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Dr Larry Creswell

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Laurent Vidal, Elite Triathlete 1984-2015

November 15, 2015 By Larry Creswell, MD Leave a Comment

200px-Laurent_Vidal_Pontevedra2011_1

 

 

 

 

 

 

The very sad news came this week that retired French elite triathlete, Laurent Vidal, died in his sleep at his home in southern France.

There has been a worldwide outpouring of emotion.  I particularly enjoyed this video.

Life-threatening heart problems are unusual in Olympic-caliber athletes, but Vidal suffered an episode of cardiac arrest at the swimming pool last spring.  I wrote about that episode and his remarkable recovery in a blog post that focused on cardiac arrest, more generally.

After his recovery, Vidal shared very little about his diagnostic evaluation, any conditions that were discovered, and any implications regarding his prognosis.  He immediately retired from the sport of triathlon, though, and I suspect that he was advised that continued participation posed some danger.  He remained physically active over these past months, though, and often shared pictures of himself bicycling or hiking.  Media reports this week mention a pacemaker and I wonder if he actually received an internal cardioverter-defibrillator (ICD) for “secondary prevention” in case of a repeat episode of cardiac arrest.  Unfortunately, even an ICD doesn’t guarantee long-term survival in situations like this.  It’s worth reflecting that Vidal’s first indication of a potential problem was a couple years earlier, when he had an episode of syncope, or fainting.  That’s an important problem to get sorted out.

Vidal’s story surely reminds us that life is sometimes too short.  The remembrances on social media this week speak to the way that Vidal embraced life.  I wish I’d had the chance to meet Vidal.  I’ll always remember his smiling face.

Related Posts:

  1. Laurent Vidal and Cardiac Arrest
  2. Elite Triathles and Heart Problems
  3. Cardiac Screening in Adult Recreational Athletes

Filed Under: Current events, Exercise & the heart, Famous athletes with heart problems Tagged With: athlete, cardiac arrest, France, heart

Laurent Vidal and Cardiac Arrest

April 30, 2014 By Larry Creswell, MD Leave a Comment

Vidal

The news last Thursday was startling.  Laurent Vidal, the 30-year-old French triathlete, reportedly suffered a “heart attack” and cardiac arrest during a swim training session.  You may recall that Vidal is the star of the French triathlon team and finished 5th in the London Olympics.  By report, he complained of chest pain and later collapsed in cardiac arrest.  News accounts indicated that he was revived, regaining consciousness, and was transported to the hospital for further care.  Follow-up reporting suggested that therapeutic hypothermia as well as induced coma had been employed in his treatment.  Over the weekend there was very little reporting, though, at least in the English news media, so I don’t have any additional information about his condition to share here.  On Monday came a Tweet from Vidal:  “Hello world.”  I’ll take that as a good sign and wish Laurent and his fiancé, fellow triathlete Andrea Hewitt, all the best during his recovery.

Interestingly, in a report this morning, came some additional information about Vidal’s medical history.  We learned that Vidal had suffered from exertional syncope (blacking out while exercising) on two previous occasions and had undergone a detailed evaluation after the 2nd episode, in 2011.  At that time he was given the diagnosis of neurocardiogenic syncope, a condition that was thought not to be serious.  I’m sure these previous incidents will be given new consideration in light of Vidal’s cardiac arrest episode.

I can tell from the questions I’ve received about this incident that cardiac arrest remains somewhat of a mystery.  Beyond cardiopulmonary resuscitation (CPR), and possibly the use of an automated external defibrillator (AED), most people don’t have much familiarity with the treatment of victims of cardiac arrest.  Non-medical folks might go a lifetime and never witness such an event.  I thought I’d use Vidal’s story as a starting point for a discussion about the treatment of victims of cardiac arrest.

Cardiac Arrest

We use the term “cardiac arrest” when an individual’s heart has stopped beating effectively.  The victim loses consciousness and stops breathing.  When this happens suddenly, without warning, we use the term “sudden cardiac arrest,” or SCA.  The victim of SCA immediately appears lifeless.

Cardiac arrest is a different problem than “heart attack.”  I’ve written a previous blog post on the terminology of cardiac arrest versus heart attack.  In short, a heart attack occurs when there is complete blockage in one of the coronary arteries that brings blood flow and oxygen to the heart muscle.  This condition typically produces chest pain.  Affected patients are evaluated with coronary arteriography and undergo procedures like coronary stent placement or heart bypass surgery as treatments.

