THE HEART AND IT’S FUNCTION

The heart is a muscle located in the left central area of the chest, behind the sternum (behind the breastbone). It’s size is approximately that of an adult’s closed fist. There are four chambers in the heart, two on the left, and two on the right. There are also valves, which direct the one-way blood flow that enters and leaves the heart.

THE CORONARY ARTERIES

The heart muscle requires oxygen to do its job — pumping blood to the body. The blood vessels that supply the oxygen-rich blood are called the coronary arteries. The heart muscle is fed by the coronary arteries, which start at the aorta. These arteries bring oxygen and nutrients to the heart muscle. Two main coronary arteries lie on the surface of the heart. They divide into smaller branches, so that each part of the heart muscle receives oxygen and nutrients.

CORONARY ARTERY DISEASE

Coronary arteries can become narrowed by a build-up of fatty layers (plaque) in the artery walls. This condition is known as atherosclerosis. As a result of these blockages, less blood is able to flow through the arteries, and the amount of blood that reaches the heart muscle is decreased.

Angina. This chest pain occurs when the heart is not getting enough blood or oxygen. Symptoms include pressure, tightness, squeezing, aching, burning, or cramping in the chest, arm, neck, or jaw, and shortness of breath.

Heart attack. Sometimes, narrowing in the artery can become worse very quickly, leading to a complete blockage. This can cause sudden chest pain, and damage to the heart muscle, known as a heart attack.

Risk Factors. Certain factors are known to increase your chance of having blockages in your coronary arteries, such as:

• Aging
• Diabetes mellitus
• Heredity (Family history)
• High blood pressure
• High cholesterol levels
• Obesity
• Smoking

Although you cannot control your family history or your age, you can manage other risk factors by:

• Controlling stress
• Controlling weight
• Exercising regularly
• Reducing cholesterol, fatty foods, and salt intake
• Stopping smoking

TREATMENT FOR CORONARY ARTERY DISEASE

Once you are diagnosed with coronary artery disease, your doctor will recommend the most appropriate form of treatment. He or she may want to do a balloon angioplasty if a blockage or narrow area is found in your artery. Other treatment options may include taking medications to control the chest pain or having coronary artery bypass surgery. Together you and your doctor will talk about the best treatment for you.

Coronary Artery Bypass Surgery. Coronary artery bypass surgery is performed to bypass one or more blockages in the coronary arteries. The bypass increases blood flow to the heart muscle to relieve angina, and improve heart function. A leg vein (saphenous vein), an artery from the chest (internal mammary artery), or an artery from your arm (radial artery), may be used for bypass grafts. The type of graft used depends on the number and location of your blockages.

Heart Valve Disease. Normal heart valves are thin, smooth structures that direct blood through the heart chambers. Valves direct the one-way blood flow that enters and leaves the heart.

Valve disease can be caused by rheumatic fever, birth defects, infection or damage to the muscle that opens and closes the valve. This disease eventually prevents the valve from functioning, as it should.

When a valve becomes diseased, one of the following occurs:

• The valve becomes stenosed (abnormally narrowed) and less blood flows through.
• The valve becomes insufficient (or regurgitates) and no longer closes completely, causing blood to leak backward through the valve.
• When valves do not open and close, as they should, less blood gets through. This causes the heart to work harder to pump blood to the body, and eventually, to become enlarged. If the heart is not able to pump blood, heart failure occurs.

Heart Valve Surgery. When possible, your own heart valve is repaired. More often, the damaged heart valve must be replaced with either a mechanical or tissue valve.

YOUR CARDIAC SURGERY PROCEDURE

Cardiac surgery usually takes three to six hours. The length depends on what needs to be done. Each surgery varies, so its duration can only be estimated.

Preparing For Surgery

Prior to having cardiac surgery, you will have to undergo certain tests, and preparatory procedures.

Electrocardiogram (EKG). You will have an EKG, a painless test that visually traces your heartbeat.

Chest X-ray. A chest x-ray will be taken to photograph your lungs.

Pulmonary Function Test. This test provides information on how well your lungs are working by using a hand-held breathing machine.

Blood and Urine Tests. These tests will be performed before surgery and are routine for all patients.

Intravenous (IV) Catheter. An IV catheter will be placed in your arm to administer medication, fluids, and anesthesia.

