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Royal Brompton & Harefield NHS Foundation Trust Harefield Hospital Your heart surgery Contents Understanding the heart 3 Problems with the heart 4 Heart surgery Coronary artery bypass grafting Heart valve surgery Aortic valve replacement Mitral valve replacement or repair Other types of heart surgery 5-15 6 10 12 13 15 Before your surgery – the pre-admission phase 16-19 After your surgery 20-24 Back on the ward 24-26 Going home 27-38 Who you can contact for further information 39 2 This booklet gives you information about preparing for your heart surgery, the operation itself and your recovery. It is not intended to replace the information and explanations given to you by our staff. We hope you will find it a helpful guide to use before, during and after your visit to hospital. Our aim is to prepare you for your operation, to reduce any fear or uncertainty you may have and to make your stay as comfortable as possible. Please ask if you have any questions or need further information. Useful contact details are included at the end of this leaflet. Understanding the heart The heart is a muscle that pumps blood around the body. The left side of the heart receives oxygen-rich blood from the lungs and then supplies this to the rest of the body. Blood that is low in oxygen then returns to the right side of the heart where it is pumped back to the lungs to receive fresh oxygen. The ‘heart rate’ is the number of times the heart fills with and pumps out blood each minute. What is considered a ‘normal’ heart rate varies from person to person, depending on things like age and fitness. An average heart rate is 60-100 beats per minute. 3 The coronary arteries All living tissues and organs (of which the heart is one) need blood that is rich with oxygen to work. There are millions of arteries all over the body that carry oxygenrich blood from the heart to organs and muscles so they can stay healthy. The coronary arteries supply oxygen-rich blood to the heart muscle itself. These arteries lie over the surface of the heart. There are three main arteries – a right coronary artery and two left coronary arteries. These then branch off into smaller arteries. Problems with the heart Coronary artery disease Coronary artery disease is also known as ischaemic heart disease. It occurs when a fatty substance called atheroma develops on the inside of an artery. The build up of atheroma in an artery means that it becomes narrower. A narrowed artery will only let a limited amount of blood reach the heart muscle, which can cause angina. Angina Angina is the term given to a cramp-like pain or heaviness felt mainly in the chest and left arm but sometimes in both arms, the shoulders, back, jaw or throat. You may also feel short of breath and tired. Angina occurs when not enough blood is reaching the heart. Although it can happen when at rest, 4 angina often occurs during exercise, after a heavy meal, in very cold weather, during sexual intercourse or during angry or excited moments. These activities may cause your heart to beat faster or your coronary arteries to become even narrower than usual. When this happens the narrowed arteries let even less blood and oxygen reach your heart muscle. This causes pain but does not usually damage the heart. Angina can be relieved by taking Glyceryl Trinitrate (GTN) tablets or using a GTN spray under your tongue. The heart muscle is not usually damaged. Heart attack You may also hear a heart attack described as myocardial infarction, coronary occlusion or coronary thrombosis. A heart attack occurs when a coronary artery becomes completely blocked and blood cannot reach a certain part of the heart muscle. When blood cannot reach a muscle it becomes damaged. A heart attack can occur at any time, whether you are resting or exercising. The pain associated with a heart attack is usually quite severe and you may feel dizzy, sweaty and sick, become pale in colour and feel cool to touch. Heart surgery You may have been diagnosed with a heart problem some time ago and already been helped by medication and lifestyle changes. However, your doctors may think you are at a stage where surgery is the best way to treat your condition and suggest you have an operation. There are different types of heart surgery and the one recommended for you will depend on your condition. 5 Coronary artery bypass grafting (CABG) In coronary artery bypass surgery (CABG, and commonly known as heart bypass surgery) any blockages or narrowing in your coronary arteries are bypassed. A surgeon takes a vein, usually from your leg, and attaches one end of it to where the main artery that supplies blood to the body leaves the heart. The other end is then connected below the blocked or narrowed part of your coronary artery. This then allows blood to go around (or bypass) the blockage or narrowing and so improves blood supply to your heart muscle. If you have several blockages, then several bypass “grafts” can be used. An artery from the chest wall (called the internal mammary artery) or one from your lower arm (radial artery) can also be used. Coronary artery bypass grafts do not cure the heart disease that caused your arteries to become blocked or narrowed. That means that it is important to live healthily to help your grafts work well and prevent narrowing of your other arteries. Traditional heart bypass surgery involves making a cut (incision) of about 25cm (10 inches) long down the middle of your breastbone. The ribcage is then opened to get access to the heart. Different procedures used British Heart Foundation ‘On pump’ surgery CABG surgery has been performed for many years using a special heart and lung bypass machine. This machine takes over the work of the heart and lungs and means that oxygen-rich blood can continue to flow around the body while the heart itself is repaired. 