These notes have been prepared by me based on my experience with patients in England and of late in India. I have tried to answer the most common questions that come after such operations. I hope you find this useful !

These notes have been prepared for you to take home, so that you and your close family can consult them as and when the need arises. In the next few days you will be leaving the hospital after your heart operation, but your recovery is not yet complete. Advice will be given to you on what to do & what not to do, but it is difficult to memorize everything, especially soon after a major operation. An attempt has been made to cover the most likely questions that might crop up in the next few weeks and to give some general advice that will help you complete your recovery quickly and stay well in the months and years to come. Sister or one of her staff Nurses will give you these notes and introduce you to them. Members of the team will help by explaining parts of them to you if they do not seem clear. Remember that some patients know quite a lot about medicine and how the body works, others know very little. If some of the explana- tions seem too simple or too complicated for you, please understand that intention is to make the meaning clear to as many as possible.

What actually happens at your heart operation :
More than half of heart surgery patients have operations to bypass blocks or narrownings in their coronary arteries. You have had this operation & you will probably have received the the following explanation before surgery. Narrowing or blockages in the coronary arteries prevent sufficient blood reaching the heart muscle. Veins from the leg, and sometimes an artery from inside the chest or from other parts of your body (the mammary artery or other arteries),have been used to bypass these narrowed arteries so that blood now flows through the new channels and reaches the heart muscle freely once more. It is expected that this will relieve angina and may also reduce the risk of a major heart attack.

Your chest incision :
To operate on the heart, an incision through the chest is necessary. This means dividing the chest bone, on sternum. The bone is wired together afterwards. The wires or sternal sutures remain forever and usually can be forgotten. The amount of pain is variable, but some discomfort around the chest and shoulders will persist for a few weeks. Following the physiotherapist’s exercise plan should help and you may be glad to have the help of a mild pain killer such as proxyvon or voveran. These pain killers are non-habit forming and can be taken as frequently as advised (usually not more than thrice a day). Generally as the days go by, the amount of painkillers required should reduce. If the pain persists or does not seem to reduce please consult your surgeon.

Some amount of clicking or a sensation of movement in your breast bone is to be expected during the recovery period especially when you cough or sneeze or turn in your sleep. This is because the sternal bone like a fracture anywhere else in your body takes at least three months before it is soundly healed; you are strongly advised not to lift anything over about ten pounds in weight during the period.

Inflammation:
Redness and inflammation around the wounds should usually have receded by the time you leave hospital. However, sometimes there are small remaining areas. If these are close to wound edges they are not usually important. Your doctor can advise you.

Stitches appearing later:
Occasionally, patient’s report that it looks as though a “stitch” has Come out from the wounds. This does happen and it is of no importance. The body usually absorbs this material but, sometimes it remains beneath the skin and emerges later. If the stitch is troublesome, arrange to see your surgeon, who can remove it immediately.

Leg incision:
Those who have had a vein bypass graft will also have an incision in the leg. In order to obtain the very best material available for construction new blood vessels to the heart, a length of your own vein, called the ‘long saphenous vein’ has been taken from your leg. Usually the cut extends from the ankle, up the leg to the thigh. The position of the cut and its length is of no particular significance as
far as the heart operation is concerned because we need the vein for an important job we try and use the best part of it.
Like all wounds, this can be rather sore, especially around the knee and the ankle. This is normal and settles down with time, but you may need to use some mild pain killer in the meantime. By the time you leave hospital healing should be well underway. There are a few things which may well cause you some concern after you have gone home so we have listed some of the common ones.

Swelling :
The leg from which the vein was taken often has a swelling, usually
around the ankle and the foot. It is most obvious towards the end of the day and is usually gone in the morning, after a night in bed. The
reason for this swelling is that the veins are responsible for returning fluid to the circulation, and since the saphenous vein has been removed one of your other veins will take over this job usually over a period of three months.