Skin Preparation. You will be asked to shower using an antimicrobial cleanser. Prior to entering the operating room, certain parts of your body will be shaved, especially your chest and legs.

Medications. You will be encouraged to take a sleeping pill prescribed by your doctor to help you get a good nights rest.

Food. You will not be able to eat or drink anything after midnight the night before surgery. If you need take medication, take it with sips of water.

Personal Articles. You should leave personal items (glasses, contact lenses, dentures, jewelry, wallet, extra clothes) at home, or give them to family members who can take them home after surgery.

In the Operating Room

The operating room (OR) nurse will escort you to the OR suite for surgery, and explain the following preparatory procedures:

• EKG electrodes will be placed on both your shoulders and hips. These electrodes will be connected to a monitor that allows the doctors and nurses to watch your heart rate and rhythm.
• The anesthesiologist will insert a catheter into one of your arteries, usually in the arm, to continuously monitor your blood pressure and obtain blood samples for various tests. It will remain in place for approximately 24 to 48 hours.
• Another catheter, the pulmonary artery catheter, will be inserted into one of the veins in your neck, to monitor heart function and fluid status. This catheter will be removed before you are transferred from the cardiac surgery intensive care unit.
• Once the catheters are in place, the anesthesiologist will administer a medication through your IV. Within a few minutes, you will be asleep.

After You are Asleep

• A breathing tube (endotracheal tube) will be inserted into your windpipe to administer oxygen. Because this tube passes through your vocal chords, you will not be able to eat or speak while it is in place. It will remain inserted for 8 to 24 hours.
• A nasogastric tube (NGT) will be inserted. This tube passes through your nose and into your stomach to drain any stomach fluids. It will remain in place for 8 to 24 hours.
• A catheter will be inserted into your bladder to monitor the amount of urine produced by your kidneys.
• An incision will be made down the middle of your chest, through the breastbone. When the surgery is completed, the bone will be reconnected with stainless steel wires, and the skin will be closed with absorbable stitches.
• Patients undergoing coronary artery bypass graft surgery also may have a leg incision. A vein in the leg called the saphenous vein is removed and used to bypass the blocked coronary arteries. The surgeon also may use the left or right internal mammary artery (found behind the chest wall) or radial artery (found in the arm) as graft sights. If used, the radial artery will be taken from your nondominant arm, that is, the arm not used for writing.
• During surgery, you will be connected to the cardiopulmonary bypass or "heart-lung" machine, which does the work of your heart and lungs while the surgeon is performing the operation.
• One or more flexible tubes will be inserted into the chest to drain any blood, fluid, or air that accumulates in the chest during surgery. These tubes are removed within 18 to 36 hours.
• Four small pacemaker wires will be placed near the bottom of your chest incision to permit pacing the heart if necessary. The wires will be removed prior to your discharge from the hospital.

TRANSFER TO THE CARDIAC SURGERY INTENSIVE CARE UNIT

Immediately after surgery, you will be transferred directly into the cardiac surgery intensive care unit (CSICU).

Your condition will stabilize during the first eight to twelve hours after surgery. Your nurse will constantly assess your needs and coordinate your care very closely with your cardiac surgeon and other members of the health care team.

You may hear high-pitched alarms in the CSICU. These sounds are all normal in an intensive care unit, and should not frighten you.

Your family will be allowed to visit you in the CSICU. Your surgeon will call them when your surgery is finished. Only two family members will be permitted at one time.

Routine Visiting Hours Are as Follows:

• 11:30am — 12:00 noon
• 2:00pm — 2:30pm
• 6:00pm — 7:00pm
• 8:00pm — 8:30pm

General Post-Operative Care

Definitions:

Telemetry. The electrode patches on your chest will be connected to a lightweight transmitter, which will enable your nurse to observe your heart rate and rhythm on a screen, and monitor your heart even while you are out of bed.

Blood transfusions. It is often necessary to replace blood loss during, and after surgery. While in the CSICU, you may be given your own blood, which is collected in a device called an Autotransfusion System. Every effort is made to avoid transfusion from donors, unless your doctor decides that it is required.

Communication. While the endotracheal tube is in place, you will be unable to speak. The CSICU staff will ask simple questions, to which you may nod, signal, or gesture in response. It will also be helpful if you plan a communication strategy before surgery.

