Rich Peverley of Stars collapses during game

[yave1964]

 Peverley collapsed during the first period of the game and the quick thinking of the trainers and the medical crew was amazing, they had him rushed down the tunnel in a matter of seconds, and had him taken to the hospital immediately.

  The league suspended the game which will be continued at a later date.

  Jim Nill told Todd Richards of the Jackets that Peverley was going to be okay.

 

 

Peverely had a procedure before the season to correct an irregular heartbeat. From the Dallas News, Stars GM Jim Nill said:

“It turns out he had an `a-fib’ condition,” Nill said. “He’ll be out three weeks and should be available close to the start of the season. He might miss one or two games.”

Nill said the procedure entailed shocking the heart and getting it back into rhythm. He said that the training staff did a good job of picking up the problem when looking at his EKG during his physical.

“The medical staff did a great job, they recognized this,” Nill said. “They picked it up on the EKG, and he’s going to be fine.”

But the heart issue resurfaced last week. Peverely "felt strange" after a game on March 3 and then missed the Stars' next game against Columbus on March 4. He returned to the lineup on Thursday, March 6.

“It was the same thing,” Coach Lindy Ruff told the Dallas News. “He’s been monitoring it the whole year and this might have been the first or second time it’s come around, but it’s something he has to deal with and it’s something that obviously we’re aware of.”

 

  My thoughts go out to the Peverley family tonight.

[pilldoc]

A-Fib.  Nothing to fool around with .  Essentially A-fib is the irregular heart beat for the part of the heart called the Atrium.  There are 2 of them.  The left and right Atrium.  Essential the electrical pulse is generated from the SA node and passes down to the AV node and through the Ventricles thus completing the heart cycle.

 

In A-Fib the electric pulse is not generated from the SA node and therefore there is no organized contraction of the Atrium.  The Atrium do indeed contract nut just not in an organized way.

 

Cardio-Conversion to normal sinus rhythm can be done via either electrical or chemical means.  Once converted the risk of stroke due to a thrombus is increased dramatic.  A patient will usually be anti-coagulated with medication for the rest of his life along with taking medication to control the rate of the atrium.  Some drugs used to control A-fib include selected Beta-blockers such as Betapace and Calcium Channel blockers such as Verapamil and Diltiazem among many others.  Amiodarone is another very common medication.

 

Here is a great description of A-fib:  http://en.wikipedia.org/wiki/Atrial_fibrillation

 

Normal Sinus Rythm (NSR)

 

 

A heart in A-Fib. (note the disorganized activity of the Atria)

 

I'm sure his season might be done until they figure out what is really going on.

 

Hope this helps abit.

 

PS this is what I due for a living and is right up my alley.  I love this part about my job.  If anyone has any further questions, please don't hesitate to ask.

 

PSS  My thoughts and prayers are also going out to his family right now.

Edited March 11, 2014 by pilldoc

[hf101]

 “He’s been monitoring it the whole year and this might have been the first or second time it’s come around, but it’s something he has to deal with and it’s something that obviously we’re aware of.”  

 

 

-- I really have to wonder if the medical tests, etc was more to justify Peverely playing each day than it was to looking as to why he maybe should have been placed on LTIR.  A tough choice.  What surprises me is the statement that the heart issue resurfaced last week and doctors only recommended he sit out one game.

 

Surely hope Peverley will be ok.  

[FlyersFan4Life]

hope the its not heart related. prayer sent. if its heart related he might want hang the skates up life is to short

[pilldoc]

hope the its not heart related. prayer sent. if its heart related he might want hang the skates up life is to short

 

if he was diagnosed with A-Fib it is heart related.  Yes it can be controlled  with medication, but these are athletes who depend on there cardiovascular system to compete.  They put such great stress on these systems, I just don't think it is worth the risk.

[pilldoc]

-- I really have to wonder if the medical tests, etc was more to justify Peverely playing each day than it was to looking as to why he maybe should have been placed on LTIR.  A tough choice.  What surprises me is the statement that the heart issue resurfaced last week and doctors only recommended he sit out one game.

 

Surely hope Peverley will be ok.  

 

if it truly resurfaced last week as they say, then he should have sat in order to figure out why it resurfaced.  He might have had a normal EKG but he should probably have had Halter Monitor on for a period of time to see what is truly going on.

 

According to NHL tonight, they said he had surgery prior to the season to fix this condition.  Sounds to me he had what is called an Ablation done.

 

Ablation

In young patients where rhythm control is desired and cannot be maintained by medication or cardioversion then radiofrequency ablation or cryoablation may be attempted and is preferred over years of drug therapy.^[3]

The Maze procedure, first performed in 1987, is an effective invasive surgical treatment that is designed to create electrical blocks or barriers in the atria of the heart, forcing electrical impulses that stimulate the heartbeat to travel down to the ventricles. The idea is to force abnormal electrical signals to move along one, uniform path to the lower chambers of the heart (ventricles), thus restoring the normal heart rhythm.[38

 

NHL is also reporting that he is alert, doing well and in stable condition.