Cardiac arrest occurs because there is a sudden change in the normal electrical activity of the heart.  There is a collection of abnormal heart rhythms, called arrhythmias, that can be responsible:  ventricular fibrillation (VF), ventricular tachycardia (VT), asystole, or pulseless electrical activity (PEA).  With each of these arrhythmias, the heart does not beat effectively and therefore does not pump any appreciable amount of blood.  The blood pressure falls to zero and a pulse can no longer be felt.

Without treatment, the victim of SCA has died.  The American Heart Association (AHA) suggests a conceptual framework called the “Chain of Survival” to outline the necessary links to increase the odds for survival:

  1. Immediate recognition of cardiac arrest and activation of the emergency response system
  2. Early CPR with emphasis on chest compressions
  3. Rapid defibrillation, if needed
  4. Effective advanced life support
  5. Integrated post-cardiac arrest care.

Initial Treatment

If a victim of cardiac arrest is to become a survivor, there must be prompt and appropriate care at each step along the Chain of Survival.

It is important for bystanders to recognize the victim of cardiac arrest–unconscious, not breathing, no pulse.  The initial treatment is CPR.  In the United States, the AHA and American Red Cross offer classes in CPR.  For people who are not healthcare workers, the AHA teaches chest compression-only CPR, instructing the rescuer to do chest compressions centered over the breastbone, or sternum, at a rate of 100 compressions per minute.  The AHA teaches that the 100 compressions per minute rhythm can be maintained by doing the compressions to the beat of the 1983 Bee Gee’s hit song, “Staying Alive.”  Healthcare workers are taught how to do rescue breathing interspersed between sets of chest compressions, either in 1- or 2-rescuer scenarios.  If no nearby bystanders are trained in rescue breathing, then chest compressions alone are appropriate as an initial treatment.

While CPR is being performed, bystander rescuers need to notify the emergency medical system (EMS) to summon more advanced care for the victim.  In the United States, bystanders can call 9-1-1 to alert the appropriate authorities.  The telephone dispatcher will arrange for emergency medical technicians (EMTs) or paramedics to be dispatched to the scene.  The dispatcher can also remain on the telephone to help provide guidance to the bystanders who are tending to the victim.

If there is an AED nearby, somebody should fetch it.   These devices are often located in public spaces such as schools, shopping centers, fitness centers, etc.  They may also be on hand for special events.  The use of the AED is often taught in conjuction with the basic CPR course.  Even without instruction, the AED is designed to “talk you through” how to use the device in an emergency situation.  The AED is opened and the ON/OFF switch is turned ON.  An electronic voice will provide instructions to attach defibrillator pads to the victim’s chest in 2 locations.  The AED will analyze the victim’s heart rhythm and determine if a defibrillation shock would be helpful.  Such a shock is helpful if the rhythm is VF or VT, but is not helpful if the rhythm is asystole or PEA.  If needed, the AED will ask the rescuers to stand clear and it will deliver an appropriate shock, asking you to resume CPR if the shock does not terminate the arrhythmia.  If the shock is successful, the AED will instruct the rescuers to just monitor the patient.  If no shock is needed, the AED will instruct to continue CPR.  The AED will continue to monitor the heart rhythm and work through this same algorithm repeatedly at several-minute intervals until EMS personnel arrive on the scene.

I mentioned at the outset that the survival rate for out-of-hospital cardiac arrest was poor.  It’s encouraging, though, that in localities or situations where CPR training is widespread, the survival rate can be much higher.  Interestingly, in a recent review of SCA at long-distance running events, the survival rate was reported at 29% and was attributed in large part to prompt CPR provided by bystanders.

Advanced Life Support

The next phase of care might best be called advanced cardiac life support (ACLS).  This care is generally begun by EMTs or paramedics who were dispatched to the scene where a cardiac arrest victim is already receiving CPR by bystanders.  Information about the circumstances leading to the victim’s collapse should be passed along to the medical professionals who respond.  Sometimes there are very helpful details.

Away from the hospital setting, advanced life support is usually provided by EMTs or paramedics who have specialized training in this area.  In the hospital setting, many employees–nurses, physicians, and others–can take classes offered by the AHA to become certified in ACLS.  As a result, there may well be ACLS-trained bystanders when somebody suffers cardiac arrest.

