A PATIENT’SGUIDE TOCARDIACSURGERY

This teaching booklet is designed to introduce you toheart surgery. In the following pages, we will try to answerquestions that are frequently asked about the procedure andits purpose. We also encourage you to ask questions of yourphysician and other health care personnel who are involvedin preparing you for the procedure. Before your surgery isperformed, your doctor will discuss the operation and anypossible risks with you. Following the discussion, you will beasked to sign a legal consent form. Staff will provide youwith any additional assistance or information you mayrequire.Some of the best heart care in the nation is found at St. Peter’s Hospital, named one of America’s Top 100Cardiovascular Hospitals. Independent healthcare qualityexperts have repeatedly honored St. Peter’s Hospital for itsdocumented excellent performance in caring for patientswith heart disease. Furthermore, St. Peter’s has receivedawards for patient safety, stroke care and overall clinicalservices. St. Peter’s has also received nursing’s highest honor– national MagnetTM Hospital status – for consistent excel-lence in nursing services. While we are grateful for and hum-bled by the prestigious awards and accolades, we are evenmore proud of what they represent – dedicated people committed to a culture of excellence.

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IntroductionRisk Factors: Heart Disease Prevention

PLAN:

Research shows that certain conditions called risk factors increaseyour chance of heart disease. There are some risk factors you canchange and some you cannot change.

Look at the following list and place an X in the boxes that apply to you. Think about your risk factors and what lifestyle changes youcan make.

Discuss your plan with your healthcare providers:

Risk Factors You CannotChange

� Age/Gender (man over45 and woman over 55)

� Family History� Personal History� Ethnicity

Risk Factors You Can Change

� Smoking� Cholesterol

� High Total Cholesterol (200 mg/dL or more)

� Low HDL (45 mg/dL or less) � High LDL (140 mg/dL or more)� Triglycerides

(150 mg/dL or more)� High blood pressure� Overweight� Lack of exercise� Diabetes/High blood sugar� Stress

Coronary Artery DiseaseCoronary artery disease is the most common form of heart diseasein the United States. A buildup of plaque can clog your arteries. Thisblocks the flow of blood and oxygen to your heart muscle. Whenthis happens, angina or a heart attack may occur.

Angina: Is a short episode of discomfort where no permanentdamage to the heart muscle occurs. Symptoms include chest pres-sure or tightness that can travel down to your arm or up into yourneck or jaw. Angina can also give you shortness of breath. You canhave angina during exercise, after eating, or at rest. Angina is awarning that your heart is not getting enough blood and oxygen.

Heart Attack: A heart attack happens when there is a permanentblockage of blood flow to an area of your heart muscle. This maycause permanent damage to your heart.

The arrows inthe drawingare pointingout plaque

buildup in thearteries that

can lead to seriousblockages

that, in turn,can

lead to aheart attack.

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The first step in preparing forheart surgery is learning moreabout the surgery. Review theinformation on the pre-opera-tive/post-operative DVD provid-ed to you in your surgeon’soffice. If you did not receive theDVD or could not view it athome, the content is availableon St. Peter’s Hospital’s internalTV channel. Ask your nurse forassistance. The following pageswill help give you an idea ofwhat the surgery will be like.

Coronary artery bypass surgeryand valve surgery are the twomost common types of heartsurgery. Since the heart is amoving organ it must bestopped in order to performsurgery. This is accomplishedwith the heart-lung machine.This machine pumps blood foryour heart and adds oxygen to your lungs to enable surgeryto be performed on the non-moving heart.

Open-Heart SurgeryIn many open-heart surgerycases, an incision is made in thecenter of your chest. It runsfrom below your neck to belowyour breastbone, called yoursternum. The breastbone is cutfor the surgery to take place.

After the surgery has beencompleted, your surgeon wiresyour breastbone back together.These specially designed wireswill remain in your chest. Yourincision will be stitched togetherand covered with a dressing.Your dressing will be changedby your nurse. Incisions areuncomfortable for a few daysand may remain sore for a fewweeks. Pain medications will beprovided for relief. Please letyour nurse know if you areuncomfortable. You will beencouraged to move aroundand get out of bed after surgery.Over time your discomfort willdecrease.

