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  • 1. Most patients are dis-charged from the hos-pital between the fourthand the eighth day aftertheir operation. 242
  • 2. CHAPTER FIFTEEN RECOVERY AFTER HEART SURGERY AND A SECOND BYPASS OPERATION… WILL YOU NEED IT? WHEN?R ECOVERY AFTER HEART SURGERY this point, progress toward a liquid diet is begins when the patient leaves the usually rapid. operating room and arrives in the By the morning after surgery, mostintensive care unit. By that time, the anes- patients are able to sit in a chair next tothesia is wearing off, and the patient be- their bed. Depending on the progress andgins to awaken. Patients are still con- also, to some extent, the preferences of thenected to drainage bottles and monitor- heart surgery team, most patients areing devices, and a temporary pacemaker transferred from the intensive care unit,may also be used. or ICU, late on the morning after the People usually start to wake up within heart surgery.an hour after their heart surgery and aresoon able to follow simple commands Transfer from the ICUsuch as “Move your foot, move your arm.”When patients are alert and breathing on After transfer from the ICU to thetheir own, and if the blood oxygenation level hospital ward, also known as the “step-is appropriate, the endotracheal tube in down unit,” the heart rhythm is still mon-the patient’s throat and windpipe (tra- itored at the nursing station. By the sec-chea) is removed. This usually occurs ond postoperative day, most people areanywhere from a few hours after heart able to walk to the bathroom and down thesurgery to the next morning. In some hospital corridors with some assistance.cases, with some cigarette smokers for By the third day after heart surgery,example, the endotracheal tube may some people are ready for discharge.need to stay in longer. Others may have to stay for a few more Chest drainage tubes can usually days, and some will have to stay longerbe removed by the next day. Sometimes even, depending on the circumstances.they’re left in until the second morningafter heart surgery. Discharge Home Eating is also introduced gradually.If the patient is awake and alert, and Today, most heart surgery patients arehis or her intestines are functioning, the discharged between the fourth and thestandard fare is ice chips and water. From eighth postoperative day. Before discharge, 243
  • 3. S TAT E O F T H E H E A R Tthey are given instructions regarding the to drink more liquids, the result can bevarious medications that are usually pre- edema, or swelling of the legs. It can alsoscribed after heart surgery. For example, lead to fluid overload, a condition inpatients with considerable heart pumping which veins become engorged and thedysfunction will fare better with ACE-in- extra fluid backs up into the lungs. Thehibitor drugs. Patients with bypass grafts patient then becomes short of breath.will likely need aspirin. Patients with ab- Salt restriction is usually no longernormal heart rhythms may require med- necessary after about a month. It is, how-ication to regulate their heartbeat. A dieti- ever, still necessary in some patients whocian also instructs patients on appropriate are on certain medications and those whodiets. Many of the instructions the patients have high blood pressure or some degreeget before discharge deal with various ac- of chronic heart failure.tivities they can and cannot do at home,and in a way this is more or less an infor- Surgical Woundsmal cardiac rehabilitation program. The most common form of incision When the patient leaves the hospital,during heart surgery is an incision down the wound’s skin edges are joined to-the middle of the breastbone, which is gether, and the wound is in the processclosed after the surgery with stainless steel of healing. Wounds should not bewires. Although the wires stay in indefinite- scrubbed with a washcloth but gentlyly, there is a period of healing after heart cleaned with soap and water. In manysurgery that demands special attention. cases, stainless steel staples are usedRecent heart surgery patients are instruct- to close the skin. If a patient goesed not to lift anything heavier than twenty home between the third and even thepounds for four to six weeks. In some ways, fifth postoperative day, the staples arethis healing process is similar to that for a usually left in, and arrangements are madebroken arm or leg bone, which takes about for them to be removed later.three months to heal. There is usually little pain associated Recovery at Homewith this incision, called a midline ster-notomy incision. Nerves come from the After finally arriving home, mostspinal cord out of the back bone and run patients discover they are weaker thanaround the ribs to the front, so there is they thought they would be. This is typi-not a concentration of nerves in the area. cal. Hospitals are very sheltered environ-However, it is worth noting that everybody’s ments, and, although confidence is gainedpain threshold is different. On some days, walking up and down the hospital hall-the incision pain can be more noticeable ways, there are obstacles at home thatthan on others. In most cases, it is gone weren’t considered, like stairs and every-after three to four weeks, although in day movements.some patients, it may be present for two Confidence usually returns fairlymonths or longer. quickly as energy levels rise, but pa- Typically, we recommend that patients tients should strive to strike a balanceavoid using excessive salt in the first few between exercise and rest. Exercise itselfweeks after the surgery. Don’t eat potato is very good for a recovering heart pa-chips, pickles, and other salty foods, and tient if done very carefully at first and indon’t add salt to food. After major opera- moderation. It will help control bloodtions, and particularly heart operations, pressure and blood sugar, burn excessthe body has a tendency to retain salt calories, and lower body fat. Before anyand water. Because salt causes people heavy exercise is possible, light stretch- 244
