Pain
Each patient's perception of pain is unique. Some patients require more pain medication than others to achieve an acceptable level of comfort. This, too, must be individually assessed and coordinated between the patient and the nurse to assure adequate pain control, which is essential to allow the patient to move, cough, ambulate and progress.

Mood Swings
It is very important to remember that mood swings and depression are common reactions to the unfamiliar environment, stress, and medications associated with heart surgery. These feelings, however, are temporary, and are best managed by a positive attitude and efforts to return to normal activity.

Appetite and Nutrition
Your diet will gradually be advanced to a normal low fat, low salt diet as it is tolerated. A temporary decrease in appetite is common in the early stages of recovery, but usually resolves within a few weeks as less medication is required.

Cholesterol
Your "lipid profile" will be tested at the beginning of your hospital stay. The results will be shared with you and your physicians when you are discharged. You may be started (or restarted) on "statin" therapy to combat the effects of cholesterol in your blood. You should continue this medication for life. Ask your physician to recheck your lipid profile and liver function tests six weeks after surgery and every year thereafter.

Going Home
Heart surgery patients generally remain in the hospital from three to seven days following the operation. Many home services are available, as are rehabilitation units where patients may stay for a short time to gain strength before returning home. Members of the cardiac services team will discuss the options with you depending upon your specific needs.

Continued Recovery at Home

Medications
Frequently, heart surgery patients are discharged home with medications that are different from those they were taking before the operation. Before you go home, we will outline the purpose of each of your medications and discuss how they should be taken. Be sure to discuss stopping or changing any medications with your physician before doing so.

Care of the Incisions
Incisions should be washed every day with soap and water, which may be done easily in the shower. Any signs of infection, such as swelling, redness or drainage, should be reported to your surgeon right away.

Ankle Edema
Swelling around the ankles is common in the first few weeks after surgery. Discomfort may be minimized by elevating the feet when sitting and by wearing the support stockings provided to you in the hospital while you are walking.

Activity
The best way to regain your stamina is to progressively increase the amount of walking that you do. Start off slowly and increase the time and distance each day until you can walk for about 30 minutes two or three times each day. Returning to normal sleep patterns is also important to your overall recovery. Avoid sleeping pills and late afternoon naps if possible. Lifting should be limited to objects less than ten pounds for about six weeks.

Cardiac Rehabilitation
Cardiac rehabilitation programs provide a monitored, graduated method to help increase your exercise tolerance. Information regarding rehabilitation programs in your area will be provided before you are discharged.

Driving
For your safety and that of others, it is best that you not drive your automobile for approximately three to six weeks. This time is needed to regain normal coordination and agility, as well as to allow your incisions to fully heal.

Returning to Work
All of your physicians should help you to determine when you can safely return to work. Of course, to some extent it is based upon the type of work you do. Most people average three to six weeks away from work.

Smoking
Abstinence from smoking is absolutely critical following cardiac surgery!

Costs
Please do not hesitate to ask about the cost of your operation. The Patient Accounts Department in the hospital may be able to assist you in dealing with your insurance company regarding specifics of your coverage.

Summary

Heart surgery is a complicated procedure which should be carefully evaluated with respect to the risks and benefits for each patient. Please feel free to discuss any questions you might have with your individual health team members.

Appendix

Call Your Doctor If...
We've listed some important warning signs that you need to be aware of following your surgery.

Introduction

Over the past 20 years, open heart surgery has become one of the most commonly performed surgical procedures in the United States. While it may be common to our medical staff, it is most likely a new experience for you, as well as one that can be rather frightening. This booklet is designed to provide you with a brief outline of the nature of heart surgery, along with a discussion of some of the risks involved.

Although it is much safer today than even just a few years ago, any type of surgery is associated with certain risks. Open heart surgery, however, is never recommended without an in-depth consultation among the physicians involved in evaluating a patient's overall medical status. These physicians discuss different treatment options for each patient's condition.

In recommending surgery, your physicians have made every attempt to individualize their assessment of the risks and benefits for your particular needs. However, the ultimate decision for cardiac surgery rests with you. In order to make that decision, it is important that you understand why this operation has been recommended for you, as well as what benefits you can expect to receive by having it. After reading this booklet, we hope you will have a better understanding of each of these issues. Please jot down any remaining questions so you will remember to ask them as members of the surgical team discuss the procedure with you.