About Your Heart Surgery

Vein graft Arterialgraft

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Coronary Artery BypassSurgeryBlood and oxygen flow to theheart muscle through the coro-nary arteries which surround it.When these arteries are blocked,the heart does not get the oxy-gen that it needs. Lack of oxy-gen is felt as angina or chestpain.

To bypass this blockage, thedoctor will perform a coronaryartery bypass graft surgery(CABG). This involves taking apart of a vein from your leg,and/or an artery from your armor chest and using it to bypassthe blocked artery. After thenew artery is grafted, bloodflows around the blocked areaand again takes blood and oxy-gen to your heart muscle. If partof a vein is taken from your leg,this will not affect circulation oryour ability to walk.

Valve SurgerySurgery on the heart valves is the second most commoncardiac surgical procedure performed. The heart valvesallow the blood to flow in onedirection through the heart.Various diseases often will causethese valves to narrow or leak.Once this narrowing or leakagereaches a critical level, it canaffect how the heart functions.

Valve surgery involves repairingor replacing the diseased valve.

Minimally InvasiveCardiac SurgeryMinimally invasive cardiac sur-gery involves using smaller inci-sions and different approachesto perform surgical procedureson the heart. Most commonly,this has been utilized for valvesurgery. Selection of patients forminimally invasive approachesto cardiac surgery is based onmultiple factors that areassessed by the surgeons.

The replacement of aorticand mitral valves is sometimesnecessary.

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Surgery for OtherCardiac ConditionsAdult cardiac surgical proce-dures may include, but are notlimited to, aneurysms in thechest, cardiac tumors, andrhythm disturbances.

The CryoMazeProcedureCertain patients with atrial fibrillation who require valve orCABG surgery are candidates for the CryoMaze procedure.This procedure can treat theatrial fibrillation and mayrestore a normal rhythm.

During the CryoMaze procedurea probe, which gets very cold, is placed on certain areas of the heart to block abnormalimpluses. This allows sinusimpulses to travel to the atrio-ventricular node (AV node) asthey normally should.

The admission process beginswith the activities listed below.During the admission processplease feel free to ask questions.

Pre-Operative Testing• Medical history and physical.

• Nursing interview (a sched-uled appointment will bemade for a phone inter-view).

• Medication history (pleasemake sure to bring all yourcurrent medications).

• Surgical and anesthesia con-sents.

• Blood testing.• Chest X-ray.• Electrocardiogram (EKG).• Ask your surgeon’s officeabout pre-op classesand tours of St. Peter’sCardiovascular Unit.

• Spiritual Care visit; ask anurse for information.

• Lung function (breathingassessment) test.

• Vein mapping.• Other tests may be orderedby your physician. Duringthis process please feel freeto ask questions.

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Your Admission

Night Before Surgery• Shampoo hair and do notreapply hair products (i.e.hair spray, hair gel, etc.).

• Remove all makeup andnail polish prior to comingto the hospital. If you haveartificial nails, remove onefrom an index finger.Women should not shavetheir legs prior to surgery– body hair clipping will bedone the day of surgery, ifnecessary.

• Shower as instructed withsurgical scrub/soap startingat chin and working downto toes – front and back.

• Do not apply any powders,lotions or deodorant afteryour shower.

• Do not eat, drink or useany tobacco products aftermidnight. This includescandy, gum, and breathmints.

Day of Surgery• Anesthesia interview.• Body hair clipping.• Shower with antimicrobialsoap.

• Review of medical data (including Health CareProxy and medications).

The doctor will instruct you onmedications to take beforesurgery. You may brush yourteeth and use mouthwash inthe morning, but do not swal-

low any water. Your stomachneeds to be empty to keep you from becoming nauseatedduring the operation. Identifythe valuables (glasses, den-tures, hearing aids) you musthave with you. Your familymember will be responsible forthese valuables during yoursurgery. Please leave all othervaluables (purse, wallet, jewel-ry) at home.

You will be admitted to the CV Pre-op area dedicated tocardiac surgery patients. Rarely,the hospital census may neces-sitate a male/female room.Please make the nurse awareof any concerns or specialneeds.