Pain. Pain medication will be given to you to make comfortable after surgery. Your nurse will continually assess your pain level and perform comfort measures, such as repositioning you in bed.

Diet. Once the breathing tube is removed, you will start a liquid diet. If you tolerate it well, you will progress to a regular, low-salt, low-fat diet.

Activity. You will be assisted in sitting at the edge of the bed, then getting out of bed and sitting on a chair.

TRANSFER TO THE CARDIAC STEP-DOWN UNIT

After your stay in the CSICU, you will be transferred to the Cardiac Step-Down Unit. Usually, most tubes and catheters will be removed before you leave the CSICU. However, you will still be closely monitored and will still continue to receive oxygen and intravenous fluids.

The staff on this unit specializes in caring for heart surgery patients. We will encourage you to be an active participant in your recovery, and to begin self-care immediately.

General Post-Operative Care

Telemetry. The electrode patches on your chest wall will continue to be connected to a lightweight transmitter, which will enable your nurse to observe your heart rate and rhythm on a screen and monitor your heart, even when you are out of bed.

Support stockings. You will wear knee-high support hose to promote circulation in your legs. They will be removed for bathing, and skin inspection, and before you go to sleep at night. Avoid crossing your legs as this may reduce blood flow in your legs.

Incisions. The dressings (bandages) on your incision sites will be removed approximately 24 to 48 hours after surgery. If your incisions are draining, the dressings will be changed more frequently.

Pain. Postoperative pain is to be expected. Pain medication will be given to you as needed. Should you feel any discomfort or pain, notify your nurse. It is very important that you feel comfortable, so that you can perform deep breathing and coughing exercises, as well as cardiac exercises.

Activity. You will be beginning walking the day you are transferred to the step-down unit, from the CSICU. You will start in your room, and gradually increase the distance. Your nurse or physical therapist will accompany you until you are steady on your feet.

Diet. Most patients are given a low-salt, low-fat, low-cholesterol diet. A special diet will be prescribed to you, if you have diabetes.

INPATIENT CARDIAC REHABILITATION

The first phase your cardiac rehabilitation will begin the fist day after your surgery and continue until you are discharged. A Physical Therapist will design an individual program of r you, which will help restore you to your prior level of function. He or She will help you plan your daily activities, such as walking, exercising and performing self-care.

The goals of cardiac rehabilitation are to:

• maintain muscle strength and joint flexibility
• evaluate your heart’s response to activity
• prevent the negative effects of bed rest
• educate you and your family

Exersise will help:

• strengthen your heart muscle
• lower cholesterol
• reduce anxiety
• improve your sleep

Monitoring your pulse

One method of monitoring your exercise activity is taking your pulse. The pulse indicates how fast your heart is beating. Your physical therapist and nurse will teach you how to take your pulse.

1. Use a clock or watch with a second hand and place it where you can see it easily.
2. Find your pulse by lacing two fingers of the opposite hand on the palm side of your wrist just below your thumb. Never use your thumb. Remember, if your surgeon has removed your radial artery, you will not feel a pulse in that arm.
3. Press lightly, moving your fingers just a little until you can find the pulse. If you press to hard, you may stop the flow of blood and not feel a pulse.
4. Once you have found your pulse, look at the position of the second hand on the watch. Count the number of beats you feel in15 seconds. If you are not sure that you have counted correctly, do it again for another 15 seconds. Then, multiply that number by four to determine how many beats per one minute.

When to take your pulse:

1. Take your pulse before exercising. If it is greater than 120 beats per minute, do not exercise.
2. Retake your pulse immediately after exercising, and then again after resting five to 10 minutes. Your pulse should return to normal.

Remember that while exercising, your pulse should remain between 20 and 25 beats above your resting heart rate.

Perform your exercises two or three times daily while sitting comfortably in a chair. Your physical therapist will review these exercises with you.

Walking

Waling is one of your most important exercises after surgery. It will improve your circulation, muscle tone, strength, and the way you feel. You should walk every day, slowly increasing the distance. It is vital that you follow these instructions:

• Wait one hour after meals
• Wait one-half hour after bathing
• Wear comfortable shoes and clothing appropriate to the weather
• During very wet, cold, hot or humid weather, walk indoors, such as at a mall, on a gym track or in a hallway.
• Walk at a pace that does not leave you breathless. You should be able to carry on a conversation while walking.
• Do not hesitate to stop and rest if necessary.
• Use the Borg Scale of Perceived Exertion (below) while you are exercising. Your physical therapist will review the scale with you. Keep in mind that you should not work harder than a "13" (somewhat hard while exercising. The scale is a subjective scale, meaning you have to grade yourself as to how hard you think you are working. You also should use this scale when you perform your self-care activities.