In the meantime the following advice should be followed :-

• When you are not actually up and about, it is helpful to sit with your leg up, so that the foot is higher than your bottom. This encourages the fluid to drain more readily away from the leg.
• The support stockings which you had in hospital are helpful in reducing this swelling. They help keep the fluid from accumulating in the tissues. At this stage you may not want to wear them in bed but instead, you could put on just one stocking, on the affected leg, when you get up.
• In general, it is wise to avoid the habit of crossing your legs for a while as this restricts the normal flow of blood in the veins.

If the swelling is worse than this description suggests, or if it is associated with a lot of pain or redness, then the advice may not be appropriate and you should consider consulting your surgeon. If this is a new thing for you, tell your doctor.
Numbness :
Around the lower end of your leg wound there may be a small area which feels rather numb. This is because a small nerve, which runs to this area of the foot and ankle, lies immediately alongside the vein and often fails to function after being disturbed. The numbness always improves and usually disappears completely over a period of time.

Hand Incision:

Most of the patients will also have a wound on their left/right forearm. This is the site from where the RADIAL ARTERY has been harvested. Removing this artery has no harmful effects on the function of your forearm, as the other artery (ULNAR) takeover the job of the radial artery. However, a small nerve that supplies the skin over your thumb usually gets disturbed causing some numbness in that area. Please do not worry, as this is not serious and is usually temporary (may last 6-8 weeks) .

Rest :
The normal recovery period after heart surgery is about eight to ten weeks. During this time you may find that you tire very easily
Take things easy at first and let the amount of activity you attempt build up gradually day by day. For the first fortnight, just potter around in the flat and the garden i.e. with interests and hobbies. Take a limited walk in the morning and once in the evening if you feel like it. The idea is to keep yourself occupied.

Diet :
Although there has been a lot of research into the effect of diet on coronary heart disease, and a lot of it has been publicized in newspapers and magazines, we are unable to honestly say that “any particular thing in the diet” causes the problem in an individual. We can say that certain factors increase the risk and it makes sense to keep your risk as low as possible. If you have had an operation to bypass some of your coronary arteries, why not look after your other ones, and the new vessels, as much as possible Our diet tends to contain more animal fat and dairy produce than is really good for us.
It is wise for patients who have already had to have surgery on their coronary arteries to limit the number of fried meals they eat and to reduce their intake of cheese, eggs, cream, chocolates, cakes and biscuits. Vegetable oils and margarine are preferable to groundnut oil and butter, and fish and beans are healthy sources of protein.
On the subject of diet, there are two other things to remember. One is that being overweight, in itself a greater risk for heart disease. If they achieve nothing else, the dietary changes recommended above will help you to keep your weight down. The other thing is remembered is that coronary heart disease tends to run in families. You cannot help the “genes” that you have passed on to your children and grandchildren, but you can help to reduce their risk of suffering heart disease by bringing them up to take a healthy diet.
MONOUNSATURATED FATS do not alter the cholesterol levels in the body. Foods obtained from animal origin such as fatty meat, organ meats, egg yolk, etc.,are rich in saturated fats. You should therefore keep away from such food items. The secret of healthy heart ultimately boils down to controlling the whims and fancies of one’s taste buds. In patients with increased cholesterol levels, diet modification should aim at reducing intake of SATURATED FATS and CHOLESTEROL and to eliminate excess calories. Saturated fats obtained from food raise cholesterol levels and are harmful, whereas POLYUNSATURATED FATS are beneficial since they lower the body cholesterol. Diet alone can lower the total cholesterol level by 10 –20%. However, in patients with very high cholesterol levels , diet modification alone may not be adequate. Various drugs are available which reduce LDL cholesterol(harmful) and increase HDL cholesterol (helpful) levels. Your physician will be the best person to guide you in this respect. However, you should remember that dietary control is the first step and perhaps the simplest approach towards a HEALTHY HEART.

Alcohol :
While you are recovering from surgery it is best to carefully limit the amount of alcohol you drink, although small quantities are permissible. You can have say, a pint of beer or a glass of wine or a small whisky a day. However, alcohol taken together with sleeping tablets, tranquilizers or analgesics is more potent so be careful. If you are taking warfarin, alcohol can make you more sensitive to it and interfere with the dosage.

