Coronary Surgery Pathway

When you discover you need to have Coronary Artery Bypass Surgery (CABG), you will have many questions regarding your journey through the operation, recovery and rehabilitation.  We hope that the following information will answer many of your questions.

The information provided is for a typical patient journey but there may be variations at the different centres across the country. Further explanations including videos are available in the Having Heart Surgery section.

Please click on the links below to find out about your journey through CABG surgery, recovery and rehabilitation.

Your operation

What are the coronary arteries?

The heart is a muscular pump that sits in the centre of the chest. Although the heart pumps blood, which is rich in oxygen, around the body, the heart muscle itself needs its own blood supply. It gets this from a network of blood vessels called coronary arteries. The two main coronary arteries are called the right and left arteries. The left coronary artery divides into two, one part goes to the back of the heart (circumflex artery), the other part goes to the front (left anterior descending (LAD) giving the impression of three arteries. Each artery is about 3-4mm wide and spreads out, like the branches of a tree, into smaller arteries across the heart so that all parts of the heart muscle receive blood. These arteries can become narrowed or blocked. If this happens the heart muscle doesn’t receive enough blood and oxygen. The pain or discomfort that follows is called angina. This pain can be felt as discomfort, tightness, or breathlessness and may be felt in the chest, in one or both arms, in the shoulders, in the neck or in the jaw. 2 Angina can happen at any time. Strenuous activity like exercise, excitement, anger and cold weather can bring it on. Resting may relieve your angina symptoms. You may also need to use a GTN tablet or spray. These usually act quickly to relieve an angina attack. The usual dose is one or two sprays or one tablet under your tongue. What is a coronary artery bypass graft? A coronary artery bypass graft is an operation that is performed to improve the blood flow to your heart. A blockage or a narrowing in one or more coronary arteries is bypassed. A vein or part of a vein is usually taken from your leg, and in many cases, an artery from your chest wall, called the internal mammary (thoracic) artery (IMA), is used. Occasionally an artery from the arm, called the radial artery, can be used. The vein or artery used creates a new route for blood to pass through and is called a bypass graft. The original coronary arteries are not removed. There would be no benefit in doing this as it could cause damage to the heart muscle. 3 The benefit of the bypass operation is that it increases the blood supply to the heart muscle. After the operation most people will be relieved of angina. A few people may still experience occasional angina, but this will usually be less severe than they experienced before. If this happens please let your doctor know. This operation is not a cure, so it’s important that you reduce the risk of further progression of disease (narrowing) of the coronary arteries by:

• not smoking

• eating a healthy diet

• watching your weight

• exercising daily

• keeping diabetes under control if you have this condition

• taking your medication as prescribed

• asking your GP/practice nurse to check your blood pressure and your cholesterol levels regularly

• attending a cardiac rehabilitation course.

Carotid endarterectomy

Very occasionally you many need to have a carotid endarterectomy before your bypass operation. This operation is done if your carotid artery/arteries are narrowed or blocked by fatty deposits (called plaques). These arteries take blood to the head/brain. 4 The operation helps to reduce the risk of a stroke/cerebral vascular accident (C.V.A.) in people who are at greater risk during a bypass operation. It is often performed under a local anaesthetic. To find out if you have a narrowing or blockage a doctor or preadmission nurse will examine your neck. If necessary a Doppler Scan will be arranged. This is done by using a simple ultrasound machine to take special images of the arteries in the neck. To do this operation the surgeon makes a cut in your neck, opens the blocked artery, removes the fatty deposits, and stitches the artery closed again.

Preparing for your operation

When you attend the outpatients department you will see a surgeon who will put your name on a waiting list. In some cases you may be given a date for your operation at this visit.

Pre-admission clinic

Approximately one to four weeks before your operation, your Advanced Nurse Practitioner (ANP) /clinic coordinator may telephone you to arrange an appointment to attend a nurse led pre-admission clinic. Advanced Nurse Practitioners (ANP) are specialist nurses in heart and lung surgery. They are part of the team who will care for you from your first appointment with the surgeon until you are discharged home. Most patients will know the name of their ANP before their admission. The purpose of this appointment is to: • identify any medical concerns which need to be addressed before your operation. If a problem is found, appropriate investigations and/or treatment will be arranged • ensure that all the necessary preparations for your operation have been completed • answer any questions you may have • have all or some of the following tests performed:

Chest x-ray To look at the size, shape and condition of your heart and lungs.