6 ‘Off pump’ surgery You may also hear ‘off pump’ surgery called the ‘octopus procedure’. It is a technique where CABG surgery is performed without using a heart and lung bypass machine. The method involves attaching the grafts while the rest of the heart continues working as normal. The actual procedure of artery grafting is carried out in the same way as standard CABG and so recovery after the operation is very similar. Your surgeon will discuss with you which procedure he/she thinks is best, taking into consideration your health and medical condition. During this time you will have the chance to ask any questions you may have. MIDCAB (“minimally invasive direct coronary artery bypass”)/MINICAB (“minimally invasive coronary artery bypass grafting”) If your condition means that you only need one bypass graft to the artery at the front of your heart, an operation called “MIDCAB” or “MINICAB” may be performed. Unlike a CABG procedure where the chest is fully opened up to perform the operation, a MIDCAB or MINICAB operation only involves a small cut (incision), usually under the left breast area of your chest. Through this cut, small instruments are inserted and used to carry out the surgery. This is carried out under a general anaesthetic. Patients who have these types of procedures tend to spend a shorter time in the intensive therapy unit (ITU) and a shorter time in hospital overall before going home. However, most of the information in this booklet about recovery from surgery still applies. The rehabilitation team, physiotherapists, doctors and nurses on the ward will give you advice before you go home. 7 What are the benefits of CABG? A successful operation will reduce symptoms such as angina and shortness of breath and improve your overall quality of life. Surgery also reduces the risk of future heart attacks and in patients with severe coronary heart disease (also called ‘threevessel disease’) may also improve life expectancy. What are the risks of CABG? No medical or surgical procedure is entirely without risk. However, it is important to remember that we would not recommend an operation if we did not believe the benefits outweighed any risks to your health. Stroke occurs in one to two per cent (one to two in every one hundred) of cases. This risk is higher in those patients who have already suffered strokes and transient ischaemic attacks (TIAs). Renal (kidney) failure after the operation, needing dialysis, occurs in one to two per cent (one to two in every one hundred) of cases. It is more common in patients who already have kidney problems. Atrial fibrillation, a type of heart rhythm in which the heart beats quickly and irregularly, occurs in as many as 30 per cent (30 in every one hundred) of cases. This is often short-lived and does not cause a major change to how the heart works or to a patient’s overall progress. A further operation due to bleeding is needed in two to three per cent (two to three in every one hundred) of cases. Deep sternal (breastbone) wound infection occurs in one to 8 four per cent (one to four in every one hundred) of patients. It is more common in patients with poorly controlled diabetes and other conditions that make a patient more vulnerable to infection. Coronary artery bypass surgery does carry a one to two per cent (one to two in every one hundred) risk of death. The risk will be slightly higher in those patients who have had very recent heart attacks or whose lungs and kidneys are not working well. The risks involved in surgery are increased if both valve replacement and CABG are needed at the same time and also if you have had one or more previous heart operations. What are the alternatives to CABG? Drugs will only control the symptoms of your heart disease and will not solve the underlying problem. It is sometimes possible to treat heart disease with percutaneous (“through the skin”) techniques such as angioplasty and stenting. This is when a small cut is made in the groin and a catheter passed into the heart. Unfortunately your doctors believe that your heart disease is now too advanced to be treated in this way. What will happen if I don’t have the operation? Without CABG your symptoms (such as angina and shortness of breath) will increase in frequency and worsen with time. In addition, the risk of future heart attacks is higher and in patients with severe coronary artery disease (‘three-vessel disease’), the chance of long-term survival is likely to be reduced. 9 Heart valve surgery The valves of the heart are like the valves in any pump. They work by making sure that blood only flows in one direction. Inside the heart there are four chambers, two at the top (called ‘atria’) and two at the bottom (called ‘ventricles’). Blood returning from the body to the heart is low in oxygen. Blood returns from the body to the right atrium, passes through a valve in the heart called the ‘tricuspid valve’ and into the right ventricle. The blood then passes through the ‘pulmonary valve’ to the lungs, where it picks up its new oxygen supply. The blood is returned from the lungs to the left atrium, passing through the ‘mitral valve’ into the left ventricle and then through the ‘aortic valve’ into the aorta (a major artery). From here the blood travels around the body to deliver oxygen to various organs. Sometimes a valve can become narrowed (known as ‘stenosis’) meaning that blood flow is reduced or slowed down. A valve may also leak (known 10 as ‘incompetence’) and this lets blood flow backwards through the valve (called ‘regurgitation’). Valve problems can be present at birth or be caused by changes that develop later in life. Rheumatic fever in childhood can sometimes cause valve problems as can an infection of the valve. The valves that most commonly need surgery are the aortic and mitral valves. Occasionally it is possible to repair a narrowed valve simply by opening it up (a ‘valvotomy’). Sometimes a leaking valve can be repaired, but if it is badly damaged it has to be replaced by a tissue or mechanical valve. Mechanical valves Mechanical valves are made from materials such as metal and plastic and do not contain any biological tissue. If you receive a mechanical valve, you will need to take medication that slows the speed at which your blood clots (anticoagulant medication) for the rest of your life. This stops the blood from becoming too thick and sticking to the mechanical valve and possibly forming a clot. The anticoagulant medication most commonly used is Warfarin. The doctors, nurses and pharmacist will give you advice about this before you leave hospital. Tissue valves These are valves obtained from humans or pigs. Sometimes tissue obtained from a cow’s heart can be made into a valve. If