Heart Surgery in the Elderly

AMERICA IS GROWING OLDER.

/^According to data compiled in the -L ^.1980 census, 43 percent of all Americans alive then were expected to live to be eighty-eighty years old. In 1990, 7.4 million Americans — 3 percent of the population — were eighty years of age or older. In 2010, the corresponding estimate is that 4.3 percent, or 12 million, Americans will be eighty years old.

Heart disease is relatively more common among the elderly. By the age of seventy years, clinically diagnosed coronary artery disease is present in approximately 15 percent of men and 9 percent of women. Likewise, hypertension affects as much as 50 percent of the population by age seventy. Among octogenarians, approximately 40 percent of the population has cardiovascular disease; 18 percent to 20 percent of those people have coronary artery disease.

Reports in the medical literature vary as to the cut-off age for being classified as elderly. One report from Israel titled "Heart Valve Replacement in Elderly Patients" published in the medical journal Geriatrics as recently as 1970 included all patients more than forty-five years of age! As heart surgery has advanced, however, age limits for performing heart surgery have been rolled back. In 1978, I coauthored a medical article published in the heart journal Circulation titled "Surgery Using Cardiopulmonary Bypass in the Elderly." At that time, our experience was with eighty-nine patients seventy years of age or older. To my knowledge, this was the first article to specifically deal with heart surgery in patients who were seventy years of age or older. Now it is likely that at least a third of the patients who undergo coronary artery bypass graft surgery are age sixty-five to seventy years or older.

As the age limit continued to advance, I coauthored an article published in The New England Journal of Medicine in 1988 entitled "Open Heart Surgery in the Octogenarian." In that article we again reviewed our results at the Hospital of the University of Pennsylvania, but this time examining one hundred consecutive patients who were eighty years of age or older. I believe this was one of the first two or three medical articles to specifically address heart surgery in those older patients. At that time the oldest patient operated on in our group was ninety-seven years old. When I did the follow-up evaluation, our ninety-seven-year-old lady was age 102. She was in good spirits and doing well.

I subsequently operated on another ninety-seven-year-old woman who had already had her heart valve dilated with a balloon catheter and had been on a mechanical ventilator two or three times because of episodes of severe shortness of breath. I replaced one heart valve, performed a coronary bypass, and installed a pacemaker. She became somewhat of a celebrity in the local news at hospital discharge.

Common sense dictates discretion when recommending major surgery in octogenarians. The aging process reduces the reserves of all organs. For example, these patients are more prone to develop strokes, kidney failure, and pneumonia after major operations. Some vital organs might lack sufficient reserve to absorb the stresses of major surgery. Moreover, these persons, having most of their lives behind them, may lack both the will and the incentive to endure the physical and mental exhaustion associated with major surgery. Generally, octogenarians do not seek open heart surgery; it is forced upon them by the onset or progression of cardiac disease. Operations become the best of the unattractive options.

The chances of complications after major surgery increase with age, particularly beyond age seventy-five years. There are, however, a considerable number of elderly patients with good minds who are limited only by their heart disease. I personally have observed a number of these elderly patients who were almost bedridden and after a relatively simple, straightforward heart operation were able to return to an active and fulfilling life, including in some cases mowing their own lawns, shopping, and so forth.

It is my opinion, however, that elderly patients should not be pushed into heart surgery, by either their family or their physician. As already pointed out, some patients age eighty years or more feel they have lived their life and will not choose to undergo a major heart operation under any circumstances. I believe their wishes should be respected. When some elderly patients are pushed into these operations by family or physicians, they sometimes lack the will to fight and to help the physicians and nurses get them through the surgery and postoperative recovery. Lacking the will and not doing what is necessary to recover make it more difficult and frustrating for the patient, the physicians, the nurses, and especially the family.

So what is the age limit at which one would not recommend performing a heart operation? The answer to that question varies. I believe most surgeons feel that patients should have a good mind and not be bedridden or incapacitated from diseases other than their heart problem. The likelihood that heart surgery can be performed to get the patients back on their feet is worth considering, regardless of age. The other factor that needs to be considered is that even though two patients may have been born on January 1, 1915, one person, in health and general attitude, could seem more like sixty-five years of age whereas the other may be more like one hundred years of age. The chronological and physiological ages of elderly patients can vary greatly. This, too, has to be considered by physicians when they consider whether to recommend heart surgery.