Electrocardiogram (E.C.G.) To show the electrical activity of your heart.

Echocardiogram (Echo) To look at an ultrasound picture of your heart.

Blood tests To check your blood count and kidney function. To identify your blood group and to prepare a blood transfusion in case it is needed during, or after, your operation.

Swabs for MRSA Swabs will be taken from your nose, throat and groin area to check for MRSA.

Don’t worry if you haven’t been invited to attend a pre-admission clinic as staff will visit you on the ward and give you any information you need. All necessary investigations/tests will be carried out when you come into hospital. If you have any questions about your treatment or care, please contact your ANP at The London Chest Hospital or at St Bartholomew’s Hospital. Please find contact details at the back of this booklet. Patient activity managers, in conjunction with your surgeon, ANP and secretary, are responsible for planning surgical admissions. You will find their contact details at the back of this booklet.

Dental care

If you have loose or decayed teeth please ensure that you have visited your dentist before your operation. This is to enable your anaesthetist to administer your anaesthetic safely.

What to bring into hospital

• wash bag with toiletries

• dressing gown

• slippers/comfortable shoes

• night-dresses/pyjamas

• towels

• tissues

• your medicines

• money for newspapers, telephone calls and your journey home

• spectacle case if you wear glasses

• hearing aid and spare batteries, if applicable.

Please do not bring large sums of money or valuables into hospital with you.

Going home

In general, most patients are discharged home within a week following their operation. If possible, try to have someone to stay with you for the first seven to 10 days. If this is not possible please tell your nurse when you attend the pre-admission clinic and/or on the day you are admitted to hospital. You will not be discharged home if you need nursing care without appropriate arrangements being made with the district nursing service. You should arrange your own transport and be accompanied home by a relative or friend. We can only supply transport home in exceptional circumstances.

In hospital

Hospital staff who will visit you before your operation

When you arrive on the ward, a nurse will greet you and will show you around. A doctor will visit you. He/she will examine you and ask about your illness and answer any questions you may have. The operation will be explained to you and the benefits and risks involved will be discussed with you. You will be asked to sign a consent form, which gives your permission for the operation to be carried out. You will be given a copy of this form.You may also be asked, at this time, to consent to samples of your tissue to be taken and used for research. Please see ‘Donation of tissue for research’ for more information.

Benefits

The benefits of this operation are to increase your life expectancy, to relieve/improve your symptoms and to reduce the likelihood of a heart attack.

Risks

Minor problems, such as wound or chest infections, may occur. Though unlikely the most serious risks associated with this operation are death and stroke. The surgeon will discuss your individual risks with you before you sign your consent form. The ward nurse will give you any further information you may need to help prepare you and your family/carers for your operation. They will give you advice about your immediate recovery, help you to plan for your discharge home and rehabilitation.

An anaesthetist will visit you. He/she is the person who will give you a general anaesthetist and help to look after you during your operation and afterwards in the intensive care unit. Your suitability for anaesthesia will be assessed and you will be told about your anaesthetic. If you have any questions or concerns it is important that you speak to your Advanced Nurse Practitioner, ward staff, your medical team or one of our cardiac education/rehabilitation team. It is important that you and your family understand what is happening to you and why it is happening.

Preparation for your operation

Before your operation you:

• may need to have some hair removed from your chest, your arms, legs or all of these areas, using hair clippers, in preparation for your operation

• will be advised by your nurse when you need to stop eating and drinking.

On the day of your operation you may be given tablets or an injection, or both, to prepare you for your anaesthetic. These will help you to feel relaxed and sleepy. After this you will be expected to stay in bed until you go for your operation. You will be taken, either on a trolley or on your bed, to the operating theatre and will be accompanied by the ward nurse. On arrival in the operating theatre a theatre nurse or operating department assistant will meet you. The anaesthetist will then prepare you for your anaesthetic by giving you an injection in the back of your hand.

During your operation

During most heart operations a heart/lung bypass machine is used. This acts for the heart and lungs during the operation. Blood flows through the machine where it receives oxygen and is then pumped back to the body, thus bypassing the heart.