Advanced life support will include both chest compressions as well as rescue breathing.  Supplemental oxygen will be provided and breaths will be administered initially using a bag-valve mask.  If the victim is not immediately revived, an oral or nasotracheal tube may be placed into the trachea (the windpipe) to continue to administer breaths to the victim.  Electrode patches will be placed on the victim’s skin and an EKG monitor will be used to determine the heart rhythm.  With CPR and rescue breathing in progress, the advanced cardiac life support phase of care is governed by algorithms that are specific to the exact type of heart rhythm.  There are 2 primary algorithms–1 for VF/pulseless VT and another for asystole/PEA.  In the hospital setting, we actually have hand-held cards with the algorithms to help guide a team of rescuers.

Included in the algorithms will be the use of medications, if needed, as well as defibrillation, if needed, depending upon the particular heart rhythm.  CPR, rescue breathing, and the resuscitation algorithm is pursued while the victim is transported to the hospital. 

Hospital Care

Efforts at resuscitation continue until either the victim’s normal heart rhythm is restored or the team of caregivers concludes that further efforts will be fruitless.  There is no absolute convention about how long resuscitative efforts should be continued, but there are certainly examples of patients who are successfully resuscitated after prolonged CPR.  As just one example, I’ve written here at the blog about the soccer player, Fabrice Muamba, who was revived after 78 minutes of CPR.

If a victim’s heart rhythm is restored, then there are 2 major immediate goals:  1) prevent a recurrence of the near-fatal arrhythmia and 2) protect the body’s organs, as much as possible, from the effects of the disturbed circulation while the resuscitation efforts were being made.  Efforts at the first goal will depend upon the known, or suspected, cause.  Evaluation and monitoring is conducted to be certain that the blood oxygen levels and blood electrolyte levels are appropriate.  Often, anti-arrhythmic medications will be used for this purpose.  The second goal is also very important.  We know that, even with CPR that is successful and results in revival of the patient, there can be insufficient blood supply to the body’s organs for a period of time.  The brain is particularly susceptible to injury because of inadequate blood floow or oxygen, even for relatively short periods of time.  One technique that has gained popularity in recent years is the use of induced coma combined with hypothermia (lowering the body temperature by several degrees) to reduce the metabolic demands on the brain for a period of about 48 hours.  This allows potentially better recovery of the brain.  We know that such an approach may improve the neurologic outcomes for at least some patients who have suffered cardiac arrest.  This technique appears to have been used in the case of Laurent Vidal.

The last issue is to determine what caused the cardiac arrest.  There’s actually a fairly long list of possible causes.  In the sports setting, for younger athletes the most likely heart-related causes are hypertrophic cardiomyopathy (HCM)–an inherited disorder of the heart muscle; a coronary artery anomaly–an artery that developed abnormally during development; an inherited cardiac ion channel abnormality (eg, long QT syndrome); or arrhythmogenic right ventricular cardiomyopathy (ARVC)–another inherited disorder of the heart muscle.  But sometimes cardiac arrest may be have a non-cardiac cause like pulmonary embolism or stroke.  Even a sharp blow to the chest can produce cardiac arrest, a situation called “comotio cordis.”  The evaluation of survivors of cardiac arrest is done in a systematic way to sort through the various possibilities.  It’s usually possible to determine a cause, but there’s a small chance that no cause is found.

Related Posts:

1.  Sudden cardiac arrest in NCAA student athletes

2.  Dana Vollmer and ICD

3.  Athletes, Sudden Death, and CPR

Filed Under: Famous athletes with heart problems, Heart problems Tagged With: bystander, cardiac arrest, CPR, life support, treatment

Shaun White, Snowboarder, 1986 –

January 6, 2014 By Larry Creswell, MD Leave a Comment

»¬°å¸ßÊÖShaun White

 

 

 

 

 

Shaun White is a 27 year old native of California who’s become equal parts snowboarder and pop celebrity.  In addition to enjoying great success in the X Games, White is also the 2-time defending Olympic champion in the halfpipe event.

Interestingly, White was born with a congenital heart condition known as Tetralogy of Fallot (TOF).  With this condition, there are 2 primary defects–a hole (septal defect) between the ventricles (the pumping chambers) and narrowing, or stenosis, of the pulmonary valve and trunk.  The remaining features include hypertrophy, or thickening, of the right ventricle which must do extra work to pump blood through the narrowed pulmonary valve, and an “overriding” aorta that is shifted in location above the septal defect.  This condition occurs in approximately 1 per 2,000 infants.