 

This is the 2nd episode within 6 months, IMO, this just might end his career.  It simply is not worth the risk.

[pilldoc]

my last post on this topic (as far as putting information out there)

 

I found this article with regard to A-Fib and athletes.  Hope this adds some insight.

 

http://www.drjohnm.org/2011/04/cw-treating-atrial-fibrillation-in-athletes-tough-choices/

 

CW: Treating atrial fibrillation in athletes: Tough choices

 

April 27, 2011 By Dr John Filed Under: AF ablation, Athletic heart, Atrial fibrillation, Cycling Wed, Uncategorized

The number of emails that come from fellow cyclists (and endurance athletes) with heart rhythm issues amazes me. I am more convinced than ever that our “hobby” predisposes us to electrical issues like atrial fibrillation (AF)—that the science is right.

Obviously, my pedaling “habit” creates an exposure bias. I hear from many of you because we cyclists understand each other. Like you, I consider not competing a lousy treatment option.

As a bike racer, I know things: that prancing on an elliptical trainer at a health club doesn’t cut it, and, that spin classes may look hard, but do not come close to simulating real competition. I know the extent of the inflammation required to close that gap, to avoid getting dropped when one of the local Cancellara-types have you in the gutter in a cross-wind, or the worst one of all, to turn yourself inside out to stay with a group of climbers over the crest of a seemingly endless hill—”ten more pedal strokes and I’m out”…Then ten turns to 20, then 40, and maybe you hang, and maybe not. The common denominator of all this: suffering.

 

It’s little wonder that we get AF.

 

With that as a backdrop, my goal for this post is to provide a modest amount of insight to the most common question asked by athletes with AF.

“Should I have an ablation, or not.”

 

Though my two episodes of heart chaos amount to only a mild case of AF, I think it’s fair to say that personal experience with a problem helps a doctor better understand your choice. I’ve thought to myself, on more than one occasion, what would I do if the watt-sucking irregularity persisted? Would I have an ablation; would I live with it; would I stop drinking so much coffee?

Here’s a stab at highlighting some of the real-world issues that come up frequently when talking with AF-patients in the office:

 

Intro: Before moving on with any AF-therapy, you should do three things:

• Make sure that the diagnosis is correct. I frequently see patients incorrectly diagnosed with AF. They are said to have AF, but actually have a focal atrial tachycardia or common atrial flutter. The distinction is important because the latter two problems can be ablated with a simpler and less risky ablation procedure.
• Stop inflaming your heart with known irritants. I am sorry to tell you this, but alcohol, caffeine, and cold remedies can exacerbate–and in some cases cause–heart rhythm problems. Before taking an AF drug, or having burns made in your left atrium, you should try eliminating mochas, gin and tonics, beer and wine. Got a cold; try my favorite remedy: low-sodium chicken soup. Remember, you are middle-aged now. What was tolerable in your twenties, is no longer such in your fifties.
• Pay attention to your sleep habits. Disordered sleep is strongly associated with AF. Because skinny people can have sleep apnea you might consider getting a sleep study. At minimum, try improving your sleep hygiene. There are few more potent anti-arrhythmic agents than a good night of sleep.

If these “simple” measures fail, and your confirmed case of AF persists, you have three choices for controlling the heart rhythm. (The below discussion assumes that your heart rate is well-controlled and your blood thinned, if appropriate.)

 

Option A: Live with AF:

 

Not treating AF is a choice. I strongly believe in patient-centered medicine. That means, I hear about your symptoms, teach you about the disease, lay out the pros and cons of treatment, and you choose what’s best for you.

For an athletic person without underlying health conditions, AF is not life-threatening. You don’t have to take suppressive drugs, or have a procedure; you could just have AF. And for some, say for example, those with infrequent episodes, minimal symptoms, or those who can accept lower power outputs, foregoing a rhythm-controlling strategy is a viable choice.

An important caveat about declining a rhythm-controlling strategy now, is that later-stages of AF are harder to treat. Many–though not all–cases of intermittent AF progress to persistent or permanent AF. You don’t have to decide on AF-treatment tomorrow, but if you change your mind five years later, restoring regular rhythm becomes a much steeper hill.

The final factor that looms large for patients who accept permanent AF is population data that suggests AF increases the risk of health complications down the road.

 

Option B: You could take medicine:

 

In general, for athletes, AF-drugs have significant limitations:

• At best, they suppress AF only half the time;
• When they do work, they are often partially effective, decreasing the frequency or duration of episodes;
• Athletes have low resting heart rates, and nearly all AF-drugs lower heart rate;
• AF-drugs reduce exercise performance by decreasing either maximal heart rate or the strength of the heart contraction, or both. This truth is a real problem for athletes.