you have a tissue valve, you may need to take anticoagulant medication for a few months after surgery. Your surgeon will discuss the type of valve that is best for you. 11 Aortic Valve Replacement (AVR) Aortic Valve Replacement (AVR) is the surgical treatment for aortic valve disease (‘aortic stenosis’ and ‘aortic regurgitation’). What are the benefits of aortic valve replacement? Most patients with aortic stenosis and symptoms such as angina, shortness of breath and blackouts, live significantly longer after AVR. Quality of life is also significantly improved and the risk of heart failure is lower. Similar benefits can be expected in patients with aortic regurgitation. Valve replacement is also recommended for some patients without symptoms to prevent future heart problems. What are the risks of aortic valve replacement? No medical or surgical procedure is entirely without risk. However, it is important to remember that we would not recommend an operation if we did not believe the benefits outweighed any risks to your health. • Need for a permanent pacemaker: Valve surgery can sometimes disrupt the heart’s regular rhythm. Often this will resolve itself in the days after surgery but in some cases, the rhythm does not return to normal. Five per cent of patients having aortic valve surgery (five in every one hundred) need a permanent pacemaker fitted after surgery to regulate their heart rhythm. • Death: Aortic valve replacement carries a two to three per cent risk of death (in other words, two to three in every one hundred patients who have the procedure die). The risks will be higher for patients who are already very unwell. 12 What are the alternatives to aortic valve replacement? Medical therapy (drugs) will only control symptoms and will not improve the condition of your aortic valve disease. For further information about alternatives, please speak to your consultant. What will happen if I don’t have treatment? Without AVR, symptoms such as angina, shortness of breath and blackouts will become more frequent and worsen over time. Without surgery most patients will experience heart failure and/or sudden death. Mitral Valve Replacement or Repair (MVR) Mitral Valve Replacement or Repair (MVR) is the surgical treatment for mitral valve disease (‘mitral stenosis’ and ‘mitral regurgitation’). What are the benefits of mitral valve surgery? Patients with mitral valve disease can have an improved quality of life and better long-term survival following MVR. This means fewer symptoms such as shortness of breath and fatigue and a lower risk of developing heart failure. Valve replacement or repair is also recommended for some patients without symptoms in order to prevent future heart problems. What are the risks of mitral valve surgery? No medical or surgical procedure is entirely without risk. However, it is important to remember that we would not recommend an operation if we did not believe the benefits outweighed any risks to your health. 13 • Need for a permanent pacemaker: Valve surgery can sometimes disrupt the heart’s regular rhythm. Often this will resolve itself in the days after surgery but in some cases, the rhythm does not return to normal. One to two per cent of patients having mitral valve surgery (one to two in every one hundred) need a permanent pacemaker fitted after surgery to regulate their heart rhythm. • Death: Mitral valve replacement carries a three to four per cent risk of death (three to four in every one hundred people who have the operation die) and mitral valve repair carries a one to two per cent risk of death (one to two in every one hundred patients who have the procedure die). The risks will be higher for patients who are already very unwell. Please see the CABG risk section (on page 8) for details of other risks that can be associated with this type of surgery. What are the alternatives to mitral valve surgery? Medical therapy (drugs) will only control symptoms and will not improve the condition of your mitral valve disease. For further information about alternatives, please speak to your consultant. What will happen if I don’t have mitral valve surgery? Without MVR, symptoms such as angina, shortness of breath and blackouts will become more frequent and worsen over time. Without surgery most patients will experience heart failure and/or sudden death. 14 Other types of heart surgery Surgery is often needed to treat other types of heart disease. These include: Congenital heart disease Congenital heart disease is a heart problem that has been present from birth. An example is a hole in the heart (known as a ‘ventricular septal defect’). Constrictive pericarditis This occurs when the outer lining of the heart (called ‘pericardium’) becomes thick and rigid, causing problems with how the heart pumps. This is normally treated by removing the pericardium. Aortic aneurysm or aortic dissection A bulge or a tear sometimes forms in the wall of the main artery out of the heart (the ‘aorta’). This can be repaired with a patch of synthetic material called ‘dacron’. Ventricular aneurysm This can sometimes occur after a heart attack. A bulge can form in the ventricle that affects how the heart pumps. This bulge can be removed and a dacron patch used to make a repair. Whatever type of surgery you have, your recovery will be very similar. We hope these explanations have helped you understand about your condition and your forthcoming operation. 