Your stay in intensive care

Immediately after your operation you will be transferred to the intensive care unit. This is where you will be cared for and closely observed, usually for six to 24 hours. After this time, you will usually be transferred to the high dependency unit or coronary care unit.

What to expect

You will be asleep to begin with and will be kept asleep with medication/drugs. During this time you will be connected, by a tube, to an artificial breathing machine called a ventilator. This reduces the work that your lungs have to do in the first few hours during your operation when you are sleeping. You will breathe through a tube which passes through your mouth and into your lungs. When you wake up, the tube may still be in place and you will not be able to talk or drink. You will be able to nod or shake your head in response to questions. A nurse will be with you at all times and he/she will keep you comfortable. He/she is experienced in communicating with patients before they are able to speak. The anaesthetist will decide when the breathing machine can be disconnected. The breathing tube will be removed as soon as possible. After this, you will be given sips of water and you will be given an oxygen mask to wear to assist you with your breathing. You will also be attached to a heart monitor. This records your heart rhythm, blood pressure, and temperature. The monitor may ‘bleep’ occasionally, but don’t worry, this is to assist the nurse caring for you. You may be aware of drips in your arms, neck or groin. These allow fluids and medicines to be given and blood samples to be taken without the need to continually pierce your skin.You will also have a urine catheter (tube) in your bladder to allow you to pass urine without having to get out of bed. It also allows your nurse to measure the amount of urine you pass. 12 At the end of the operation, the surgeon will have inserted a number of tubes into the area around your heart. These will drain away any blood that may collect following your operation. You may also have a drain in your leg. These are usually removed on the first day after your operation.

Pain relief after your operation

You will receive pain-relieving drugs through the drips both during and after your operation. Initially the doctors or nurses give these drugs. As soon as you are awake, you may be given a device called PCA (Patient Controlled Analgesia). This will allow you to control the amount of pain-relieving drug you receive. The PCA device has a safety mechanism which controls the amount of the pain relieving drug you are given, so you will not receive too much. If this device is used, a full explanation will be given to you. It is important that your pain is controlled so that you are able to cough and take deep breaths comfortably. Please tell your nurse if you have any pain, as he/she will be able to adjust the dose of the drug you receive. They can also contact the doctor to review your pain relief. After a stay in intensive care you may be transferred to a High Dependency Unit (H.D.U.) or Coronary Care Unit (C.C.U.), as you will not need such close observation. The nurses who work in these areas are specially trained to meet your needs. You will stay there for one or two days. These areas provide specialist care for people who are not connected to a breathing machine, but who still need close supervision. This is normal after such an operation. From here you will be transferred to one of our wards, as you will require less supervision. Here the staff will monitor your progress and help prepare you for your discharge home.

Your recovery

Physiotherapy

Patients who have mobility or chest problems will be seen by a physiotherapist if necessary. There will be a physiotherapist available if you require advice. Your nurse can arrange this for you. Following your operation it is advisable to do breathing exercises. You will be encouraged to walk along the ward corridor. The best treatment for you is to be up and mobile as soon as possible to help prevent chest infections and to re-expand your lungs. By the time you are ready to leave hospital you should be walking independently.

Guidelines for your recovery

You may experience some pain or discomfort after your operation. Some people may have more pain than others. You will be given regular pain relieving tablets and/or injections. If you still feel pain after your medication you must let your nurse or doctor know. Pain is often worse in the morning after waking and when moving your arms, shoulders and legs. We suggest you take your early morning pain relieving tablets before you get out of bed and regularly throughout the day. You may also experience muscular aches and some soreness in your neck, your back and bottom from lying in bed. It is not advisable to lie in bed, or sit in a chair in one position, for long periods. 15 You may notice numbness and ‘pins and needles’ in your chest, legs or arms if an incision (cut) has been made. If a vein has been taken from your leg(s), you may notice that the leg from which it has been taken is more uncomfortable when walking. The ankle may be swollen. Sometimes it can be more painful than your chest wound. The length of vein needed can vary from ankle to knee or ankle to groin. Aches and pains may persist for three months or longer. Muscular pain can sometimes be mistaken for angina. However, if angina re-occurs it is usually the same sensation/type of pain that you had before the operation. If this happens, please let your General Practitioner (GP) know. If you have had an internal mammary artery (I.M.A.) bypass graft, you may be aware of a numb sensation, pins and needles or ‘twinges’ in your chest. This is due to the way the operation is carried out. These feelings may last for six months or more.

