whole process and environment that this wakeup never felt onerous. My blood came back that night with an elevated white blood cell count, which might mean that your body is fighting an infection, or is sometimes just a thing that happens post-op, especially in younger patients. We had to wait and see.

 

Day 3 post-op

This is when it started getting boring. I was certainly up and walking, but I can't recall if that started a day prior to this. Anyway, I definitely felt foggy, especially when I was up and about. My vision seemed not quite right, which I hadn't noticed prior. I hadn't so much as thought of looking at my phone or reading a book before this day, so I was surprised at how my vision wasn't cooperating to do either of those things. I was assured that was a typical effect of the drugs still working their way out of my system, and indeed that has proven to be the case. 

I caught up on some podcasts and listened to some music, and slept a lot. It was great to feel like a person again, no matter how compromised.

This evening's blood draw ended up coming back with my white blood cell count still a little higher than normal, but less than the last night's. A good sign that there probably wasn't an infection.

 

Day 4 post-op

This had been the stated target day for me to be sent home, for the preceding couple of days. It was the first day that getting up to use the bathroom (since the catheter had been removed the same day as the drain) felt like a fun outing and not like a major hardship. It was also the day that I learned that there were POPSICLES in the fridge down the hall that NOBODY HAD TOLD ME ABOUT, so I went on lots and lots of walks, and reaped commensurate rewards. 

I was apparently low on potassium, so I had to take two of the biggest pills I've ever seen in my life. The least fun pills of the process.

The last real piece of equipment to be removed from my much-punctured body was a pair of wires that everyone gets during surgery to provide an easy and effective way to get electricity right to your heart at any time during your hospitalization, in case things are going south. The wires were removed, which felt novel as it had been more than a day since something was pulled out of my body. One has to lie still for a half-hour following this particular extraction for observation in case of any internal bleeding caused by the extraction or anything else funny. All good for me. I had to wait the mandatory four hours between wire extraction and discharge, and I managed to slowly and carefully dress myself, then I walked on out of there. What a crazy few days.

Surgery day

I'm Home! It's been a whirlwind punctuated by intense boredom since my surgery on Tuesday morning. The TL;DR is that I'm home and doing well on day 4 post-op and I think my stay was just the right length. Here are the details I can recall of surgery day, more to come about those that followed as I have chance to write. Please don't hesitate to ask for clarification or further details, I really want this stage of my story to be a resource for anyone else going through heart surgery.

Operation Day

Early morning, 6AM call. I was planning on taking the bus, but the bus didn't start running early enough so there went my dream of that particular righteous story. The whole process through my discharge took place up on the 9th floor on the main building of Foothills hospital, very close to home for me. I had very little notice (I found out on Thursday before a long weekend for a Tuesday operation), so I was unable to get my last-minute bloodwork done beforehand, so they did that first thing. I was greeted by the nurses and staff, and asked to give myself an almost-complete wipe down with some serious disinfectant wipes and get into a hospital gown. 

Then I was given my first of many little cups of pills. If you have any difficulty taking pills I would really recommend working to get over that before you have any major medical event. I never had to take any meds regularly until my heart problem was diagnosed, and I had never really gotten the knack of doing it smoothly. I've since had a couple of years of experience with little caplets of ramipril, a blood pressure medication, and I'm good now, but I had to take some big chalky ones by the end (for low potassium just before I left hospital). 

Then I was given an ativan, and boy howdy, that's the pre-op finish line right there. I remember lots after that, but if you're worried about holding your nerve you have nothing to worry about after the ativan. Shortly after, I said bye to my wife and was wheeled away to the surgery/ICU part of the floor. A small parade of doctors came by to brief me and introduce themselves, I recall talking with the anesthesiologist and the perfusionist, who operates the heart-lung machine, and I'm certain there were others. I experienced no anxiety at this point, whatever I had had going was all ativaned away. 

Soon I was wheeled into the OR, which I recall as being the most thoroughly-lit room I've ever seen in my life. LEDs everywhere. I was chatting happily with the nurses who were putting lines in me and I recall not having a care in the world. My surgeon, Dr. Kent, stuck his head in the door and greeted me, then gave a everyone short recap briefing of what we were there to do: a valve-sparing aortic-root replacement if possible (David procedure), or if not, aortic-root replacement and replacement of my aortic valve with a mechanical one (Bentall procedure). I'll detail the implications of each in a future post. 

And I don't remember anything pre-op after that.

When I woke up, I felt like a zombie. I should emphasize first that never did I experience significant pain, from beginning to end of my hospitalization, and while I never felt like I needed to ask for additional pain meds I was always made aware that they were there for me and I shouldn't hesitate to ask for them. So, when I say I felt like a zombie I mean that I instinctively knew that my body was just functioning on a bare subsistence level. There was no panic or anything, just an understanding that for example deep relaxed breathing just wasn't going to be possible, and my job was simply to continue getting by while my body and the doctors started to sort things out. I have fleeting memories of the ICU, but almost nothing to latch on to. I recall the extraction of the carotid artery probe down into your heart that they put in when you're under, and it not hurting at all. I asked for a look at it after it was out, and I recall it looking pretty neat. 