Where Things Are and What They Do

Your heart may be the hardest working muscle in your body. You can estimate the size of this hollow, muscular organ by making both hands into fists and holding them together. Your heart is located directly behind your breast bone, often contracting more than 100,000 times a day and rarely resting for more than a second at a time. The heart pumps over 2000 gallons of blood in 24 hours. Looking at the picture opposite, you can see that blood from the body enters the heart through the right side into a compartment called the right atrium. It then flows through the tricuspid valve into the right ventricle and out through the pulmonic valve into the lungs where it receives oxygen. Blood returns from the lungs via the left atrium, flows through the mitral valve into the left ventricle, and is then forced out to the rest of the body under higher pressures through the aortic valve. The aortic valve keeps the blood from running backwards into the heart after it is pumped out.

Blood is carried to all the organs in the body through blood vessels called arteries. Veins are the blood vessels that carry blood back to the heart so that it can be recirculated. Like all of the muscles in your body, the heart requires a constant flow of the nutrients and oxygen found in blood in order to keep working. The blood carrying the oxygen and nutrients to the heart muscle itself is transported by the heart's own arteries, the small coronary arteries. There are two main coronary arteries. They are located on the outside of the heart, and come from the base of the aorta. The right coronary artery wraps around and supplies the right side and back of the heart with blood. The left coronary artery divides almost immediately into two branches: the left anterior descending artery which supplies the front of the heart, and the circumflex coronary artery which feeds the left and back sides of the heart. Each of these coronary arteries has several branches which get progressively smaller as they give off additional branches. In this way, each area of heart muscle receives its own blood supply.

As with all arteries in the body, the coronary arteries are susceptible to hardening and a buildup of fibrous tissue and cholesterol between the layers of the vessels, a process called atherosclerosis. If the buildup of atherosclerosis becomes severe enough, it obstructs the flow of blood and oxygen to areas of the heart muscle. When the physical demands on the heart are increased, such as with exercise, emotional events, heavy meals, etc., the heart may require more oxygen than it can get because the blocked coronary arteries cannot carry enough blood. If this imbalance lasts for a short period of time, the result may be pain (angina pectoris) and/or shortness of breath. If the process is prolonged, the effected area of heart muscle may die, producing a heart attack (myocardial infarction). A scar then forms in that area of the heart muscle which cannot contract to pump blood normally.

During your cardiac catheterization study, your cardiologist identified the coronary artery occlusions which may be causing your symptoms. We use the films from this study much like a "road map" for surgery. The number of bypass grafts any patient needs depends on the areas of obstruction found on the films. The bypass graft is designed to function as a new conduit or pipeline around the area of obstruction. The site of attachment of the new conduit is called the graft and can be pictured much like the graft of a new branch onto a tree limb. With the new graft in place, blood can flow freely around the obstructed area. Restoring normal blood flow to the heart decreases the patient's symptoms and provides vital nutrients needed for the proper functioning of this important muscle.

The valves of the heart must also function properly in order for the heart to do its job. They must open and close in a carefully timed sequence, and must seal tightly with each and every beat to facilitate adequate blood flow. Occasionally, the valves, especially the aortic and mitral valves, become diseased or damaged. This abnormality can start as a birth defect, occur as a process of aging, or result from an infection such as rheumatic fever. Blood flow through the valves may be restricted due to narrowing (stenosis), or the blood may "swish" back and forth through the valve (regurgitation) due to incomplete closure of the valve leaflets. In either case, repair or replacement of the valve may be indicated.

If replacement of the valve is required, either a mechanical or a tissue valve will be used. Generally speaking, a mechanical valve will last a very long time, but requires that the patient take "blood thinners" (anticoagulants) for the rest of his or her life. A tissue valve (made from pig or cow heart tissue) may wear out in eight to fifteen years, but does not usually require the use of anticoagulants. When making this decision, you and your physicians will need to consider your age, lifestyle, activities, risks, etc., in order to determine which form of treatment is appropriate for you. Of course, any artificial valve can become infected or develop a leak and require replacement before it wears out. Following valve replacement, antibiotic therapy is essential if the patient has any further surgical or dental work.

Causes of Coronary Artery Disease

Very often patients ask, "Do I really have coronary artery disease? How did this happen to me?" No one knows for certain why some people are affected by coronary atherosclerosis and others are not. Well-known and very important risk factors for coronary heart disease include high levels of cholesterol and other fatty substances in your blood, diabetes, high blood pressure, being overweight, inactivity and smoking. Other important factors which make it more likely that you will have coronary heart disease include older age, being male, and having a family history of heart disease.

You may or may not be able to pinpoint the risk factors which apply to you. While identifying them right now won't change your need for heart surgery, it will be helpful in the near future. Changing "risky" habits, such as smoking or high fat diets, will be necessary to help prevent the progression of atherosclerosis within your arteries (and new grafts!). Heart surgery cannot "cure" atherosclerosis and you must do everything you can to decrease the chance that your blood vessels will continue to build up the obstructing material. These lifestyle changes will be discussed in greater depth before you return home.

