I KNOW HEART ATTACKS, and this wasn’t a heart attack, even though a doctor back home in Austin later speculated that it was. It happened a few days before last Thanksgiving, as my wife, Phyllis, and I were walking from our hotel in Paris to the Musée d’Orsay, having just been rudely rebuffed by a cabdriver who apparently had more important things to do than drive us a mere twelve blocks. The French have a term for the growing resentment that was welling up in my chest: l’esprit de l’escalier. Roughly translated, it means discovering on your way down the stairs what you should have said or done in reply to an insult in the drawing room. It would be easy—oh, so easy—you miserable Frog mutant, to crush your windpipe with my thumb and be halfway to Marseille before they find your body. It was at that moment that I sensed that something else was wrong. I felt dizzy and exhausted. A dull ache filled my right arm. I paused to catch my breath, walked another half-block, and stopped again, on the verge of collapse. I spotted a park bench and rested for maybe twenty minutes. After that I felt better. The problem didn’t reoccur for the remainder of our vacation. But I knew that it would be back.
Coronary artery disease is an old and much-hated enemy of mine. The beast attacked me without warning in 1988 as I strolled with my Airedales along Shoal Creek’s hike-and-bike trail. Heart attacks, as I learned, are not necessarily sharp, stabbing pains: This one felt like a bear squatting on my chest. It was hard to breathe, and the pain was constant. At first I dismissed it as indigestion, but seven hours later I was flat on my back in an emergency room. Doctors subjected me to a coronary angiogram, a procedure in which a catheter is run from the groin to the heart. There it injects X-ray dye and films evidence of blockages, which are visible on a TV monitor. It showed that five arteries were clogged with plaque, the residue of more than fifty years of unrighteous living. The blockages were preventing blood from flowing from my aorta to my heart muscle, hence the pain. I had two choices, a doctor explained: Undergo quintuple-bypass surgery or die.
A few days later, while I was in the merciful recesses of anesthesia, a surgeon ripped open my chest with a power tool, pried apart my breastbone, and located the clogged arteries. Using a long section of saphenous vein that he had removed from my right leg, he attached one end of the new vessel to my aorta and the other to a coronary artery downstream from the blockage, creating a detour. Once all the grafts were in place, blood was able to flow freely for the first time in months, if not years. For the better part of an hour, my own heart was stopped, and my life was sustained by a heart-lung machine, dead time that some patients believe lowers their IQ a few points. After his own bypass, in 1991, Larry McMurtry wrote to me and explained that the dead time “opens a gap that’s nearly impossible to close—at least I can’t close it.” McMurtry stopped writing, lecturing, traveling, or visiting his three bookstores. “I couldn’t even read, not a book for two and half years,” he wrote. “I felt that I had become an outline; then I felt that someone was erasing the outline and that I was simply vanishing—evaporating.”
Recovery takes anywhere from six weeks to more than three months, and a big part of that is psychological. I became convinced that I would never write again because it was impossible to write without a cigarette, or so my history had instructed. Yet six weeks later, I forced myself to sit down and write a long letter, thanking friends for standing by me. It was a perfectly wonderful letter, if I may say so, bordering on pure poetry. I had smoked my last cigarette on the way to the ER, and now I began researching the other causes of heart disease, with the idea of writing a book. I went on a diet and lost thirty pounds, began exercising at a gym three times a week, and in 1998 published the book HeartWiseGuy. Judging from his recent win at the Academy Awards, McMurtry also got over it—as much as you can get over these things.
In fact, two years after surgery, I began experiencing blackouts, brief moments where I would slip away to somewhere dark and lifeless. The blackouts were caused by an abnormally slow heartbeat, so doctors implanted a pacemaker in my chest wall, just above the heart. After that, when my heart rate got too slow, the device sent a small electrical impulse that prompted the heart muscle to adjust its rhythm. Despite the pacemaker, however, over the next decade I developed a condition called atrial fibrillation (also known as afib), in which scrambled stimuli cause the heart to beat either too fast or too slow. In 2003 I went to see a heart rhythm expert in Austin named James Black. He changed my medications and implanted a newer, jazzier pacemaker, which doesn’t completely control the problem but at least keeps a record of how often it occurs. Lately I’ve had an irregular heartbeat more than 60 percent of the time.