The thing that many doctors don’t know about competitive athletes is that the difference between first and last place in a bike race is razor thin. Those five beats per minute, or twenty watts off the top end produce huge differences in results, and thus, in many cases, self-esteem.

The final point to make about the use of AF-drugs in competitive athletes is one of risk. People talk about the high-risk of AF-ablation, but what is not often mentioned is that studies demonstrating the safety of AF drugs did not include large numbers of “extreme” people like you. We know that smartly-administered AF-drugs in regular people with normal hearts is safe. But is that data generalizable to those of us who close gaps, battle headwinds, and push ourselves to Ironman-like feats? I don’t know for sure, but I wonder whether racing (aka, red-lining) around on drugs that affect the electrical properties of the heart could be called “safer” than ablation?

 

Option C: You could have an AF-ablation:

 

The treasure of AF-ablation is eliminating episodes without taking drugs that impair our athleticism. For the afflicted, that’s a big pot of gold.

In people with intermittent AF and normal hearts, AF-ablation equals Pulmonary Vein Isolation. The triggers (or “drivers”) of most cases of early-stage AF arise from the muscle sleeves that wrap the pulmonary (lung) veins. AF-ablation, through point-to point burns, seeks to electrically isolate (“build an electric fence”) around the orifices of these veins. Though an oversimplification, the notion holds that this electric fence keeps the AF from getting to the atrium. The “success” rate of AF-ablation in endurance-athletes is probably the same as the general population–around 70-90%.

 

AF-ablation in 2011 is much different than it was just a couple of years ago. Approaching AF with a catheter now represents a majority of my procedures. What was once a four hour procedure that sapped you for the day, can now be done in two hours. It is routine to do two ablations in a day. What took sixty minutes of X-ray exposure now rarely exceeds twenty-five minutes.

Here are three reasons for this renaissance in AF-ablation: (there are more)

• Like many AF-centers, both my own, and our lab’s experience have reached a threshold. AF-ablation has become routine. We have a great team of players. Though it’s not always politically correct to say this: AF-ablation, like much of modern, tech-intensive medicine, is best done by dedicated, specialized personnel.
• The neural pathways required to perform point-to-point navigation of a catheter in the left atrium have become etched in my brain. The largely human task of feeling the tactile sensations of an ablation catheter in a three dimensional heart chamber took years, and hundreds of cases to learn.
• GPS technology built into catheter mapping systems—made by medical companies like J&J, and St Jude Medical—succeeded in the rare feat of delivering more than promised. Could I do AF-ablation without expensive mapping systems? Sure I could, but these systems clearly increase the effectiveness and safety of the procedure.

Though AF-ablation has improved greatly, it still could not be called a mickey-mouse procedure. It requires general anesthesia, thousands of dollars of equipment, and a half-dozen specially-trained personnel. It is a shining example of the fury of modern medicine. And there is risk. Major complications include, death, stroke, pulmonary vein blockage, esophageal damage, heart perforation, and blood vessel damage to the legs. The published complication rates are in the range of 2-10%. There’s little doubt that complication rates vary with experience, and that many ablators minimize the risks.

 

Even when AF-ablation goes well, it’s hard on you. A past AF-ablation patient who happened to be a gifted writer sent me a note describing that his groin areas felt as though they had been stomped on by a guy wearing golf cleats.

 

The most nagging problem with AF ablation is that AF can come back. Recurrence after a “successful” ablation occurs because the electric fence around the veins isn’t as durable as we would like. More than one in three patients require a second ablation to “spot-weld” leaks in the electric fence—to re-isolate the pulmonary veins. You should hear this fact loud and clear from your AF doctor. We all hope that technology can help us make more lasting lines of electrical block. We need more fury.

 

Finally, there are many unknowns about the long-term effects and real outcomes of AF-ablation. For the relief of AF-symptoms, we know that ablation crushes medicines. But does it reduce hard outcomes like hospitalizations, stroke rates, and mortality? These are the big questions that ongoing clinical trials (like CABANA) will surely shed light on. In this regard, some early and preliminary data show promise. This look-back (retrospective) study presented at last month’s ACC meeting showed that AF-ablation may reduce the risk of stroke.

 

Here’s a hunch from years of following AF patients that I have ablated: AF-ablation is going to look better than current-day AF-drugs.

 

Summary:

 

Athletes with AF face a tough choice. The disease tugs at what we hold so precious: our beloved vigor. Each treatment has limitations, risks and benefits. No magic potion exists. No hike to the treasure easy.

 

I wished you didn’t have to decide.

But…I hope this helps.