In some countries where the government controls health care, there have been official or unofficial age limits mandating who can and who cannot have heart surgery. This of course involves sensitive ethical and economic issues. Some countries can afford to offer expensive operations to elderly patients at high risk. Is there a level of risk that precludes operation? And if so, who will decide what it is? Is it ethical to refuse to perform high-risk operations when the alternatives have higher risks? Are surgeons justified in exercising preoperative selection criteria without including the patient in the decision-making process? Can patients demand operations? These and other questions deserve open discussion both within and outside the medical community.

On the basis of the heart surgery results published in the medical literature, surgical intervention can be a reasonable therapeutic option in elderly patients with advanced cardiac disease in whom alternative approaches have failed or are not feasible. Nonetheless, the risk of death and other complications is somewhat higher in these patients.

Although there is no particular medical reason to set an age limit for patients undergoing heart transplantation, there is in fact an age limit set by most heart transplant centers of about age sixty-five years or less. This age limit is arbitrary and not related to patient characteristics but rather to the scarcity of heart donors. The feeling is that younger patients who have more of their life ahead of them should receive the heart transplant.

Coronary Artery Disease and Viagra

As male patients get older, the chance of developing coronary disease increases. The incidence of erectile dysfunction or impotence also increases with aging. Recently, a new medication called Viagra has become available to treat erectile dysfunction. Although effective, it should not be used with certain heart medications. Those of us who specialize in heart disease receive many questions regarding Viagra and sometimes questions on other treatment options for impotence from patients who shouldn't take Viagra. I have therefore asked my colleague, Dr. Chipiiya B. Dhabuwala, who specializes in impotence and is a professor of urology at Wayne State University, to discuss Viagra as it relates to heart medication and to also discuss other treatment options available for erectile dysfunction.

Erectile Dysfunction, Viagra, and Heart Disease by C.B. Dhabuwala, MD Professor of Urology Wayne State University, Detroit, Michigan

Impotence, or erectile dysfunction, is the inability to achieve or maintain an erection for sexual intercourse. The incidence of erectile dysfunction increases with age. It is estimated that 20 to 30 million men suffer from erectile dysfunction in the United States.

Mechanism of Erection

Erection is a complex process that begins with impulses of sexual arousal at the brain centers of sexual excitement. The impulses travel along nerves from the brain to the penis, where they cause secretion of a substance called nitric oxide. Nitric oxide sends signals that cause dilatation of blood vessels and increase blood flow to the penis. It is estimated that during the early stages of erection, the blood flow in the penis increases 2,000 percent to 4,000 percent. This increase in blood flow, along with the relaxation of the smooth muscles of the penis, causes the penis to increase in length and diameter (engorgement). The veins that normally drain the blood away from the penis are closed during erection. Any disturbance in the whole chain of events can contribute to erectile dysfunction.

Causes of Erectile Dysfunction

The incidence of erectile dysfunction increases with age. Hardening of the arteries and blockage within the arteries is the most common cause of erection problems. Very often, blockage of the arteries of the penis occurs with blockage of the coro

C.B. Dhabuwala, M.D.

Erectile Dysfunction:

Also referred to as impotence. The inability to achieve or maintain an erection for sexual intercourse.

Leriche's Syndrome:

Involves blockages of the lower aorta as well as the arteries in the pelvis coming off the aorta, including the iliac arteries. It is characterized by claudication, which is pain, aching, and tiredness of the legs and buttocks. It is associated with erectile dysfunction.

Guanosine Monophosphate (Cyclic GMP):

A chemical neuromediator that helps to transmit messages through the nervous system.

nary arteries of the heart. In many individuals, the erection problem is followed a few years later by coronary artery disease and even heart attack. Blockage of the terminal aorta (Leriche's syndrome), internal iliac arteries, or internal pudendal arteries by the atherosclerotic process can also lead to erectile dysfunction.