You will be interviewed by amember of the anesthesiadepartment. In the CV Pre-oparea several monitoringcatheters will be placed afteryou receive local anesthesia.

Your family members shouldwait in the CVICU area and register with the surgery vol-unteer. The surgeon will con-tact your family when yoursurgery has been completed.There is a phone in this areathat visitors should use to callthe nursing desk prior to eachvisit. Once you are settled inyour room after surgery yourfamily may visit for a brief time.

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The CVICU can be a stressfulexperience for both you andyour family. The nursing staffwant to help you through thiscritical period by providing aclear understanding of yourcondition. Your status may belisted as “serious” while you arein the CVICU. This should notcause undue concern to yourfamily or friends. Your familymay not feel comfortable in thissetting. The optional tour willmake them feel more familiarwith the CVICU.

The nurse in the CVICU will askfor one family member to serveas the family spokesperson during your stay. The nurse will keep this family memberinformed of your condition, asking him or her to share thatinformation with family mem-bers and loved ones. Weencourage your family to gohome and rest; this is a stressfultime for them also. Our nursingstaff will work with patients and

their loved ones to develop avisitation plan that meets theneeds of the patients, their families and their guests.

A critical care nurse will remainat your bedside while yourecover from anesthesia in theCVICU. Your family may visitwith you after speaking withthe physician. In most cases ittakes 60 minutes or longer toget you settled in the CVICUwith the monitoring equipmentset up. You will be connected toa heart monitor, which recordsthe heart rate and rhythm atyour bedside and at the nurses’station. You will have a breath-ing tube inserted during surgerythat is connected to a ventilator.This provides oxygen and helpsthe lungs to breathe whilerecovering from anesthesia. As you wake up, the ventilatorsettings are adjusted so thatyou gradually begin breathingon your own. The tube will notbe removed immediately.

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Cardiovascular IntensiveCare Unit – CVICU

During this time, you will beunable to speak and it is impor-tant to resist the urge to pull onthe tube. You need to stay calmand keep your hands at yourside. The nurse and respiratorytherapist will be monitoring youclosely. Once your blood testsindicate you are breathing well,the breathing tube is removed.You will be placed on oxygen viaan oxygen mask or nasal can-nula (oxygen tube). You will beasked to take deep breaths atfrequent intervals.

Chest tubes will be inserted intoyour body during surgery, whichdrain bloody fluid from yourchest to provide room for yourheart to pump. A catheter,which is used to drain urine, willbe placed into your bladder. You may feel discomfort whenyou awake, but the catheter iscritical in assessing your kidneyfunction and urine volume. Youmay require transfusion of bloodproducts and alternatives totransfusion may be discussedwith you prior to surgery.

Intravenous solutions assureproper hydration and supportblood pressure and heart rate.These solutions will gradually betapered off depending on yourstability. In addition, you maynotice monitoring lines havebeen placed in your neck, wristor groin. Ongoing assessments

are taken by your nurse toassess your progress. Data fromthe monitoring lines is shownon the screen above the bed,which may transmit beeps orbuzzes. These sounds, althoughstartling to visitors and patientsalike, are being carefully moni-tored by your nurses. In additionto a bulky dressing on your inci-sion, Ace bandages arewrapped on your legs for 48hours for those with leg inci-sions. You may also have awarming blanket after surgery.

During your surgery, your physi-cian may have attached severalwires, known as pacing wires,to the surface of your heart.These may be attached to anexternal cardiac pacemaker youwill wear as necessary duringyour post-op course of treat-ment. These wires will beremoved before you leave theCV Progressive Care Unit.

Your comfort is a primary concern and your doctor mayprescribe medication to reducediscomfort. Complementarytherapies are also available. Besure to let your nurses know ifyou are in pain. You will remainin the CVICU for 12 to 48 hoursfor close observation. Chesttubes are removed when thefluid discharge levels decreaseto a safe level.

