My Emperor’s leaflets: time for open-heart surgery
openDemocracy’s founder confronts his mortality.
This is a brief story of images and words, death and life. To get to it I have to tell you something about my body.
I’m 76, relatively fit and pretty carefree. While I’m constantly restless, I’ve never done serious exercise or gone to the gym and have been untroubled about my diet. I used to justify this to myself with Freud’s claim that it is “impossible to imagine one’s own death”; taking it as a permission to be careless. I only survived such irresponsibility thanks to my meeting Judith when we were young - and who knew how to live when I did not.
Of course there is wear and tear. Some implants where otherwise there would be gaps in my teeth; hearing aids since a virus knocked out my left inner ear; my glasses need upgrading most years. I’ve had little scares and been prodded and examined and found to be OK. But wear and tear and the odd knock seemed only to confirm my invulnerability.
About two years ago after a stint of writing I felt stiff and read somewhere that Yanis Varoufakis did 80 press-ups every morning. I discovered I couldn’t manage even one! So as a new year resolution I decided as follows: a single press-up a day for January, two a day in February until I got to a dozen a day in December. All went well until August when the eighth one was hard. September was harder still and my lack of discipline crept in. One day I only got round to my nine press-ups just before going to bed. Then I had an arrhythmia.
We’ve just won a three-year transparency battle against Michael Gove’s department.
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Had I known the word I’d have been more worried. I said to Judith, “Put your hand on that”: my heart was doing about 130 and not stopping. She murmured sleepily, “See the doctor.” My heart returned to a normal tempo, I thought nothing of it but went for a check nonetheless.
One consequence of being my age is that your family doctor retires. I was seen by a young woman I’d never met who was about the age of my younger daughter. She listened to my heart and very coolly and without any sense of alarm booked me in for a check-up at the hospital.
Four months later I go for an appointment at the cardiology unit. As I’d never felt better I had no concerns. As we laughed about Brexit, a nurse from the Philippines did a transthoracic echocardiogram rolling a scanner across my chest. I’d not known there were such things and said, “That’s just like the ultrasound you have for pregnancies.” I was soon to learn that the ones for the heart are in colour.
It was followed by a twelve-point ECG wired to every limb of my body. As this was happening she came back in to take another echocardiogram image from my left side. I thought nothing of it.
After a short wait I was called to the specialist. He told me that I have a mitral valve. He explained it was given this name because it looks like a bishop’s turban. I didn’t know I had a mitral valve let alone that it looked like the headgear of a bishop. While I was absorbing the idea that this was inside me he went on about it not working and the operation to fix it being very successful.
Then he showed me the screen. There was my valve pumping away but with disturbing colours. There was dark blue with bright red and even brighter yellows flashing with excitement. He pointed out two little white arms, that were opening to let the blood through and then shutting, or in the case of one of them, trying to shut. He told me they are called leaflets.
I’ve written quite a few leaflets. I’ve handed out many hundreds if not thousands of leaflets. But never have I seen a leaflet that was so important. A strange process began in which familiar words acquired dramatic new meanings.
I could see very clearly that one of the leaflets – and I was trying to absorb that it was one of my leaflets – the posterior leaflet, was flopping instead of shutting firmly. It seemed as if it was waving in the wind. As a result blood was rushing back through the valve. The echocardiogram uses ultrasound to discern and measure which way fluids move. This information is then colour-coded to reveal how much is flowing back and how fast. The faster, the more intense the colour. It was like a little firework display.
He told me it is called regurgitation. My leaflet was lapsing or rather had a prolapse and this had led to what appeared to be severe mitral regurgitation. If confirmed it would be best to operate while I was healthy as I’d have a very good chance of survival and improvement.
I nodded sagely and asked questions. All the while I was furiously trying to absorb what I seen.
The tip of this tiny leaflet, no more than a centimetre, was waving helplessly. The sight of it went far deeper than the consultant’s words.
In the months that followed I replayed the moment time and again. I gradually understood that I had been traumatised.
I had seen my own death.
