Before your heart operation

People need heart surgery for different reasons. The most common reasons are:

Coronary artery disease

The coronary arteries supply the heart with blood. In some patients, if fatty material builds up inside the wall of the arteries (atheroma), these arteries become narrowed. If this happens, the blood supply to the heart is reduced and it does not get enough oxygen. This causes chest pain called angina. If the artery becomes totally blocked, the result is a heart attack.

Damaged heart valves

The heart has four heart valves that control the flow of blood in and out of your heart.

Heart valves can get damaged through ageing, rheumatic fever or a heart attack. They may become stiff and their openings narrower or floppy, which may allow blood to flow in the wrong direction.

If the valves are damaged, your heart has to work harder to pump blood. Over time, the heart becomes enlarged (bigger) and inefficient.

An enlarged heart that does not work well is called heart failure. Symptoms include shortness of breath, tiredness and fluid retention.

Enlarged aorta

The aorta is the main artery that carries oxygen-rich blood to the body. The aorta can become enlarged and rupture (burst). This abnormality is usually caused by a genetic disorder.

Coronary artery bypass grafting (CABG)

What is CABG?

Coronary artery bypass grafting (CABG) involves taking a vein or artery from another part of the body, usually the chest or leg, and attaching it to the coronary artery above and below the narrowed area or blockage. This replacement vein or artery is called a graft and allows blood to bypass the narrowing or blockage, improving blood supply to your heart muscle.

Heart bypass surgery does not cure the heart disease that caused your arteries to become narrowed or blocked. It is important to follow a healthy lifestyle to help the graft(s) work well and to prevent the narrowing of other arteries.

What are the advantages of CABG?

A successful operation will increase the blood flow to your heart muscle. This will reduce symptoms such as angina (chest pain), shortness of breath and improve your overall quality of life. The surgery also reduces the risk of future heart attacks. At your consultation, your surgeon will always discuss with you what they expect the outcomes to be for you as an individual.

What are the risks of CABG?

All medical procedures carry some risk. It is important to remember that we would not recommend any procedure if we did not believe the benefits outweigh any risks. The risks will be different for each patient, so we will discuss the risks that apply to you in more detail before the procedure

The risks of CABG surgery include:

• Atrial fibrillation – a fast, irregular heartbeat that usually settles after a few days. It rarely causes a major change to how the heart works or to the patient’s overall level of health.
• Bleeding – some patients may need a further operation after surgery to control bleeding.
• Wound infection – this is more common in patients with poorly controlled diabetes or other conditions that make them more vulnerable to infection. If you do get an infection, this can be treated with antibiotics.
• Renal (kidney) failure – this is more common in patients who already have kidney problems and can be treated with dialysis.
• Stroke – this happens when a blood clot develops and travels to the brain, cutting off the oxygen supply. The risk is higher in patients who have had a stroke or transient ischaemic attacks (TIAs, commonly known as mini-strokes). To reduce the risk of stroke, we will give you medications both during and after the operation to slow down the rate at which your blood clots. We may also ask you to wear special stockings after your operation. These have been shown to reduce the risk of clots.
• Death – the risk of not surviving the operation will be higher for patients who are very unwell before the surgery. Your surgeon will discuss your risk with you at your consultation.
• Are there any alternatives to CABG? Drugs will only control the symptoms of your heart disease and will not solve the underlying problem.
• What will happen if I do not have CABG? Without heart bypass surgery, symptoms such as angina and shortness of breath will get worse and more frequent over time. You will also have a higher risk of having a heart attack. Patients with severe coronary artery disease may have a shorter life expectancy

Heart valve surgery

What is heart valve surgery?

In heart valve surgery, damaged valves are either repaired or replaced. The valves that most commonly need surgery are the aortic and mitral valves. In some cases it is possible to repair a narrowed valve by simply opening it up (valvotomy). Sometimes a leaking valve can also be repaired, but if it is badly damaged it has to be replaced.

There are two types of replacement valves

• Mechanical valves – made out of metal and plastic.
• Tissue valves – made out of tissue from pigs, cows or from human donors.

