General Questions

What are the risks of my heart operation?

At LC&VA we undertake major surgical procedures and any heart operation carries a potential risk of death and complications. However our experience and expertise gives us very low risks: Coronary bypass surgery has less than 2% mortality, Mitral Valve surgery has 3% mortality and Aortic Valve surgery has less than 2% mortality. These figures are overall rates and will vary depending on the individuals pre-existing problems and age. Your surgeon will compute your particular operation’s risk taking into consideration several factors. A risk stratification system called “euroScore” has been devised to allow a preoperative assessment of a patient’s risk.  You may wish to calculate the risk yourself by visiting the “EuroScore” web site – http://www.euroscore.org/patienteuroscore2logistic.html Apart from death, there are several other complications which can  occur:

What is Coronary artery bypass surgery?

This operation is often abbreviated to CABG It has been used for nearly 50 years to improve the supply of blood to the coronary arteries distal (down-stream) to the area of disease and narrowing. Once the patient has been diagnosed to have coronary artery disease by angiography, your cardiologist and surgeon will decide on the most suitable treatment – either Angioplasty (catheter based balloon dilatation) with stent insertion or CABG. CABG usually involves a cut in  the center of the chest with splitting of the breast bone. Patients circulation is diverted to a Heart-Lung machine  which performs the functions of the lungs ( puts oxygen into the blood) and the heart (pumps it into the aorta and hence the body). This allows the surgeon to stop the heart and carry out delicate microsurgery. The coronary arteries are opened and a blood vessel ( vein from the leg, Internal Thoracic artery or radial artery from the arm ) is joined with a very fine nylon stitch so that the join is “water-tight”. This blood vessel is then joined to the main aorta so that blood now flows directly from the aorta, through the ”bypass” into the coronary artery distal to the blockage. Usually three or more such arteries are bypassed whilst the heart is still. Once the surgeon is happy with the procedure, the heart-lung machine is disconnected and the patient’s heart and lungs take over their function. The chest is then closed using stainless steel wires to reconstruct the breast bone. These wires are permanently buried under the fat and skin. They rarely cause any problems.This operation has been done millions of time and has been the most studied surgical procedure with a proven track record. It has been shown to provide the best long-term, trouble free survival in patients with coronary disease.

Where will the surgeon take the tubes for bypass from?

The vein from the leg has been traditionally used for bypass surgery and has proven to be a very good conduit. However, it does develop disease with time and 30-40% will block off by 10 years. This may lead to the need for a repeat bypass operation or, increasingly nowadays, to balloon angioplasty with stent insertion. The internal thoracic or mammary artery is taken from inside the chest wall and has the best long term patency rate of all the conduits. It has over 90% chance of staying open over 10 years and this fact has been responsible for increased survival. I tend to use both (right and left ) mammary arteries more often then not as I believe that this will result in best long term results.The radial artery from the arm is another increasingly used conduit which has better patency then vein.

What is Aortic Valve Replacement?

Your aortic valve may need attention if there is an obstruction to forward blood flow from the heart. This Aortic Stenosis is usually due to abnormal calcium deposition in the valve leaflets and the only solution is to change the aortic valve. In this procedure a heart-lung machine will be used and the diseased aortic valve will be removed through the aorta. Care is taken to remove all the calcium. An appropriately sized artificial valve (Tissue or Carbon) is prepared and inserted using non-absorbable sutures. The aorta is closed and the heart-lung machine disconnected from the patient.Similar surgery is needed for patients who have a leaky aortic valve. Occasionally, the leaky aortic valve can be repaired with sutures, obviating the need for a prosthesis.

What is Mitral Valve Replacement and repair?

The mitral valve is a complex apparatus which can be damaged significantly by rheumatic fever. When the valve is not repairable, it is partially excised and a prosthesis inserted using several non-absorbable sutures. Rheumatic valve disease is not so common in the UK and the majority of valves have problems with leakage. In this procedure these can usually be repaired by cutting out the flail segment of the valve and suturing the cut edges together. If a retaining chord is broken, a new artificial chord (gortex) can be created, so as to make the valve competent again. A artificial ring is usually attached to the annulus of the valve to narrow the dilated opening and prevent future dilatation. This gives a very good long term result.

