Heart and Aorta

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'Heart and Aorta' is an initiative from Dr. E V John (Senior Consultant and HOD, Cardiovascular Surgery, Sunrise Hospital) to bring the facts about heart and aortic diseases, treatment options and complications to the common man.

​What Precautions One Has To Take During The Recovery Period, After Heart Surgery?

February 15, 2018 09:02AM, 0 comments

The precautions one has to take during the recovery period, after heart surgery-

Wound care and cleanliness: Wounds have to be kept clean and dry. During bath the wounds can be washed with mild soap and dried with clean towel. Wound should be cleaned with antiseptic solution.

Bone takes 6-8 weeks to heal. It is mandatory that strain on the sternum be avoided during this stage. One should avoid weight-bearing on the hands until 6 weeks. While getting up from bed and lying down, back should be supported by someone. Assistance during bathing is also required.

40-70% of CABG patients are diabetics depending on the geographical location and ethnicity. Diabetics are prone to infection. Apart from wound and body hygiene, one should be careful not to contract infection from external sources.

  • Avoid visitors at least during first three weeks and restrict until two months.
  • Avoid crowded places and public functions.
  • In case of fever, wound discharge, productive cough or urinary symptoms, contact doctor.

Strict adherence to medicines: Some of the medicines prescribed after heart operation are to be taken lifelong. Get advice from your doctor and clear your doubts. Do not stop or modify medicines without consulting your doctor.

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What About Long Term Lifestyle Modification?

February 14, 2018 10:02AM, 0 comments

Yes, this is a very important aspect of long term prevention especially in case of Coronary artery disease, as we all know, Coronary Artery Disease is caused by Atherosclerosis.

Atherosclerosis has multi-factorial causation. Some of these risk factors are modifiable whereas some are non-modifiable. Success in keeping CAD away is in manipulating these modifiable risk factors effectively.

  • Stop Smoking and tobacco use completely
  • Control of Diabetes, Hypertension and Cholesterol
  • Regular physical activity (Walk 3 kilometers in 30 minutes daily)
  • Reduce weight if obese (to ideal BMI)
  • Take medications regularly (Do not stop antiplatelets and statins without doctor’s permission)
  • Regular follow up checks.

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What To Expect After Heart Operation During First Few Weeks?

February 14, 2018 10:02AM, 0 comments

Here, are things to expect after heart operation during first few weeks-

Tiredness: This is quite common after a major operation. The body is busy doing the repairing process of the wound. Heart is getting accustomed to the changed scenario. Allow adequate rest for the body and mind. Engage yourself in light recreations like reading and listening to music. Take a short (half an hour) afternoon nap. Watching TV excessively is not good as eye strain may cause exhaustion. As the days progress, you will feel better.

Reduced Appetite: There are several reasons for loss of appetite. Distaste caused by some of the medications (especially antibiotics and painkillers) is a common problem. Acidity caused by stress and some medicines is another reason. Pain and discomfort from the wounds can at times be disturbing.

Pain: is the commonest problem. We are all aware of the bad effects of some of the pain medicines like acidity and kidney problems. This apprehension prevents many patients and relatives of patients from using adequate pain relief. Remember there are safe painkillers which may be used regularly until pain in relieved fully. It is important to take regular pain medications in the first two weeks – at least one in the morning and one at bedtime.

Sleeplessness: Anxiety and pain are the villains. In the first few weeks you require adequate pain relief. Along with this, many patients need a mild anxiety relieving medicine to help them to get comfortable sleep. The medicines prescribed by our team are mild and the addiction potential is very low. So do not be afraid to take these for a short period. As the health improves, your normal sleep habit will return.

Swelling of Legs: Mild or even moderate swelling of feet and legs are common after veins have been removed during CABG. This is because the venous blood return is affected. This is not a disease. The deep vein system will take care of the blood circulation adequately. It takes some time for the body to make this adjustment. The Swelling is usually absent or minimal in the morning when you get up. It gradually increases over the day as ‘gravity’ acts. Simple methods like leg elevation and crepe bandages or elastic stocking can relieve this problem. However, if there is redness, severe pain or discharge in the wounds, you must contact your doctor.

Sore Throat: The plastic tube which is kept in the windpipe during anesthesia and immediate postoperative period can cause mild inflammation and pain in throat during first few days. Mild pain killers and warm saline gargles can take care of this.