  • 4. C H A P T E R F I F T E E N : R E C OV E RY A F T E R H E A RT S U R G E RYing is a good idea. There are several ef-fective stretches that will help the inci-sion heal properly. ♥ Arm raises — forward: In a sitting position, straighten your arms, and raise them over your head. ♥ Pectoral stretches: In a sitting po- sition, begin with your hands on top of your head, and push your elbows back until they are in line with your hands. Relax, bringing elbows slightly forward. ♥ Arm raises — side: In a sitting po- sition with your arms at your sides, straighten your arms and raise them over your head. Keep your palms up. ♥ Sideways body bends: Place your feet about 11⁄2 feet apart for bal- ance while sitting in a chair. Bending slowly sideways at your waist, reach your right hand up- ward towards the ceiling and lower your left hand towards the floor on the left side of your chair. Hold for three seconds. Return slowly to sitting position. After these light exercises have beenperformed, check your pulse. Within a week or so, many patientshave progressed to taking walks outside.Within a month, they can often walk amile or two without difficulty. Driving,however, is not recommended for the firstseveral weeks after heart surgery. I mustadmit, however, that one of my patientsowned his own eighteen-wheeler tractor-trailer rig, and I found out when he camein for his routine postoperative visit fiveweeks after the heart surgery that he hadgone back to driving his rig across thecountry a week after he returned homefrom his heart surgery. Clearly, we don’trecommend this. 245
  • 5. S TAT E O F T H E H E A R T LEARN HOW TO TAKE YOUR PULSEA FTER HEART SURGERY, FATIGUE ♥ If you cannot feel a pulse, light- and stress during exercise should en the pressure. If that doesn’t always signal that a rest is need- work, move up along the wristed. Before that, however, patients should until a pulse is located.check their pulse during exercise to makesure the heartbeat is staying within a ♥ Count the beats for ten seconds,reasonable limit. then multiply by six. This is the It is important to remember that “resting pulse” per minute.pulse rates vary from individual to indi-vidual. There is no “magic number” but ♥ To determine a good “speed limit”rather a range of about sixty to one hun- for exercise, add three to thedred beats per minute when the heart is resting pulse. For example, if theat rest. The pulse rate is increased by resting pulse is fifteen (or 90exercise as well as emotional states like beats a minute), a reasonableanger, fear, excitement, and anxiety. exercise target would be 18 beats Your pulse can be taken anywhere in a ten-second period (or 108on the body where an artery near the beats per minute).surface can be compressed against afirm surface. Most commonly, doctors The pulse should be checked inuse the inner forearm (wrist), where the middle and at the end of exercise.the radial artery can be compressed If it rises above a reasonable limit,against a bone in the forearm. There take a break or slow down. This can beare some practical approaches to tak- done with abdominal breathing exer-ing a pulse. cises. During an abdominal breathing exercise, the hands are placed over the ♥ Sit in a comfortable position. abdomen and a deep breath is drawn in through the nose, allowing the abdomen ♥ Place the index, second, and to rise under the fingers. Breathe out third fingers of one hand on the through the mouth while pushing in wrist of the other hand. on the abdomen. Repeat this eight to ten times. This will lower your respira- ♥ Exert firm pressure. tory rate. 246
  • 6. C H A P T E R F I F T E E N : R E C OV E RY A F T E R H E A RT S U R G E RY Usually, after five or six weeks, patients emotional support system is very helpfulcan begin driving again, but even this in getting through this period.should be avoided if the patient is suffer- Even after several weeks of healing,ing from dizzy spells, blackouts, or light- excess stress should not be put on theheadedness. When driving, it is a good breastbone. The arms are connected toidea to put a pillow between the seat belt the collarbones, which are anchoredand the incision to protect it. on the sternum. Any exercise that re- Sexual activity can usually be re- quires arm strength, including push-upssumed three or four weeks after heart and lifting objects weighing more thansurgery, depending on how the patient twenty pounds, puts pressure on thefeels and how recovery is progressing. breastbone and could cause it to become Decreased appetite is common for the loose. For this reason, it is recommendedfirst several weeks after heart surgery, but that patients push with their body weightappetite will gradually improve. Insomnia instead of pulling whenever possible.is experienced by some patients at times. Similarly, sports such as bowling,Moodiness, irritability, and mild depres- tennis, and golf should be avoided forsion are not uncommon on some days of the first three months. After that time,the recovery phase. Usually, over several any of these activities can usually be re-weeks, these symptoms disappear, and sumed, although you should alwayspatients will have the type of personality check with your cardiologist before re-they had before heart surgery. A strong suming these activities. After their surgeries, patients are transferred to the intensive care unit, where they are constantly monitored. 247