There are many other reasons for erectile dysfunction. People with diabetes are at increased risk of developing erection problems. Several studies suggest that almost half the people suffering from diabetes develop erectile dysfunction. High blood pressure can lead to progressive thickening of the arteries of the penis and is associated with erection problems. Smoking cigarettes, excessive use of alcohol, and abuse of substances such as marijuana and cocaine are also associated with erection problems. Automobile and motorcycle accidents causing fracture of the pelvis can very often interrupt the blood supply or the nerve supply of the penis, leading to erection problems.

Other causes of erectile dysfunction include surgeries for cancer of the rectum or prostate cancer, which can damage the nerves that register sexual excitement. Certain medications used for treating high blood pressure, diseases of the nervous system such as multiple sclerosis and spinal cord injury, and even radiation therapy for prostate cancer can also lead to erectile dysfunction.

In younger individuals without any risk factors such as diabetes, high blood pressure, and cigarette smoking, the cause of erectile dysfunction is often psychological.

About 5 percent to 10 percent of men with erection problems have low levels of male hormones. Many men can be effectively treated with male hormones.

Medical Treatment of Erectile Dysfunction

Treatment of erectile dysfunction very often depends upon the cause of erectile dysfunction. A person with hormone deficiency will respond best to hormone replacement. Erectile dysfunction due to the use of medications may respond to a change in the medications. Very often, replacing one medication with another may resolve erectile problems.

Viagra, a Pill that Helps Men with Erectile Dysfunction

Viagra, which is also called sildenafil, has provided a breakthrough in the oral treatment of erectile dysfunction. An erection normally occurs with the relaxation of the smooth muscles of the cavernous sinuses and an increase in blood flow to the penis. Nitric oxide produced in response to erotic stimuli acts through a secondary system involving cyclic GMP. This cyclic guanosine monophosphate, or GMP, relaxes the smooth muscles, which increases blood flow and penile erection. The human body naturally inactivates cyclic GMP. Viagra prevents this local in-activation of cyclic GMP, thereby enhancing the erection.

In clinical trials, Viagra-related improvement in erections occurred in 70 percent to 90 percent of patients. The pill is taken one hour before sexual activity. It is effective in enhancing penile erection in a wide variety of patients with erectile dysfunction.

Viagra and Heart Patients

The side effects reported with Viagra are usually mild to moderate in nature. These include a flushing sensation, indigestion, nasal congestion, some alteration in vision, diarrhea, and headache. Viagra should not be used by men with coronary artery disease who are taking medicine containing nitrates. Nitrates are found in many prescription medicines used to treat chest pain, or angina, due to coronary artery disease. These medicines include nitroglycerin sprays, ointments, pastes, or tablets that are swallowed, chewed, or dissolved in the mouth. Nitrodur, Imdur, and

Ismo are a few popular ones. If you are not sure whether any of your medications contain nitrates, or if you do not understand what nitrates are, consult your doctor or pharmacist.

Taking Viagra and nitrates can be dangerous. It can lead to a sudden decrease in blood pressure, dizziness, or even death.

Similarly, patients taking medicines to treat high blood pressure and patients who have had heart attacks should check with their doctors before using Viagra.

Some medicines like erythromycin and cimetidine can affect the metabolism of Viagra. Liver problems, kidney problems, or even old age can also affect the way Viagra is handled by the human body. One should never experiment with Viagra by borrowing a pill from a friend. It must always be used under medical supervision after an adequate history assessment and physical examination.

Penile Injection Therapy

Besides Viagra, there are numerous other options for treating erectile dysfunction that are proven and have been used for some time. Medications such as pa-paverine and prostaglandin, for example, dilate blood vessels, increasing the blood flow and dilating the smooth muscles of the penis. These medications are best administered by a direct injection into the side of the penis using a very fine needle. After the injection, patients experience increase in the blood flow and an erection within fifteen to thirty minutes.