By report, White underwent 2 operations to repair this condition while he was an infant.  Today, most children have a complete repair in a single operation that involves closing the septal defect and enlarging the opening at the pulmonary valve or replacing the valve altogether.  Most patients do quite well after operation to repair TOF.  Over the long term, these patients may develop problems, even years later, like arrhythmias or leakage of the pulmonary valve.  For that reason, these patients need periodic monitoring indefinitely.

White is an example of the growing population of adult athletes who have some form of (often corrected) congenital heart disease.  It’s really not surprising that there are elite athletes in this situation.  In the specific case of corrected TOF with a good outcome, the most recent guidelines from the 36th Bethesda Conference suggest that athletes can participate fully in their sports.  There will be specific guidelines regarding the safety of sports for each of the many different congenital heart conditions.

There is increasing awareness in the medical community of the importance of exercise for teenagers and adults who have congenital heart disease.  Recent guidelines will help athletes and their doctors make thoughtful decisions about exercising safely.

 

Photo by http://www.flickr.com/photos/bfishadow/ User:bfishadow.

Filed Under: Athletes & preventive care, Famous athletes with heart problems Tagged With: congenital heart disease, heart surgery, snowboard

Sergei M. Grinkov, Figure Skater, 1967 – 1995

September 29, 2013 By Larry Creswell, MD 1 Comment

 

At the time of his death at age 28 in 1995, Russian Sergei Grinkov was at the top of his career in figure skating.  He and his wife, Ekaterina Gordeeva, had won four world doubles figure skating championships and were the Olympic champions in 1988 and 1994.

While skating during a practice session in Lake Placid on November 20, 1995, Grinkov became light-headed, slumped to the ice, and then lost consciousness.  His coach recognized the urgency of the situation and provided CPR almost immediately.  EMS personnel arrived within minutes and inserted a breathing tube.  But despite their efforts for more than an hour, Grinkov never regained a heartbeat and died later at the Adirondack Medical Center.

An autopsy showed extensive coronary artery disease (CAD), with nearly occlusive blockages affecting two of the three main coronary arteries.  Moreover, there was significant enlargement of the heart.  The pathologist concluded that Grinkov had suffered from an acute myocardial infarction, seemingly unrecognized, sometime during the 24 hours preceding his death and then suffered a fatal arrhythmia at the ice rink.

Grinkov’s death was obviously unexpected.  In retrospect, it was learned that Grinkov had long-standing, untreated high blood pressure, with typical diastolic blood pressure measurements of more than 110 mm Hg.  This was thought to contribute to the marked enlargement of his heart.  According to reports, though, the high blood pressure measurements had often been attributed simply to “nerves.”

It also turns out that Grinkov’s father, Mikhail Grinkov, died at age 52 after his fourth heart attack.  But like Sergei, his father had none of the typical risk factors for CAD.  These unusual facts caught the attention of Johns Hopkins cardiologist, Pascal Goldschmidt, MD, who was able to study a sample of Grinkov’s blood and find through DNA analysis that he carried a variant of a platelet antigen gene that we now know as PLA-2 or the Grinkov factor.  That variant, present in about 20% of the general population, is now known to be associated with both heart attack and stroke at an earlier age than the general population.

Filed Under: Famous athletes with heart problems Tagged With: coronary artery disease, figure skating, gene, heart, heart disease

Jeff Green, NBA Basketball Player, 1986-

May 13, 2013 By Larry Creswell, MD Leave a Comment

 

Jeffrey Green is a forward for the NBA Boston Celtics basketball team.  After a college career at Georgetown he was one of the top draft picks in 2007, playing first for Seattle and later returning to the Celtics for the 2010-2011 season.

As part of a physical examination related to his contract for the 2011-2012 season, he was found to have an aortic root aneurysm.  He underwent a valve-sparing aortic root replacement operation with a Dacron graft on January 9, 2012.

We’ve talked previously here at the blog about aortic root aneurysm, or enlargement of the aorta just as it exits the heart.  There have been discrepancies in the media coverage of the details of Green’s situation, but aortic root aneurysm can develop in individuals with bicuspid aortic valve or Marfan’s syndrome.  A handful of other NBA players, including Green’s Celtics’ teammate, Chris Wilcox, have had similar operations.  I’ve also written about triathlete, Normann Stadler, who had a similar but urgent operation when a large aortic root aneurysm was discovered unexpectedly.

Green made a very quick recovery from operation, returning to dedicated rehab in March and returning to basketball by summer.  He signed a new 4-year contract with the Celtics in August and had an outstanding 2012-2013 season.

 

Filed Under: Famous athletes with heart problems Tagged With: aortic aneurysm, basketball, heart surgery

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