Bob McKenzie: Rich Peverley Exploring Possibility Of Comeback From Heart Condition

Peverley, who hasn't played since suffering a cardiac arrest on the bench last March, is reportedly considering a return to the NHL if he can get the proper medical and insurance clearances.

Ever since Dallas Stars management asked for time and space during training camp, all has been quiet in terms of news about Rich Peverley.

The versatile forward, who hasn't played since suffering a cardiac event on the bench at the American Airlines Center last March, has been with the team at practice and home games, and he even went down to Cedar Park for several stints helping out with the Texas Stars in a coaching role.

With no news, many assumed Peverley would quietly call it a career this offseason. After all, he's won a Stanley Cup and has had a very full career for a player who started his professional career in the ECHL. But on Wednesday afternoon, Bob McKenzie reported Peverley may very well have other plans.

McKenzie goes on to mention there are further medical clearances Peverley would need as well as insurance waivers and all sorts of fun on the business side. It's not quite as simple as removing an ICD and being ready to play again.

There's a lot to unpack in McKenzie's five Tweets. The first of which is a bit of news that Peverley had been fitted with some sort of ICD sometime in the aftermath of his cardiac arrest on the bench last March.

An ICD (implantable cardioverter defibrillator) is a small device, a little less than three inches in diameter and a centimeter thick, that is implanted under the skin in the chest with leads running to the heart itself. Its job is to monitor the rhythm of the heart and deliver a shock if a dangerous abnormal one is detected.

Peverley would have been a candidate for one because he suffered ventricular arrhythmias during the incident in March (tachycardia and fibrillation) which resulted in sudden cardiac arrest. The ablations he underwent theoretically should have eliminated the bad pathways that led to the dangerous rhythms, but an ICD is a safeguard just in case something came up again.

ICDs are wonderful, lifesaving devices, but they are not compatible with the vast majority of sports, particularly contact sports. Not only is there a risk that the extremely high but healthy heart rates found in athletes could trigger a shock, but the device itself is also somewhat sensitive and has a small possibility of being set off by a hard hit.

Up until today, it wasn't known whether or not Peverley had an ICD implanted. The fact that he talked about taking baby steps toward playing again last summer suggested he did not, since ICDs would be a barrier to that. Having one certainly explains why he would have been unable to obtain medical clearance to play this year.

"Removal" seems to be a trickier question to answer. In a quick search in both academic and non-academic databases, I couldn't find much on guidelines for when it is appropriate to remove an ICD from an apparently asymptomatic individual. A real-life cardiac surgeon suggested that "removal" could mean several things. The device and the lead wires that run to the heart could be removed. Or the wires could be capped and the device removed, as removing those wires can cause complications. Or the device and wires could be left in place but turned off with some functionality removed.

Assuming the ICD is somehow deactivated enough for clearance, as far as further medical recommendations go, my go-to document on that is the "Eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities" from the Journal of the American College of Cardiology.

Recommendations in the v-tach section also apply to athletes who had episodes of v-fib (with the understanding that v-fib is most often treated by permanent ICD implantation). Here's the recommendation for athletes with no structural changes to the heart:

Athletes with a structurally normal heart and monomorphic or sustained VT that can be localized to a specific site(s) in the heart are candidates for a catheter ablation procedure that may potentially offer a cure. Following such a successful ablation procedure, with subsequent failure to induce VT during electrophysiologic study (EPS) with/without isoproterenol when the VT was reproducibly induced before ablation, the athlete can resume full competitive activity within two to four weeks. A more conservative approach is recommended for the athlete who chooses drug suppression because catecholamines released during athletic activity can counter the suppressive effects of the drug, and the VT can re-emerge. In that situation, generally the athlete should not compete in any sports for at least two to three months after the last VT episode. If there have been no clinical recurrences, and the VT is not inducible by exercise/exercise testing or EPS, and the athlete has no structural heart disease, all competitive sports may be permitted. Because deconditioning can result in the loss or lessening of ventricular arrhythmias (19), a short period of deconditioning and retesting can be considered in some athletes.

In English, athletes with a normal heart or single abnormal pathway who have v-tach can often be cured by ablation or medication, and if the rhythm does not come back after those fixes, they are cleared for all sports.

For the record, the Stars physicians have said repeatedly that there are no structural abnormalities or changes in Peverley's heart, essentially ruling out the possibility of hypertrophic cardiomyopathy, the condition that is most associated with sudden cardiac death in young athletes. The structural changes in HCM are irreversible and why athletes who survive an arrest caused by it do not return to competition -- they remain at much higher risk of more arrests.

And professional hockey does have a handful of players with known heart conditions that are occasionally symptomatic. Jonas Gustavsson has had several ablations, and Derek Meech of the Texas Stars has a condition called Wolff-Parkinson-White Syndrome, which can result in an abnormally fast heart rate.

There's still obviously a long road ahead for Peverley if he does want to make a return to the NHL, not to mention the fact that he's an unrestricted free agent this summer even if he does get all his clearances. But the fact that he's trying to move in that direction is great news from not only a hockey perspective, but also a human one as it likely means he feels his risk of further heart problems is behind him.