JMM

Edited March 11, 2014 by pilldoc

[yave1964]

if it truly resurfaced last week as they say, then he should have sat in order to figure out why it resurfaced.  He might have had a normal EKG but he should probably have had Halter Monitor on for a period of time to see what is truly going on.

 

According to NHL tonight, they said he had surgery prior to the season to fix this condition.  Sounds to me he had what is called an Ablation done.

 

Ablation

In young patients where rhythm control is desired and cannot be maintained by medication or cardioversion then radiofrequency ablation or cryoablation may be attempted and is preferred over years of drug therapy.^[3]

The Maze procedure, first performed in 1987, is an effective invasive surgical treatment that is designed to create electrical blocks or barriers in the atria of the heart, forcing electrical impulses that stimulate the heartbeat to travel down to the ventricles. The idea is to force abnormal electrical signals to move along one, uniform path to the lower chambers of the heart (ventricles), thus restoring the normal heart rhythm.[38

 

NHL is also reporting that he is alert, doing well and in stable condition.

 

This is the 2nd episode within 6 months, IMO, this just might end his career.  It simply is not worth the risk.

this hits home with me, I had quadruple bypass six years ago, followed by a leaky valve that needed replaced (they should have just put in a zipper) followed by a defibulator/pacemaker when my infarction ratio consistently stayed in the low 30s. After keeping me on long term disability while discussing a possible transplant which mercifully after losing fifty six pounds and walking away from cigarettes they have finally (for now) ruled out. I am 'prescription poor' as the wife and I call it, taking eleven pills in the morning and six at night.And I am only 49.

  But I was a middle aged car salesman who ate bad and worked 60 hours a week and smoked two packs a day, Peverley is young and in peak physical shape. Tragedy rides along with some people, Jiri Fischer of the Wings ended his career in a similar incident. That young man Alexei Cheraponov in Russia playing in the KHL died of a heart attack due to poor equipment and no properly trained medical personnel on hand. Hank Gathers from basketball. Going back a ways, John Hiller had a heart attack pitching for the Tigers and came back several years later.

  Anyway, life is short, I hope this does not end Peverley's career, a pesky guy I always hated him playing my Wings. I wish him nothing but the best and he is in my thoughts and prayers this evening.

[ruxpin]

A-Fib. Nothing to fool around with . Essentially A-fib is the irregular heart beat for the part of the heart called the Atrium. There are 2 of them. The left and right Atrium. Essential the electrical pulse is generated from the SA node and passes down to the AV node and through the Ventricles thus completing the heart cycle.

In A-Fib the electric pulse is not generated from the SA node and therefore there is no organized contraction of the Atrium. The Atrium do indeed contract nut just not in an organized way.

Cardio-Conversion to normal sinus rhythm can be done via either electrical or chemical means. Once converted the risk of stroke due to a thrombus is increased dramatic. A patient will usually be anti-coagulated with medication for the rest of his life along with taking medication to control the rate of the atrium. Some drugs used to control A-fib include selected Beta-blockers such as Betapace and Calcium Channel blockers such as Verapamil and Diltiazem among many others. Amiodarone is another very common medication.

Here is a great description of A-fib: http://en.wikipedia.org/wiki/Atrial_fibrillation

Normal Sinus Rythm (NSR)

A heart in A-Fib. (note the disorganized activity of the Atria)

I'm sure his season might be done until they figure out what is really going on.

Hope this helps abit.

PS this is what I due for a living and is right up my alley. I love this part about my job. If anyone has any further questions, please don't hesitate to ask.

PSS My thoughts and prayers are also going out to his family right now.

@pilldoc if you would, please explain how this is different from SVT/WPW. We went through this (WPW masked as SVT) with my eldest daughter (scariest time of my life) and had it corrected with RF ablation at Boston Children's. It sounds eerily similar. I'm aware a-fib is a type of SVT so I'm now wondering about Peverly and why they had him playing.

[pilldoc]

@ruxpin

 

Good Morning Rux,

 

I'll try to do my best. I'm not a cardiologist.  However before I became ACLS certified (advanced cardiac life support), I had to take an arrhythmia class so I had a basic understanding of these different types of disrrhythmia's out there.  The basic categories included:

 

1. Atrial Arrhythmia's
2. Junctional Rhythms
3. Heart Block
4. Ventricular Arrhythmia's

Both A-Fib and WPW (Wolfe-Parkinsison White) Syndrome fall in the category of Atrial Arrhythmia's.  They are very similar indeed.

 

In A-Fib there is total disorganized activity in the atria of the heart.