Here is a schedule to help you slowly increase your walking time once you have left the hospital.

Once you are walking one mile, gradually increase your pace. However, do not run or jog at this time. Do not increase your pace and distance simultaneously.

Cardiac Precautions And Warning Signs

While you are exercising, if you experience excessive fatigue or sweating, shortness of breath, dizziness or you feel light headed, rest until the symptoms disappear and decrease your pace the next day. If you still experience these symptoms, decrease your distance and let your doctor know.

Contact your doctor immediately if you are experiencing and of the following symptoms while exercising:

• Chest Pain, discomfort or tightness other than pain from your incision
• Pain radiating to your arms, jaw, neck and back
• Nausea or vomiting
• Severe headache
• New numbness or tingling in your hands and neck

Resume walking only if approved by your doctor.

OUTPATIENT CARDIAC REHABILITATION

Outpatient cardiac rehabilitation is available to patients following cardiac surgery. The program begins approximately four weeks after discharge and consists of a telemonitored exercise in a supervised setting. The goal of the program is to teach you how to safely become more active and independent. It provides you with the opportunity to make lifestyle changes that reduces the risks and symptoms often associated with cardiac disease. Services available include monitored exercise sessions, stress management, nutrition counseling, group support, educational lectures and a variety of complementary or integrative therapies.

During your follow-up appointment with either your cardiologist or surgeon, please discuss your interest in participation in the program. If you have any questions, ask your physical therapist or contact us at 212-420- HEART.

GOING HOME

On the day of your discharge, your nurse will provide you with verbal and written instructions for your care at home.

If the car ride to your home is longer then one hour, you should stop along the way and get out of the car to walk around. This will prevent any stiffness and improve blood flow in your legs. Be sure to use your seatbelt in the car. You may want to place a pillow in between the seatbelt and your chest for comfort.

If you are flying home, ask for help with your bags and transportation at the airport. If the flight is long, change positions and do your leg exercises to help the blood flow in the legs.

GETTING BACK TO NORMAL

Recovery from heart surgery takes about four to six weeks. During this time you will begin to build your strength and return to normal. Your daily activities should be the same as they were in the hospital and should include a shower, walking, exercise and rest. Go slowly at the beginning and avoid over-exertion, as doing too much can cause fatigue. Remember to rest when you are tired.

Lifting. The breastbone takes about 12 weeks to heal. For four to six weeks after returning home, do not lift anything that weighs more than 10 pounds. Lifting strains the breastbone and prevents proper healing. Do not lift suitcases, groceries, children, pets, big purses, and laundry baskets. Do not move heavy furniture, open windows that are stuck, or push or pull heavy doors.

Driving. During your recovery, your reaction time will be slowed due to fatigue or weakness. Do not drive a car until your surgeon says it is all right to do so. If you have and accident, you could hit the steering wheel and injure your breastbone. You may ride as a passenger in a car for short distances only.

Swelling. If you have swelling in your feet or ankles you should elevate your legs when sitting so your toes are higher than your heart. Also, do not cross your legs when sitting, as doing so reduces the blood flow in your legs. Do not stand for long periods of time, and at bedtime place a pillow under your legs.

Incision Care. Shower daily, washing your incisions gently with soap and water. Do not rub the incision sites; pat them dry only. Do not use any lotion or powder and the incisions until the scabs have fallen off. You can expect to see some redness and feel some soreness and numbness on all of your incisions — all of which will go away slowly.

Examine your incisions daily. Call your doctor if you notice increased redness, swelling, or drainage, or experience pain, tenderness or fever.

Sex. If you can climb one or two flights of stairs without being short of breath, you can resume sex if you feel well rested.

Talk about your feelings with a partner to help you ease your worries. You may find that sharing emotions in a non-sexual way, such as dancing and dining out for example, can be very satisfying.