Controlling your pain after the operation

You are strongly recommended to take your pain-relieving tablets regularly as prescribed by your doctor. Don’t wait until the pain is severe. It is not advisable to reduce or stop taking these tablets too soon. They will not harm you when taken as prescribed. However, some pain-relieving tablets can cause drowsiness, in which case you should not drive or use dangerous equipment/machinery. You may also need to take a laxative for constipation. If this happens after your discharge your pharmacist will advise you on what is available and best suited to you. When you feel ready, after your return home, you can gradually reduce your painkillers from two tablets to one or as advised. If in doubt you can get advice from your GP or pharmacist. To help reduce any pain when coughing, sneezing or laughing, support your chest wound as you were shown whilst in hospital. On discharge from hospital, you will be given a minimum of two weeks’ supply of your tablets and a copy of your prescription. After one week, arrange to get a prescription for more tablets from your GP. 16 Consult your GP or your ANP if:

• you experience any sudden or severe pain in your chest

• you develop pain in your calf muscle (at the back of either leg)

• your wound becomes red, inflamed or discharging (weeping) pus.

If your GP is not available you can contact Accident and Emergency Department at your local hospital. For more general enquiries contact the ward on which you were a patient or your ANP. It is advisable to visit your GP or practice nurse on a regular basis to have your blood pressure checked.

Wound healing

After your operation, there will be a scar along the length of your breastbone on your chest. Depending on where the artery or vein has been taken from, you may have a wound on your leg(s), arm or both. At first you may notice some redness, bruising and perhaps a slight discharge (weeping) from your wound. This discharge will often clear up within the first few days. You may also experience some soreness or numbness around the wound area. The skin may feel tight. This is all quite normal. A daily shower will keep your wounds clean and encourage healing. Don’t use soap or scented products on them. Pat them gently with a clean towel to dry.

When your wounds have healed, you may expose them to sunlight for short periods only. It is advisable to use a sunscreen for your protection. If you have diabetes, healing may take longer. If you have had a vein taken from your leg, you may notice some swelling. Your ankles may also appear swollen. It is advisable to put your feet up on a stool or chair when sitting down; this should be above hip level. Don’t cross your legs, as this will reduce the blood flow. You will be given support stockings to wear, which will help to reduce swelling, support the wound and help reduce the risk of a blood clot (deep vein thrombosis). The stockings should be worn at all times for four weeks. You may take them off for a half an hour while you wash/shower. Wash them, by hand, daily with a mild detergent, as this will help them stay clean and retain their elasticity.

Lifting weights/heavy loads

It is important that you don’t carry or lift anything that is heavier than 5 kilograms or 10 pounds in weight for eight to 10 weeks following your operation. This is about the same weight as five bags of sugar (1 kilogram or 2 pound bags ). It takes eight to 10 weeks for the breastbone to rejoin. Very occasionally you may notice a clicking noise in your breastbone. If this happens contact the ward from where you were discharged or your Advanced Nurse Practitioner.

Your heart beat

It is quite normal to be more aware of your heartbeat after the operation. You may feel that it is beating irregularly or missing a beat. This often happens after a heart operation. Don’t worry. If this happens whilst you are in hospital, let your nurse or doctor know. If it happens when you are at home, contact your GP. If he/she is not available and you feel unwell, visit your local Accident and Emergency Department. If any of the problems mentioned occur, please contact your ANP who will be happy to call you back. Please don’t think you are being a nuisance, we are here to help you.


Medication

After your operation your surgeon will review, and may change, your medication. Any changes will be discussed with you before you go home. You will probably be advised to take Aspirin and/or Clopidrogel and a cholesterol lowering drug (statin) on a long term basis, as this will reduce your risk of further cardiac events. You may be discharged on painkillers and diuretics (water tablets) and will be given a two week supply. After this your GP will review and advise you on the need to stop or continue with these. This section aims to give you useful information about the medicines that you might be taking. It is intended to tell you what each drug is for, how to take it and any possible side effects. Please remember that it might not include all the tablets you are taking and you might not experience all or any of the side effects listed. This information does not replace the advice that doctors, nurses or pharmacists give you but it should help you to understand what they tell you. For further or more personal information, please contact your GP or cardiac rehabilitation team. Medication which is taken for cardiovascular disease needs to be taken correctly to be of most benefit. Many different types of medicine may need to be taken to prevent further heart problems. It is important to keep taking the medication, even if you feel better and to check with your doctor before stopping any medication. Try to keep an up-to-date list of medication with you at all times. You should check with your doctor or pharmacist before taking any other medicines especially if bought over the counter e.g. cold remedies and herbal supplements.