 

Atrial fibrillation
(AF or AFib) is the most common SVT, affecting more than 2 million Americans in the United States. It is a main cause of stroke, especially among elderly people.¹ During AF, the heartbeat produced by the atria is irregular and rapid—typically more than 300 bpm—where muscle fibers in the heart twitch or contract. With such a fast heart rate, the heart does not pump efficiently. This may cause blood to pool and can lead to the formation of clumps of blood called blood clots. A stroke can occur if a blood clot travels from the heart and blocks a smaller artery in the brain (a cerebral artery). About 15% of strokes happen in people with atrial fibrillation.

 

AV Nodal Re-entrant Tachycardia (AVNRT)
AVNRT is the second most common SVT. In a normal heart, there is a single electrical pathway, or “gate,” called an atrioventricular node (AV node). The AV node controls the timing and direction of the electrical signal as it travels from the upper chambers (atria) to the lower chambers (ventricles) of the heart. With AVNRT, an extra electrical pathway forms which allows the electrical signal to travel backward through the “gate” (AV Node) at the same time, starting another heartbeat. During AVNRT the electrical signals continuously go around the 2 pathways in a circular pattern called re-entry. This can lead to a very fast heart rate of 160 to 220 beats per minute. AVNRT is most common in people in their 20's and 30's but can occur at any age. It is more common in women than in men.

 

Wolff-Parkinson-White Syndrome
Wolff-Parkinson-White (WPW) syndrome is a group of fast, irregular heart beats caused by extra muscle pathways between the atria and the ventricles. In WPW, the pathways cause the electrical signals to arrive at the ventricles too soon, and the signals are sent back to the atria in a loop or short circuit. The result is a very fast heart rate. People with this syndrome may feel dizzy, have chest palpitations, or have episodes of fainting. People with WPW may be more likely to develop atrial fibrillation or a more dangerous rhythm called ventricular tachycardia.

These pathways are present at birth. People of all ages, including infants, can experience the symptoms related to Wolff-Parkinson-White syndrome. Episodes of a fast heartbeat often first occur when people are in their teens or early 20s.

 

Note the extra-pathway from the Ventricle to the Atrium. The bundle of Kent is an abnormal extra or accessory conduction pathway between the atria and ventricles that is present in a small percentage (between 0.1% and 0.3%) of the general population.^[1][2][3] This pathway may communicate between the left atrium and the left ventricle, in which case it is termed a "type A pre-excitation", or between the right atrium and the right ventricle, in which case it is termed a "type B pre-excitation".^[6] Problems arise when this pathway creates an electrical circuit that bypasses the AV node. The AV node is capable of slowing the rate of conduction of electrical impulses to the ventricles, whereas the bundle of Kent lacks this capability. When an aberrant electrical connection is made via the bundle of Kent, tachydysrhythmias may therefore result.

 

 

Rux, essentially they are very similar(the fact that they both occur in the atria of the heart)  however the difference is how they manifest themselves. A-Fib occurs when the SA node fails to fire in a regular way.  Thus leading to very fast disorganization of the atrium contracting.  WPW occurs when there is an abnormal pathway leading from the ventricles to the atrium.  These beats are fast and irregular. Thus causing the heart to beat much faster.

 

in regards to your daughter, yes I feel for your concern and how scary it must have been for  your family.  Yes, ablation is usually a primary treatment option in which you are hoping to zap away that extra pathway.  How is she doing now?

 

In regards to Peverly, it sounds to me he also had an ablation prior to the season starting.  I'm not sure what the protocol is as far as clearing him to play hockey.  As I stated in a previous post, hockey causes such a high demand on the cardiovascular system.  I can't help to not think that this playing could lead to further episodes which it appears from last night was the case.

 

I am not his medical doctor and i will not speculate on the outcome, but one must think that after having 2 types of these episodes within 6-8 months of each other, that playing hockey for a living may not be an option anymore.

 

It was certain very scary to watch and read about last night.

 

i hope this answered some of your questions. 

 

Have a great day Rux!

[DaGreatGazoo]

Dang....Doc is one smart cookie.  He should be immediately banned from this site.  No one with intelligence is allowed on here.  

 

Seriously, though...thanks for the info.  Great reading.

[pilldoc]

@DaGreatGazoo

 

LOL!!! Thanks!!!

[ruxpin]

@pilldoc

Some on here are aware of the situation with my daughter via PM because we again had issues this past summer. We were again fearful despite the understanding that it was very unlikely it would return almost 15 years later. It turned out to be something else which was workable (although she is 18 and getting her to remember to take pills at college is a struggle).

At the time she was 5 and our cardiologist wasn't on board with ablation given her size and since the procedure on someone that young was still in its infancy. They kept telling me it was SVT but I kept insisting it was WPW.

I finally convinced the cardiologist (the fact the meds were not helping made this easier) and we were off to Boston for the ablation. That surgeon told me immediately following the procedure that it was WPW.

