My Journey of the Heart Continues- Father Prodromos Nikolaou The Hidden Danger: A Patched Coarctation It was the spring of 2014, and I felt strong enough to put in practice the “home test” Dr. Raissi had told me about a year earlier. I remember that day we talked about it, in June 2013, vividly. It was just about a month after my ascending aortic aneurysm repair and recovery was great, so we were discussing about my long- term surveillance. I was asking him a series of questions focusing mainly on the future aortic valve replacement I would need since I had a bovine one now. I was a little puzzled to realize that Dr. Raissi, on the other hand, was more concerned about my coarctation. A short reminder. Back in 1981 I had my first surgery at the age of two: repair of coarctation of the aorta at the level of the isthmus (proximal descending aorta). That was in Leeds, UK. They performed the repair by using a Gore-Tex patch. That patch was what Dr. Raissi was worrying about. At the time I didn’t really understand the measure of his concerns. The probability of yet a new surgery was far beyond my perception. However, that patch there on my aorta was not a very promising life-long solution. To be sure, Dr. Raissi told me to perform a test myself as soon as I felt strong enough for that. I would have to tire myself up to the point where my systolic blood pressure would reach 150. Then I should immediately check my blood pressure on my legs (below the thighs). If the difference was more than 20mm/Hg (meaning lower BP on the legs), then I would need to let him know. I forgot about the whole issue. It was almost a year after my surgery, spring 2014, when I remembered about it again. And so I decided to do the test. The test showed a difference of 25mm/Hg. I called Dr Raissi and let him know, and he asked me to have a treadmill stress test to confirm the results. I did, and the results were confirmed. In the meantime I started my research to see the literature about my new issue, and again I found myself in front of a new dilemma. The American Guidelines where different from those of Europe. Furthermore, between physicians one could come across a wide variety of opinions regarding my issue. Obviously I was confused, but Dr Raissi’s instructions – having also reviewed my last CT scan - were unambiguous: I had a significant residual coarctation. When I had my 1981 surgery they should have completely removed the narrowed part using the “end to end anastomosis” method instead of putting a patch. While I was growing up the patch naturally got stretched and the result was re-coarctation. A new surgery to completely remove the narrowed part would definitely be beneficial, because the residual coarctation was putting pressure on the upper system; on the heart and on the brain. Longevity and quality of life would be much safer and longer if no coarctation was present, because in order to have quality of life people have to be active, they can’t be resting all day. So active lifestyle without the presence of coarctation - which causes blood flow obstruction - results to a longer and safer life. That was Dr. Raissi’s suggestion. The surgery was not an emergency one - that’s what we all thought at the time - so Dr. Raissi told me that if I decided to proceed, I could plan it at a time convenient to me. After coming to know Dr Raissi’s unique experience, for me it was a one way decision again. I completely trusted his suggestion even though he left it on me to decide. At this same surgery he would also remove a descending aneurysm at the site of the coarctation which was also the result of the patch repair from 1981. It was an asymmetrical bulge of around 45mm. Normally, this number for descending aortic aneurysm should not be of urgent importance, but the shape of it made Dr. Raissi worry about it. At the end of May 2014 I scheduled my new surgery for January 20th 2015. The time came, and my brother Georgio, pictured with me here, came with me from Cyprus. There I was once again at Providence St. John’s Health Center in Santa Monica. They were all so good at the hospital. They made this new surgery possible for me in a very touching way. Being a patient from abroad I had to pay a cash price for my procedures. It was really hard to manage the first one, and this second one was coming very close to appearing impossible. It was just a month before the scheduled date, and we still weren’t able to collect the full amount for the procedure’s price. I informed the financial office of St. John’s and their response was really beautiful. They gave me a discount that was covering exactly the amount we were missing! God bless them for this. I am forever obliged to their kindness. In the operating room, Dr. Raissi’s experienced intuition was proved once again perfectly right. While they were detaching the lung, they found themselves in front of an unpleasant surprise. The lung was being successfully detached until the point when they reached the site of the coarctation and the aneurysm. As soon as they started detaching the lung from the aorta, at that point they saw a very thin layer of aorta. I was not on the heart lung machine at that moment, so Dr. Raissi ordered that they stop. He knew I was going to rupture right there. So they opened the groin, they put me on the heart lung-machine, and they started the circulatory arrest procedure to cool me down. They were waiting. Only five minutes had passed when all of a sudden blood shot up! Immediately Dr. Raissi put his left thumb on the rupture site and closed the hole to stop the bleeding. He then had to keep the hole blocked with his thumb for 45-50 minutes! That was how long I needed to cool enough before proceeding to the repair. So until the time they could shut off the circulation, there was nothing he could do but wait, while keeping his thumb on my broken aorta! My