(Author: John Stapleton – Pharmacy, The James Cook University Hospital)

Aspirin (‘antiplatelet’). Prevents platelets (small blood cells that can clump together to form a clot) from becoming “sticky”. Used to prevent a heart attack or stroke, used following angioplasty or coronary artery bypass surgery, and to treat atrial fibrillation and angina. How to take Taken as a 75mg to 150mg once a day with food (usually breakfast). Swallow whole (can be mixed with water if necessary). Side effects Indigestion, nausea and vomiting. Can provoke or worsen bleeding in stomach. Tell your doctor if you have any unexplained bleeding/bruising, blood in the urine or black/tarry bowel motions. Information Should be taken for life unless your doctor advises otherwise. Do not take additional aspirin or other aspirin containing products (eg cold remedies. Check with your local pharmacist.

Clopidogrel (‘antiplatelet’). Prevents platelets from becoming “sticky”. Often used with aspirin after coronary angioplasty with stenting. Reduces the risk of having a heart attack or stroke. How to take Take once a day with food (usually breakfast). You will be told how long to take it for and given a card. Side effects Indigestion, nausea and vomiting. Can provoke or worsen bleeding in stomach. Tell your doctor if you have any unexplained bleeding/bruising, blood in the urine or black/tarry bowel motions. Information This is a vital part of your treatment; do not stop taking without talking to your doctor or cardiologist.

Beta-blockers (e.g. bisoprolol, atenolol, carvedilol). These slow the heart rate and reduce the amount of work the heart muscle has to do so that it needs less oxygen, blood and nutrients. They can be used to prevent symptoms of angina, control abnormal heart rhythms, improve symptoms and prognosis in heart failure, and to treat high blood pressure. How to take Normally taken once a day. Your doctor may ask you to take them twice a day. Side effects Dizziness, cold hands or feet, tiredness or fatigue. These tend to disappear with time. Rarely, sleep disturbance, rashes and difficulty with erections can occur. Information These are started at a low dose and your doctor should gradually increase the dose. Do not stop taking suddenly as this may cause severe angina.

ACE Inhibitors (e.g. ramipril, lisinopril, perindopril). These block an enzyme from working in the body. The enzyme is called Angiotensin Converting Enzyme (or “ACE”). As a result they allow the blood vessels to relax and the heart to work more efficiently. How to take Taken once a day. Your doctor ma sometimes ask you to take them twice a day. Side effects May cause dizziness or light-headedness when first started or when you stand up. Other side effects include dry cough, rash or loss of taste. Information These are started at a low dose and your doctor should gradually increase the dose. Information Your doctor will take regular blood tests to check your kidney function and potassium levels. Avoid indigestion or heartburn preparations that contain potassium salts.

Statins (e.g. simvastatin, atorvastatin). These are used in conjunction with diet, weight reduction and exercise in patients with heart disease or at risk of developing coronary heart disease. They reduce the chance of further heart attacks. They block enzymes responsible for forming cholesterol by the liver. They reduce “bad” cholesterol (LDL) and raise “good” cholesterol (HDL). Too much cholesterol in the blood can be laid down in the walls of the blood vessels causing “narrowings”. How to take Take once a day (you should take simvastatin in the evening). Taking with a meal may help reduce side effects. Side effects Constipation, diarrhoea, indigestion and flatulence. Rarely they cause muscle damage; tell your doctor if you have unexplained muscle pains. Information To be taken long term. If you are taking simvastatin you should avoid eating grapefruit, drinking grapefruit juice. You may have small amounts with atorvastatin.

Other medicines that may be used Angiotensin II receptor blockers (e.g. losartan, candesartan) These are very similar to ACE inhibitors and may be used when ACE inhibitors cannot be tolerated.