That was Jan. 26,2001. She's been issue free since

[yave1964]

@ruxpin

An amazing story Rux. Thanks for sharing.

[ruxpin]

@pilldoc

 

Thank you so much for both the explanation and the concern!  

[jammer2]

@ruxpin  Gotta like the decision to shut down Peverly for the season. The "it's just a game" theory was never more evident than the other day. This guy has a family to worry about. Hopefully the Stars give him a front office/scouting gig and he calls it a day.

[ruxpin]

@jammer2 @pilldoc

I,too, assumed the procedure done in the off-season was ablation.

But I am curious why still the beta blockers, then. I know that I am drawing on experience with a slightly different animal, but I know my daughter never took another dose of digoxin or atenolol again. It sounds like Peverley was still taking meds and was starting to struggle with the dosage . (@pilldoc,do you suppose digoxin or digitoxin was what they hit him with during the crisis or do we know that they cardioverted him?)

So if the procedure was catheter ablation (I cannot imagine what else it would be.. @pilldoc, an internal pacemaker wouldn't be appropriate would it? That's more for ventricular issues, yeah?) I can only think it didn't work as expected.

They could try the ablation again and /or switch medications. I don't *think * this necessarily has to be career ending

[caitlinb2012]

Excuse me for the ignorance. I am in school now and a hockey fan and a Peverley fan. I can find nowhere where A-fib is risk for cardiac arrest (if he just has A-fib). The major risks for A-fib are strokes. I also learned about anti-arrhythmics and how they treat arrhythmias but also put you at risk for more deadly arrhythmias. So all I can think is that he was on a drug that led to a more deadly rhythm that led to cardiac arrest. Pilldoc can you help me out in understanding this? I have read numerous articles and can't quite understand what happened. 

 

Also he had a procedure in September. I had assumed that was an ablation then. Now people are saying he will have an ablation in the next few days. Is that because the one in September failed? 

 

Thoughts with Peverley and his family. Between him and Letang there are too many heart conditions I am learning about being displayed to me by these hockey players!

Edited March 14, 2014 by caitlinb2012

[caitlinb2012]

one thing I forgot: or could it just be that he was cardioverted back in September to correct the A-fib temporarily? 

[yave1964]

one thing I forgot: or could it just be that he was cardioverted back in September to correct the A-fib temporarily? 

hey welcome aboard from a Lexington Ohio native and lifelong Wings fan. We need more Buckeye fans in here!

[hf101]

@caitlinb2012

 

Welcome Caitlin

 

I found this article to be helpful, and maybe it answers some of your questions.   http://www.defendingbigd.com/2014/3/12/5501486/dallas-stars-rich-peverley-collapse-heart-press-conference-season-over-ablation-CPR

 

According to the doctors, including team director of medical services Dr. Robert Dimeff, who did much of the talking, at the bench, Peverley's pulse was thready. Once they got him back to the hallway, they could no longer feel a pulse. It took about one minute for the team to get the AED set up, all the while they were doing CPR, and, as has been previously reported, it took only one shock to bring his heart back to a normal rhythm.

 

Then he woke up, and the first thing he saw was coach Lindy Ruff standing over him.

 

"To him, it was the coach looking at him, and it was either he's afraid I'm going to yell at him, and he asked 'How much time is left in the first period?''" Ruff said with a small chuckle. "And I thought 'Don't worry about the first period.'"

 

Medically, it's a little difficult for the doctors to pin down precisely what happened, as they were focusing mostly on reacting and only had a small rhythm strip once they attache the AED to go off of. Dr. Dimeff said that strip indicated Peverley's heart was bouncing between two abnormal and extremely dangerous rhythms, ventricular tachycardia and ventricular fibrillation.

 

Dr. Sharon Reimold, the cardiologist present at the press conference, said being in those rhythms for more than 4-5 minutes is extremely dangerous, which only underscores the fabulous job the Stars medical and training staff did in this situation.

 

They were joined by a season ticket holder who was a trauma nurse or doctor (reports varied). No one seems to know her name, but the doctors complimented her proficiency as she helped the team resuscitate him.

 

As far as how we got to this point, Peverley had a physical in January of 2013 with the Boston Bruins, and at that time, his EKG was normal. But when the Stars did his preseason physical in September, the abnormal rhythm was discovered. Based on blood test and other results, the Stars doctors suspected he'd been in the rhythm for a significant amount of time, perhaps as long as the previous Stanley Cup Finals.

 

There was nothing the doctors could discover that would have caused it to start, so doctors believed it was most likely the expression of a genetic condition. Peverley's mother has atrial fibrillation as well, though she is obviously older.

 

At the time, they discussed several options with Peverley and decided to do a cardioversion therapy to reset his heart into a normal rhythm. Once that was effective, they planned for a more permanent procedure in the offseason to permanently address the problem because there would be a 2-3 month recovery time.