Vacuum Devices

Vacuum devices are another treatment option. They consist of three common components: a plastic cylinder, a vacuum pump, and a constriction ring. The quality of erection produced by the vacuum device, however, is inferior to that of a normal erection. Numbness or a cold sensation of the penis occurs in nearly 75 percent of patients. This can be quite un comfortable. The tight rubber band used to maintain erection also leads to altered feelings of orgasm and may cause a blood clot to form under the skin. Similarly, tiny purplish spots may appear under the skin from microscopic hemorrhages.

Surgical Treatment

There are three different types of surgical treatments available:

1. implantation of a penile prosthesis,

2. vein ligation for venous incompetence, and

3. vascular surgery for arterial blood flow abnormality.

Penile Prosthetic Implants

Semirigid Prosthesis

The surgical implantation of this semirigid device is simple. With this type of device, the penis is rigid all the time. However, during sexual activity it is possible to adjust the angle so the penis is at a right angle to the body. After sexual activity, the penis can be bent downwards.

Inflatable Penile Prosthesis

Unlike the semirigid prosthesis, with which the penis is rigid all the time, the inflatable penile prosthesis induces an erection at will. The three-piece inflatable penile prosthesis is one type of these devices. It produces an excellent and cosmetically attractive penile erection.

The inflatable cylinders are placed into the corpora cavernosa, and the pump is placed in the scrotum. The reservoir of fluid is implanted inside the pelvis. Very often, the entire operation can be performed through a one-inch incision on the scrotum. The hospital stay is usually less than twenty-four hours.

Postoperative Complications

The incidence of mechanical malfunction of the prosthesis has decreased

In many cases, erectile dysfunction, whether caused by heart disease or not, can be treated successfully and allow patients and their partners to return to a normal sex life.

greatly during the last several years because of better manufacturing methods and better materials. The vast majority of patients can expect trouble-free functioning of the implant for eight to ten years. If the implant develops any malfunction, such as fluid leakage, the whole implant or the leaking part can be replaced.

Another possible complication of penile implant surgery is infection. This occurs in 3 percent to 5 percent of patients. The prosthesis is usually removed to allow the infection to be controlled and is replaced at some other time. Other complications such as erosion and persistent pain are rare. Some patients complain of reduced penile length.

Patient and Partner Satisfaction

There is very high patient and partner satisfaction with the quality of erection and sex life after penile prosthesis placement. Penile prosthesis placement, when performed correctly, does not alter sensation during sexual intercourse, nor does it interfere with ejaculation or fertility.

Surgery for Venous Incompetence

Venous ligation surgery, or tying off veins that drain blood from the penis so the blood drains more slowly, was designed to improve penile erection. The outcome of this surgical intervention has been very poor.

Penis Arterial Revascularization

Surgical Arterial Revascularization

Obstruction of penile blood flow can occur as a result of atherosclerosis in the terminal aorta, such as in Leriche's syndrome, which can produce erectile dysfunction. Similarly, obstruction of the internal iliac or internal pudendal arteries in the pelvis also leads to erectile dysfunction. Vascular disease occurring in the arteries of the penis as a result of diabetes or high blood pressure can also lead to erec tile dysfunction. Arterial revascularization surgery in the aorta and iliac arteries may eliminate the original obstruction and lead to improved erectile function.

An alternative form of revascular-ization such as bypass surgery in the penis has been tried. Unfortunately, the long-term results of this type of bypass surgery are disappointing. Very careful patient selection combined with good surgical technique can sometimes lead to successful results.

Most patients are discharged from the hospital between the fourth and the eighth day after their operation.

Pacemaker Surgery Recovery

CHAPTER FIFTEEN

Recovery After Heart Surgery and a Second Bypass Operation... Will You Need It? When?

ECOVERY AFTER HEART SURGERY begins when the patient leaves the _!_ V. operating room and arrives in the intensive care unit. By that time, the anesthesia is wearing off, and the patient begins to awaken. Patients are still connected to drainage bottles and monitoring devices, and a temporary pacemaker may also be used.

People usually start to wake up within an hour after their heart surgery and are soon able to follow simple commands such as "Move your foot, move your arm." When patients are alert and breathing on their own, and if the blood oxygenation level is appropriate, the endotracheal tube in the patient's throat and windpipe (trachea) is removed. This usually occurs anywhere from a few hours after heart surgery to the next morning. In some cases, with some cigarette smokers for example, the endotracheal tube may need to stay in longer.