Calcium channel blockers (e.g. amlodipine, diltiazem, verapamil). These prevent calcium from entering heart muscle and blood vessel cells. They cause the arteries to relax and widen which reduces blood pressure, improves blood supply to the heart allowing it to work more efficiently. You may experience flushing of the face, headache, dizziness and swollen ankles. These side effects tend to settle and go away.

Anti-arrhythmics (e.g. digoxin, amiodarone). Arrhythmias are abnormal heart rhythms. These drugs help to normalise these rhythms. Digoxin can also be used in heart failure as it increases the force of heart contractions. It may sometimes cause nausea and vomiting. Amiodarone can sometimes affect the thyroid, liver and lungs; your doctor will monitor for these side-effects.

Anticoagulants (e.g. warfarin). In some cases your surgeon may prescribe Warfarin after your operation to prevent blood clots. It may be prescribed and is most often used for people with disease of the heart valves, especially those who have been given an artificial heart valve, or for some people who have an irregular heart rhythm such as persistent atrial fibrillation. It is given to thin your blood and slow down the time it takes for your blood to clot. When you are discharged from hospital, you will be given a booklet containing details of your blood test results and information on Warfarin. If you have any questions or queries regarding your medication please speak or contact your pharmacist, GP or ANP.

Diuretics (e.g. furosemide) These are commonly called “water tablets”. They remove excess water from the body and make you pass more urine for a few hours after taking. You can use this space to note down any questions you may have. The doctor, nurse or pharmacist may also write additional information here.


Diet and appetite

Following your operation it is normal to experience:

• nausea

• lack of appetite

• lack of taste.

Try to:

• eat little and often

• eat what you fancy for the first two months after your operation

• drink lots of water. If you have diabetes or are on a special diet, please get advice from the dietitian.

Returning to work

Returning to work depends on the kind of work involved. As a general rule, patients with light occupations can consider returning to work any time from around 12 weeks. Those who have heavy manual occupations may need longer recuperation time before returning to work. The decision to return to work should be taken in consideration with your doctor and with your employers, who may well be able to give you lighter duties for the initial period before you resume your full duties again.

Emotional adjustments

There may be times following your operation when you feel low or depressed. You may be tearful, irritable and unable to concentrate. Often you will not be able to explain why you feel like this. These feelings are known as the ‘post-op blues’ and may persist when you get home. Here are some suggestions to help you:

• Try to talk about your feelings with your family/carers.

• Try to adopt a positive attitude, resume hobbies when you feel well enough or take up new ones.

• Take regular exercise.

• Rest and relaxation are also important for your recovery.

You may also be more aware of other emotions such as:

• Anger and resentment—you feel that your body has let you down despite efforts to keep fit.

• Worry—due to changes in your body image, perhaps because of your scar.

• Frustration—that to start with your physical activities will be limited.

• Fear—that you will need further surgery in the future.

If you experience any of these feelings whilst in hospital, the nurses caring for you are skilled in helping you through these difficulties. You may wish to talk to a member of the cardiac education/rehabilitation team. When you are at home, you may need to talk to your GP, your practice nurse or your local cardiac education/rehabilitation nurse.

Resuming regular activities/taking regular exercise

Guidelines

During the first three months, you should try to increase your activities. Introduce new activities gradually and not all at once. During the first few weeks after your operation it is normal to feel tired, after even the smallest amount of effort. You should try to walk every day, gradually increasing the distance and the pace. Wear warm clothing when outside on cold, wet or windy days.

By six to seven weeks after your operation, you may be walking one to two miles daily. This will depend on your previous fitness level, your recovery and any other medical conditions that you may have. Not everyone is the same and everyone will recover differently, therefore it is important to discuss your individual requirements with your cardiac rehabilitation team. Cardiac rehabilitation generally begins at 6 weeks after discharge from hospital. During your first 6 weeks at home it is important that you gradually increase your activity levels, for example gradually building up your daily walking. Your physical activity levels will then be progressed during the cardiac rehabilitation course, where more specific advice can be given depending upon your individual goals.

The first two to three days at home

Take regular walks around your home. Continue with deep breathing exercises. Get plenty of rest and don’t allow too many well wishers to visit you, as this can be tiring.