Numbness: One of the most common and consistent complaints after bypass operation is the pain and numbness in the left side of chest. Fine nerves along the Internal Mammary Artery (IMA) are cut while harvesting this artery for bypass. These are nerves that supply the front of chest. There may be numbness, burning pain, different feeling during touch or shooting pain. Usually Left IMA is taken. So the symptoms are on the left side of chest (may involve breast in women). If both IMA are used these symptoms can occur on both sides. The symptoms gradually resolve. In some cases it may persist for up to one year. On the same count similar symptoms may appear in the leg along the vein harvesting wound.

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Is OPCAB Worth The Pain And Effort?

February 14, 2018 09:02AM, 0 comments

Isn’t it interesting to know that the first ever successful bypass was done as a beating heart operation? This was way back in 1964 by a Russian surgeon, Colosev. But since then the conventional bypass operation has developed as a safe procedure and has stood the test of time.

Interest in OPCAB was rekindled in the late 80s and 90s. Due to the steep learning curve and lack of evidence for better outcome compared to standard operation, many surgeons lost initial enthusiasm and went back to the old time tested methods. The few who persisted – many of them in India- have provided valuable information regarding the safety and efficacy of this demanding surgery.

From the emerging data across the world it is now clear that OPCAB can be as complete a bypass operation as the standard one. It provides better results in terms of early deaths, strokes and kidney failures. The difference becomes far more apparent in high risk patients especially very old and those having diminished kidney or lung functions. One of the most important areas where OPCAB is making its mark is the field of repeat operations. OPCAB reduces the blood loss and recovery time in those situations.

In short, OPCAB in experienced hands is as complete and more safe than the standard operation. It may be ideally suited in very old and critically sick patients.

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​How Wounds Heal After Heart Operation?

February 08, 2018 10:02AM, 0 comments

Body has a natural resparative process for healing wounds. Generally wounds take about 6-8 weeks to heal completely. Bones may take a little longer. The new tissues will need some time to get used to the stress and strain of activities of daily life. This process is called the remodeling. It is natural to experience some discomfort during healing and remodeling stages.

How Are These Wounds Stitched And Are There Any Stitches To Be Removed?

The surgical wounds are stitched using special needles and suturing threads. Some materials are biodegradable or self absorbing. They need not be removed. Some need to be removed after the necessary period (like silk and nylon).

Generally all the wounds of heart operation are repaired using self absorbing stitch materials. These can not be seen outside and need not be removed. Small wounds are sometimes repaired using silk or nylon sutures. These are usually removed just before discharge.

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​Getting Back To Work After Heart Operation: When And How?

February 08, 2018 10:02AM, 0 comments

One of the biggest concerns in patients’ minds while considering heart surgery is whether he would be able to do the same work as before.

On a positive note let me assure you that most of the patients undergoing heart surgery would return to normal physical activity and work pattern in about 3 months.

However this depends on certain factors. Most important of these is the preoperative condition of the heart and the time required for heart to return to normalcy. For example, if the patient has suffered multiple major attacks in the past and the pumping capacity (LV function and Ejection Fraction) has suffered badly, there would be a limit to the level of physical activity possible after heart surgery.

Also, recovery is an individual feature and varies from person to person. Mental strength and preparedness plays an important role in smooth recovery.

Some people are back to normal in 4 weeks while some take up to 6 months to recover. It does not matter!

As a rule most office work can be resumed after 4-6 weeks. Work involving moderate to severe physical activity (driving, lifting weights, prolonged hours of standing etc.) can be resumed only after 3 months.

When you get back to work, start with simple and less strenuous tasks and gradually increase the level of activity.

It may be reassuring to know that patients have returned to jobs which require extreme physical strength after undergoing CABG or Valve repair/replacements.

I personally know people in almost all walks of life (including Door to door marketing, Public Bus driving, Masonry, Head load work etc.) even after heart surgery. But all these have to be started or resumed after due discussion with your doctor.

Some Common Concerns - What About?

Driving/Riding: Driving a four wheeler with power steering for short distance (up to 5 km) can be resumed after 2 months. You can resume normal driving pattern after 3 months. Bike riding is not advisable until 3 months.

Travel: Travelling short distances can be done after 3 weeks. But it is better to avoid this if possible. Bus travel is not advisable until 3 months. You can travel by train/air if required. Unrestricted travel can be resumed after 3 months.

Sports Activities: Light sports can be resumed after 8 weeks (Practice only). You can gradually start the sports activities after 3 months and slowly get back to full activity level.

Sex: There will be lot of questions in the minds of patients and their partners regarding sexual activities after heart surgery. Just like any other physical activity, sex can also be resumed gradually.