Heart valve surgery involves making a cut of about 25cm (10 inches) down the middle of the breastbone to access the heart. Some patients are suitable for a minimally invasive operation. This involves making a smaller cut and may lead to quicker recovery times. If a minimally invasive operation is suitable for you, your surgeon will discuss this with you in more detail.

What are the advantages of heart valve surgery?

Heart valve surgery should help improve the quality of your life by reducing symptoms such as shortness of breath, blackouts, tiredness, chest pain and fluid retention. It will also reduce the risk of your heart failure developing further and help increase your life expectancy.

What are the risks of heart valve surgery?

The risks of heart valve surgery include:

Need for a permanent pacemaker – the operation can disrupt the heart’s regular rhythm. This will usually return to normal in the days after surgery. Sometimes this does not happen and patients need a permanent pacemaker fitted after surgery to regulate their heart rhythm.

Are there any alternatives to heart valve surgery?
Drugs can be used to treat the symptoms of your condition, but cannot cure the underlying problem.

What will happen if I do not have heart valve surgery?
Without heart valve surgery, your symptoms will get worse and more frequent over time.

Aortic surgery

In aortic surgery, the enlarged aortic artery is either replaced or repaired by placing a graft (a synthetic tube) around it to stop it from getting any bigger.

What are the advantages of aortic surgery?
Aortic surgery will remove the risk of the aortic artery getting any bigger and rupturing (bursting), and will help increase your life expectancy

What are the risks of aortic surgery?
All medical procedures carry some level of risk. However, we would not recommend a procedure if we did not believe the benefits outweigh any risks to your health.

Immediately after your operation you will be taken to the intensive care unit. You will be connected to a monitor to check your heart rate, blood pressure and blood oxygen levels. A nurse will be with you at all times.

At first, we will keep you asleep so that we can make sure your heart is working well and that there is no major bleeding from the wound.

We will then turn off the anaesthetic and allow you to wake up gradually. You will become aware that the tube helping you to breathe is still in your mouth. As soon as we are happy that you can breathe strongly enough on your own, a nurse will remove the tube.

Several drips will provide you with the fluid, medications and pain relief you need. You will also have a catheter in your bladder. This means that you do not have to worry about going to the toilet.

You will also have some chest drains in place after your operation. These remove blood, fluid and air that may collect in the chest after surgery. The drains are removed once they have finished draining all the fluid

Most patients pass through the following stages during their recovery. Remember that every patient is different and so this is just a guide:

Stage one (generally day one)

• You will still be connected to some drips and tubes
• A nurse or physiotherapist will help you sit in a chair and spend some of the day out of bed.
• You will be able to eat and drink small amounts

Stage two (generally day two)

• We will remove most of your drips and tubes. If you have had heart bypass surgery with a vein from your leg, we will remove the bandage from your leg.
• Your nurse or physiotherapist will encourage you to take regular short walks around the ward.
• Your nurse will help you with personal hygiene, if needed.
• You will be able to dress in your own clothing

Stage three (generally days three to four)

• You will be able to walk longer distances.
• You will be able to have a shower – a nurse can help if needed.
• Your nurse will help you with personal hygiene, if needed.
• You should have a better appetite.

Stage four (generally day five)

• You should be able to climb stairs.
• If your mobility is limited, or you are worried about climbing stairs, a physiotherapist will help you with this.
• Plans for your return home will be finalised – including support from social services, if needed.

Stage five (generally days six to seven)

• You will go home.

Before you leave hospital, we will discuss the things that may affect you when you are back at home, such as:

• How to care for your wound
• Your medicines and when to take them
• Getting back to your daily activities and how to organise any support or special equipment you may need
• exercise and other activities.

If you have any of the following concerns about your helth when you back at home plesase contact using this links.

• think your heartbeat is too fast or irregular when it has previously been stable
• are experiencing angina-type pain in your chest or any other new or unusual pain
• have shortness of breath that does not go away after a rest
• have an unexplained cough or have green or yellow sputum (phlegm)
• have an unexplained temperature
• notice new redness, swelling or discharge from your wound
• notice a clicking sound from your breastbone when you are moving around
• have fainting or dizzy spells for no reason
• notice unusual swelling in your ankles
• find you are not able to exercise as much as usual
• are worried about anything to do with your health or recovery that seems unusual to you and is making you feel unwell.