During the first three weeks at home

Introduce light tasks into your daily routine, eg light dusting, washing up, cooking light meals. It is recommended that you take daily walks. You may enjoy a quiet evening out. Don’t do anything more strenuous at this stage. Avoid heavy lifting, pulling or pushing, as this will put a strain on your breastbone, which will take eight to 10 weeks to heal. Avoid activities that could cause sudden jerking or twisting of your chest, eg walking a dog on a lead.

From four weeks after your operation You can start to do more demanding tasks such as dusting, preparing vegetables, light shopping, light gardening, making tea/coffee. It is recommended that you walk for 20–30 minutes daily.

From six weeks after your operation Introduce other tasks into your daily routine, such as hoovering, mowing the lawn with an electric mower, raking leaves, small car repairs.

From eight weeks after your operation You may start cleaning the windows, cycling, fishing, playing bowls and practising your golf swing.

From twelve weeks after your operation You should now feel that you are getting back to normal. You may start to undertake more strenuous exercise. If you wish to play competitive games, consult your doctor first.

Returning to work

You should be able to return to work depending on the type of work you do and on your recovery following your heart bypass operation. Most people will be able to return to their previous employment. Please discuss this with your doctors and your employers. You should negotiate with your manager to work shorter hours and shorter weeks to start with.

Sexual relations

When you first return home, you may be worried about returning to your usual sex life, and your partner may also feel anxious. It is normal to feel like this. Sexual activity can be resumed when you feel ready. Choose a position that you find comfortable and does not place strain on your chest. In the beginning you may wish to take a less active role. Research shows that the effort involved during sexual intercourse can be compared to climbing two flights of stairs. If you suspect that the medication you are taking for your heart is causing side effects, such as impotence (inability to develop/maintain an erection), you should consult your doctor, who may be able to alter the dose/type of medication.

Driving

After your operation, your chest will take time to heal. Sudden movements can bring on pain, soreness or discomfort. Remember that strong pain relieving tablets can cause drowsiness and can affect your concentration. You should inform your insurance company of the operation. Nondisclosure could render your insurance invalid.

Group one (ordinary) license You don’t normally need to inform The Driver and Vehicle Licensing Agency (D.V.L.A.) if you have had a coronary artery bypass operation. You may need to inform them if you have heart rhythm problems.

The D.V.L.A. recommends that you don’t drive for one month following your operation. In some cases, a longer period may be necessary for example experiencing persistent discomfort or if you are taking strong painkillers. If you have had a pacemaker implanted (a mechanical device that helps control the rate at which your heart beats), you will need to inform them. Don’t forget to wear a seat belt. Place a small cushion between your chest and the seat belt if you find this helps to make it more comfortable.

Group two license Please see guidelines for group II licenses. If your job involves driving, talk to your employer or licensing authority about conditions of returning to work. If you are a taxi driver (Black Cab), the Public Carriage Office in London asks that you inform them immediately if you have had a coronary artery bypass operation. They would also like you to hand in your badge, original and copy cab driver’s licence for safekeeping. For further driving advice following heart surgery please follow the link below to the DVLA website. Please note that is guidance only everyone is different and therefore please discuss with your surgeon before you start to drive (www.dvla.gov.uk/medical/ataglance.aspx).

Holidays/Flying

A restful holiday in this country may be taken as soon as you feel ready. Holidays abroad, by air, may be taken from eight weeks after your operation. Avoid strenuous holidays and long journeys at first. Remember to take a supply of your tablets with you in your hand luggage. You must inform your travel insurers that you have had heart surgery. British Heart Foundation can supply a list of insurance companies that are sensitive to cardiac patients’ needs. (http://www.bhf.org.uk/?pid=g&gclid=CI7n3JiXkbACFUxlfAodzVEntA) There is no reason why you should not travel by air. If you have had a pacemaker implanted, it can trigger off metal detectors at airports — carry your identity card with you.

Hint and tips Plan your journey with care – this will avoid unnecessary stress Give yourself plenty of time to avoid rushing Make sure you take enough supplies of your medications To avoid heavy lifting make use of luggage trolleys

Social workers

Illness and major surgery can cause severe disruption to family and working life, or it may lead to changes in circumstances. Social workers can offer advice and help on how to manage some of the effects of illness or disability. Ask the nurse caring for you to arrange an appointment for you if needed.