What can I expect after surgery in the hospital?

The operation takes about 3 to 4 hours and you will be transferred to the Surgical Recovery unit or Intensive Care unit where a nurse will be dedicated to looking after you. It will take a few hours before you are able to wake up and breath without the ventilator and at that stage your breathing tube will be removed. Your pain will be well controlled by infusion of drugs into your vein. Your fluid requirements will also be given through the cannula in a vein until you are able to drink. There will be drains (tubes) in your chest and the nurse will measure hourly blood loses to alert the team if excessive. A catheter will be in your bladder to allow measurement of urine production – this means you do not have to worry about your bladder! If all is well, you will be transferred to the High Dependency unit later on that day or the next where similar level of monitoring will continue. All your tubes and venuous cannulae will be removed and you will be transferred to your room. Low dose of oxygen will be given to you for the first two nights. The physiotherapist will encourage you with the breathing exercises and start you walking. We expect you will continue walking increasing distances daily and by the sixth or seventh day you will be in a position to be discharged home.

What do I do when I get home?

You will be allowed home when your surgeon feels that there is no more to be gained from hospital stay. You will need help at home. You could travel by car or by train to get home. Once there, you must continue with your programme of increasing exercise, mainly walking.

Your recovery is going to take 6 to 12 weeks. You may drive a car 4weeks after your operation. You cannot lift heavy bags or furniture for at least 12 weeks – until the breast bone is fully healed and strong. The same applies to playing golf!
You can fly long distance after 2 weeks.Do contact your GP for any wound problems and your hospital ward for advise. They will get in touch with your surgeon.

What about follow-up?

Your surgeon will review your progress at about 6 weeks and if all is well, he will discharge you to the care of your Cardiologist and your Family Doctor.
My full report will be sent to your Cardiologist, your GP and a copy will be sent to you for your information and safe-keeping. It is advisable to travel with this report just in case any medical help is required.Patients with heart valve replacement/repair will need long term follow up by a specialist. The function of heart valve will need to be assessed annually with a stethoscope and maybe an echocardiogram. The response of the heart size and shape to the valve surgery can be assessed as needed by echocardiography. If Warfarin is prescribed by your doctor, it will need to be controlled well so that the valve stays free of blood clots. Although generally there is no need for antibiotics before a visit to the dentist or surgery, I feel that it is still advisable for patients with prosthetic heart valves.Patients with coronary disease will need to remain on anti-platelet agents (Asprin, Plavix) and Cholesterol lowering agents (Statins – Simvastatin, Atorvastatin etc) for life. There is no need for further testing unless symptoms recur. Regular checks will include Blood Pressure, Diabetic control and Cholesterol level.

How long will I have pain?

Pain is usually well controlled by analgesics (pain-killers) after surgery. Paracetamol is the mainstay of pain control after discharge home but some may need stronger medication. A dull ache  over the breast bone is to be expected and may last for several weeks but should resolve by 2 months. Initially, it may not be possible to ay on one’s side, but by 3-4 weeks it should be pain-free.

If a clicking  noise is heard or painfully felt from the breast bone, it is important to contact your surgeon as it may indicate loosening of the sternal wires. There is no need to be alarmed and your surgeon will most probably reassure you after examination. It is best to avoid the movements which make the bone click and over two to three weeks the click will disappear.

What about my lifestyle?

It is hoped that your heart operation will result in increasing your exercise capacity, reduce the chances of angina and breathlessness and prolong your survival. There should be an improvement in the quality of life in most patients. Those in work will be able to return to full time work after about 3 months. Those retiring or retired will get a new lease of good quality life.

It is essential that the patient makes changes in life-style which will complement the surgery. Stopping smoking, controlling cholesterol and blood pressure and fighting obesity should take priority. Most of these will helped by increasing physical activity.

Walking is the best exercise and you should be walking briskly for an hour daily by 6 weeks after surgery.

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