Nature of the Operation

Before Surgery

Based on the findings of your cardiac catheterization, your physicians may feel that it is safest for you to stay in a hospital environment and have the operation on an urgent basis. In other cases, it may be possible for you to go home and return at a more convenient time. Either way, you will need to complete a number of tests and meet various members of your health care team before the operation. If you are not admitted until the day of surgery, you will need to visit the hospital pre-admission clinic a few days before admission to complete the tests and discuss matters of your operation.

One of the important team members we would like you to meet is the anesthesiologist. This is the physician who puts you to sleep and provides care for you during the course of the operation. It is important to discuss your past medical history with the anesthesiologist, including any previous operations and any allergies you might have to food or medication. It would also be helpful to bring an up-to-date list, including dosages, of all medications you are currently taking. If you are taking Coumadin or aspirin, be sure to ask your doctor when it should be discontinued prior to surgery.

A physician assistant many visit you to review your medical history and to perform a physical examination. Physician assistants are highly trained members of our surgical team with many years of experience caring for patients undergoing heart surgery.

You will also meet one of our nurses who will discuss what you and your family might expect during the pre- and post-operative stages. They will also follow your progress regularly and work with you regarding discharge plans and follow-up care after you leave the hospital.

Clinical Trials

Part of our mission is to provide the highest quality care to all our patients. Therefore, our practice actively participates in FDA approved clinical trials, or research studies. These studies offer our patients access to the newest and most exciting developments in the field of cardiothoracic surgery. These studies have also been approved and are considered safe, as well as potentially beneficial, by our hospitalsâ investigational review board. You may be asked to consider participating in such a study if it appears you are an appropriate candidate. Your involvement is strictly voluntary, and will, in no way, negatively affect the quality of care you will receive should you decline participation. Should you have questions about our clinical trials, please feel free to ask any member of our team.

The Day of Surgery

In spite of our best efforts, it is occasionally necessary to postpone an operation, even at the last minute. This is usually caused by an emergent surgery required for another patient which displaces the time allotted for your operation. It may also be that your surgeon has been in surgery for many hours and may not be able to perform another operation with the necessary safety margin. We recognize that a postponement produces disappointment and inconvenience for the patient, family members and the entire surgical team. Be assured that we would not allow it to occur unless it was absolutely necessary for the safety of all concerned. Should this happen, we ask for your patience and understanding, as well as your cooperation with rescheduling.

To reduce nausea and the risk of a lung complication associated with surgery, you will be asked not to eat or drink anything for several hours before the operation. It is important that you follow the instructions carefully. If you are asked to take some of your prescribed medications on the day of surgery, swallow them with a small amount of water, drinking only the necessary amount.

Prior to the operation you will be given an antiseptic soap to use when bathing or taking a shower. This is intended to limit the growth of germs which may be present on your skin. In addition, the hair on your chest, legs, and abdomen will be shaved by a surgical technician in order to help make your skin as free of germs as possible.

Before your trip to the operating room, you will be given a sedative to help you relax. You won't be asleep when you go to the operating room, but you will feel calm. And although you may recall some of the conversations and events as if you have had a dream, you won't remember much of what happens after you enter the operating room area.

In the Operating Room

You will be taken to the operating room on a narrow rolling bed with a very hard mattress. You will be greeted in the pre-surgical area by a nurse who will verify your identification and confirm that you are having open heart surgery. When you go into the operating room, you will slide over onto a bed and receive some additional medication to make you even more sleepy. During this time, the anesthesiologist will place a catheter through a vein in the side of your neck and into your heart chambers. This is a small plastic tube or "line" which allows us to administer fluid and medications during the procedure, as well as monitor the performance of your heart and blood vessels. An arterial catheter will also be placed in your wrist to facilitate continuous monitoring of your blood pressure.

After you go to sleep, a tube will be placed through your mouth, past your vocal cords, and into the windpipe. This tube assures that the flow of air in and out of your lungs will not be obstructed. In some patients, it can be removed very quickly after surgery, while others (especially those with a long smoking history or other severe lung disease) may require it longer. Most of our patients tell us that the breathing tube was not really uncomfortable, although all are happy to have it removed.

Another tube will be placed in your bladder in order to drain urine. Again, this tube will be removed in the first day or two following surgery.

Heart surgery is performed with the patient lying on his/her back. Once again, the body is washed from chin to toes with an antiseptic soap, or painted with a special antiseptic solution. The body temperature is gradually lowered to reduce metabolic demands. The surgeon will begin by making an incision from the top of the breastbone to the upper portion of the abdomen and separate the breastbone by dividing it down the middle with a special surgical instrument. During this time, another member of the surgical team may be removing a radial artery from the forearm and/or a portion of the saphenous vein from the leg(s) to use for the bypass graft conduit. Adequate blood flow to these areas is maintained by the remaining arteries and veins.