15 Before your surgery – the pre-admission phase Hospital appointments After your consultation with the cardiac surgeon and once you are on the waiting list, you will get two appointments: • A pre-operative information day where you will get advice and support about your forthcoming operation, details about recovery from heart surgery and information on how you can reduce your risk of further heart problems. • An outpatient clinic where we will carry out a number of tests to check your condition and make sure you are ready for surgery. These may include a chest x-ray, ECG (electrocardiogram) to monitor your heart rhythm, and various blood tests. Other tests may also be carried out depending on your health and medical condition. All the tests will be explained to you. We will do our best to carry out all the tests on the same day. However if this is not possible, you will get an additional appointment to attend the hospital at a later date. If you are unable to keep these appointments, it is important that you contact us immediately using the contact number on your letter. This means we can give you another appointment and give your original slot to someone else. 16 Coming to hospital for your operation What should I bring to hospital? Please do not bring too much with you when you first come to hospital. When you are in theatre and recovering in ITU we will have to store your belongings. We suggest that you bring the following items with you when you first come to hospital for your operation: • One pair of pyjamas or a nightdress • Dressing gown • Slippers (these should fit you comfortably, have a good grip and if possible, offer support to the foot and ankle) • Toothpaste and other personal items (please note that we will provide you with wash items such as towels and liquid soap) • Any medication you are currently taking • For women we also advise bringing a soft, comfortable support bra Please don’t bring anything of value such as large amounts of money, credit cards, expensive jewellery or other valuable personal items. When you are back on the ward after your operation, your family and friends can bring in other items that will make your stay more comfortable (such as books and magazines). There are day rooms on most of the wards where you can watch television. If you prefer, you can hire a television with headphones to watch in your bed area. Your family should also bring in comfortable day clothes and shoes for you. Most people feel much better if they get dressed a few days after their operation. 17 Staff members involved in your care You will come across many staff during your time in hospital. Our staff are trained to give you the best care possible, to treat you with courtesy and consideration at all times and to listen to you and answer your questions. As well as our nursing and medical staff on the ward, the following staff will visit you: Surgeon or senior doctor – He/she will talk to you about your operation and answer any questions you may have. Junior doctor or cardiac nurse practitioner – He/she will take an update of your medical history, check that this update is recorded in your notes and repeat any tests that are needed. Anaesthetist – He/she will be responsible for giving you an anaesthetic for the operation. The anaesthetist will look at how well your lungs are working and will explain to you about the medication you will be given before your operation. Please let the anaesthetist know if you have had surgery before and if you are allergic to any medication. Physiotherapist – He/she will play an important part in your recovery. Physiotherapists are highly trained in techniques of breathing, coughing and exercising, which are important after your operation. Other members of staff who will visit you during your hospital stay include: Cardiac rehabilitation team – You may have already met members of the cardiac rehabilitation team in the outpatient department or on your pre-admission day. They will visit you during your stay in hospital, help you prepare for going home and give you information about your rehabilitation. 18 Pharmacist – A pharmacist visits the ward every weekday. He/she will review your medication chart and supply medication if necessary. If you have any questions about your medication, please ask the pharmacist when he/she visits the ward. The pharmacist works closely with the nurses and doctors to make sure that your medication treatment runs smoothly while you are in hospital and when you go home. If you miss the pharmacist and you would like to speak to him/her please ask your nurse. Eating and drinking before surgery It is very important that you don’t eat or drink for approximately four hours before your operation. The nurses will remind you about this as it is important not to accidentally eat or drink as this may affect the anaesthetic. The ‘pre-med’ Before leaving the ward for your operation, we like you to feel relaxed. A ‘pre-med’ contains medication that will make you feel quite sleepy and relaxed. This will be given to you an hour or so before your operation is due to begin. You will need to stay in bed after you have been given the pre-med and ring for the nurse should you need anything. You may also be given oxygen through a mask at this stage. The anaesthetic A family member can stay with you until you go to theatre. You will be wheeled down to theatre on a trolley with a nurse and a porter. When you arrive, the anaesthetic will be given to you through a small needle in the back of your hand. This will make you fall asleep until after the operation. 19 After your surgery The intensive therapy unit (ITU) and the recovery unit As you will be undergoing major surgery, it is important that you understand exactly what will happen to you in the first few days following the operation. After heart surgery, most patients spend at least one night on either the ITU or the recovery unit. Those close to you can visit soon after you are back from the operating theatre, although much of the time on ITU or the recovery unit will be spent asleep. The ITU and the recovery unit use modern equipment to record the actions of your heart and lungs. The equipment can be noisy and appear frightening, but it is important to your recovery. A nurse will explain each item of equipment to your family when they visit. On the day of your admission, you (and your partner) are welcome to visit our ITU. Hopefully after a brief visit and an explanation of the different equipment used there, you will feel more at ease about the first few days following the operation. Equipment on ITU Please remember that everybody is different and no two people recover in exactly the same way after heart surgery. Some people need to be connected to the equipment for longer than others and some patients stay in the ITU a few days longer. Much of the equipment will be connected to you and put in place while you are unconscious. After heart surgery, you will be kept unconscious with sedative medication that makes you sleep. This may be for a few hours or overnight. All patients are different and some are ready to wake up from the anaesthetic sooner than others. 