life was saved because Dr. Raissi could recognize the danger of the situation at that very crucial moment. Five minutes. If the rupture had happened 5 minutes earlier I wouldn’t have survived. And if the surgeon was not experienced enough to understand that he had to stop the procedure immediately and put me on by-pass, I wouldn’t have survived. If I had not trusted Dr. Raissi’s suggestion to proceed to surgery no one knows when that aneurysm would have torn apart, taking my life instantly. He felt the danger, and I felt his concern. That coarctation had to be repaired and that aneurysm had to come out. You simply can’t trust the behavior of such an aneurysm. When you have a surgeon like Dr. Raissi, whom you can trust for a perfect procedure, then the odds are clear: you go for it! There’s no reason for waiting without knowing what the future will bring. At this point I have to say a great “thank you” to the nurses of St. John’s. They really are true angels. Their help and support gave me all the strength I needed for that difficult part of my procedure: recovery. I never met such a wonderful team in any of my in-patient experiences in other places. I remember the names of them all in my prayers. Once again I take the chance to express my deep gratitude to these two wonderful persons which God has brought in my life: Dr. Raissi and Mrs. Arlys have saved my life. For us monks, life is just a temporary state of our existence, and what we long for is our eternal union and life with God. Nevertheless, this present life is a gift of God. It’s the time given to us to perfect ourselves through love for God and our neighbor and through this spiritual maturation to fulfill the pre-eternal purpose of our creation: the eternal cohabitation with God in His Kingdom. So, life is precious. And through the help of these wonderful people I was granted the chance to extend its length so as to work on my spiritual cultivation even more. I thank them with all my heart.

“Father Prodromos is still a young man, with much to accomplish in his life. I am privileged to continue to walk this BAV journey with him, and with all those who need help with the complications they face along the way.” When I wrote those words after his 2013 surgery, I had no idea that a very serious threat remained in Father Prodromos’ chest. He needed to take more steps, another surgery, soon. When he told me that he was to have surgery on his old coarctation repair and the aneurysm next to it, I needed time to be at peace with this thought. It had not been very long since we were all so happy with the outcome from his last surgery. He had avoided injury or worse from the strands on his valve and his ascending aortic aneurysm. Now the coarctation area, present at his birth and repaired so long ago, would put him back into surgery once again, the fourth chest surgery of his life. If I had known that he was so fragile there, the patch pulling away from such thin aortic tissue, the irregular bulge escaping rupture only because it was supported by the lung to which it had grown attached, there would have been no peace without the surgery. But imaging is still limited in what it can reveal. Time passed, and the day of surgery came at last. By that time, doors had opened in a beautiful way to make the surgery possible, a comforting reasurrance that there were to be no obstacles to this surgery. Time is a strange thing. It flies by when we most want it to slow down, and it almost stops when we want it to hurry! How very true on the day of surgery. The nurse had given us updates from time to time. There was a question about whether or not the entire surgery would take place in one day or not. It wasn’t very long after one update, and the nurse came again. Why so soon? She was a little less calm, but still reassuring, as she told us that there was a lot of scarring between the lung and the aorta. She said something about tearing, a word I never want to hear. But she assured us that things were ok, and they were going on circulatory arrest now. It was not for her to tell us about the drama in the OR that Father Prodromos writes about. The blood gushing out, the cry for a nurse to wipe that blood from the surgeon’s face lest it drip back into the sterile wound, the surgeon’s finger in the aortic rupture, where it would remain until the brain and body would be cold enough to stop circulation and proceed. All this we learned later. It is difficult to describe the wait now. What kind of compications were there? I felt there was no stopping now, no finishing this another day. Not if the aorta had torn. Time slowed to a crawl now, then it stopped, as we waited for the surgery to end. It was late in the afternoon, nearing evening, when at last we spoke with the surgeon. He told us what they had found, what had happened. Now, with all of his vital signs excellent, and the terrible threat removed, it was time to focus on healing. This is the surgeon’s finger in the rupture site, steady and unmoving for all those minutes, as the tissue became colder and colder. Later, we stood just outside the door in intensive care, looking once more at Father Prodromos before letting the nurses care for him. As we lingered a moment, his surgeon said “God has a plan for him.” Yes, there is no doubt there is a plan for this young man and also for this surgeon. No doubt whatsoever. Included in that plan is helping others understand this, especially those with a coarctation patch, by sharing this story. Father Prodromos has returned to his monastery once again, high in the mountains of Cyprus. But he has left something with us here, and with all who meet him through these words. We have his beautiful heart with us still. What an indescribable privilege it is to share in this journey and to share this message of warning and hope with others. - Arlys Velebir, Chairman, BAF