But unlike other activities the emotional aspect plays a major role here. First thing to be reassured is that you can enjoy normal sexual behavior after heart operation. In patients who had dyspnea or angina before surgery, it may even more comfortable and enjoyable after surgery. Partners have to be supportive and encouraging. In case of men, it is advisable to avoid traditional ‘man on top’ position for the first 3-4 months. There is no restriction on kissing, petting or foreplay even during first few weeks. Consult your doctor if you need specific advice.

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​How is OPCAB done?

February 08, 2018 10:02AM, 0 comments

It is clear that OPCAB would be technically more difficult to perform than conventional bypass for the plain fact that the fine surgical work needs to be done while the surface is still moving. There are certain devices which make the process a bit easier for the surgeon. Most important of them is called a tissue stabilizer (See the figure given below). This, when applied over the heart stabilizes a small portion of the heart wall and reduces the movement in that region. This makes surgical procedure a lot easier to perform. There are other devices which add to the safety like shunts which prevent blood loss and blowers which help to clear operating field.

Is OPCAB a ‘key hole’ operation?

Generally this form of operation is done through a standard opening in front of the chest that bypass operation is infamous for. The reason why this approach is widely popular is because of its safety and adaptability. In various unexpected difficult situations it gives the surgeon many options to achieve the desired result. So to put it the right perspective, OPCAB is not a ‘key hole’ operation.

Is OPCAB a more expensive option?

There is no difference in the cost between the standard bypass and OPCAB. In many patients, as the ICU and hospital stay become much shorter and usage of costly antibiotics reduces, the total cost may even be less.

How safe is OPCAB?

Bypass operation has become a very safe operation. The success rate for bypass operations in the best centers over the world is 96-99%. Last year the OPCAB success rate at Medical Trust Hospital was a proud 100%.

If OPCAB is not ‘Key Hole’ operation, what is ‘Key hole Bypass operation’?

The ‘key hole bypass operation’ is known as Minimally Invasive Coronary Artery Bypass or MICAS. In this operation the large wound in front of the chest is totally avoided. Through small incisions at the side of the chest main blocks can be treated. The recovery is much faster and patient can be back to work in 4 weeks.

MICAS can also be combined with Stenting in what is called a HYBrid operation to treat complicated disease patterns. The first HYBrid operation in Kerala was done at Medical Trust Hospital last year.

Beating heart operations form 30-40% of all bypass operations worldwide. Some of the institutions in India (including Medical Trust Hospital, Kochi) perform more than 90% as beating heart procedures. As bypass operations enter fifth decade of their existence, the number of patients requiring repeat operations is on the rise. This is one place where beating heart operation has a special role. It helps to reduce the blood loss, hospital stay and ICU stay in repeat bypass situations.

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​Exercise After Heart Operation: What And How Much?

February 02, 2018 11:02AM, 0 comments

Immediate postoperative period (after heart operation) is not the time for heavy exercise schedules. The aim is to get back to routine lifestyle and be active. Let your body decide how much you can exercise! In the first two weeks, walking indoors for 10 minutes each 2-3 times a day along with mild stretching and deep breathing exercises as prescribed by your doctor would suffice. By this time intensity of pain and other discomforts would have settled significantly.

After first follow up visit, most patients are advised to walk outdoors and increase the time and speed of walking. By about 4 weeks one should aim to do 1 kilometer gentle walk (in about 30 minutes) daily. Gradually the speed can be increased. By 8 weeks most patients are able to walk 2 kilometers in 30 minutes. Remember, these guidelines differ depending on the pre-operative condition of the heart and the capacity of the heart to exercise. So ask your doctor what is suited for you.

Generally, one can get back to normal activities and do full weight bearing on hands by 10-12 weeks. Continue the stretching and breathing exercises. Shoulder joints should be given special attention, as inactivity can make this joint very stiff. This can lead to painful Shoulder Periarthritis or Frozen Shoulder.

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​Can All Patients Needing Bypass Have OPCAB?

February 02, 2018 11:02AM, 0 comments

This is a very technical question and one need to consider many factors before reaching a decision.

Even when OPCAB is planned for a certain patient the decision can be changed on the operating table depending on conditions unique to individual patients.

A heart suffering from critical shortage of blood supply, as in the case of many undergoing bypass, may not tolerate the long operation on beating heart.

The blood vessel needing bypass may be buried deep inside the heart muscle or its wall may be very thick and hard like stone.

These situations make the operation technically difficult and may necessitate the use of CPB machine. Needless to say, every patient is unique and there is no one treatment suiting all.

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