20 Ventilator While you are sleeping, you will be connected to a ventilator (artificial breathing machine) so that your body can rest after the operation. This means that there will be a tube in your mouth leading into your lungs. During this time you will not be able to talk or swallow. The nursing staff will use thin plastic tubes to clear your mouth so that you don’t need to swallow; this may make you cough a little. A nurse will always be nearby to observe your condition and respond to any concerns that you may have talking to you and giving you reassurance at all times. As you gradually become more awake, the ventilator will be disconnected and once the doctors and nurses are sure you can breathe safely on your own, the ventilator tube will be removed. An oxygen mask will then be placed over your nose and mouth and you will be allowed to sit more upright in bed. You will probably be allowed to drink at this stage. A physiotherapist will visit you soon after the operation to help you begin your breathing and leg exercises. Chest drains These are tubes which are put into the hollow space around your heart to drain off any blood that collects there after the operation. They will probably be removed one to two days after your operation. The stitches that hold the drains in place will be removed four days later. Urine catheter This tube is passed into your bladder to drain away any urine that collects during and shortly after your operation. The urine drains into a bag attached to the side of the bed. The nurse who is looking after you can measure the amount accurately and you don’t have to worry about using a bottle or bedpan 21 again until you are feeling more awake. This tube is usually removed one or two days after surgery. Additional equipment is used on the ITU such as a monitor to see your heart rate and pumps to make sure you receive the correct amount of fluid after your operation. An intravenous line (drip) inserted into a vein in your neck is used to give antibiotics and to measure the pressure in your heart. This information means that we know exactly how much fluid you need to be given. You will also have an intravenous line in your arm to help replace this fluid. All this equipment is needed so that ITU staff can check your progress and make sure that you recover properly after your operation. Visiting ITU Close family can visit ITU or the recovery from 10am to 1pm and from 3pm to 7.30 pm. Visitors should ring the bell at the end of the corridor leading towards the unit and a member of staff will then take the visitors through. The telephone number for ITU is 01895 828 685. The recovery unit can be contacted via switchboard (01895 823 737) on extension 5339 or ask for ‘Harefield Recovery’ on the voice recognition system. Accommodation for relatives If your partner/family would like to stay at the hospital there is accommodation available. The hotel block is called Parkwood House. A receptionist is on duty from 8am-6pm Monday to Friday and 10am-2pm on Saturday and Sunday. The receptionist can be contacted on 01895 828 823. For daily charges, please ask for our separate information sheet. 22 If you need any help in arranging accommodation, please contact the rehabilitation team. Your family is welcome to use the Pavilion coffee shop and the Hungry Hare restaurant for meals and refreshments during your time at Harefield. Your wounds Leg wound If you are having bypass surgery, you may have a wound running down the inside of your leg where grafts have been taken. Your leg will be bandaged along its full length at first. This will soon be replaced with an elastic stocking. Some swelling around the ankle area of the leg that has been used for the grafts is very common. Dissolvable stitches are usually used to stitch up the incision made in your leg. Occasionally metal clips are used instead and the district nurse will remove these after you have gone home. Arm wound If the radial artery has been used for one of the grafts, you will also have a wound on the underside of your left or right forearm. Small metal clips are used to close the skin. These are normally removed 10 - 15 days after the operation by your practice or district nurse. As with all wounds you may experience some numbness caused by bruising to the nerve endings for some months following surgery, but this will improve. 23 Pain We want you to be as comfortable as possible after your surgery and will do everything we can to control your pain. At first, you may be given regular pain-relieving medication using an infusion pump connected to a thin tube, which is inserted into a vein in your hand. You will be able to control the amount of medication you receive by pressing a button on the handset (this is known as patient controlled analgesia or PCA). You may have an epidural instead – a small plastic tube inserted into your spine delivering a constant amount of painrelieving medication. As your pain reduces, this method of pain relief will be replaced with medication taken by mouth. It is important to your recovery that you have as little pain as possible and the nurses will be constantly checking your pain level. Back on the ward High dependency unit (HDU) From the ITU, you will be taken to the high dependency unit (HDU) for a day or so. You will then move back to the main ward where you will stay until you go home. The first two to four days You may feel very tired and find that you sleep a lot. This is your body’s way of recovering after heart surgery. You will need to concentrate on deep breathing and coughing at this stage and a physiotherapist will help you with this. You may still need a little extra oxygen for a few days. At this time you may feel some discomfort in your chest as you cough and take deep breaths – the pain-relieving medication will help. Holding your chest to cough will also help relieve discomfort. Please talk to your nurse if your pain is not controlled. 