Smoking :
Smokers carry a 3-6 fold greater risk of developing a heart attack than non smoker.
Smoking is bad for you and particularly bad for your heart. It narrows the coronary arteries every time you smoke and encourages
the development of atheroma (furring Of Arteries) to block them
permanently. The more you smoke, the worse it is. You have not been smoking in hospital for the last two weeks, (we hope), so why start again now.

Driving :
Do not drive following discharge from hospital until you have been advised that this is safe by your surgeon. He will generally permit this after your first appointment after 7-8 weeks. The psychological stress caused by driving is considerable. Also it, may place more stress on your shoulders and chest wounds than you expect. There is exemption from wearing seat belts!

Sports :
You should make a gradual return to sport activities. Cycling may be resumed two months after discharge, but you must keep to flat areas and at a leisurely pace. Avoid very cold water. Golf may be resumed two months after discharge from hospital. If you have any question about these or any other sports, ask the consultant for his advice at your outpatient appointment.

Return to work
Many patients are concerned about when they will be able to return to work. Of course, this depends on the kind of work involved the progress of your recovery and the results of the tests carried out during our outpatient appointments. When your recovery is complete
and you feel able to cope with a return to work discuss with your own doctor who will be able to help you with this decision. You will find that a rest in the afternoon as well as a good eight to ten hours sleep each night may be necessary for the first few weeks. If you feel tired during any particular activity, such as when climbing stairs, sit down and res. Try to limit visitors to one or two per day as this also can be very tiring. You are the best judge of how much activity you can manage each day. Don’t let well-meaning family or friends become overprotective and slow you return to normal activity by not letting you attempt as much as you feel capable of.

Exercise
Modern lifestyles are often associated with lower levels of physical activity. Exercise reduces blood cholesterol levels and slows down the process of atherosclerosis A regular exercise programme also decreases body weight and promotes mental relaxation. However , begin exercises very gradually, under the guidance of your doctor/physiotherapist. Regular, moderate exercise is good for you and your heart, and so we suggest a daily walk. It is advisable to keep to flat areas, and to plan your route to include somewhere you can sit down. Do not push yourself to distances you cannot easily manage.

People Recover at Different Speeds
Try to increase the distance slightly, but have a rest when you want one. You could be walking a distance of between two and six miles by your six-week post operative out patient appointment.
If you feel exhausted, YOU ARE OVERDOING IT. Do not be alarmed if you still experience good and bad days; this is common but tends to stop in the five to eight week period. However, the full period of convalescence is three months and IT IS NOT A RACE.
To help relieve pain around the chest, back and shoulders, due to stiffness of the muscles and ligaments which have been stretched during the operation,the following exercises should be carried out twice daily for two months :-
shoulder girdle exercises sit make big circles by rolling you shoulders forwards then backwards.
arm exercises stand, raise one hand out to the side, then up above your head.
Repeat with other hand and do this ten times in a day. If full range of shoulder movements is not achieved daily there is a risk of ‘frozen shoulder’ occurring (excessive stiffness)

breathing exercise Place your hands on either side of your chest to feel your ribs move as you breathe in. Sigh out, then take a big, deep breath in to fill up your lungs. Hold for three second, then sigh out. Repeat five times.

Emotions
Don’t be alarmed if you feel more than usually emotional or irritable during the first few weeks after your operation. This is fairly common, but should improve within four to six weeks. If you feel unduly depressed or have problems with loss of memory or concentration, consult your doctor. Patience and understanding on the part of your family and friends should also help to overcome these problems.
Bathing :
Once the sternal wound has healed, you will be able to take either baths or showers. However, avoid extremely hot or cold water temperatures as this may make you feel weak or dizzy. Wash the wounds area gently with soap but do not scrub it. If at first you have difficulty climbing in or out of the bath, have someone standing by to help you. When taking a shower, a firmly placed stool in the shower cubicle may be until you feel stronger.