Chest drainage tubes can usually be removed by the next day. Sometimes they're left in until the second morning after heart surgery.

Eating is also introduced gradually. If the patient is awake and alert, and his or her intestines are functioning, the standard fare is ice chips and water. From this point, progress toward a liquid diet is usually rapid.

By the morning after surgery, most patients are able to sit in a chair next to their bed. Depending on the progress and also, to some extent, the preferences of the heart surgery team, most patients are transferred from the intensive care unit, or ICU, late on the morning after the heart surgery.

Transfer from the ICU

After transfer from the ICU to the hospital ward, also known as the "step-down unit," the heart rhythm is still monitored at the nursing station. By the second postoperative day, most people are able to walk to the bathroom and down the hospital corridors with some assistance. By the third day after heart surgery, some people are ready for discharge. Others may have to stay for a few more days, and some will have to stay longer even, depending on the circumstances.

Discharge Home

Today, most heart surgery patients are discharged between the fourth and the eighth postoperative day. Before discharge, they are given Instructions regarding the various medications that are usually prescribed after heart surgery. For example, patients with considerable heart pumping dysfunction will fare better with ACE-inhibitor drugs. Patients with bypass grafts will likely need aspirin. Patients with abnormal heart rhythms may require medication to regulate their heartbeat. A dietician also instructs patients on appropriate diets. Many of the instructions the patients get before discharge deal with various activities they can and cannot do at home, and in a way this is more or less an informal cardiac rehabilitation program.

The most common form of incision during heart surgery is an incision down the middle of the breastbone, which is closed after the surgery with stainless steel wires. Although the wires stay in indefinitely, there is a period of healing after heart surgery that demands special attention. Recent heart surgery patients are instructed not to lift anything heavier than twenty pounds for four to six weeks. In some ways, this healing process is similar to that for a broken arm or leg bone, which takes about three months to heal.

There is usually little pain associated with this incision, called a midline sternotomy incision. Nerves come from the spinal cord out of the back bone and run around the ribs to the front, so there is not a concentration of nerves in the area. However, it is worth noting that everybody's pain threshold is different. On some days, the incision pain can be more noticeable than on others. In most cases, it is gone after three to four weeks, although in some patients, it may be present for two months or longer.

Typically, we recommend that patients avoid using excessive salt in the first few weeks after the surgery. Don't eat potato chips, pickles, and other salty foods, and don't add salt to food. After major operations, and particularly heart operations, the body has a tendency to retain salt and water. Because salt causes people to drink more liquids, the result can be edema, or swelling of the legs. It can also lead to fluid overload, a condition in which veins become engorged and the extra fluid backs up into the lungs. The patient then becomes short of breath.

Salt restriction is usually no longer necessary after about a month. It is, however, still necessary in some patients who are on certain medications and those who have high blood pressure or some degree of chronic heart failure.

Surgical Wounds

When the patient leaves the hospital, the wound's skin edges are joined together, and the wound is in the process of healing. Wounds should not be scrubbed with a washcloth but gently cleaned with soap and water. In many cases, stainless steel staples are used to close the skin. If a patient goes home between the third and even the fifth postoperative day, the staples are usually left in, and arrangements are made for them to be removed later.

Recovery at Home

After finally arriving home, most patients discover they are weaker than they thought they would be. This is typical. Hospitals are very sheltered environments, and, although confidence is gained walking up and down the hospital hallways, there are obstacles at home that weren't considered, like stairs and everyday movements.