24 Eating and drinking At first you will be given fluid and nutrients through a drip - a thin plastic tube that is fitted into a large vein (usually in your neck). Once you feel like eating and drinking again this will be removed. Your appetite may be poor at this stage so please eat what you can. If you have indigestion or you become constipated please don’t worry, this is normal and we can help. Hallucinations During these first few days you may also feel a little vague at times and find that you forget things easily. Bad dreams and hallucinations are also common. These will gradually disappear as your condition improves. Palpitations (strong heart beats or ‘arrhythmias’) Palpitations are very common following heart surgery. At times your heart rhythm may feel different and you may experience occasional extra beats. If your heart has a new blood supply or a new valve, it may beat more efficiently and stronger than before the operation.While in hospital you will be given extra medication to control this. It is less likely to occur once you have gone home, but if it does please contact the rehabilitation team or your GP for advice. Irregular heart beat (also known as ‘atrial fibrillation’) An irregular heart beat is also quite common at this stage. The heart rhythm may be irregular and beat a little faster than usual. Medication may be given to control this if necessary. 25 Getting up and about Two or three days after your surgery you will be able to get up and walk around your bed area. You will feel tired and some muscles, especially those in your chest and neck, may ache. The physiotherapist will teach you exercises to help relieve your discomfort. The sooner you get up and about, the quicker your recovery will be. The exercises need to be done at least once a day for six weeks after you have gone home. You may continue them for longer if you like. At first you may need the help of the nurses to wash, change and move about. You may also need to wear special stockings for the first few days after surgery. These stockings help the blood flow to and from the legs until you are able to move about more. However, by the third or fourth day after your operation you will be able to walk to the bathroom and look after yourself. Before you go home, you will be able to dress in your normal clothes and walk freely around the ward area and perhaps take a short walk outside. You will also be able to climb a full flight of stairs. The rehabilitation nurses will visit you before you leave hospital. A day or so before your discharge, they will discuss with you and your family all the ‘dos’ and ‘don’ts’ for the first three months after your operation. You will also be given advice about your ‘risk factors’ for heart disease and information about the rehabilitation programme at Harefield or your local hospital. 26 Going home (discharge) Preparing to go home You may have some tests as a final check-up before you go home, such as an ECG (electrocardiogram) to look at the rhythm of your heart, or a chest x-ray to look at the size and shape of your heart. The rehabilitation nurses, surgeons, physiotherapists and the nurses who have cared for you on the ward will make sure you are fully prepared for your return home and will be able to answer any questions you may have. You may need to take some medication for a few weeks or more after you have been discharged – this may differ from the medication you took before your operation. The hospital will give you a week’s supply, together with a letter for your GP. Please take this letter to your GP surgery or your GP may want to visit you during your first week at home. Your GP will organise a repeat prescription for your continuing medication. This will normally be continued until your follow-up outpatient appointment at the hospital. An outpatient appointment date will be sent to you in the post for you to attend the hospital about six weeks after your discharge. If you are coming to Harefield for your rehabilitation programme, the cardiac rehabilitation nurse will give you a date for the first part of the programme. This will be about one to two weeks after discharge. If you would prefer to attend a rehabilitation course at your local hospital, your rehabilitation nurse will arrange this. Rehabilitation courses at most other hospitals will not begin until after your first follow-up appointment at Harefield. 27 At home It should take approximately eight to twelve weeks to recover from heart surgery but this depends on the extent of your operation and how active you were before your operation. Your whole body will have slowed down following the operation and so it is important not to overdo things in the first few weeks. Please remember that no two people recover at the same rate. Some people feel very well after six weeks, others will not feel back to ‘normal’ for three to six months or a little longer. Pain After your discharge, you may still experience some discomfort - particularly around the wound sites, together with aches and pains in your chest, neck, shoulders and back. This is quite normal and we advise you to continue taking your painrelieving medication regularly. Please do not be afraid to take the maximum dose, as advised, if you are experiencing a lot of discomfort. Most patients are able to reduce their pain-relieving medication within six weeks of discharge. It is important not to suddenly stop your pain medication. Instead, reduce the dose gradually. If you have had bypass grafts, the surgeons will often have used the right or left internal mammary artery for one of the grafts. In this case, it is common to experience slightly increased discomfort over the left or right side of your chest, neck or shoulder area. At first, you may feel numbness and as the muscles and nerves heal, the area may become tender to the touch. The exercises 28 you have been taught will help reduce your pain so it is very important to keep doing them for at least six weeks and for longer if you wish. If you are worried about pain or if you find that pain-relieving medication is not helping, please do not take extra tablets but contact the rehabilitation team, ward staff or your GP for advice. Your pain relieving medication may need to be changed to something more effective. You may also find that warm showers or baths help relieve some of the discomfort. Wounds By the time you leave hospital, you will be able to get your wounds wet. A daily bath or shower will keep them clean and help healing. Please do not use highly perfumed soap along the scars as this may cause irritation. The stitches along your chest and leg wounds will dissolve (the stitches from the chest drain will have been removed before you leave hospital). Please check your wounds each day. If you notice any swelling, discharge, or if the wounds are red and sore, you should let your GP know as soon as possible, in case you have a mild infection. If this is the case, a short course of antibiotics may be needed. Your wounds will gradually fade over the next few months. Usually a thin white line is all that remains. If you have had CABG surgery, it is common for your ankle to swell for a few weeks afterwards in the area where the grafts were taken. To help reduce the swelling please keep exercising, avoid standing still for too long and keep your feet raised when you are sitting in a chair. 