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Approximately 12 to 24 hoursafter your surgery, you will betransferred from the CVICU tothe CV Progressive Care Unit.Your heart monitor will be asmall box that will fit in thefront pocket of your hospitalgown. This will allow you tomove about while your heartrate and rhythm are constantlymonitored. This monitor will bein place until discharge from thehospital.

A nasal cannula (oxygen tube)in your nose will help yourbreathing. Your nurse will bechecking your oxygen levels frequently and soon you will bemoving around without theoxygen tube. You may have ahoarse voice or sore throat fromyour breathing tube, but thiswill get better in a few days. Ifat any time you feel short ofbreath, let your nurse knowimmediately.

Your IV line will be capped offand flushed multiple times perday by your nurse. Your chesttube may also still be in place.IV antibiotics will continue to beadministered for 48 hours or asnecessary. When your tubes areremoved, a chest X-ray will indi-cate if your lungs have fullyexpanded.

Your diet will progress from liquids to a low-salt, low-fat,caffeine free, carbohydrate con-trolled diet. Due to the medica-tion you will be receiving andthe stress of surgery, you mayexperience a spike in bloodsugar levels. This does not nec-essarily mean you are a diabetic.Your blood sugar levels will bemonitored throughout yourstay. Eating a well-balanced dietspeeds healing. A RegisteredDietitian will review with you adiet specific to your needs. Aphone number will be providedfor any questions after discharge.Early morning lab work andweight will be done daily.

It is normal to experience painafter surgery. The surgical procedure involves cutting into muscle and bone. It isimportant to take your painmedication regularly. Often,pain decreases once the chesttubes are removed. You need tobe comfortable enough aftersurgery to cough, take deepbreaths, get out of bed, andwalk. The more you move, thebetter you will feel. Please letstaff know as soon as you haveany discomfort or if your painmedication is inadequate. Thediscomfort or pain should notbe the same as the cardiac

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Cardiovascular ProgressiveCare Unit

discomfort you may have expe-rienced before surgery. Reportto your RN immediately if you experience this type of pre-operative discomfort aftersurgery.

In the hospital, your nurse willcare for your surgical incisions.Dressings will be changed asneeded. One of the heart sur-geons and an assistant will visityour room every day. They willbe checking your progress and needs. Any problems orconcerns you are having can beexpressed to any staff member.

You will be expected to useyour incentive spirometer 10times an hour while you areawake. This simple breathingdevice forces you to take adeep breath and may make youfeel the urge to cough. Hug apillow to protect your chest(sternum) while coughing.Coughing is necessary to pre-vent pneumonia and otherhealth problems. Deep breath-ing opens up the tiny air sacs inthe lungs and coughing helpsbring up the mucus.

The first day after surgery youwill need to get out of bed andwalk. You will progress to fouror five short walks a day. Atfirst you will be accompaniedby your nurse or exercise physi-ologist, but you will quicklyprogress to walking with yourfamily and by yourself.

Remember to keep good pos-ture and avoid slumping, even ifyou are sore. Standing straightwhile you walk gives you betterbalance and allows you tobreathe easier. Be sure to wearslippers that fit and have non-skid soles. Taking your painmedication at regular intervalswill help you feel less stiff andsore while you are up andabout. Each day you willincrease your activity and thelength of time you are out ofbed. Before you are discharged,you will be walking up stairswith your nurse or exercisephysiologist.

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Your doctors, nurses, and thera-pists will all work together tocreate a plan for your care tomake sure your discharge planmeets your needs. You mayrequire rehabilitation or homecare. Upon discharge, a phonenumber will be available for anyquestions or concerns.

You will receive individualizedwritten instructions when youare discharged from the hospi-tal. These instructions willinclude information about yourdiet, activity, medications, andcaring for yourself.

Coumadin® (Warfarin)Some cardiac surgery patientswill need to take Coumadin®after discharge from the hospi-

tal. Coumadin® is an anticoagu-lant. Anti means against, andcoagulant refers to blood clotting.In most cases, your surgeonanticipated the use ofCoumadin® and will have dis-cussed it with you prior to yoursurgery.