Confidence usually returns fairly quickly as energy levels rise, but patients should strive to strike a balance between exercise and rest. Exercise itself is very good for a recovering heart patient if done very carefully at first and in moderation. It will help control blood pressure and blood sugar, burn excess calories, and lower body fat. Before any heavy exercise is possible, light stretch-

ing is a good idea. There are several effective stretches that will help the incision heal properly.

y Arm raises — forward: In a sitting position, straighten your arms, and raise them over your head.

y Pectoral stretches: In a sitting position, begin with your hands on top of your head, and push your elbows back until they are in line with your hands. Relax, bringing elbows slightly forward.

y Arm raises — side: In a sitting position with your arms at your sides, straighten your arms and raise them over your head. Keep your palms up.

y Sideways body bends: Place your feet about P/2 feet apart for balance while sitting in a chair. Bending slowly sideways at your waist, reach your right hand upward towards the ceiling and lower your left hand towards the floor on the left side of your chair. Hold for three seconds. Return slowly to sitting position.

After these light exercises have been performed, check your pulse.

Within a week or so, many patients have progressed to taking walks outside. Within a month, they can often walk a mile or two without difficulty. Driving, however, is not recommended for the first several weeks after heart surgery. I must admit, however, that one of my patients owned his own eighteen-wheeler tractor-trailer rig, and I found out when he came in for his routine postoperative visit five weeks after the heart surgery that he had gone back to driving his rig across the country a week after he returned home from his heart surgery. Clearly, we don't recommend this.

Learn How to Take Your Pulse

AFTER HEART SURGERY, FATIGUE /% and stress during exercise should .Zm. always signal that a rest is needed. Before that, however, patients should check their pulse during exercise to make sure the heartbeat is staying within a reasonable limit.

It is important to remember that pulse rates vary from individual to individual. There is no "magic number" but rather a range of about sixty to one hundred beats per minute when the heart is at rest. The pulse rate is increased by exercise as well as emotional states like anger, fear, excitement, and anxiety.

Your pulse can be taken anywhere on the body where an artery near the surface can be compressed against a firm surface. Most commonly, doctors use the inner forearm (wrist), where the radial artery can be compressed against a bone in the forearm. There are some practical approaches to taking a pulse.

y Sit in a comfortable position.

y Place the index, second, and third fingers of one hand on the wrist of the other hand.

y Exert firm pressure.

y If you cannot feel a pulse, lighten the pressure. If that doesn't work, move up along the wrist until a pulse is located.

y Count the beats for ten seconds, then multiply by six. This is the "resting pulse" per minute.

y To determine a good "speed limit" for exercise, add three to the resting pulse. For example, if the resting pulse is fifteen (or 90 beats a minute), a reasonable exercise target would be 18 beats in a ten-second period (or 108 beats per minute).

The pulse should be checked in the middle and at the end of exercise. If it rises above a reasonable limit, take a break or slow down. This can be done with abdominal breathing exercises. During an abdominal breathing exercise, the hands are placed over the abdomen and a deep breath is drawn in through the nose, allowing the abdomen to rise under the fingers. Breathe out through the mouth while pushing in on the abdomen. Repeat this eight to ten times. This will lower your respiratory rate.

Usually, after five or six weeks, patients can begin driving again, but even this should be avoided if the patient is suffering from dizzy spells, blackouts, or light-headedness. When driving, it is a good idea to put a pillow between the seat belt and the incision to protect it.

Sexual activity can usually be resumed three or four weeks after heart surgery, depending on how the patient feels and how recovery is progressing.

Decreased appetite is common for the first several weeks after heart surgery, but appetite will gradually improve. Insomnia is experienced by some patients at times. Moodiness, irritability, and mild depression are not uncommon on some days of the recovery phase. Usually, over several weeks, these symptoms disappear, and patients will have the type of personality they had before heart surgery. A strong emotional support system is very helpful in getting through this period.

Even after several weeks of healing, excess stress should not be put on the breastbone. The arms are connected to the collarbones, which are anchored on the sternum. Any exercise that requires arm strength, including push-ups and lifting objects weighing more than twenty pounds, puts pressure on the breastbone and could cause it to become loose. For this reason, it is recommended that patients push with their body weight instead of pulling whenever possible.

Similarly, sports such as bowling, tennis, and golf should be avoided for the first three months. After that time, any of these activities can usually be resumed, although you should always check with your cardiologist before resuming these activities.

After their surgeries, patients are transferred to the intensive care unit, where they are constantly monitored.