My wife tells me she spoke with me briefly that night, but the nurses let her know that I almost certainly wouldn't remember anything, and that if she was there for her well-being that was great, but it probably wouldn't impact mine. 

I also remember being told that Dr. Kent was able to save my valve with a great result, so the big question that couldn't be answered until the procedure itself went the way I wanted it to. I don't think that how great that is for me going forward has really sunk in yet, but there will be time for that.

Tomorrow is the day!

A bit of a whirlwind here. I was told at my pre-op appointment that I'd probably get 1-3 weeks notice, but I got a call Thursday morning before the long weekend telling me I'd be in first thing on Tuesday the 22nd. I finished up my last week of concerts (the first Harry Potter movie live to film, good fun!) and my ongoing project to have all my trumpets squeaky clean for their vacation, washed and unplayed, has been successful. We've been getting the house in order and the bedroom all set up for me. 

After the call informing me of my date, I had a CT scan the next morning. I was told not to have any caffeine or alcohol before, as well as to avoid exercise. It turns out the reason for this is that your heart rate needs to be nice and low for the images to come out crisp, and if it takes hours of sitting around and application of beta blockers to get it where it needs to be then you're in for a long day. My resting heart rate is usually 60-65, but sitting in the waiting chair it was sitting between 67-73, which was too fast. The nurse said they might give me some beta blockers but I asked her to give me five minutes, and with good relaxed slow breathing I got it down to 62, which was good enough for them. They moved me into the machine, lying down, and I got my HR down to 57, so they got good pictures easily.

They gave me a spray of nitroglycerine right in the mouth, which dilates your heart's blood vessels and allows them to get better pictures. I went straight from my scan to work, and I mentioned to a colleague that they gave me that nitro and its manner of application, and boy was that a first. He chuckled and said that the violas probably didn't think it was the first time.

So I'm to be at the hospital at 6AM tomorrow. I'm really looking forward to getting this over with. And I'm very very curious about how good I'll feel after I'm recovered. My heart has been so leaky for so long that I think I probably don't even realize how tired and generally sapped I have been over recent years. I'll report back about that in six months or so. Next post will probably be 4-7 days after surgery, when I'm home from the hospital and all settled.

A brief overview of the story so far

There are lots of blogs on the internet about undergoing and recovering from heart surgery, but strangely the huge audience of brass players wondering about what it might be like to get back to playing professionally after undergoing something like this is dreadfully underserviced. I hope this blog will not only be a good way for me to get my thoughts down, but will help other people, musicians or not, get ready for and get back in the game after heart surgery. Expect this to be frank and not overly copy-edited; perhaps I'll polish things up later. For now, I'm just going to try to get things down.

Where to start? I suppose I'll dive right in. 

A couple of years ago, in February of 2016, I found myself in an urgent care centre with a gallbladder attack brought on by an overly ambitious encounter with a large assortment of fine cheeses. A gallbladder attack is no fun, and it was pretty scary to have sudden upper-right quadrant pain. I thought it might have been some sort of heart event, but luckily that was not the case. 

While I was being looked after, a doctor listened to my heart and asked "you know you have a heart murmur, right?", which was the first indication I ever had of a problem I'd been living with for my whole life. The gallbladder event was an isolated event, and I've had no trouble since. But I was told to follow up about my heart murmur. 

My GP sent me in for a transthoracic echocardiogram (echo for short), a non-invasive ultrasound of the heart. This revealed that I have a bicuspid aortic valve (BAV), a not-uncommon defect that substitutes a bicuspid valve of some sort for the correct tricuspid aortic valve. A tricuspid valve has three leaflets, and looks kind of like a skewed Mercedes logo; while a bicuspid valve has two leaflets and can be in several different configurations. Mine is pretty much 50/50, two equal leaflets, while for some people it's effectively a tricuspid valve with two fused leaflets, making a very different configuration. One of the four valves in a normal heart is indeed a bicuspid valve, so it's not a totally unfeasible configuration.

The problem is that a bicuspid aortic valve can get leaky. One big reason for this is that when you have a bicuspid valve your aorta (the main blood vessel taking oxygenated blood to the rest of your body) often ends up dilating over time. This causes the valve to be pulled apart and become increasingly leaky, and it also causes progressive weakening of the walls of the aorta, which can lead to pretty dramatically bad things. 

The normal diameter of the aorta depends on your body type, but mine was pretty big. The normal recommendation for surgery is to go when it reaches 5cm. Mine has been steady in the 4.8 range since we spotted the problem. But due to my job, which certainly puts stress on my circulatory system, and the relatively low risk of surgery for me due to my age and general state of health, my cardiologist and cardiac surgeon have recommended that we go ahead and do it, and I'm following their advice. 

My pre-op appointment is booked, and I'm waiting to hear about a surgery date. I assume this will all happen by the end of May, but the scheduling process is arcane and opaque, and I've decided not to stress about possible permutations of the schedule. I'll just take it as it comes, and be glad that the problem was diagnosed before my aorta went pop.