In addition, we will most likely mobilize one or more small arteries located on the underside of the breastbone called the internal thoracic or internal mammary arteries. We use these arteries because, as grafts, they tend to stay open longer. However, they are more fragile and more difficult to use and doing so tends to somewhat prolong the operation. Occasionally, it may be necessary to remove other arteries from inside the abdomen or veins from inside the arm if other sources of graft material are not available.

To perform the operation, it is necessary to open the sac that surrounds the heart and to place several plastic tubes in the heart chambers and great blood vessels in order to connect the patient to the heart-lung machine. This machine is controlled by a specially trained perfusionist and pumps blood to the various organs of the body so that the heart can be made still during the operation. It is necessary to perform the operation while the heart is quiet because the work is so very delicate. Many of the arteries that need grafting are smaller than a strand of uncooked spaghetti, and the material used to sew the graft in place is finer than a human hair. In contrast to a few years ago, we now have a number of different techniques to keep the heart quiet while continuing to provide it nutrition and protection during the procedure.

After we have completed the majority of the operation on the heart itself, we begin raising the body temperature and allow the heart to resume beating so that it becomes accustomed to pumping blood as it did before. During this period, we complete other stages of the operation and continue to prepare the patient to withdraw the support of the heart-lung machine. This is a critical time in the operation. We will notify family members and friends who may be present in the waiting room when we have successfully discontinued use of the heart-lung machine and the heart is functioning adequately.

The remainder of the operation usually takes two to three hours. It is during this time that increased bleeding may occur due to the disturbance in normal clotting mechanisms. Patients vary greatly in their ability to form blood clots after heart surgery. Often, it is not possible to accurately predict how long it will take the body to reestablish normal clotting times. Consequently, the length of the entire operation changes from one patient to the next, but is usually in the area of three to six hours.

Prior to closing the wounds at the completion of surgery, small wires are connected through the chest wall to the surface of the heart so that, if needed, we may use a temporary pacemaker to regulate your heart beat. In addition, two or three larger plastic chest tubes will be placed in a space behind the breastbone and in the chest cavity in order to collect any blood that may have accumulated there. Blood that we collect in this manner may be re-infused into your body both during and after surgery. Since this method returns only your own blood to you, the process carries very little risk of disease transmission.

More About Blood Transfusions

The concern surrounding the use of blood generally relates to the possible transmission of diseases, especially AIDS. Several years ago, some cases of AIDS were related to virus transmission through blood transfusions. However, in 1985 a blood test came into common use to detect the presence of the AIDS antibody. Since that time, blood that has tested positive has been rejected and transmission of the disease through contaminated blood has been exceptionally rare. The blood bank also screens blood for many other types of viral infections including hepatitis. The risks of blood-borne disease transmission are diminishing every year.

In general, we don't administer blood unless we think the benefit to the patient greatly exceeds the risk. Nevertheless, it is important to realize that there is no known satisfactory substitute for human red blood cells and there are times when we have no realistic option but to administer a blood transfusion.

The Blood Bank always has a limited supply. While this issue is fresh in your mind, we urge you, your family members and friends to donate blood whenever possible so that it is always available for those who need it. Cascade Regional Blood Services (formerly Pierce County Blood Bank) is located at 220 South I Street in Tacoma, and may be contacted at (253) 383-2553.

Surgical Risks and Possible Complications

Our bodies represent a network of closely related organs, each with its own job to do. Each organ depends upon the function of all the others. If one organ fails, it may decrease the function of another. Sometimes this makes it difficult to know exactly how the body will respond to surgery.

All operations carry a certain risk. As you can see, heart surgery is a particularly complicated procedure and involves many different organ systems. Some patients have a higher risk than others, although most patients have a survival rate of over 90-95%.

Regardless of the risk category into which any patient falls, surgery is only recommended when it is felt to be the option with the least risk and the greatest potential benefit. Obviously, we take extensive precautions to prevent complications and diminish risk. Unfortunately, however, we cannot guarantee that some complication won't arise. For that reason, patients and their families should discuss the operation and its risks with the physicians prior to the procedure.

While risks must always be individualized, let us discuss some of the most common concerns here:

The most serious concern patients usually have is the fear of death during or after surgery. The possibility of death is determined by a patient's age, sex, and the overall "health" of their heart. The presence of other ailments such as diabetes, lung disease, or kidney disease also influences the risk of death. For example, a man under the age of 65 without other disease processes has a lower risk than a woman over 75 with previous heart attacks or lung disease.