Approximately 1/3 of cardiac surgery patients in the USAdevelop a rapid, irregular heartrhythm after cardiac surgerycalled atrial fibrillation. If theatrial fibrillation does notresolve prior to discharge, youmay need to take Coumadin® athome as determined by yourhealthcare provider. Informationregarding Coumadin® dosing,blood tests, and diet will be pro-vided for patients going homeon Coumadin®.

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Discharge Planning

After Your Hospital StayDuring your recovery, thingsmay seem to be moving slowly.Time and activity will help youregain your strength and energy.

EmotionsAfter heart surgery, you mayexperience changes in youremotions. During your recoveryperiod you may feel and act differently. Your family may

notice some changes. It isimportant to remember thatthese are usually temporary. You may feel angry, depressed,fearful or anxious all at once, oryou might experience one ortwo of these feelings at onetime. You should be feelingmore like yourself in four to sixweeks. If these symptoms are aconcern for you or your family,please call your doctor.

Keeping yourself healthy givesyou the energy to handle stressyou will experience in life. Tomaintain or improve yourhealth, get enough sleep, eat awell-balanced diet, and walkdaily. Know what you value inlife and put your energy into it.Make time to do the things youenjoy. You cannot rid your life ofall stress, but you can choosehow to respond to it.

IncisionsFor the first few weeks you areat risk for infection. Guidelinesabout wound/incision care andsigns of infection will be provid-ed for you at discharge. You willneed a thermometer to monitoryour temperature after you gohome. Most incisions are sealedwith a thin layer of glue/sealant.This will peel off over time.Please note that leg incisionstake longer to heal and ankleswelling is common. Walkingwill help to decrease theswelling, as well as elevating thelegs when at rest. Incisions onthe arm may appear bruised andswollen, but this will resolveitself over time. Make sure youdo not have blood pressuremeasurements or blood takenfrom that arm for three months.If you have any questions aboutyour care after you return home,call your surgeon.

Sternum (Breast Bone)PrecautionsOne of your main concerns aftersurgery is your broken sternum.Like any other broken bone, thiswill take six to eight weeks toheal. If you broke your arm orleg, a cast would be applied tohelp protect your broken bonewhile it is healing. Since no castcan be applied to your chest, weneed to rely on you to protectthis healing bone by not push-ing, pulling or lifting anythingmore than 5 to 10 lbs. Avoidupper body twisting and repeti-tive arm motion (i.e. laundry,vacuuming, washing floors,sweeping, raking, etc.). It willtake pre-planning to follow thisrule. Guidelines and suggestionswill be outlined by your nurse.Feel free to ask questions.

BathingYou may take a shower asinstructed by your nurse, butremember:

• Take your first shower withsomeone nearby, if possible.

• Use warm water rather thanhot; do not let the showerstream directly onto yourincision.

• Use a mild unscented soapand do not scrub your inci-sion.

• Do not use lotions or pow-ders near your incision.

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• Pat steri-strips dry (removethem as they begin to falloff).

• You may shampoo your hair.

WalkingDaily walking is necessary foryour recovery. Space your activ-ity and allow plenty of restthroughout the day. Start witha 10-minute walk, four times aday. As you become stronger,increase your walks to 15 min-utes and then to 20 minutes.Slowly add to your distance andspeed. How far and how fastyou walk is what helps theheart get stronger.

Your goal is one mile each dayby the end of two weeks. It isrecommended to walk on a flatsurface as it takes less energy,but if you must walk up anddown hills, shorten the totaldistance. You will get lessfatigued and enjoy your walkmore if you wear comfortableshoes with non-skid soles andwell-fitting socks.

Remember that walking can bedone almost anywhere butextreme hills and inclementweather makes exercise moredifficult. Exercise indoors if necessary (mall, grocery store,museum, or a local school in theevening). Do not use exerciseequipment until cleared by yourhealthcare provider.

When walking, you shouldavoid:

• Very hot or cold weather.• Humid weather.• Strong winds.• Sun – if outside be sure to wear a shirt and do not use sunscreen near yourincision.

• Sand and deep snow.• Icy conditions.• Stairs – climbing stairs takesmore energy than walking,so take your time and goslowly. Plan your day sothat you are going up anddown the stairs less often.There is no need to changewhere you sleep if yourbedroom is upstairs. Stopand rest if you becomeshort of breath or dizzy.

