What Are the Next Steps For Dallas Stars Forward Rich Peverley?

Jerome Miron-USA TODAY Sports

A look at the medical side of Rich Peverley's cardiac incident and what the next steps in his recovery process might be.

Rich Peverley looks entirely tired of talking about himself.

When you watch the video from the Dallas Stars final media interviews, the veteran forward addresses some questions about his future. And as the interview goes on and eventually returns to his health and future, questions he honestly can't answer at this point, it looks like he'd rather be anywhere else.

It's understandable really. Peverley has made his NHL living as a complimentary player, a guy who stays out of the spotlight, does his job well but doesn't end up in the limelight a lot. And to have all this attention focused on him for an incident that was a.) totally out of his control, b.) only barely related to hockey and c.) was likely among the scariest moments of his life, at least in retrospect, is something that was bound to be uncomfortable.

The questions do need to be asked. From a bottom-line hockey perspective, Peverley is a potential top six player under contract next year who would need to be replaced if he can't play. And from the much more important human perspective, he's a part of the Stars brotherhood, a man facing a real crossroads in both his career and life.

So I wanted to dive back into the medical aspect of what happened to him, how doctors addressed it medically and take a what the next steps in his future might be.

A disclaimer - I am not a doctor, nor do I play one on TV. But I am studying on a pre-med track and like to think I have a fair grasp of what's going on. I also sourced a family member who is a paramedic for some extra guidance. So I won't try and get into the true nitty gritty, which I only barely start to understand, and instead focus on generalities to the best of my knowledge.

First, let's reset what we know about Peverley's condition.

He was diagnosed with atrial fibrillation before the start of training camp, an abnormal rhythm of the top half of the heart that he may have been in as far back as the 2013 Stanley Cup Finals with the Boston Bruins. He was cardioverted, or shocked in a controlled setting, to bring the top half of his heart back into normal rhythm at that time and put on blood thinners to recover for a few weeks. The plan was to have the more permanent cardiac ablation (which we'll get to below) done after the season.

His conditioned was managed with monitoring and education, and to our knowledge, he did not have another episode of a-fib until early March, which it happened during a game. The rhythm resolved, adjustments were made to his medication and he missed one game.

Then, on that frightening evening of March 10, another abnormal heart rhythm began during a game against the Columbus Blue Jackets. It deteriorated and ended up up bouncing between ventricular tachycardia and ventricular fibrillation, both life-threatening rhythms that may have stemmed from a bout of atrial flutter. He went into cardiac arrest (which is the term for any time the heart does not pump well enough to maintain circulation), but his heart responded to the first shock from the automatic external defibrillator and settled back into normal sinus rhythm. About a week after that, he had the cardiac ablation procedure, which he is currently recovering from.

We'll get to the ablation, recovery time and the next step in a bit, but first, let's talk about who is and who is not a good comparable to his situation.

To start with, Alexei Cherapanov is not a good comparison. Although the reports out of Russia were sketchy after his death, they strongly suggested that he had an underlying change to the muscle of the heart called hypertrophic cardiomyopathy. This is also what killed junior hockey player Mickey Renaud, and it has been floated several times in connection with Jiri Fischer and Sergei Zholtok, though in a less verifiable way.

Because there is an underlying, irreversible structural change with HCM that can lead to electrical conduction problems, almost every athlete who is diagnosed with it is no longer cleared for sports.

Given that the doctors said there are no structural abnormalities with Peverley's heart, it is nearly certain that he does not have HCM. His a-fib is likely caused by one or more aberrant electrical circuits rather than a structural issue with a heart muscle itself.

Who is a good comparable then? The closest I can find is goalie Jonas Gustavsson, who has had multiple cardiac ablations to correct a fast heart rate problem that has plagued him since joining the NHL. The underlying electrical issues appear to be different, and as can be the case, his first ablation did not entirely correct the problem. But he was obviously able to continue with professional sports as a career.

For you true medical nerds, I have seen some commenters float the idea of Peverley having Wolff-Parkinson-White Syndrome, which is an extra electrical pathway between the hear't's upper and lower chambers. However, going through all the comments from the team, doctors and Peverley himself, I can find no mention of this as a concrete diagnosis - all the mentions of WPW come from outside commentary as speculation on possible causes of the incident on March 10. Given that, we'll stay away from it for now because it's purely conjecture.

So since Peverley has no structural abnormalities within his heart, the likelihood is that his problem is purely electrical. The heart runs on an electrical circuit system that relies on all the parts talking together in the correct order and with the correct strength. Sometimes, for a variety of reasons, those connections don't work right. In WPW, there are extra pathways. Other times, some of existing pathways short circuit and start to occasionally misfire. Depending on the location of the electrical pathway issues, it is possible for doctors to go in and isolate those aberrant areas so they are no longer able to talk to the rest of the heart.

That brings us to the cardiac ablation procedure, which is well described from a first-person perspective here and from a medical one here. The goal of this procedure is to isolate off the one (or more) spots that are causing the abnormal rhythms so they can no longer communicate with the rest of the electrical system of the heart and pull it out of whack.

This procedure works to isolate this signal after the first procedure much of the time. The number cited by Stars team doctors was 85 percent for a person of Peverley's age and health. If it does not work the first time, as was the case with Gustavsson, it can also be repeated.  The only way to know if it will be necessary to repeat the ablation procedure is if the abnormal rhythm comes back.

Therein lies the problem of predicting anything, including timelines, for Peverley. The doctors are essentially trying to prove a negative at that point - that the abnormal atrial fibrillation rhythm will not return after a full recovery. And during the recovery period, while the heart muscle recovers from the ablation itself, some abnormal rhythms are common. The time frame for the recovery period lasts in the vicinity of three months.

Peverley had his surgery in mid-March, so that three-month period will be up sometime in mid-June. At that point, assuming he and his family have made the decision that he's ready to try a return to the NHL, I'm sure the doctors will do everything they can to try to induce the atrial fibrillation. Again, it's about proving a negative, so the testing will be fairly extensive. What they do then will depend on the test results, and there's no telling exactly how long everything will take.

If the arrhythmia comes back at that point, Peverley may need a repeat ablation - depending on the individual studies I found, it looks like this happens from 20 percent to 50 percent of the time across all age and health ranges. But as Gustavsson shows, repeat ablations are not necessarily a barrier to return to the NHL.

The answer may be clear. It may not be. No one knows at this point, from Peverley himself to doctors to anyone involved with the process. Medicine is sometimes the business of playing the odds in ones favor and then hoping everything works out, and this is one of those cases.

So like Peverley said multiple times in that exit interview, there's no knowing what will come next at this point. The atrial fibrillation could very well be gone forever, never to cause him problems again. It could need another procedure or it could be something that prevents him from returning to the NHL at any point. And regardless of the medical outcome, he and his family may or may not be mentally ready for him to return to hockey.

There are more unanswered questions than answered ones that this point, and while that's frustrating in one sense, the most important thing to remember is what Lindy Ruff said in the days immediately following the incident. At the end of the day, this is a good story the Stars get to tell.

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