The same atherosclerotic disease that effects the heart arteries may also attack other arteries in the body. If it involves the large arteries in the chest, neck, or brain, it makes the chance of a stroke (damage to the brain caused by a small blood clot) more likely. Overall, the risk of a stroke occurring during heart surgery is less than 3%, although it is somewhat higher if a patient has had previous symptoms of a stroke. Your surgeon may suggest a special study of your neck arteries (carotid arteries) before surgery to assess the pathways for blood flow to the brain.

Although heart surgery is sometimes recommended to decrease the likelihood of a heart attack, in spite of our best efforts, it is possible for one to occur during or after surgery. Should it happen, it could go relatively unnoticed or it could present serious heart failure, depending upon the amount of heart muscle involved. Identifying the heart arteries can be difficult during surgery, and even this poses a small risk.

When the patient's heart has to take over from the heart-lung machine, it may experience irregularities in the beating pattern. The small wires attached to the heart at the end of the procedure can be connected to an external pacemaker to temporarily assist the patient's own heartbeat. If the pumping action of the heart is not strong enough to support the circulation, even with the help of intravenous medications, a special internal auxiliary pumping device called an intra-aortic balloon pump may be needed to rest the heart until it is capable of taking over.

It is possible that not all of the new bypass grafts will remain open. Arteriosclerosis is a generalized disease of the body's chemistry which cannot be cured by surgery. Therefore, there is a chance that a bypass graft will become occluded over the months or years following surgery. New symptoms may present in the form of recurring chest pain, which would probably lead to a treadmill test, or another heart catheterization study, and possibly further surgery. Although arteriosclerosis is progressive in nature, changing the "risky" habits discussed earlier can help prevent the return of the disease. This will be a very large part of your recovery process.

A small amount of bleeding from the tissues inside the chest is normal following heart surgery. Excessive bleeding, however, may necessitate a return to the operating room to identify and repair the bleeding sites. This only rarely requires that the patient be placed on the heart-lung machine, although general anesthesia is required. If the fluids around the heart do not completely drain out through the tubes provided, they may interfere with normal heart function. This occurs very rarely, but could also require a return trip to surgery.

Although we take extraordinary precautions to prevent infections, any surgical procedure comes with that risk. Sites of infections can be anywhere from the chest incision to the urinary bladder, or even involve a newly placed artificial valve. Therefore, we use antibiotics before and after surgery.

Occasionally patients experience lung or kidney problems after surgery, especially if there is pre-existing disease in these areas. These problems are usually temporary, but may require prolonged ventilator support or the use of kidney hemodialysis. We try to discuss such situations with patients and their families before starting "extraordinary" treatments and will follow any "living will" guidelines.

Advance Directives

You will be asked at the time of your admission to the hospital if you have an "Advance Directive". This is a global term referring to a "Durable Power of Attorney for Health Care," which identifies an individual with decision-making responsibility in the event a patient is unable to make decisions for him/herself, and a "Living Will" which outlines the patient's wishes for long-term care/life support. Designating a spokesperson to act on your behalf in the event that you cannot speak for yourself is one of the most important aspects of Advance Directives. The person you choose to be your agent should know how you feel about long-term mechanical life support, the kind of life style you find acceptable, and any other issues you feel are important regarding your quality of life.

If you have an Advance Directive, state law requires that we ask you to supply a copy for the hospital chart. If this type of document is not in place at this time, please consider addressing this with your physician and formally implementing it at a convenient later date. Written information will be provided to assist you in this process.

Immediately Following Surgery

Heart surgery patients are transferred directly from the operating room to the Cardiac Surgery/Coronary Care Unit (CSU/CCU). The nursing staff here has been specially trained to care for heart surgery patients. Patients are supported on a respirator or ventilating machine to assist breathing for at least the first few hours following the operation. During the early postoperative period, you will be very sleepy and will be kept sedated until we are certain that all of your physiologic functions are as stable as possible. After that, we will decrease the sedation to allow you to regain consciousness and to become alert enough to have the breathing tube removed. Although you won't be able to talk while the breathing tube is in place, the nurses caring for you are very experienced and quite good at anticipating your needs. They will be continually monitoring your vital signs, heart rhythm, lab results, etc., communicating this information to your physicians and treating any problems that may arise. They will also be certain that you receive adequate amounts of pain medication to control most of your discomfort.

In the early postoperative period, the family should anticipate some changes in the patient's appearance. Heart surgery patients often experience a fair amount of puffiness in their hands and face following the operation and are often noticeably pale. This results from extra fluids received during the operation, and should resolve over the first few postoperative days.

