Thinking Out of the Box: Defibrillator Surgery Offers New Hope

A box won't define me anymore. I won't feel like I'm carrying a small "purse" or camera anymore. It will be implanted inside me. The defibrillator will be part of me. I may face new obstacles in my recovery, but with two heart-related operations in six months under my belt, I've become a stronger person -- inside and out.
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The sound of a piercing alarm shattered the afternoon calm. A recording followed: "Machine activated, bystanders beware." As I rushed for a cab to get me to my cardiologist's office, the alarm kept blaring. The bystanders around me looked concerned. A red light from a small box hanging by a strap to my hip blinked ominously. The alarm blared once more. The voice kept repeating itself. I hastily reached for my box and fumbled as I tried to remove its battery. "Wee-O-Wee-O," went the alarm. The cab passed me by. The man's voice issued another warning. Finally I pulled out the battery. My heart was pounding. Not a good thing.

This has been my reality for the last five months. There have been a few "false alarms" from the 3-pound black box always hanging at my side. Some people have asked if it's a camera. Others have joked that it looks like a "murse" (a man's purse). It's neither, I've explained. The box is an external defibrillator attached to a "life vest" by wires. The vest is outfitted with electrodes and metallic-like pads that grip my chest and back. In the event of cardiac arrest, I'll receive a jolt that will shock my heart back into rhythm. Now, six months after a massive heart attack that resulted in quadruple bypass surgery, another surgery looms. Soon an "Implantable Cardioverter Defibrillator" (ICD) will be put into my body. According to the patient guide: "If it senses a dangerously fast heart rhythm, the ICD delivers electrical impulses and/or shocks to restore a normal heart rhythm." So one box goes and another one gets put in. I'll no longer have to deal with the cumbersome portable box I've worn 24/7.

Great news, you say? It's not that easy. For the many Americans who will get the small electronic device implanted into their bodies, there's a lot to consider. Many patients experience anxiety. The patient guide states: "Other feelings such as fear, depression and anger are normal too." I've experienced these very feelings with my external defibrillator. Now, as the date for my ICD surgery nears, I realize this latest procedure is critical. My doctors have informed me that without it, I'm at increased risk of sudden cardiac death. That is because of my history of heart attack. My heart has been seriously weakened. Although another surgery is scary, it's time to put these fears aside. It's time to think out of the "box."

I received my first "box" about a month following my quadruple bypass surgery. My cardiologist, Dr. Dayana Eslava, informed me that my "ejection fraction" was quite low. She explained that an ejection fraction is the percentage of blood that flows through the body after the heart contracts. My fraction or percentage was 20 percent. The average for most people is 55 percent. Dr. Eslava told me that wearing a portable defibrillator was a precaution -- an important one. Without it, she said, I was at risk for "sudden death." The news startled me. After my open heart surgery, I believed I was on the quick road to recovery. Now my cardiologist was telling me I needed to wear an external defibrillator. I wondered if I could increase my "ejection fraction" by more "cardio" at the gym. Dr. Eslava explained that in some cases exercise could increase the fraction. But if the heart was damaged, I might not be able to raise the percentage significantly. She explained that in that case I would need another surgery to implant an ICD.

I had suffered a serious heart attack in May. An artery supplying blood to the heart had become totally blocked. As my cardiologist explained, the blockage cut off critical blood supply to a part of the heart muscle. It caused that part of that muscle to die. Still, I was hopeful. For the next few months I increased my cardio activity. Besides hitting the treadmill, I took long walks at a quick pace. I entered a cardiac rehabilitation program at Beth Israel Hospital in New York City. Three times a week for about an hour each session I would walk on a treadmill, ride a stationary bike and work out with weights. I was monitored by hospital clinicians. I wore adhesive electrodes. My heart rhythms were conveyed on a computer screen that the clinicians watched closely. All the while I was wearing my portable defibrillator box. I was confident I'd be able to skip another surgery. Finally, it was time for a sonogram test that would record my "percentage." But when the results came back, it was clear that the ejection fraction hadn't budged. Still 20 percent. I became depressed. I wondered if I would ever be able to return to a normal life. Before my heart attack, I had worked out five times a week. Would another surgery set me back?

At the same time, my "external" box, or defibrillator, was always on my mind. Walking down the street, I'd think people were looking at it strangely. I would try to hide the "box" under my clothes. I found myself constantly explaining what I was wearing. "If you're wondering what this is," I would say, lifting up the leather-encased camera-like device, "it's a defibrillator, and it will send a shock to my heart in the event I have a heart attack."

My friends would make fun of me. "Chuck, why are you always leading with the heart attack?" my pal Daniel would ask. Many times the alarm would go off unexpectedly. Once it happened inside a restaurant. Although I successfully removed the battery and stopped the alarm I felt patrons and waitresses were suspicious. Could I be a terrorist? Was the box a bomb? I was self-conscious and fearful. I was allowing the box to define me. So I sought out psychological counseling. I found an excellent therapist. "You've put all your fears into that little box," he told me. "You have to go beyond that." He was right. And now a new reality. My external box will be replaced by an internal one. On the one hand I'm relieved I won't have to wear a confining life vest attached to a box. The vest has caused some blistering rashes. But on the other hand I'm undergoing another surgical "procedure" -- my second one in six months.

So how exactly does an ICD work? It has two parts: a pulse generator and one or more leads. The generator is a light metal case outfitted with a battery and circuitry. The battery gives an electrical charge. It will send impulses or shocks. It will control the timing at which the impulses will be delivered to the heart. The leads are wires that will be placed in my heart. Those wires will carry electrical energy from the ICD to the heart. The leads will be threaded into the heart through a vein. If the ICD senses a life threatening "tachycardia" (a very rapid heart rhythm), it will deliver an electrical charge to restore a normal rhythm to the heart.

Dr. Emhad Aziz, a prominent cardiac electrophysiologist, will perform the procedure. He has assured me that implanting an ICD is a simple operation with little risk. Dr. Aziz says the case will be implanted in my upper left chest -- barely visible under the skin. After the scars heal, the ICD will be virtually undetectable to the human eye, he says. But I worry about complications. Some patients develop bleeding at the incision site. According to my patient's guide: "In rare cases, the procedure may lead to more serious complications, including damage to the heart and blood vessels, a punctured lung infection and blood clots." Still, I am confident the benefits will far outweigh the risks. The implanted defibrillator will give me a kind of life insurance. It will send electrical charges to my heart that will prevent cardiac arrest. "In a month you'll even be able to play tennis," Dr. Aziz says. I smile to myself. Too bad I don't know how to play.

My meeting with Dr. Aziz made me come to a new realization. A box won't define me anymore. I won't feel like I'm carrying a small "purse" or camera anymore. I won't have to think about it or explain it anymore. It will be implanted inside me. The defibrillator will be part of me. I may face new obstacles in my recovery, but with two heart-related operations in six months under my belt, I've become a stronger person -- inside and out. My heart may still be damaged, but my spirit is soaring. With my new "box" there's a much better chance of living longer and living healthier, too.

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