Hi folks! Welcome!
Jerry had ascending aortic aneurysm surgery in February of this year, 2013, including a Dacron prosthesis. What would be a wise approach to marathon and other training in his case? He asked, so I want to provide the best answer I can find.
As a result of experience with an abdominal aortic aneurysm stent graft surgery in 2010, combined with a decision to return to Ironman training, I find myself approached increasingly for advice by those undergoing a similar experience. Each time I wonder how to help people find the information they need in order that they can make the best decisions for themselves with respect to getting their lives back on track. Just asking their doctor is not good enough, it requires a lot more.
This post is being written [with permission] in response to a question posed by Jerry Katell, on the Heartosaurus website, as follows:
Excessive Exercise after Open Heart Surgery: “I am interested to hear what other people have experienced and have to say about this.” by Larry Katell.
FitOldDog’s Response To Larry’s Question: In spite of an extensive background in Pathology (the study of mechanisms of disease) and endurance training, when I consider providing advice on exercise following aortic surgery I ask myself a wide range of questions related to rates of wound repair, application of safe and appropriate training loads, graft or stent endothelialization, integration of aortic stents and Dacron prostheses into adjacent aortic tissues, the impact of such constructions on local and remote vascular physiology and hemodynamics, device-specific risks, and so forth. I’m always seeking the weak link in the chain that might just take us down during training.
One man’s survival of open heart surgery and return to life to run the New York City Marathon with his surgeon one year later. Highly recommended reading by FitOldDog.
I also have concerns about how my comments are interpreted by those with little biological knowledge or medical training. Sending a message is one thing, but how it might be interpreted upon receipt is quite another. This is why I always say that it is critical to keep your health professionals in the loop, especially the surgery team and cardiologist, if they have time to listen.
But then, there was precious little advice for me out there when it came to Ironman training, thus this blog.
I don’t think this situation has changed a great deal with respect to sports following aortic surgery, be it in the case of Alan and golf, myself and Ironman, or Larry and marathons.
In my opinion, it is up to the individual patient to make their own risk-benefit assessment for their sport by following their heart, whilst becoming educated in the nature of their condition, combined with the best medical advice they can find.
For instance, Benjamin Carey at age 37 had open heart surgery to install an ascending aortic Dacron prosthesis, due to an aortic aneurysm, and one year later he and his surgeon completed the New York City Marathon. This fascinating and instructive story is presented in Benjamin’s excellent book, Barefoot in November.
Did Benjamin return to marathon training too soon after surgery, taking an unnecessary risk, or did he make the right decision?
A while ago, in response to a request on Twitter, I wrote a blogpost providing guidance on how to approach exercise following a corrective surgery for aortic dissection that had been carried out two years previously. On rereading the guidelines in this blogpost, I still consider my advice, which is further developed in my Aortic Surgery Recovery Guide, to be sound. At his request, I provided Jerry Katell with a hard copy of my guide, which is now available as an e-book.
Recently, out of curiosity I asked Jerry how things were going, and I received this response (remember, Jerry had his open heart surgery only 5 months ago):
“Kevin, Ran the Pacific Palisades 10k on July 4th -good news, no walking or stopping even on steep switchbacks up to Will Rogers Park – bad news it took me 84 minutes putting me 8th out of 10 in the 70 to 74 age group and way towards the back of the overall pack – not used to that bad a performance but I suppose I shouldn’t complain, I did it and had no problems. Hopefully I can bring my pace back to what I was used to sometime soon.”
Is Jerry trying to bring his running pace back too fast?
Even though I completed the Lake Placid Ironman (extremely slowly and carefully) one year after my aortic stent placement, it took me a full two years to feel that I had fully recovered from a surgery that was much less invasive than Jerry’s.
Three years later my performance is finally back on track.
Modification of FitOldDog’s Ironman Training Approach For AAA Stent Protection: As I returned to endurance training following my surgery in 2010, the last thing I wanted to do was stress or displace my stent, with the risk of a premature demise. As a result of careful research and contemplation, I (1) gave up use of the rowing machine and inclined leg press machines in the gym, (2) use a full restraint seat belt in cars, and (3) place airplane belts as low as possible to catch any pressure on my hip bones rather than my lower abdominal soft tissues, and (4) stand up on very rough roads on the bike to avoid percussive shocks to my distal (lower) aorta. I also (5) restrain intensity training, (6) replacing it with less intense exercises combined with increased volume. All of these changes are directed towards protecting my lower aorta and the stent that holds it together.