 

As far as whether Peverley should have been playing in the first place, Dimeff called this sort of decompensation "extremely rare." And when talking about his future in hockey, he said they were "Not ready to make that kind of decision yet." It seems like the ablation procedure can be a permanent fix in some cases with one or more applications, so they will likely know more after the procedure is complete.

 

Until he can get the surgery, he is wearing a device that automatically detects his heart rhythm and will deliver a shock if necessary.

 

 

[ruxpin]

@hf101

@pilldoc correct me if I'm wrong but hf's article sounds more like Wolfe Parkinson White than I initially thought.

If they really thought cardioversion was going to get him through the season.. I'm really quite bothered by that. I realize this is a hockey player that really wants to play hockey, but it seems to me they were rolling some pretty ugly dice.

It's all fine and good to say they had medical personnel onsite and everything worked well, but this could just as easily triggered during a drive home or on a team flight or in a whirlpool bath by himself or any number of places where there wasn't personnel right there.

I'm assuming with other forms of a-fib this would be the case as well but I know with SVT that cardiac arrest was a really real threat. We had several trips to the ER that the heart rate was very near the very dangerous 240 bpm threshold.

I remember spending thanksgiving evening with my daughter's rate hovering between 235 and 240 and repeatedly telling the resident in the ER that if he proceeded to give my 5 year old Cardizem I'd kill him myself. But we'd been told by a couple different doctors that 240 would be very bad.

So I'm not sure about other forms of a-fib but with SVT/WPW it's a very present danger.

And it sounds to me they allowed a very dangerous situation for him rather than advise him prudently.

[pilldoc]

Sorry for getting back to everyone so late....was a very busy day yesterday....

@jammer2 @pilldoc

But I am curious why still the beta blockers, then. I know that I am drawing on experience with a slightly different animal, but I know my daughter never took another dose of digoxin or atenolol again. It sounds like Peverley was still taking meds and was starting to struggle with the dosage . (@pilldoc,do you suppose digoxin or digitoxin was what they hit him with during the crisis or do we know that they cardioverted him?)

So if the procedure was catheter ablation (I cannot imagine what else it would be.. @pilldoc, an internal pacemaker wouldn't be appropriate would it? That's more for ventricular issues, yeah?) I can only think it didn't work as expected.

They could try the ablation again and /or switch medications. I don't *think * this necessarily has to be career ending

 

Excuse me for the ignorance. I am in school now and a hockey fan and a Peverley fan. I can find nowhere where A-fib is risk for cardiac arrest (if he just has A-fib). The major risks for A-fib are strokes. I also learned about anti-arrhythmics and how they treat arrhythmias but also put you at risk for more deadly arrhythmias. So all I can think is that he was on a drug that led to a more deadly rhythm that led to cardiac arrest. Pilldoc can you help me out in understanding this? I have read numerous articles and can't quite understand what happened. 

 

Also he had a procedure in September. I had assumed that was an ablation then. Now people are saying he will have an ablation in the next few days. Is that because the one in September failed? 

 

Thoughts with Peverley and his family. Between him and Letang there are too many heart conditions I am learning about being displayed to me by these hockey players!

 

 

@hf101

@pilldoc correct me if I'm wrong but hf's article sounds more like Wolfe Parkinson White than I initially thought.

If they really thought cardioversion was going to get him through the season.. I'm really quite bothered by that. I realize this is a hockey player that really wants to play hockey, but it seems to me they were rolling some pretty ugly dice.

It's all fine and good to say they had medical personnel onsite and everything worked well, but this could just as easily triggered during a drive home or on a team flight or in a whirlpool bath by himself or any number of places where there wasn't personnel right there.

I'm assuming with other forms of a-fib this would be the case as well but I know with SVT that cardiac arrest was a really real threat. We had several trips to the ER that the heart rate was very near the very dangerous 240 bpm threshold.

I remember spending thanksgiving evening with my daughter's rate hovering between 235 and 240 and repeatedly telling the resident in the ER that if he proceeded to give my 5 year old Cardizem I'd kill him myself. But we'd been told by a couple different doctors that 240 would be very bad.

So I'm not sure about other forms of a-fib but with SVT/WPW it's a very present danger.

And it sounds to me they allowed a very dangerous situation for him rather than advise him prudently.

 

 

@caitlinb2012

 

Welcome Caitlin

 

I found this article to be helpful, and maybe it answers some of your questions.   http://www.defendingbigd.com/2014/3/12/5501486/dallas-stars-rich-peverley-collapse-heart-press-conference-season-over-ablation-CPR

 

 

 

 

Great stuff everybody!.... (Again ..full disclosure, I'm not a cardiologist, I don't have access to his medical history...I'm just a clinical staff pharmacist in a hospital/surgical setting,  who deals with these types of patients everyday)

 

Sounds to be he might have been cardioconverted with an AED.  (and reading further the article HF present confirms this)

There simply was not enough time to start an IV line.  Per protocol for an AED, once the leads are attached, the device recognizes if the current condition is a shock-able rhythm or not.