After the breathing tube is removed, you will probably receive oxygen through a mask or small nasal prongs for a few days. During your stay in the special care units, small, sticky monitor patches will be attached to the surface of your chest which allow the nurses to monitor the continuous electrical pattern of your heartbeat. This pattern and a variety of numbers will be displayed on the screen in your room. It is normal to see the numbers vary up and down. However, if you notice a change and have a question, don't hesitate to ask about it.

The chest tubes, pacing wires, most of the IV lines, and the bladder catheter are usually removed within the first one to three days following the operation, depending upon the patient's strength and overall status.

Respiratory Therapy

It is very important to begin productive coughing exercises soon after the operation. These help open the small air compartments in your lungs and are the most effective means of preventing pneumonia. We will also encourage you to use a "breathing exerciser" on an hourly basis to promote deep breathing. With routine pain medication, you should be able to take deep breaths and cough without significant discomfort.

Pathway to Recovery

Believe it or not, confidence and conviction are important ingredients of recovery. While it is true that younger, healthier patients may recover faster than patients with more associated disease conditions (e.g. diabetes, emphysema, etc.), everyone can influence the speed of their recovery with a positive attitude and self-confidence. One of our goals is to provide you with enough information and exposure to the entire process to enable you to actively participate in your own recovery.

Although every patient is unique and may progress along the pathway at a slightly different speed, we hope you will look at the steps identified as small goals for improvement and work hard to accomplish each one. Keep in mind that these are generalized guidelines for all patients which need to be individually adjusted based on each patient's overall state of health.

After your stay in the Critical Care Unit, you will be moved to another area where you will begin a progressive exercise program. The more time you are up and out of bed and the more walking you do, the more rapidly you will recover. While in bed, you should move about as much as possible and assume any position which is comfortable. To move up in bed, push with your feet, but avoid pulling with your arms. The best way to get out of bed is to move the head of the bed to the upright position and then swing both feet sideways onto the floor. In the first few days, the nurse will assist you in order to diminish the chance of a fall or other injury. Sitting, standing, and walking require gradual but progressive effort.

	Pre-Operatively	Day of Surgery	Day 1-2	Day 2-3	Day 3-4
Activity	Pre-screening appointment Sign consent form Antiseptic shower or bath Preparatory shave	Surgery lasts 3-6 hours Removal of breathing tube Sit up in bed and dangle feet; sit in chair	In chair for meals Walk with assistance Use Incentive Spirometer Cough and deep breathe each hour	Increase activity Shower with assistance Use Incentive Spirometer Cough and deep breathe	Walk 7-10 min., 3 times per day; increase as tolerated Incentive Spirometer at home
Nutrition	No food or drink after midnight the night before surgery	Clear liquids Advance as tolerated	Low sodium, low cholesterol diet	Low sodium, low cholesterol diet Small, more frequent meals	Continue healthy and nutritious eating habits at home
Medications	Continue medications as per MD, taking pills with small sips of water morning of surgery Take a laxative Ask MD about continuing aspirin/Coumadin	IV medications, advancing to oral medications, including pain pills	Oral medication, including regular pain medication	Possible medications for irregular heartbeat or high blood pressure	Laxatives as needed Continue regular pain medication
Education	Open Heart video Tour of Cardiac Surgical Unit	Continuous progress reports with patient/family	Post-Open Heart video Discharge plan: Patient care Meal preparation Driving duties	Rehabilitation instruction Discuss the possibility of home health care	Pharmacy instructions Attend "Healing Hearts & Healthy Living" meetings Follow-up appointments: surgeon cardiologist primary care MD

Pain

All patients experience some pain after the operation, though most report that it was less than they anticipated. Some complain of pain around the chest incision, while others experience more pain in the legs. There are often areas of numbness on the surface of the chest, on the fingers and hands, and along the incision on the arm or leg(s). You may also have multiple muscle aches, especially in the back, shoulders, and arms. Most of these symptoms disappear within several weeks to months following the operation, but may be annoying in the interval.

Mood Swings

Open heart surgery is associated with the administration of many different kinds of drugs. For much of their stay in the hospital, our patients are in a unit where it is hard to distinguish night from day, privacy is at a minimum, and uninterrupted sleep is hard to come by. All of these things combine to produce occasional periods of confusion or memory problems, which usually clear with time. Patients are often encouraged and elated on the first day or two, only to find themselves discouraged and depressed on the third or fourth day following the operation. The emotional letdown following surgery is common and is one of the body's natural reactions to the different medications and abnormal surroundings. While these feelings may occur up to several weeks after surgery, it is important to remember they are temporary and are best managed by a positive attitude and efforts to return to normal activity. A counselor or chaplain may visit you sometime after surgery to offer help in dealing with these emotions. Please feel free to ask if these services are needed earlier or at any time during your recovery process.

