**2. My aortic heart valve history (the first four decades)**

I was born in 1940 with an undiagnosed aortic heart valve defect. When I was 4 years old, my granddad gave me a two-wheeler bicycle. I considered myself to be a pretty good athlete based on my interactions with my buddies in the neighborhood, but I quickly noticed that I did not have the stamina to ride my bike up hills. However, all the other kids in the neighborhood had no trouble riding up hills. I knew something was wrong, but being a little kid, I thought very little about it.

In 1951, General Dwight David Eisenhower (Ike) was elected President of the United States. I was 10 years old. Ike served two terms as president from 1953 until 1961. My grandfather was a devout supporter of Ike, and his devotion to Ike caused me to pay special attention to Ike's health, especially from 1955 until Ike's death in 1969. In 1955, Ike had a massive heart attack. In the 1950s and 1960s, there was little being done for cardiac infarctions. Nevertheless, a legendary and highly respected physician by the name of Paul Dudley White was rushed to Ike's side [2]. White was a pioneering cardiologist and advocate for preventive medicine. Ike's cardiac team prescribed long term use of anti-coagulants (non-traditional treatment at the time). In addition, White prescribed light exercise, cessation of Ike's heavy smoking, and a revised diet. White remained Ike's cardiologist, and over the remainder of his life, Ike had at least four other myocardial infarctions, a stroke in 1957, and 14 other cardiac arrests. Ike's case is an amazing example of a strong-willed leader who benefited from having complete trust in his cardiologist. White successfully used his public forum as Ike's cardiologist to educate the public about heart health. Little did I know at the time, but Paul Dudley White's path and my path would 1 day cross.

Early in my freshman year in college, 1958, I decided to try out for the college's freshman basketball team (I was 17 years old). In those days, freshmen were not allowed to join a varsity team. The physician conducting the physical was concerned about my heart and referred me to a heart specialist before he would approve me joining the team. The referral cardiologist listened for quite a while to my heart with his stethoscope and suggested it might be best if I did not play competitive sports. However, he wrote a permission slip for me to play if I felt strongly about it. He told

me that I had a loud aortic valve murmur, but he could not tell what the cause might be. He felt it better not to stress my heart with the rigors of competitive basketball. I played college basketball for one semester and then dropped out. I would sometimes need to leave the court and throw up, and frequently I did not feel well after vigorous exercise.

Later in my freshman year in college, but now 18 years old, I had my tonsils removed. The physician performing the tonsillectomy also listened to my heart. He told me he had heard many heart murmurs in his career, and he felt certain I had a bicuspid valve. He told me I would not live much past my early 40s and that I should plan my life accordingly. Today, his warning might seem overly harsh and misguided, but remember, that was 1959. The first mechanical replacement valves did not take place until the 1960s [3]. The physician was advising me based on what treatments were known to him to be commercially available at the time.

Growing up, our family was attended by a General Practitioner (GP), but that physician never mentioned a heart murmur to my parents or to me. I asked him about my heart murmur when I was 22 years old, and he told me lots of people have heart murmurs and he did not think it was overly significant. A couple of years later I saw another GP, and he referred me to a cardiologist who listened intently to my murmur and suggested I just wait and see what might happen and recommended I take no further action for the time being. However, occasionally I would have angina or angina-like discomfort, and that discomfort was always worrisome to me.

In 1967, now 26 years old, I moved from the West Coast to the East Coast and started being treated by an Internist specializing in the treatment of heart disease. The internist sent me to a local clinic for an x-ray in the hope that it might show calcification on the aortic valve if such calcification in fact existed. The results of the x-ray did not clarify much about my condition. The x-ray showed extensive calcification in the heart, but it could not be determined exactly where it existed in my cardiovascular system. However, the radiologist believed that the calcification likely was in the aortic valve area. Remember, MRIs and CT scans were not yet in use at that time [4].

I told my internist about my chest discomfort, and he prescribed nitroglycerin sublingual tablets to ease my discomfort. He told me to always carry the tablets with me and to dissolve one under my tongue whenever I had angina discomfort. I put a couple of the tablets in a small envelope and carried them with me in my wallet for several months. I used them a couple of times and did not like the way I felt when using the drug, and besides, I did not notice any improvement in my angina. After a couple of years, my internist told me it would no longer be necessary to use the nitroglycerin tablets.

When I was 28 years old, my internist sent me to a major hospital (near where I was living) for a heart catheterization. That procedure did not go well. I was taking a full aspirin at the time (on a daily basis) for my migraine headaches and because my internist thought that aspirin also might be helpful for my heart. The hospital did not give me any instructions about ceasing the aspirin before the catheterization. In fact, I had heard that a possible side effect of the catheterization could be a blood clot. So, I mistakenly took two full aspirins on the morning of the procedure. The two physicians performing the procedure gave me blood thinner, and after they wheeled me back to my room, I internally bled an estimated two pints of blood into my groin and leg. The hematoma on my groin, and the black and blue discoloration of my entire leg did not clear up completely for about 5 months. The good news for me, however,

#### *Perspective Chapter: Complication Using TAVR – A Patient DOI: http://dx.doi.org/10.5772/intechopen.112120*

was that the cardiologists performing the procedure did not see any need for further medical intervention involving my heart condition.