 

PER ACLS (advanced cardiac life support) 2014 guidelines:

• For the patient with unstable tachycardia due to a tachyarrhythmia, immediate cardioversion is recommended. Drugs are not used to manage unstable tachycardia.

 

In regards to meds, Betapace (Sotalol HCl) is the drug of choice for patients with A-Fib and other atrial rhythms.  For some patients, even after an ablation, some patients require a pacemaker.  And "YES" it can either be an Atrial Pacemaker or a Ventricular Pacemaker.

 

Regards to his history, @ruxpin, yes it sounds like there is a family history of atrial disrrhythmias. If that is the case, I would be leaning on the side of WPW. 

 

@caitlinb2012

you are correct, the major issue one has with A-fib, especially after an ablation or cardioconversion, is the formation of blood clots.  That is why a vast majority of patients are put on Coumadin (Wafarin).  They need to have a target INR of 2.0-3.0.  Unfortunately one must have weekly blood tests in order to check for the target INR and adjust the coumadin dose as necessary.  One must also watch their diet too. There is a new drug Xarelto (Rivaroxaban) whicj does not require this constant monitoring.

 

According to the the doctors that attended to him, they state that the rhythm that he was in, per the EKG strip,  was either V Tach or V Fib, both which are extremely serious rhythms.  So they used the AED to bring him back to normal sinus rhythm.  One can speculate that if he was on Betapace (again I don't have his char in front of me), that if they did increase his dose, one of the precautions with this med is the possibly inducing a Ventricular arrhythmia.  If this is truly the case, I don't know. 

 

It is also possible, though highly unlikely that he did have a moment of A-Fib and that at this time it was so severe enough that it led too V-Tach / V-Fib.

 

Occasionally, if the heart is quivering very quickly in AF, the rhythm can “degenerate” to VF, but this is a very rare occurrence. VF is a malignant heart rhythm leading to quick deterioration of the patients, and if not treated immediately it results in sudden cardiac death (SCD).

 

You ask why these rhythms are not interrelated. Atrial fibrillation originates in the upper heart chambers (atria) or pulmonary veins that bring the blood from lungs to the atria. Then, the impulse is conducted to the lower chamber (ventricle), causing a fast heart rate. But, coordinated organized contraction is preserved in the ventricle. Basically, this means that heart (as a pump) is still functioning.

 

In atria, there is no organized electrical activity. As a result, there is no coordinated contraction of the atria. But atria are believed to contribute only 20% to overall function of the heart as a pump, and this decrease is usually not significant enough to cause a quick decline in clinical status.

 

If AF goes for hours and the heart rate is high, eventually the patient can develop some symptoms. In the case of VF, there is no organized electrical or mechanical activity in the ventricles (which are the main pumping chambers), and that results in sudden cardiac death in a matter of seconds.

 

Bottom line, it sounds to me that Peverly has a serious heart issue right now and that needs to be corrected for the sake of his family.  Hockey in general is a very cardio sport to begin with and one must be in excellent health to perform at the top level such as the NHL.  As Rux said, it is a scary thought that this episode could have happened anytime.  Was is exasperated because he was just coming of the ice after his shift, one can only speculate.

 

It does sound like the first ablation failed and they are going to try again here in a few months.  I would really need to do some research in regards to these types of heart conditions and pro athletes.

 

Hope this answers some more questions you guys might have.  If you have have any other please continue to ask away in this thread or PM me.

 

PS (BTW...I love this part of my job)

[caitlinb2012]

Thanks everyone, I also found this article which confirmed some of my suspicions. 

http://www.drjohnm.org/2014/03/atrial-fibrillation-features-prominently-in-rich-peverley-collapse/

Hoping Peverley has a successful ablation, recovery, and career! 

[pilldoc]

Thanks everyone, I also found this article which confirmed some of my suspicions. 

http://www.drjohnm.org/2014/03/atrial-fibrillation-features-prominently-in-rich-peverley-collapse/

Hoping Peverley has a successful ablation, recovery, and career! 

 

Excellent article and great find!

 

I am really interested in the part he mentioned he "upped" his medicine dose.  If that is the case, did he do it himself, or by his cardiologist?  If he is on Betapace, then any healthcare professional should know to monitor the patient closely for any type of abnormal arrhythmia .  I am absolutely shocked they let him play.  Polymorphic V. Tach (torsede' de point) is a deadly rhythm, if that is what he was in when they used the AED on him.

 

This is a great teaching moment as we call it.