Exercise Stress Test:

A test during which a patient is connected to an electrocardiogram, or possibly other types of monitoring machines, and asked to walk on a treadmill or possibly pedal a stationary bicycle while being monitored.

Anticoagulant:

A drug that prevents or slows the blood clotting process. Also referred to as a blood thinner.

Recovery from Coronary Bypass Surgery

About three to eight weeks after heart surgery, some cardiologists recommend an exercise stress test for all of their patients. The stress test is performed as a baseline evaluation. The test may also be done to assess the patient's status in case of recurrent angina. This is not true for all doctors, however. Others perform the test only for those patients who may be doing activities that require more blood going to the heart. A good example is the patient who plans to run in a marathon or plans on playing tennis or perhaps patients who have the lives of many people in their hands, such as commercial pilots.

Repeated tests are also performed in patients with recurring or ongoing angina. If the exercise stress test result is normal, one can usually resume virtually any activity provided it is approved by a cardiologist. If it's abnormal, the cardiologist may recommend some limitation of activity or change in medication.

Recovery from Heart Valve Surgery

Recovery from heart valve surgery is similar in many ways to recovery from coronary artery bypass surgery. The incision is similar, and the breastbone needs time to completely heal. Again, excess salt should also be avoided.

Some patients will be taking coumadin (warfarin), an anticoagulant or blood thinner. As long as coumadin is being taken, patients should avoid all vigorous contact sports such as rugby, soccer, and football. Dangerous sports like skydiving, in which one might receive blows to the head or begin bleeding, should also be avoided.

If the blood is not anticoagulated enough, blood clots can form on the heart valve or break off the valve and go to the brain, causing a stroke, or the valve itself could even clot off. If the anticoagulation level is too great, bleeding from the intestines or kidneys or even a stroke caused by bleeding into the brain could develop.

With heart valve surgery, the ventricle itself may be very thickened or enlarged as a result of the long-standing heart valve disease that was present before the valve surgery. In this case, the muscle tends to outgrow its blood supply, and although the valve has been fixed or replaced, the heart itself will likely take several months to recover. Patients should therefore avoid vigorous exercise such as running and playing tennis until these activities are approved by a cardiologist.

Stress tests are sometimes used after valve replacement that did not include coronary artery bypass grafting to assess postoperative exercise ability and heart rhythm during exercise. An echocardiogram is often recommended to see how the ventricles are recovering after the valve has been repaired or replaced.

Patients who have had heart valve surgery will need to undertake a regimen of antibiotics before and after dental surgery or additional surgical procedures.

Cardiac Rehabilitation

Cardiac rehabilitation actually begins when one leaves the operating room. By the time patients arrive home, they are starting the second or third stage of cardiac rehabilitation, depending on whose definition of cardiac rehabilitation is used.

It is important to only gradually increase physical activities like walking. This promotes recovery. People who live in cold areas often do their walking in large shopping malls because extreme temperatures (less than 30°F and more than 90°F) should be avoided for the first month or so. During that period, patients should avoid contact with people with colds and other types of illnesses that, if contracted, will cause coughing.

Formal Cardiac Rehabilitation Programs after Heart Surgery or Heart Attacks

Some cardiologists feel strongly that all patients should be enrolled in a formal rehabilitation program. These programs typically last six to twelve weeks after heart surgery or heart attacks. Other cardiologists feel that the need to enter a formal cardiac rehabilitation program should be more individualized, and not all patients, particularly those that are already quite active, need to be enrolled.

These programs are typically located at a hospital, community center, or rehabilitation facility. They are designed to help build the patients' confidence. Patients are closely monitored for abnormal blood pressure and irregularities of the heartbeat by trained personnel in a group or class setting. They are taught to monitor their pulse rate and to look for signs of chest pain (angina type), particularly if they are coronary patients. Their activity level is slowly increased. During rehabilitation, they are educated about diet and other types of behavior modification that lead to a healthier lifestyle and a healthier heart.

The Second Coronary Bypass Operation: Will I Need It? When?