Here are some things to keep in mind:

• Avoid sex if you’re tired or tense, or after eating a large meal.
• Cuddling and kissing can be very satisfying
• Foreplay helps prepare the heart slowly for intercourse. Allow plenty of time for intercourse.
• Use positions that are comfortable, that don’t pull in your chest or cause discomfort.

Contact your doctor if you have any of the following symptoms:

• Chest pain during or after sex
• Elevated pulse and rapid breathing 15 minutes or longer after sex.
• Palpitations continuing 15 minutes after sex
• Sleeplessness after sex.

Medications. Before going home, your nurse will review your medication prescribed by your doctor, and give you a written schedule of when to take them. If you should forget, or miss, a medication, do not try to "catch up" by taking two tablets next time. You make take your pain medication at home as needed. Some people find it helpful to take their pain medication before they exercise.

Your medications can sometimes cause constipation. We recommend that you eat plenty of bran, fruits and vegetables to prevent this. A laxative may be used, as prescribed by your doctor.

Emotions. It is normal to feel depressed after surgery, as it takes lots of energy to deal with fear and anxiety. You may show your feelings more than usual. At times, you may be irritable, tearful, weepy, embarrassed, or worried. These emotions should decrease by the end of your recovery period.

Adjusting to life after cardiac surgery may take from six months to two years. If you continue to have difficulties, contact your doctor.

Work. The decision regarding your return to work will be made by you and your doctor. Usually after eight to twelve weeks, you can resume working, depending on your occupation.

Follow-up. A follow-up appointment with your surgeon is usually made before you are discharged from the hospital. This appointment takes place typically one month after surgery. Your cardiologist also will schedule a follow-up appointment and may see you before discharge from the hospital. It is very important to keep all of these appointments so you can receive the best care available. If you have any questions or concerns about your postoperative recovery, do not hesitate to call your surgeon.

FOR VALVE SURGERY PATIENTS

Prevention of Valve Infection

Patients who have had heart-valve surgery need to be protected against infection of the inner lining of the heart, which can destroy the valves. This infection is known as bacterial endocarditis.

Bacteria can enter the body through skin infections or during minor or major surgery, including dental work, and attack your weakened heart muscle. This usually can be prevented if antibiotics are given before, and sometimes after, any medical, surgical, or dental procedure. It is important that your doctor or dentist know that you have had valve surgery, so they can give you the most appropriate antibiotic.

Anticoagulation

You may need to take coumadin, a medication that prolongs the time it takes the blood to clot. It also helps prevent small blood clots from forming on your new valve. While in the hospital, you will have a daily blood test called prothrombin time (PT) to determine what dose of coumadin is right for you.

When you are discharged from the hospital, the PT test will be done frequently to ensure that you receive the most appropriate dosage of coumadin. Later, this test will be done routinely to test your blood.

SMOKE-STOPPERS PROGRAM

Your heart condition may require you to quit smoking. Because smoking can be very difficult to stop, the Continuum Heart Institute participates in a nationally recognized smoking-cessation program called Smoke-Stoppers. To sign up for this program, please call our health information center at 212-420-4247.

GENERAL INSTRUCTIONS REGARDING COUMADIN

Anticoagulants (commonly called "blood thinners") lengthen the time it normally takes for blood to clot. Your doctor prescribes an anticoagulant such as coumadin if you have mechanical heart valves, irregular heartbeats, or previous blood clots. If you are taking a blood thinner, keep appointments for regular blood tests (prothrombin time). This test tells your doctor how long it takes for your blood to clot. When you first go home, a prothrombin time should be done once a week or more frequently. Later, this test may be needed only once a month.

1. Do not use aspirin, or any medicine that contain aspirin (e.g. Excedrin, Bufferin) unless instructed by your doctor.
2. Keep appointments for regular blood tests (prothrombin time).
3. Take your blood thinner exactly as prescribed by your doctor.
4. For planned surgery or dental work, let the dentist or surgeon know that you are on anticoagulants (coumadin).
5. Avoid food rich in vitamin K, as vitamin K counteracts the effect of coumadin. For a list of foods rich in vitamin K, and for more information, please consult your doctor or nutritionist.
6. The following are signs of bleeding that must be reported to your doctor immediately:

• Black bowel movements
• Heavy nose bleeds
• Pink or red urine
• Heavy menstrual periods
• Excessive bruising or swelling
• Vomitus that looks like coffee grounds