One of many great photos by Jerry, this one taken during a bicycle trip in the Loire Valley in France. Click image for Jerry’s photo portfolio.
I’m sure an ascending aortic Dacron prosthesis comes with its weak points, and I wonder what they might be – I can think of a few. As I want Jerry to continue enjoying his remarkably active life, including a fascinating photographic side-career, I started to wonder about the risks that he might be taking if he ramps up his training too quickly.
A chain is as strong as its weakest link. What is Jerry’s weakest aortic link, I wonder? Impatience, I bet!
What we really need is clear advice from the research community, especially those familiar with the integration of stents and prostheses into aortic structure and function. I have questions, and I’m sure Benjamin, Larry, and Alan (a golfer with a 4.2 cm. diameter ascending aortic aneurysm) do also. Here are some of mine, and all input would be much appreciated:
- Is my AAA stent graft or Jerry ‘s Dacron insert likely to endothelialize? If so, this would have me much less concerned about the formation of clots and emboli.
- Does an ascending aortic Dacron prosthesis negatively impact aortic arch dynamics (energy storage and recoil for instance), to impair cardiac vascular perfusion during diastole? I would expect a delayed, and thus less efficient, cardiac perfusion due to reduced compliance and elasticity in the prosthesis, versus the powerful aortic elastic laminae that generate the recoil needed to provide blood to the heart muscle as it relaxes after systole.
- Are there particular activities of concern for such a graft, which Jerry might want to avoid, especially for the first few months or years following surgery?
- Should Jerry consider shifting his training emphasis away from intensity towards volume combined with improved biomechanics? I recommend this approach for Ironman training with a stent or for aging in general, for that matter.
- Is there any kind of stress test that can be applied to installed Dacron prostheses or AAA stent grafts to assess training impact?
- Is anyone working on materials for such devices, Dacron or whatever my stent is made of, to increase their compliance and energy storage (elasticity, storage modulus) characteristics, which would reduce the risk of adverse effects, such as hypertension or impaired cardiac perfusion?
Live your dreams, but do so wisely, Larry, Alan and Benjamin, as I hope to meet you inspiring guys one day.
Remember, we are following in the footsteps of an inspiring woman, Pauline, who is now running again following her open AAA repair.
-k @FitOldDog
Kevin, you know how I’ve been struggling to figure out if I should keep playing golf with my ascending aneurysm. This one is much tougher. I myself would never do anything extreme such as a marathon after surgery, I could never muster up the courage. Why doesn’t he contact Dr. Allen Stewart as he has the most knowledge of training for a marathon after AA surgery. He was really helpful to me in making my decision to keep on playing golf.
Alan
Hi Alan, yep, it’s a conundrum. We each have to choose. In cases such as ours I’m never sure which of the following apply:
1. All we have to fear is fear itself.
2. All we have to fear is stupidity itself.
3. All we have to fear is impatience itself.
4. All we have to fear is ignorance itself.
We each have to carry out our own risk-benefit assessment, along with appropriate research, to avoid 4, and thus 2, but as athletes surely we can cope with 3, whilst I really think that the biggy is 1.
How’s golf feel? Which reminds me, body awareness is still one of the key skills in my book.
Thanks for your comment, it’s much appreciated.
I (we, my stent, Rupert, and I) leave for my 7th. (Rupert’s 3rd.) attack on the Lake Placid Ironman on Friday. We take about a week getting there and doing our taper workouts along the way. Fun!
Cheers,
Kevin
Kevin, what I fear the most is losing the fear and then doing stupid things come into play.
Hi Alan, the answer is to shed the fear (we all die, eventually, so die before you die; easier said than done), and use this survival energy to gather information, massage it into knowledge, and apply this to the generation of the wisdom needed to do what your heart desires, which surely isn’t killing oneself for no good reason. You seem to be doing exactly this, my friend – you are an inspiration for this old fart. Fascinating topic, which you and I (and everyone else, but most don’t know it), have to address every day as we chose how to live this day. Happy Day! -kevin