  • 7. S TAT E O F T H E H E A R T Recovery from Coronary Bypass Surgery to the brain, causing a stroke, or the valve itself could even clot off. If the an- About three to eight weeks after ticoagulation level is too great, bleeding heart surgery, some cardiologists rec- from the intestines or kidneys or even a Exercise Stress Test: ommend an exercise stress test for all stroke caused by bleeding into the brain A test during which a of their patients. The stress test is per- could develop.patient is connected to formed as a baseline evaluation. The With heart valve surgery, the ventri- an electrocardiogram, test may also be done to assess the pa- cle itself may be very thickened or en-or possibly other types tient’s status in case of recurrent angi- larged as a result of the long-standing of monitoring ma- na. This is not true for all doctors, heart valve disease that was present be- chines, and asked to however. Others perform the test only fore the valve surgery. In this case, the walk on a treadmill or for those patients who may be doing muscle tends to outgrow its blood sup- possibly pedal a sta- activities that require more blood going ply, and although the valve has been tionary bicycle while to the heart. A good example is the pa- fixed or replaced, the heart itself will being monitored. tient who plans to run in a marathon likely take several months to recover. or plans on playing tennis or perhaps Patients should therefore avoid vigorous patients who have the lives of many exercise such as running and playing people in their hands, such as com- tennis until these activities are approved mercial pilots. by a cardiologist. Repeated tests are also performed Stress tests are sometimes used in patients with recurring or ongoing after valve replacement that did not angina. If the exercise stress test re- include coronary artery bypass graft- sult is normal, one can usually re- ing to assess postoperative exercise sume virtually any activity provided it ability and heart rhythm during exer- is approved by a cardiologist. If it’s cise. An echocardiogram is often rec- abnormal, the cardiologist may rec- ommended to see how the ventricles ommend some limitation of activity or are recovering after the valve has been change in medication. repaired or replaced. Patients who have had heart valve Recovery from Heart Valve Surgery surgery will need to undertake a regimen of antibiotics before and after dental Recovery from heart valve surgery is surgery or additional surgical procedures. similar in many ways to recovery from coronary artery bypass surgery. The inci- Cardiac Rehabilitation sion is similar, and the breastbone needs time to completely heal. Again, excess salt Cardiac rehabilitation actually begins should also be avoided. when one leaves the operating room. By Some patients will be taking coumadin the time patients arrive home, they are Anticoagulant: (warfarin), an anticoagulant or blood starting the second or third stage of car-A drug that prevents or thinner. As long as coumadin is being diac rehabilitation, depending on whose slows the blood clot- taken, patients should avoid all vigorous definition of cardiac rehabilitation is used. ting process. Also re- contact sports such as rugby, soccer, It is important to only gradually in- ferred to as a blood and football. Dangerous sports like sky- crease physical activities like walking. thinner. diving, in which one might receive blows This promotes recovery. People who live in to the head or begin bleeding, should also cold areas often do their walking in large be avoided. shopping malls because extreme temper- If the blood is not anticoagulated atures (less than 30˚F and more than enough, blood clots can form on the 90˚F) should be avoided for the first heart valve or break off the valve and go month or so. During that period, patients 248
  • 8. C H A P T E R F I F T E E N : R E C OV E RY A F T E R H E A RT S U R G E RYshould avoid contact with people with help build the patients’ confidence.colds and other types of illnesses that, if Patients are closely monitored for abnor-contracted, will cause coughing. mal blood pressure and irregularities of the heartbeat by trained personnel in a Formal Cardiac Rehabilitation Programs group or class setting. They are taught to after Heart Surgery or Heart Attacks monitor their pulse rate and to look for signs of chest pain (angina type), particu- Some cardiologists feel strongly that larly if they are coronary patients. Theirall patients should be enrolled in a formal activity level is slowly increased. Duringrehabilitation program. These programs rehabilitation, they are educated abouttypically last six to twelve weeks after diet and other types of behavior modifica-heart surgery or heart attacks. Other car- tion that lead to a healthier lifestyle and adiologists feel that the need to enter a for- healthier heart.mal cardiac rehabilitation program shouldbe more individualized, and not all pa- The Second Coronary Bypass Operation:tients, particularly those that are already Will I Need It? When?quite active, need to be enrolled. These programs are typically located I frequently hear comments from pa-at a hospital, community center, or reha- tients or their family members such as,bilitation facility. They are designed to “My neighbor told me these bypass opera- Moderate exercise after heart surgery is a very valuable tool in rehabilitation. The level of exercise, however, should be determined at first by a cardiologist. 249