29 If both your ankles swell, or if the affected leg swells up to the knee or beyond, please contact us or your GP for advice. Please do not expose your wounds to direct sunlight (such as by sunbathing) for the first eight to twelve weeks after surgery or until they are completely healed. Shortness of breath This is very common during the first few weeks after heart surgery. You and your lungs will have become less fit because of being less active. As you become more active, any shortness of breath should disappear gradually. If this is not the case, please telephone the rehabilitation nurses or your GP for advice. Unusual mood swings In the first few days following your heart surgery, you may feel ‘down in the dumps’ and anxious about the future. You may experience changes in your mood and feel very tired and irritable. After any major operation, people often experience poor concentration and loss of memory and a lot of people find they become very emotional and cry a lot. All these symptoms are normal and some people experience them more severely and for longer than others. To help you and your family and friends cope during this time, please feel free to contact one of the cardiac rehabilitation team or telephone the ward and speak to the nurses who looked after you. Attending a rehabilitation course will also help you and those closest to you to feel better at this time. 30 Sleep It is a good idea to try to get back to your normal routine as soon as you get home. If you have had difficulty with sleeping whilst in hospital, you may have been prescribed medication to help you sleep. You will probably find that once you have settled back into your familiar surroundings and you are back in your own bed, this medication is no longer necessary. It may take you a few nights to find a comfortable position in which to sleep. You may have slept slightly raised in hospital, but it is safe to lie flat if that is how you prefer to sleep. For the first few weeks, most people find that they also need a ‘nap’ during the day, usually after their walking exercise. Remember though, that if you sleep for long periods during the day you may have problems sleeping at night! Visual disturbance As it is quite common to experience some visual disturbance during the first six to eight weeks, we do not advise you to have an eye test during this time. Visual disturbances after heart surgery are usually only temporary and go away completely in time. Appetite Immediately after surgery, your appetite may be poor but by the time you leave hospital you should be starting to enjoy your food a little more. After a few days at home, you should notice your appetite returning to normal. Some weight loss is quite common at this time. If your appetite remains poor and weight loss continues, please contact the rehabilitation nurses or your GP for advice. 31 Medication You should make sure that you take only the heart medication prescribed by the hospital on discharge and that you take it as prescribed. If you normally take medication to lower your cholesterol, please make sure you start taking this again. Anxiety at home You and those closest to you will probably have found this experience very stressful. It is common for those closest to you to be ‘over cautious’ when you first go home. Your partner or family are encouraged to attend the talk before you go home so that everyone is prepared for your return and understands what is expected from you. The rehabilitation teaching programme, which you and those closest to you are invited to attend, will also help to put everything into perspective. Driving As a result of surgery the bones, muscles and tissues within the chest area are temporarily damaged. It is important that you do not drive until you are well enough to be able to cope in an emergency situation. Your concentration and ability to think clearly may not be as good shortly after surgery and this could also make it dangerous for you to drive. Please do not drive until you have had your first outpatient appointment. You do not need to tell the Driving Vehicle Licensing Agency (DVLA) about having heart surgery but you will need to tell your insurance company. It is still compulsory to wear a seatbelt as a front or back seat passenger. If this causes any added discomfort to your chest, please try a small cushion or a rolled up towel placed between your chest and the seatbelt to help remove the pressure. 32 Work Around 75 to 80 per cent of people who worked before having heart surgery (75 to 80 in every one hundred people) return to their jobs afterwards. How soon you can return to your job after surgery depends on the type of work you do and the decision should be made in discussion with your surgeon, GP and the rehabilitation team. It may be helpful to start back part-time or to be offered lighter duties at first. As a rule, patients with light occupations should consider going back to work after two months. Those who have heavy manual occupations may not be able to return to work for at least three months. Your surgeon will be happy to discuss this with you at your outpatient appointment. Sexual relations Sex can be resumed as soon as you feel able. Please apply the same common sense approach you do to building up your general physical activity. It is a good idea to find a position that is most comfortable for you. Please try to avoid positions that put weight on your breastbone or upper arms. Before your operation, you may have felt less interested in sex. This could be for various reasons, such as anxiety whilst waiting for surgery or because some of the medication you were taking may have had this effect. After your operation, some of your medication will change and hopefully you will feel less anxious and more positive about the future. Try to adopt a relaxed attitude towards enjoying sex again and please don’t worry if early attempts are unsuccessful or difficult - you will soon be back to normal. 