We will discuss your medicines with you and when to take them.

If you are using anticoagulant medication (such as warfarin) to reduce the risk of blood clots after your operation, you will need to have regular blood tests to make sure you are on the right dose.

It is safe to get your wound wet, so please continue to shower every day using liquid soap. It is important that you do not put soap directly on your wound or rub your wound very hard before it has healed completely – usually about eight weeks after your operation.

Always use clean, dry towels and do not share them with anyone else. Dry your wound first before drying the rest of your body. Please be gentle when drying your wound and dab it dry with the towel rather than rubbing it.

If you are a female patient, you need to wear non-wired, front- fastening bras for six weeks after your operation. You also need to put on a clean bra every day to reduce the risk of infecting the wound.

Contact as soon as possible if you have any concerns about your wound, or if you notice any of the following symptoms of infection:

• a red or angry-looking wound
• heat or swelling around the wound
• change in the amount of pain from the wound
• pus or discharge from the wound
• an unpleasant smell from the wound
• any new opening of the wound.

If your wound has become infected, it can be treated with antibiotics.

Managing your pain at home is a really important part of your recovery, as it means that you can return to your normal activities more easily. It is important to take pain killer medication as prescribed by your doctor.

When you are able to do your normal daily tasks and can exercise without pain, it is important that you do not suddenly stop your pain relief medication. You can start to slowly reduce it over a period of time by leaving out a dose, or taking one tablet instead of two after meals.

Remember that you may have aches or pains in your chest, shoulders and / or back up to four months after your operation.

It is important that you do not drive for at least six weeks after your operation.

The strength of your muscles and your general ability to move around will be reduced during the first few weeks after your operation. You may feel pain from sudden movements and may experience moments where you suddenly cannot concentrate.

It is very important that all these symptoms pass before you start driving again. The length of time it takes for the body to heal and for these symptoms to disappear is different from person to person.

Please remember to wear a seatbelt when driving. You may find it more comfortable to wear your seatbelt if you place a rolled- up towel or small pillow between your chest and the seatbelt.

When you can return to work will depend on how quickly you recover from your operation and the type of work you do. If your job is office-based and not too physically or mentally demanding, you may find that you can return to it six to eight weeks after your operation. However, if your job involves heavy manual labour or is stressful, you will need to wait up to 12 weeks.

It may be helpful to go back to work part-time or to ask for lighter duties at first and build up gradually.

If you have had heart valve surgery, you should go to the dentist every six months. We recommend that you take antibiotics before you have any dental work that could make your gums bleed, such as having a filling done. This is because patients who have had valve surgery are at a higher risk of developing a potentially serious infection of the heart called endocarditis. This is caused by bacteria getting into the bloodstream when the skin is broken.

If you have not had valve surgery, you will not need antibiotics before going to the dentist. You should make sure that you clean your teeth regularly to prevent possible infection.

After your operation, you can have sex again as soon as you feel comfortable doing so. It is a good idea to find a position that is most comfortable for you. Please avoid positions that put weight on your breastbone or upper arms.

If you are a woman who has had valve surgery and have not yet gone through the menopause, you should avoid becoming pregnant until you have completely recovered from the operation.

In the first few weeks after your operation, you should avoid taking holidays that involve a lot of travelling or activities.

You should not fly before you have had your first follow-up outpatient appointment at the hospital.

If you are going away, please take enough medicine with you and a copy of your prescription. If you are taking anticoagulant medication (such as warfarin), you may need to have a blood test before you go away and as soon as you get back.

It is important that you do not put strain or pressure on your breastbone in the first few weeks after your operation. Do not lift, push or hold anything heavier than 10lbs / 4.5kg (such as babies or pets) for six to eight weeks after your operation.

Please avoid heavy work in and around the house such as vacuuming or mowing the lawn. You should also try not to make any sudden twisting movements.