I frequently hear comments from patients or their family members such as, "My neighbor told me these bypass opera

Moderate exercise after heart surgery is a very valuable tool in rehabilitation. The level of exercise, however, should be determined at first by a cardiologist.

tions have to be redone every three to four years. Is that true?" Patients are naturally very apprehensive about surgery to begin with, and when it comes to the possibility of having to repeat a procedure, they want to know the bottom line. Will they need a second bypass operation? If so, how long before it is needed?

The answer that heart surgeons and cardiologists would always like to give is, "Never!" The realistic answer, however, is more complicated. One can say, "Hopefully never," but the fact is that every patient is unique, and every situation depends upon a number of variables.

When arteries are used as the bypass grafts, they tend to stay open longer than veins. Sometimes, however, the patient's vessels considered for use as bypass grafts may not be in the best shape. This can influence how long the bypass stays open.

The arteries normally considered as candidates for grafts may be too small or diseased, or the amount of blood flow through them may make them unac-cep table. Likewise, the diameter of the veins may be too big or too small, or the vein itself may have other abnormalities. The surgeon will not use arteries unless he or she feels they are acceptable, and he will try to use the best quality segments of vein available.

How long bypass grafts stay open also depends on the condition of the coronary arteries themselves. Ideally, the coronary artery that was originally bypassed was a relatively large artery, appearing to be normal except for one localized area of blockage. Unfortunately, sometimes we find coronary arteries that have multiple blockages, or the entire artery has significant atherosclerosis build-up. In addition, some arteries are only a millimeter or less in diameter (there are twenty-five millimeters in an inch). Sometimes the arteries are so brittle with calcium that it is difficult to find a spot to place a bypass graft, and some times the needle used to stitch the bypass to the coronary won't go through the coronary's calcified wall. Also, bypass grafts tend not to stay open as long in insulin-dependent diabetic patients and those with cholesterol disorders.

Bypass Grafts Closing

If you have three, four, or more bypasses and one or two of them close, that does not necessarily mean you need a second bypass operation. In fact, if they all close, you still may not need a second operation. You might need a balloon angioplasty (PTCA) and maybe a stent. After bypass surgery, your cardiologist may have more treatment options. For example, if you need a balloon angioplasty, your doctor may be able to dilate either the coronary artery or the bypass graft. It may turn out that if the bypass fails, translaser myocardial revascularization (TMLR) may be a better option than a second bypass operation. This procedure can be done either with an operation or with catheters passed from an artery in the groin or arm into the heart.

The Second Operation

In addition to all of these factors, doctors' criteria for recommending a second bypass operation can be somewhat different than they were for the first operation because the risk of a second bypass operation is usually higher than that of the first. The patient is older. The atherosclerotic coronary disease is usually more advanced. Some of the arteries and veins used to do the first bypass are no longer available for the second operation.

Adhesions will be present that formed after the first operation. This means that the surfaces of all the tissues will be stuck to each other so that it is more difficult and time consuming for the surgeon to expose the heart and coronaries or sometimes just to find the coronaries. Also, because of the adhesions, bypass grafts that are still functioning may be damaged while exposing the heart, which also adds to the complexity of the operation. The recovery after the second bypass operation, however, tends to be similar to the first.

So how risky is a second coronary bypass operation, and what are the chances of needing a second operation? The risk of not surviving a second operation varies depending on various factors, but in most cases is less than 10 percent.

What are the chances you will need a second coronary artery bypass operation? The field of cardiology, particularly interventional cardiology in which balloons and stents are used to treat coronary blockages, is advancing rapidly, as well as the specialty of cardiac surgery. My guess is that a person currently undergoing coronary bypass surgery has about a 10 percent chance of having a second coronary bypass operation. (A third bypass operation is uncommon, and having more than that is rare.)

Although unlikely, some patients need a second bypass operation within a year of the first. But for the majority of patients who will need a second bypass operation, it will most likely occur more than five years after their first and sometimes more than twenty years after it.

You Can Help

Lifestyle after coronary surgery plays an important role in keeping bypass grafts open longer. Keeping your cholesterol in a safe range is important. If you are a smoker, quit. Watch your weight and exercise. Also, taking an aspirin a day makes platelets in your blood less sticky and probably helps to keep bypass grafts open longer.

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