Follow-up appointments

On leaving hospital you will be given or sent an appointment to see your surgeon—usually six to 12 weeks after your operation. If you are unable to keep this appointment please ensure that you inform the appropriate department.

Advice for family/friends

Your relative/friend should be independent on leaving hospital and must be allowed to resume activities gradually. It is recommended that, where possible, they have someone with them for the first seven to 10 days after their discharge home. It can take time to recover from the operation. Support and encourage them if they feel anxious or depressed. Visitors can be tiring, however well meaning and caring, so you may want to restrict them. It is normal to be anxious about the recovery of a loved one. If you share a bed with someone who is/has been ill or has had an operation, it is natural to be more aware of them. You may find yourself checking their breathing etc. This is all quite normal. Please remember the helpline service is for you too. You may also wish to attend the cardiac rehabilitation course to help you understand the benefits and to aid the recovery of your loved one.

The benefits of cardiac rehabilitation

After discharge from hospital it is advisable to attend a cardiac rehabilitation course at your local hospital. These courses are designed to be both informative and enjoyable. You can contact your GP or the hospital concerned for details. The aim of these courses is to help you resume your normal lifestyle and reduce the risk of ill health. They will help you regain confidence and assist you to plan a healthy lifestyle programme. They will give you insight into

• heart disease and how to manage it

• exercising safely

• introducing relaxation into your daily life.

Cardiac patients are entitled to an assessment by their cardiac rehabilitation team. Cardiac rehabilitation has been shown to increase survival beyond the first 3 years of a heart attack or bypass surgery by as much as 26%.

What is Cardiac Rehabilitation?

Cardiac rehabilitation is the process of helping people with a heart condition make any necessary changes to their life and get back on their feet again – physically, emotionally, socially and vocationally. It helps in a number of ways.

• Cardiac rehabilitation helps people to consider changes to their lifestyle

• Cardiac rehabilitation helps people to regain their confidence

• Cardiac rehabilitation helps people to recover psychologically.

• Cardiac rehabilitation helps people to deal with social issues

• Cardiac rehabilitation helps people to live longer.

BACR 2007 (British Association of Cardiac Rehabilitation)

Finding your local cardiac rehabilitation course

If you do not receive any information about cardiac rehabilitation from your hospital or to find your local cardiac rehabilitation team please follow the link http://maps.cardiac-rehabilitation.net/

Maintaining a healthy heart

• Healthy eating / cholesterol

• Alcohol consumption

• Smoking

• Maintaining a healthy weight

• Controlling your blood pressure

• Family history

• Physical activity (linked to section above)

For more details see here

Cardiothoracic audit

During your stay at Hospital, the clinicians involved in your care will enter information about your operation into the cardiac surgery audit database. This database consists of a set of questions from the Society for Cardiothoracic Surgery in GB & Ireland (SCTS). This information is used to monitor clinical activity and forms part of individual Cardiothoracic Consultants yearly appraisals and could be used in cardiac research. The cardiac surgery database is managed by the Cardiac Information and Audit team who adhere to the Data Protection Act (1998), Department of Health’s code of confidentiality and the Caldicott Principles. Should you wish to discuss how your data is managed or you do not want your data to be used for research purposes in the future then please contact the Cardiac Information and Audit Team using the details shown below. All research projects are approved by a Research Ethics Committee.

Donation of tissue for research

The human body is made up of collections of cells which make up tissues. During your treatment or operation, samples of tissue may be taken to help us plan your treatment or to understand your condition. This tissue can then be used for research; by studying tissue, scientists can understand how diseases start and progress and may be able to develop new treatments. Your tissue can only be taken, kept and used for research with your consent. Consent will normally be taken at the same time as you give your consent for your operation or treatment. Your decision to consent to, or to refuse, medical research will not affect the standard of care you receive. The Human Tissue Act 2004 ensures that all tissue donated for research is used in a safe and ethical manner.

 

The information provided in this section was written and revised by the following and the Society for Cardiothoracic Surgery in GB & Ireland is grateful for their huge support :

London Chest Hospital
Cardiac Rehabilitation Unit

James Cook University Hospital
Annette Johnson, Esther Carr

For further detailed information on individual units, please click on the links below:

London Chest Hospital
James Cook University Hospital