Appetite and Nutrition

In the initial period following surgery, limited nutrition is supplied by the fluids administered into your veins. After the breathing tube is removed, patients will be allowed to begin a diet which will be advanced to include normal low fat, low salt foods. All of us will encourage patients to eat more because of the additional need for nutritional support following the stress of an operation. However, it is common for patients to experience a decrease in appetite and a feeling that "nothing tastes right". This feeling may persist for several weeks, but does eventually go away.

Constipation may occur after surgery due to the changes in your normal schedule and activities and/or as a side effect of certain medications. Drinking fluids, increasing the fiber in your diet (fruits, vegetables, and whole grains) and increasing your activity will all help your body return to its normal elimination patterns. You will most likely be prescribed stool softeners to aid in this process, as well. If constipation persists and/or you are uncomfortable, a gentle laxative, such as Milk of Magnesia, may be used as needed.

Cholesterol

At the beginning of your operation, you will have a blood draw to evaluate your "lipid profile". This will determine the levels of total cholesterol, triglycerides, high-density lipoproteins (HDL--the "good" cholesterol) and low-density lipoproteins (LDL--the "bad" cholesterol) in your blood. You, your cardiologist, and your primary care physician will be given this information when you leave the hospital. You will most likely be started (or restarted) on a medication (a "statin") to combat the effects of cholesterol in your blood vessels and stabilize the plaque which already exists there. Unless your physician recommends stopping it, it is important that you remain on this medication for life, even if your lipid profile shows "normal" levels. Additionally, you should ask your physician to recheck your lipid profile and liver function tests six weeks after your surgery and every year thereafter. The most recent American Heart Association goals for lipid management are:

LDL: < 100
HDL: > 35
Triglyceride: < 200

Going Home

Most patients stay in the hospital somewhere between three and seven days, depending upon the nature of their operation, their age, and general medical condition. Sometimes it is necessary to alter the patient's stay in the hospital or spend a short time in a rehabilitation unit depending on the amount of assistance available at home and the patient's level of strength and stamina. We will be talking to both the patient and the family well in advance of the anticipated discharge day in order to assess potential needs outside the hospital. Many home services are also available following discharge from the hospital and members of the team will discuss them with you as needs are identified.

A physician assistant many visit you to review your medical history and to perform a physical examination. Physician assistants are highly trained members of our surgical team with many years of experience caring for patients undergoing heart surgery.

You will also meet one of our nurses who will discuss what you and your family might expect during the pre- and post-operative stages. They will also follow your progress regularly and work with you regarding discharge plans and follow-up care after you leave the hospital.

Clinical Trials

Part of our mission is to provide the highest quality care to all our patients. Therefore, our practice actively participates in FDA approved clinical trials, or research studies. These studies offer our patients access to the newest and most exciting developments in the field of cardiothoracic surgery. These studies have also been approved and are considered safe, as well as potentially beneficial, by our hospitals' investigational review board. You may be asked to consider participating in such a study if it appears you are an appropriate candidate. Your involvement is strictly voluntary, and will, in no way, negatively affect the quality of care you will receive should you decline participation. Should you have questions about our clinical trials, please feel free to ask any member of our team.

Continued Recovery at Home

Medications

Each patient requires a slightly different combination of medicines to fit his/her specific needs, and they are likely to be different than those taken before the operation. Before discharge, we will outline the purpose of each of your medications, and how they should be taken.

Although there is usually some discomfort along the leg incision(s) or between the shoulder blades, as your surgical wounds continue to heal, you should require less and less pain medication. You can decrease the number of pain tablets that you need OR increase the amount of time between doses as you feel is appropriate. After a while, over-the-counter preparations, such as Tylenol (acetaminophen) or Advil (ibuprofen), should sufficiently control your discomfort.

If you have a radial artery removed from your forearm, it may be necessary for you to continue taking a type of medication known as a calcium channel blocker for approximately 90 days after your surgery. These medications, typically Cardizem, diltiazem, Norvasc or amlodipine, are thought to decrease the potential for spasm in the radial artery graft. Please be sure to consult your cardiologist before discontinuing this (or any other) medication.

Care of the Incisions

Prior to discharge, you will begin showering in your usual manner, and should continue to do so at home. Incisions should be washed every day with soap and water and patted dry. Small pieces of tape may have been applied to your incision(s). These can be removed as the edges curl up. If you notice any areas of swelling, enlarging, redness or drainage, you should notify your surgeon right away. You may apply a softening agent, such as Neosporin Ointment, to your incisions to soften and control itching during the healing process. In addition, most women find the support of a loose brassiere decreases incisional strain and discomfort. Be very careful, however, to avoid direct pressure across the new sternal wound.