Cardiac Rehabilitation(Outpatient)Your doctor may suggest youjoin a cardiac rehabilitation(rehab) program. These moni-tored exercise programs arefound at a hospital, clinic, orsites in the community. You will learn what your risk factorsare and how to control them.Additional information regard-ing outpatient cardiac rehab programs will be provided atdischarge.

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Sexual IntercourseBe honest with your partner.You are encouraged to cuddle,focusing on the importance ofcommunication of feelings andconcerns. It takes about thesame amount of energy to haveintercourse as climbing twoflights of stairs. Do not get tootired. Do not lie on your chestfor the first six weeks. Lie onyour back or use the side-to-side position instead during sexual intercourse.

NutritionRemember to follow the specificdiet guidelines provided by yourRegistered Dietitian while in thehospital. Here are some generalrecommendations:

• Eat fruits, vegetables,whole-grain breads/cereals,and fat-free milk and milkproducts (i.e. yogurt).

• Avoid the salt shaker andsalty foods.

• Introduce lean meats, poul-try, fish and beans in yourdiet.

• Limit saturated fats andtrans fats (read food labels).

• Fluids, grains, and fruit skinsall help promote bowel regularity.

• Remember, color/variety/ moderation.

Should you have any additionalquestions about your specificdietary needs contact theRegistered Dietitian (refer to thephone number on your writtennutrition materials).

Pain Pain medication will be dis-cussed at discharge. You canexpect some pain around theincision for several months afteryou get home. Sneezing, cough-ing, sudden changes in bodyposition, and sitting around forlong periods of time may causepain. This happens because painstarts in the muscle and bonerather than in your heart. Donot be surprised if the locationand amount of your painchanges from day to day. Sixweeks after surgery, you willfeel much better and after threemonths, you will be well on theroad to recovery. If you needrefills on your pain medication,please call your doctor’s office.

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SleepingDo not sleep on your stomachuntil cleared by your surgeon. If you are experiencing difficultysleeping:

• Take your pain medicationat bedtime.

• Continue gradual exercise (do not exercise withinthree hours of bedtime).

• Minimize naps during theday.

• Avoid caffeine.• Utilize relaxation techniques.

DrivingNo driving is allowed until youhave physician approval. Ridingin the car is allowed. A seat beltis always recommended foryour safety. It may be morecomfortable to place a smalltowel between the shoulderbelt and your chest incision. Forlonger trips, get out of the carand walk around for a few min-utes every hour. This improvescirculation and helps preventdangerous blood clots in yourlegs. Anticipate being able todrive in approximately fourweeks.

Smoking and AlcoholUseIf you smoke or use tobaccoproducts, you need to stop foryour health. If you think you will

have difficulty eliminatingtobacco from your daily routine,please inquire about smokingcessation resources. If you havetried to quit smoking before butwere unsuccessful, do notdespair. Most people have triedto quit several times before theyare successful. So try again.

Alcohol consumption should be discussed with your physician.

Health MaintenancePlease discuss with your health-care provider before receivingany flu or pneumococcal vac-cines.

Returning to WorkYour return to work depends onyour recovery, type of surgery,and job characteristics. Be sureto ask your physician duringyour follow-up visit. You needto contact your surgeon’s officefor any paperwork provided toyou by your employer for yourmedical leave.

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Medical InformationPatients’ Medical Information is ConfidentialUnder the Health Insurance Portability and Accountability Act(HIPAA) all hospitals must inform patients how their medical infor-mation is used, and give patients the right to ask to alter or with-hold certain information. Patients must also be told how to inquireor complain about privacy issues.

These elements are explained in detail in the Notice of PrivacyPractices provided to each patient. To see a copy, ask your nurse orother staff member. Inquiries or complaints should go to:

Patient RepresentativeSt. Peter’s Health Partners315 South Manning BoulevardAlbany, NY 12208(518) 525-1192

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315 South Manning BoulevardAlbany, NY 122081-800-HEART-76

www.sphp.com

Revised 7/2013