I was finding it hard to admit. Also I wasn’t prepared for it. It was different from being diagnosed with, as far too many friends have been, a life-threatening disease or, thanks to the toxicity of our environment, a cancer. Sometimes the condition is inoperable: one emailed all of us with the subject line “The Grim Reaper has called’” Often surgery, chemotherapy or radiation will ensure recovery. There are good accounts of both the fatal progress of an irreversible condition and of a return to health. Another friend, Todd Gitlin, wrote a novel Undying on his successful battle with lymphoma. George Monbiot has shared his encounter with prostate cancer and the support he got in recovering from it.
All such illnesses, cancer especially, are ‘enemies within’. They generate a familiar sense of struggle as they call on your life-force to do everything to combat them with all the medical aid you can get.
What I was seeing was different. This wasn’t an illness. I was not being attacked by a disease.
The little leaflet is me.
It has been opening and shutting many thousands of times a day for years on end. It has done so without my giving it the slightest thought. Indeed, I did not know it existed. Now it is suffering from, yes, good old wear and tear. Only its strategic position means that this time wear and tear is in the heart of me. Later, a friend told me that the Chinese call the heart ‘the emperor’. I liked that - centrality without sentimentality – and I witnessed that my emperor is wearing out.
Sure, my emperor’s leaflets can be mended or the valve replaced. This was something my conscious mind began to consider. But underneath I was in shock. If you are fortunate enough to see the tiny embryo of a child or grandchild after their mother’s first scan, you’ll know the amazing explosion of life that you feel. Well, this was the reverse. My heedless sense of energy and boundless new projects came crashing to a halt.
During the months it took to come to terms with this, I faced a new challenge. Thanks to its brilliant diagnosis and prognosis the NHS had bestowed on me a medical condition. It is one that has been caused by modern science. I am asymptomatic. I may look and feel well and suffer no impediment to normal behaviour. Yet something is known to be wrong, potentially fatally wrong, behind the appearance of wellbeing.
The NHS is at its best in emergencies. I had no symptoms that needed to be cured. I was asked to come back in six months.
Instead I went to another consultant (with Judith so I didn’t have to try and remember all the details while taking them in). His scan confirmed the first and he gave me a detailed report. Our hearts have two atriums. These are not glass-covered zones of modern architecture but spaces in the heart behind valves that the blood enters before being pumped through them. Oxygenated blood from the lungs is drawn down the pulmonary vein into the left atrium, whence it is pumped through the mitral valve. My left atrium was twice its normal size. It had grown under the pressure of the blowback from the regurgitation. Had this happened suddenly, he told us, I’d be “on the floor”. The heart is a marvellous organ, immensely tough and it can expand and keep on going, he explained, “until it stops”. His recommendation was unequivocal: “A stitch in time saves nine.”
I asked my GP to refer me to a specialist heart hospital. There a marvellous registrar assessed the situation. When she listened to my heart with her stethoscope and got to my left side she almost laughed with delight at the confirmation of the diagnosis. Later she reported that I had a grade 5/6 late systolic murmur. It means that the mitral valve is giving out an almost palpable thrill – you can just feel its vibration on the surface of the skin.
Her consultant ordered that they do their own scans including a transoesophageal echocardiogram, when they put a thick cable down your throat and scan the heart from there. The images are extraordinary (see above). Afterwards I watched a screen that showed the blood rolling back through the valve like an ocean wave. The scan identified that the chordae of one of my leaflets are ruptured. The chordae look like a web of rigging and they hold the leaflets firm as they are pushed back into closed position by the pressure of the blood. Severe regurgitation was confirmed. About 35% of the blood being pumped through was rolling back. Wear and tear indeed. They agreed to operate.