Ankle Edema

It is quite common to have swelling around the ankles for several weeks following the operation. This is caused by a disturbance in the small lymphatic vessels that drain fluid from the leg, as well as an alteration of the overall fluid balance caused by the operation. It may be beneficial to wear the support stockings provided to you in the hospital when you are up walking for any extended period of time. You may continue to wear the stockings during the day as long as they make your legs feel better, but remove them at night. Be sure to elevate the feet whenever sitting for any length of time, as well. If possible, the feet and ankles should be elevated above the level of the heart. Recliner chairs are not as effective as lying on the sofa or floor when elevating your legs. Any increase in swelling around the ankles, especially that associated with shortness of breath, should be reported to your physician immediately.

Activity

The best way to improve your stamina and get back to a normal routine is to progressively increase the amount of walking that you do. The open heart team will have provided you with some guidelines to accomplish this based upon your age and general condition. Generally it is best to start off slowly and increase the distance and time a little each day, working up to 30 to 60 minutes a day at a brisk pace. It is important not to baby yourself, but you should also avoid becoming overly tired. We encourage you to get outside daily, weather permitting, for your mental, as well as physical, well-being.

Returning to normal sleep patterns is important in your overall recovery as well. Plan to sleep only at night, and be awake during the entire day. If you must take a nap, take a short one in the early afternoon, not late in the day. If needed at all, limit sleeping pills to only occasional use.

Continue to use your Incentive Spirometer, or "breathing exerciser" for the first week or two following surgery. Ten to twenty deep breaths every two to four hours while you are awake will help keep your lungs clear. Perform the exercises slowly and with full, deep breaths.

Sexual activity may be resumed whenever you are inclined, and whenever it is comfortable.

Lifting needs to be limited to objects less than ten pounds for at least six weeks (this includes grandchildren!). Light housework, gardening, etc., may be undertaken, again as long as it doesn't cause pain.

Cardiac Rehabilitation

Before discharge, you should receive information with respect to cardiac rehabilitation programs in your area. These programs provide a monitored, graduated method to help increase your exercise tolerance. They also provide feedback to your physicians about your progress. In addition, you will receive information about exercise, nutrition, weight control and smoking cessation. We recommend that you enroll in the cardiac rehabilitation program which will be most convenient for you to attend, and will gladly facilitate your enrollment as needed.

Driving

We recommend that you do not drive for three to six weeks following your operation. Your incision needs time to heal, and sudden turns of the steering wheel might disrupt that process. You also need time to regain the necessary mobility and coordination to avoid accidents. Always remember to wear your seatbelt!

Returning to Work

Depending on the type of work you do, you should be able to return to your job in four to eight weeks. This, too, needs to be individually determined, and will be discussed during your postoperative visit with your surgeon.

Smoking

Stopping smoking is the single most important thing you can do to diminish the likelihood that atherosclerotic buildup will continue and begin to obstruct the new blood vessels. Abstinence from smoking is absolutely critical! Access to smoking cessation classes can be accomplished through your physicians or through your cardiac rehabilitation director.

Nicotine patches narrow arterial bypass grafts, as does smoking, and are not recommended for post-operative patients.

Costs

Please do not hesitate to ask about the cost of your operation. As individual insurance benefits vary, it is advisable to consult your insurance company directly regarding the specifics of your coverage. The Patient Accounts Department in the hospital may be able to assist you in this matter.

Summary

As you can see, heart surgery is a particularly complicated procedure which involves many different body systems. As with any form of treatment, it should be carefully evaluated, taking into consideration the potential risks and benefits to the patient. This booklet has been designed to provide you with the information you need to help make this important decision, as well as to support you through the recovery phase. Please feel free to discuss any aspect of the process with your individual health team members.

You may contact us at any time through the office phone number listed on the front of the booklet if you have questions or concerns. In addition, you can continue to check our Web site for the latest information on new developments in heart surgery, lipid management, links to other important "heart care" sites and more.

Appendix: Call Your Doctor If...

If you experience any of the following symptoms after your surgery, please call our office right away:

• Weight gain greater than four pounds within one or two days, or any weight gain over ten pounds.
• Temperature of 101 degrees or greater, or a persistent temperature over 100 degrees.
• Pulse rate less than 50 or greater than 120 beats per minute while you are at rest.
• Increasingly severe shortness of breath or cough.
• Angina or other chest pain which is getting worse rather than better.
• Excessive fatigue, weakness, dizziness, or fainting.
• Signs of incisional infection: redness, swelling, drainage, or excessive tenderness.
• Persistent nausea, vomiting, diarrhea or constipation.

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