33 General advice for the first three months following surgery Weeks one to six Do: • • • • • Take a bath or shower each day and get dressed The exercises you have been taught Take a short nap mid-morning or afternoon if needed Eat a healthy, well-balanced diet Make a cup of tea/coffee or a light meal and wash up a few dishes afterwards! You may also do anything gentle about the house or garden. • Get out for your walking exercise sometime during the day. Walking is the best form of exercise in the first weeks following your surgery and you can build up gradually. At first this may be around the garden but once you feel more confident you can walk away from the house. You may like to go with a friend or family member at first to give you added confidence. It is normal to feel slightly breathless and a little tired when you return from a walk, so take a short nap if you need one. If you feel absolutely exhausted you have probably done too much. Please avoid hills for the first few weeks and remember to wrap up warm if the weather is cold. We encourage you to walk further – anything from half a mile to two miles or more – once six weeks have passed following your surgery. Please remember everyone is an individual so the amount of walking exercise you do depends on your age and general fitness before surgery. 34 Please do not: • Overdo your walking exercise • Lift, push or pull anything heavy such as lifting children or heavy pets, moving furniture or cleaning your car. You should also avoid heavy housework such as vacuuming and heavy gardening such as mowing the lawn, digging, etc. • Drive • Play any sports • Carry out any DIY that involves stretching or heavy lifting. Weeks six to eight Do: • Consider driving again after your check up with your surgeon • Mow the lawn and light digging in the garden • Vacuuming and other moderate housework. Please do not: • Perform any tasks that are particularly strenuous. 35 Weeks eight to twelve Do: • • • • • • Some gentle swimming Go cycling Hit a few golf balls on the practice range Start playing bowls Play table tennis (gently) Go back to work if you have a job that doesn’t call for a lot of activity (our medical staff/rehabilitation team will advise on this). Please note that all the above should be started very gradually and built up over a few weeks. Please do not: • Play contact sport such as football or rugby • Play racquet sports such as squash, tennis or badminton • Do weight lifting exercises. Generally you should still avoid anything that would put a lot of strain on your chest or upper body. 36 What can I do to reduce my risk of heart problems? There is a combination of factors that may make certain individuals more likely to develop coronary artery disease. You can reduce your risk of further heart problems by: • • • • • • • • Giving up smoking Controlling high blood pressure Learning how to cope better with stress Making sure your weight is suitable for your height and build Eating a healthy, well-balanced diet Making sure your cholesterol stays within normal limits Taking regular exercise Drinking sensible amounts of alcohol. Cardiac rehabilitation Rehabilitation programmes have been set up to help you and your family cope during the first few months after your surgery. Once a week at Harefield, we give you the opportunity to meet other people who have the same heart problems and are also recovering from heart surgery. It will give you a chance to share experiences. Each week there will be a talk on a variety of topics relating to your recovery and future well-being. All sessions will be repeated at eight weekly intervals and each one is very informal. Time is also spent talking over particular worries you may have once you have been discharged from hospital. The rehabilitation team will be available to answer any queries you may have about your recovery in general. 37 Following on from the educational/support classes, you will be referred to the second stage of the programme. This consists of an individual exercise regime, which will help you to become fitter safely and effectively. Regular exercise will improve the flow of blood and oxygen to the muscles and reduce the risk of further heart disease. We feel that the programme will be of great benefit to you by helping you get back to a ‘normal’ lifestyle as soon as possible. Please ask the rehabilitation team for further information. If for any reason you were not seen by the rehabilitation team before your discharge and you would like to join the programme or you have any worries or concerns, please contact them through the secretary on 01895 823 737 extension 5944. You can find more contact details on the next page. 38 Who can I contact for more information? If you would like further information about heart surgery or have any questions or queries, please contact us on one of the following telephone numbers: Harefield switchboard 01895 823 737 Cardiac rehabilitation nurses Call switchboard on 01895 823 737 and ask for bleep 6170, 6151 or 6131 Answer phone 01895 828 944 Rehabilitation physiotherapist Call switchboard and ask for bleep 6268 Intensive Therapy Unit (ITU) 01895 828 685 Parkwood House visitor accommodation 01895 828 823 Outpatient department 01895 823 737 ext. 5696 If you have concerns about any aspect of the service you have received in hospital and feel unable to talk to those people responsible for your care, call PALS on 020 7349 7715 or email [email protected]. This is a confidential service. 39 © Royal Brompton & Harefield NHS FoundationTrust Royal Brompton Hospital Sydney Street London SW3 6NP tel: 020 7352 8121 textphone: (18001) 020 7352 8121 Harefield Hospital Hill End Road Harefield Middlesex UB9 6JH tel: 01895 823737 textphone: (18001) 01895 823 737 website: www.rbht.nhs.uk October 2010 Brosürteki bilginin Türkçe tercümesi için tedavi gorüyor oldugunuz bolüme bas vurunuz. Bolüm personeli tercümenin gerçeklesmesini en kisa zamanda ayarlacaktir.