  • 9. S TAT E O F T H E H E A R Ttions have to be redone every three to four times the needle used to stitch the by-years. Is that true?” Patients are naturally pass to the coronary won’t go throughvery apprehensive about surgery to begin the coronary’s calcified wall. Also, bypasswith, and when it comes to the possibility grafts tend not to stay open as long in in-of having to repeat a procedure, they want sulin-dependent diabetic patients andto know the bottom line. Will they need a those with cholesterol disorders.second bypass operation? If so, how longbefore it is needed? Bypass Grafts Closing The answer that heart surgeons andcardiologists would always like to give is, If you have three, four, or more by-“Never!” The realistic answer, however, is passes and one or two of them close,more complicated. One can say, “Hopefully that does not necessarily mean you neednever,” but the fact is that every patient is a second bypass operation. In fact, if theyunique, and every situation depends upon all close, you still may not need a sec-a number of variables. ond operation. You might need a bal- When arteries are used as the by- loon angioplasty (PTCA) and maybe apass grafts, they tend to stay open stent. After bypass surgery, your cardi-longer than veins. Sometimes, however, ologist may have more treatment op-the patient’s vessels considered for use tions. For example, if you need a bal-as bypass grafts may not be in the best loon angioplasty, your doctor may beshape. This can influence how long the able to dilate either the coronary arterybypass stays open. or the bypass graft. It may turn out The arteries normally considered as that if the bypass fails, translaser my-candidates for grafts may be too small or ocardial revascularization (TMLR) maydiseased, or the amount of blood flow be a better option than a second bypassthrough them may make them unac- operation. This procedure can be doneceptable. Likewise, the diameter of the either with an operation or with cathetersveins may be too big or too small, or the passed from an artery in the groin orvein itself may have other abnormalities. arm into the heart.The surgeon will not use arteries unlesshe or she feels they are acceptable, and The Second Operationhe will try to use the best quality seg-ments of vein available. In addition to all of these factors, How long bypass grafts stay open doctors’ criteria for recommending aalso depends on the condition of the second bypass operation can be some-coronary arteries themselves. Ideally, the what different than they were for thecoronary artery that was originally by- first operation because the risk of a sec-passed was a relatively large artery, ap- ond bypass operation is usually higherpearing to be normal except for one lo- than that of the first. The patient iscalized area of blockage. Unfortunately, older. The atherosclerotic coronary dis-sometimes we find coronary arteries that ease is usually more advanced. Some ofhave multiple blockages, or the entire the arteries and veins used to do theartery has significant atherosclerosis first bypass are no longer available forbuild-up. In addition, some arteries are the second operation.only a millimeter or less in diameter Adhesions will be present that(there are twenty-five millimeters in an formed after the first operation. Thisinch). Sometimes the arteries are so brit- means that the surfaces of all the tis-tle with calcium that it is difficult to find sues will be stuck to each other so thata spot to place a bypass graft, and some- it is more difficult and time consuming 250
  • 10. C H A P T E R F I F T E E N : R E C OV E RY A F T E R H E A RT S U R G E RYfor the surgeon to expose the heart and surgery has about a 10 percent chancecoronaries or sometimes just to find the of having a second coronary bypass op-coronaries. Also, because of the adhe- eration. (A third bypass operation issions, bypass grafts that are still func- uncommon, and having more thantioning may be damaged while exposing that is rare.)the heart, which also adds to the com- Although unlikely, some patientsplexity of the operation. The recovery need a second bypass operation within aafter the second bypass operation, how- year of the first. But for the majority ofever, tends to be similar to the first. patients who will need a second bypass So how risky is a second coronary by- operation, it will most likely occur morepass operation, and what are the chances than five years after their first and some-of needing a second operation? The risk of times more than twenty years after it.not surviving a second operation variesdepending on various factors, but in most You Can Helpcases is less than 10 percent. What are the chances you will Lifestyle after coronary surgeryneed a second coronary artery bypass plays an important role in keeping by-operation? The field of cardiology, par- pass grafts open longer. Keeping yourticularly interventional cardiology in cholesterol in a safe range is important.which balloons and stents are used to If you are a smoker, quit. Watch yourtreat coronary blockages, is advancing weight and exercise. Also, taking an as-rapidly, as well as the specialty of car- pirin a day makes platelets in yourdiac surgery. My guess is that a person blood less sticky and probably helps tocurrently undergoing coronary bypass keep bypass grafts open longer. 251