It was some time before I got my appointment with the surgeon. When I did, I found myself waiting for two hours and then learnt that cardiology appointments were running three hours late (one of the two members of the surgeon’s team had to be in court). As the waiting area emptied a small group of us remained. I was sitting among a cross-section of heart patients, most of whom had already had the operation and were in for a check-up. There was the guy with an Irish accent who, when I asked how it had gone, put his head in his hands at the memory of morphine-induced hallucinations of the roof falling in. There was an east end, working-class couple: she’d had the operation and then watched a one-hour BBC documentary, “to see what they did to me”. She was full of quiet praise for the way she had been looked after. A fifty-year old with a drinker’s tummy had had a triple bypass but one part of his wound had not healed. A tall, younger guy wanted keyhole surgery “like Mick Jagger”: no one felt like telling him that mitral valve repair could not be done like that. The hearts of London.
By the time I was called it was three hours late and I was exasperated. Instead of the surgeon, who is a man, I was met by a woman. I didn’t quite say, “Who are you?” but I did express my surprise. Very calmly she replied with what must be the best one-liner ever for establishing one’s authority. “I am,” she explained, “the person who will cut you open”.
That put me on my very best behaviour.
She was the surgical registrar. It was equally late in the day for her, but she answered my questions very patiently, showed me images of what mitral repairs look like. She told me that statistically, mitral valve repair or replacement has a 97% success rate but people can die because of the scale of the operation. There is also a small likelihood of a stroke due to the heart bypass machine. I’d be on one for some hours, pumping my blood while my heart was being fixed, and they occasionally generate small bubbles of air which the brain reacts against. She ordered a battery of preparatory tests and scans, and a visit to a shrewd senior nurse.
When I went to see the senior nurse she prepared me for all the various tests, gave me my pack for coming in with special antibiotic cleaning materials I’m to wash with beforehand, and told me to lay off alcohol and clear my diary.
I met her again briefly with the surgical registrar and the surgeon himself. He listened through his stethoscope and talked. I felt I would be in safe hands. A big question is whether my mitral valve can be repaired, as is best, or whether it needs to be replaced. This is something only they can judge when they have opened me up. As I left he looked me in the eye and said, “Take it easy,” adding that if “anything happened” I should let them know immediately
When someone who is soon to put his hands into your heart says take it easy, then that is what you do.
My tests are now finished. I go in to see him for the operation later this week. It’s a departure lounge from which one in forty flights do not make it to their destination. I fully hope to make it to mine. Throughout I’ve followed George Monbiot’s three principles:
- Imagine how much worse it could be, rather than how much better.
- Change what you can change, accept what you can't.
- Do not let fear rule your life.
The excellence of modern medicine comes from specialising, while recuperating from a big operation is about looking after the whole person. The NHS is poor on this thanks to underfunding and also because aftercare demands time and is ongoing. I’m fortunate in that a close friend’s sister-in-law is a GP who has experienced a big heart operation. She has guided me on the phone about what to expect.
What world will I arrive back into? I’m part of a new wave of human beings who have passed their three-score years and ten and fulfilled what was once a lifetime. Yet we are still lively. Thanks to the skill and dedication of the doctors, surgeons, registrars, and nurses of the NHS and medical scientists not least William Harvey, we have been given, or in my case promised, what is literally a new lease of life. How should we live now that the world is no longer ours but we have not retired from it?
Much has been written about the downside such progress can eventually lead to, the extended years of debility and senility and the thankless task of palliative care. But in the meanwhile I’ve books to write and arguments to settle and in no way do I feel any desire to withdraw. Last year, a Greek scholar who is a professor in Germany and therefore a more serious student of British politics than most academics in Britain, congratulated me. “Why?” I asked. “Because you have lived to see the constitutional crisis you predicted!” It is also one I tried to prevent by telling the Left it should take the initiative. It is therefore a product of my generation’s failure, as I recently acknowledged in a graduation speech at Goldsmith. A big part of me says that it’s never too late to do something about it and roll up the old sleeves. Or should I steady myself? I’m enjoying taking it easy.
With special thanks to Judith Herrin, Tamara Barnett-Herrin, Portia Barnett-Herrin, Miranda Tufnell, George Monbiot, Annie Elliot and the amazing professionals of the NHS.
Anthony’s account of his recovery from the surgery is here
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