A week after returning from vacation, I told Black about the episode in Paris. Another doctor I’d talked to guessed that I had had a heart attack, but Black thought otherwise. “If it had been a heart attack, you wouldn’t have felt better after resting,” he told me. “But you obviously had a spell where your heart wasn’t getting enough oxygen.” He recommended a nuclear stress test, which is like an ordinary treadmill stress test except instead of walking at increasingly fast speeds for ten to twelve minutes, you walk at a leisurely pace for five minutes. But in my case, after the doctors injected me with radioactive tracer material, my heart started racing as if I were running a marathon.
This test was followed by an echocardiogram, which evaluated my heartbeat. The results of the two tests showed that my heart function had diminished from 50 percent in 2003 to 30 percent or less today. Grafts can wear out after ten years, Black told me; mine were nearly eighteen. He suggested a procedure called coronary balloon angioplasty. Rather than ripping open my chest and creating new grafts around the blockage, a team of doctors and nurses would find the clogged artery with a diagnostic heart catheterization, then fix the problem with a fairly simple and safe technique that would lay me up for no more than a day or two.
In late January they wheeled me into the cath lab at St. David’s Medical Center, in Austin, and rolled me onto an X-ray table, with a large camera overhead and TV screens and other devices positioned around the room. It was freezing cold, and I was nearly naked, but once the sedatives were flowing through the IV in my arm, I forgot about the chill and concentrated on bunnies and butterflies. I felt some pressure as the doctors threaded a guide wire into a vein in my right groin and worked it up toward the right coronary artery; the blockage was just below one of the old grafts, about where it connected to the natural artery. A short plastic sheath was slipped over the guide wire so that a cardiologist named David Garza could insert and remove several catheters into the tube. I could hear them talking, but I was too zonked to understand what was said or what it portended.
In a perfect world, this is what should have happened: A guiding catheter would be snaked into position inside the diseased artery and then a thinner, balloon-tipped catheter would be slipped in behind until it nudged against the blockage. When inflated, the balloon would expand the constricted artery, pushing aside the blockage and allowing more blood to flow. Once the balloon had done its job, it would be removed and a small expandable metal tube called a stent would be inserted to act as a scaffold supporting the artery walls. In my case, however, the balloon worked fine, but the blockage was too calcified to permit the stent to reach the newly expanded section of artery.
Still, the immediate problem was fixed. Garza told me that, with one small exception, the old grafts looked good. It would be necessary to monitor my condition with nuclear stress tests or maybe CAT scans every six months. He suggested that I might want to work out for a while at the St. David’s Rehabilitation Center rather than my regular gym so doctors could keep an eye on things. I’m also a candidate for a defibrillator, which is something like a pacemaker, only with an ability to deliver a high-energy shock if the heartbeat gets dangerously out of control; the zap can knock you across the room but can also save your life. It’s a miniature, internal version of the shock paddles paramedics use to bring people back to life after cardiac arrest. “Our goal is for you to hold your own or maybe improve a little,” Black told me. At my age, none of that is bad news.
I spent that night at St. David’s, prohibited from moving my right leg, the one adjacent to the groin wound where the catheter had gone. The plastic sheath was still in place, allowing an attractive young nurse named Lisa to check the treated artery from time to time. After six hours, Lisa removed the sheath and stood over me for about thirty minutes, pressing firmly on the spot where the sheath had been, preventing the artery from hemorrhaging.
I lay quietly, smelling the freshness of her hair, making small talk, thinking disconnected thoughts. I thought about my friend Bud Shrake, who is three years older than I am and had also suffered from afib. When we get together with other old farts, we talk about drugs—just like we did fifty years ago—except now the subjects are medications for heart disease, diabetes, high blood pressure, and failing kidneys. After a trip to his proctologist a few weeks ago, Shrake told me that the highlight of the visit was when a nurse looked up his rectum with a flashlight. She told him that she had been Miss Teenage Fort Worth back in the late fifties, at roughly the same time the two of us were rival police reporters in the same city. “I had a vision of us drinking beer in that bar across from the police station,” he told me. “And suddenly I would say, ‘Boys, call me crazy, but in some distant future, me and Miss Teenage Fort Worth are going to be alone in a room together, and you’re not going to believe what she’s doing.’’’
Yeah, old guys dream too. I can’t wait to tell him about Lisa.