Housework and gardening
You must avoid the following activities for three months: –
Lifting, pushing, carrying heavy weights. In practice, this means you cannot do a number of common household chores such as using a vacuum cleaner, moving furniture, carrying shopping or lifting children, mowing the lawn or digging the garden for first 2-3 months. All these activities are strenuous and will put stress on your chest wounds. To keep yourself occupied, stick to very light housework such as laying the table, dusting furniture or watering the plants.

Blood pressure
If your blood pressure was high before the operation it is likely to return to the same levels over a couple of months. We will check it in the outpatients but it is also good idea for your own doctor to measure it occasionally. If your blood pressure is high, it must be treated and brought down to normal levels.

Your love life-SEX :
Many patients who have undergone cardiac surgery experience feelings of anxiety about resuming sexual relationships. This is perfectly normal. We hope the following information will help and guide you. You should try to wait four to six weeks after your operation before resuming sexual intercourse, to give your body heart time to recover. Of course, you are the best judge as to show when you feel able and ready to resume relationships. The ideal time should be when you feel relaxed, comfortable and in familiar surroundings. However you should avoid those times when you feel tired, or tense, or after a large meal as this will increase the stress on you and your heart. The position you choose must be one which is comfortable, does not restrict breathing and not stress your chest wounds. A recumbent position, adopting the less active role in initially, is preferable. Please discuss this with your partner. If you get disappointed to begin with, do not be alarmed, this is not uncommon. Rest and try again at a later date.

Do remember that the doctor and the nursing staff are there to discuss and answer any question you might have. When you get back home, if you have any queries, your surgeon or cardiologist, who has great deal of experience advising on this subject, will not be embarrassed and can be very helpful.

Walking Program :

Lack of exercise is one of the risk factors for heart disease, it is a risk factor that if controlled will help you control several of the others,
eg: being overweight, high cholesterol and high blood pressure.
Exercise can also reduce stress and the negative effects that this has on your lifestyle. Walking is an easy way to start regular exercise, it easy to organize and gentle on the joints of the body. It also provides excellent aerobic fitness, which is the sort of fitness heart patients need to have.

Tips for Your Walking Program :

• Start with a comfortable distance and gradually build up,
• Increasing both your pace and the distance you walk. Another way to make your walk more challenging is to add a hill or tow. The distance you start with will depend on your age and mobility prior to your hospital admission. The amount of activity you have been able to do while in hospital will also need to be taken into account. Your physiotherapist will advise you if you are unsure.
• Avoid hills initially if you can. When you do start walking on them you will have to expect to reduce you pace and distance of your walk. Always walk up the hill first so you have enough energy left to return home.
• After walking you may feel slightly puffed but you should not feel distressed or exhausted.
• You should be able to comfortably talk to someone while you are walking. This is a good indication that you are not pushing yourself too hard.
• Stop and rest if you have any symptoms of chest pain or undue shortness of breath.
• Avoid walking straight after a meal. Digestion will take enough of your energy.
• Wear sensible clothing.
• Enjoy yourself and keep us informed at rehabilitation about your progress.

Outpatient Walking Guidelines for Cardiac Patients

Week one :

 
WEEK TWO:

 
WEEK THREE:

WEEK FOUR:

WEEK FIVE:

WEEK SIX:

TWO MONTHS:

THREE MONTHS:

 
Warning signs :
Should you develop any of the following signs then it is advisable to contact your surgeon/cardiologist:

• Palpitations
• Shortness of breath
• Excessive sweating
• Fever
• Unusual fatigue
• Dizziness

We hope you are now on your way to a full recovery and that you will get a great benefit from your operation. Most patients find that, in time, they are able to lead full, healthy and active lives. If there are any points not covered in this booklet, be prepared to ask for help, from your surgeon or by telephoning the hospital. you will be meeting your surgeon again in his outpatient clinic. Meanwhile good luck and good bye !

Dr. MANOJ PRADHAN