When I was 30 years old, my Internist referred me to another Cardiologist at a different major university hospital in the area where I was living. The Cardiologist performed a heart catheterization (my second). The next morning after the catheterization, the Cardiologist asked me if he could present my case at his rounds, and I agreed. Around 11 a.m. I was wheeled out of my hospital room, down a corridor and through a door leading directly onto the stage of an auditorium with about 300 people in attendance. The cardiologist was presenting data from my catheterization to the audience when I arrived in the theater. There were two other physicians sitting in chairs on stage, but they were located off to the side of the stage. One of the two other physicians appeared noticeably older than the physician sitting beside him on stage. Clearly, the cardiologist who performed my catheterization was center-stage and appeared to be fully in command of the audience. I was very surprised. I had expected "rounds" to mean I might meet and discuss how I was feeling with maybe a handful of young physicians. The cardiologist briefly introduced me to the audience, and then he continued with his explanation of the blood pressures in my heart chambers and connecting blood vessels as determined by the catheterization.

At first, he spoke about how he had found no blockages in the arteries feeding my heart muscle, and that made me feel pretty good. He then began to discuss the calcification he had found on the aortic valve. Again, reviewing the pressure numbers from the catheterization, he said that he was recommending that I immediately be scheduled for a replacement valve. Remember, I'm 30 years old and being told in front of an audience of 300 people that I need open heart surgery. My jaw dropped. With great aplomb and apparent satisfaction with his diagnosis, the cardiologist took a seat in an empty chair next to the older physician still sitting onstage. The older physician then rose to address the audience.

His comments were brief. He said, and I will never forget his words, "This patient may surprise you. I do not recommend surgery at this time." No sooner had he uttered that statement than all hell broke loose on the stage and in the audience. Apparently, it is rare for one physician to contradict another physician, and especially in front of an audience of 300. There were murmurings and wild conversations throughout the audience. The cardiologist who had been presenting my case jumped up and began yelling about how he had been misunderstood. Someone, who I did not see, walked up being me and whispered in my ear, "You listen to Dr. White, he's God to you." Bingo! All of a sudden, it became clear to me that the older physician on stage was none other than Paul Dudley White, the physician who had attended President Eisenhower. The cardiologist who had performed my catheterization was jumping around on stage like a wild man and ordered that I be removed from the stage and taken back to my room immediately. A nurse quickly pushed me in my wheelchair out the backdoor of the stage. I do not know how ordered was restored, but it was a wild time for all involved. I doubt there has been anything like it since.

The cardiologist who performed my catheterization visited me in my room later that day. He repeated to me that I needed a replacement value urgently, and that I should not listen to Dr. White because he was old and did not understand modern medicine. I told the cardiologist that I had decided to postpone the heart valve replacement, and I went home the next morning. The cardiologist wrote a letter to my internist and told him I needed valve replacement surgery and told him I should get

a Multigated Acquisition Scan (MUGA) every 3 months to check for changes in my ejection fraction or to check for any other changes in the heart functions.

Dr. White's advice not to rush into surgery clearly influenced my decision to put off surgery. Also, there were a couple of other reasons that informed my decision not to replace my aortic valve at that time. One, I was working for a publishing organization, and while we did not publish medical journals, we were the recipients of a regular medical journal that I read religiously when it crossed my desk. The journal frequently contained articles about heart valve surgery with pictures of failed "ballcage" or "ball in cage" valves removed from cadavers. Frequently, a metal prong from the cage was broken, or in some instances the ball was missing. I could see why it would not be a good outcome for a piece of metal to be loose inside the cardiovascular system let alone for the ball to break free and travel through an artery until it became stuck. Surgical replacement using tissue valves had been introduced at this time, but they would not last very long primarily because it was not known how to adequately preserve the tissue valves. Another reason I decided to delay surgery was that I had read an article written by a surgeon who said to "remember that absent strongly compelling evidence to the contrary, the best heart valve is the one you are born with." In any event, I knew about all the shortcomings of replacement valves at that time and was both relieved by Dr. White's advice and most willing to follow his advice.

My decision to delay surgery was made overnight as I lay on my hospital bed. However, from that time forward I thought of my life as being pre-and-post heart valve surgery. I was convinced that I would need surgery at some point and that that point might not be too far away. Assuming the likelihood of surgery not being too far off impacted all decisions about my personal life for the rest of my life.

In the early 1970s, I began my MUGA scans every 3 months. These scans required the injection into a vein in my arm of a radioactive chemical called technetium-99 m-pertechnetate (Tc-99 m). I would lie on my back and a special camera would take pictures of my aortic valve as the blood pumped through it. At the end of the exam table were bicycle pedals I could pump to elevate my heart rate. For some exams I pumped the pedals and other times I did not [5].

My ejection fraction (EF) was always around 60%. This meant that 60% of the blood in my left ventricle would pump out each time my heart took a beat. A normal heart will have an ejection fraction of about 50–75%. This meant that my EF was perfectly normal. There was one anomaly: when I pumped the bike pedals and my heart rate increased, my EF did not increase. The only way my heart could deliver more blood when needed was by pumping faster. My EF never rose above 60%. For a normal heart, the EF goes up with increased heart rate. However, this was not a factor in determining whether or not to replace the valve. The MUGA scan every 3 months went on for several years with no change in my EF, and my internist eventually decided to scan every 6 months, and the six-month scans went on for several years with no change in my EF. Eventually, my internist agreed with Dr. White and ceased all scans. After every scan I was told to go home and drink plenty of water to flush the radiotracer out of my system; and I did as I was directed.

In case you were wondering, the echocardiogram (echo) was just beginning to be used in the early 1970s [6]. An echocardiogram is totally noninvasive: there is no radionuclide injected into the blood. In the early 1970s, the pictures from an echo were not as clear as they are today. In addition, the results from an echo were not as accurate as the results from a MUGA especially involving EF data. Use of the echo has grown in popularity, and over seven million echocardiograms are now performed annually in North America. However, the MUGA scan is still widely used today as well.