You should be able to start normal lifting 12 weeks after your operation. It is important to always use the correct lifting technique, keeping your knees bent, back straight and the object you are lifting close to your body.

Exercise is an important part of your recovery. It will help your body to heal, increase your overall fitness, improve your sleep patterns and reduce levels of stress after your operation.

It is important not to overdo things in the first few weeks. It sometimes takes longer than three months to heal properly and the doctors and rehabilitation team will give you advice on exercises that are suitable for you. Avoid anything that puts extra strain on your chest. Please do not strain or hold your breath while you are doing any activity or exercise.

Walking is the safest and best form of exercise after your surgery. You will have been walking short distances before leaving hospital. Once home, try and walk a similar distance. This could be simply walking in the garden or park. You should start slowly for the first few minutes and build up your pace gradually. Towards the end of your walk, you should spend a few minutes slowing down. It is a good idea to walk with someone for safety until you are confident about going out on your own.

For the first two weeks after your operation, try to walk for five to 10 minutes, two or three times a day. It is important that you choose a route that is flat and easy.

From the third week, you can start to build up your time gradually and include gentle hills. If you have other health problems such as arthritis or asthma, you may not be able to increase the amount you walk this quickly. It is important not to compare yourself to others.

Set a pace that makes you short of breath but able to hold a conversation. If you become too out of breath, stop and rest for a while then continue at a slower pace. You should become less breathless as time goes on after your operation.

Activities where you have to move your arm regularly will increase the strain on your breastbone and make your heart work harder. Take special care when introducing these activities and build them up gradually. Do not play contact sports such as football, or racquet sports such as tennis.

Please avoid:

• exercising if you are in pain or if you feel unwell
• exercising in very humid conditions or if it is very hot or cold
• sudden twisting or straining movements
• activity that causes clicking or pain in your breastbone
• lifting, pushing or pulling heavy objects over 10lbs / 4.5kg
• heavy tasks that involve a lot of strength, such as moving furniture.

Remember to:

• take regular exercise rather than sudden bursts of frantic activity
• rest when you feel you need to
• watch your posture and avoid hunching your shoulders or straining your neck.

Eating well is another important part of your recovery. Healthy eating will help you to lose weight if you need to and will help control your cholesterol.

You should wait six to eight weeks before thinking about any weight loss or making major changes to your diet.

Get enough rest

It is important that you rest and try to get eight to 10 hours of sleep a night during the first week after your operation. Try to limit the number of visitors as entertaining them can be tiring.

Pace yourself

Give yourself enough time to do everyday activities such as getting washed and dressed. Sit down when you can and break up your activities with periods of rest. As you start to feel that you have more energy, slowly increase the amount of activities you do. Remember not to lift, push or pull anything heavier than 10lbs / 4.5kg and to avoid sudden twisting movements.

Cooking and cleaning

If you live alone, it is a good idea to stock up your freezer with frozen meals before your surgery. Make a ready meal, hot drinks and snacks such as toast. Please avoid any heavy cleaning as it is likely to be very tiring and may involve lifting or twisting movements.

Taking a shower or bath

You can take a shower at any time after your surgery, as long as you are able to get in and out of the shower easily. Please contact your occupational therapist who can give advice if you have difficulty getting in and out of your shower.

If you have to take a bath, please do not cover your wound in bath water or clean it directly with bath water. This is to help it heal faster and to prevent infection.

Start to reintroduce other activities

Six weeks after your operation, you can start to slowly reintroduce other activities. If you start feeling tired or uncomfortable while doing an activity, you should stop and rest.

Cooking and cleaning

You should be able to reintroduce activities such as cooking a meal from scratch, making your bed, vacuuming, and doing your laundry. It is important that you introduce each activity slowly and plan to rest. For example, you can vacuum one room and then rest before moving on to the next room.

Taking a bath or shower

If your wound has healed, it should be fine to take a bath again. If you have any concerns about your wound, please discuss this with your GP.

Your breastbone should be fully healed. Patients can usually continue their normal activities (as before their operation) at this stage.