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         Bypass surgery

What are the reasons for needing bypass surgery?
This operation is for people who have coronary heart disease or angina. It aims to improve the blood supply to the heart muscle. This will help to relieve angina symptoms and for many people improve their quality of life.

What happens during the surgery?
The aim of coronary bypass surgery is to bypass (get around) the narrowed sections of coronary arteries. The surgeon does this by grafting a blood vessel between the aorta (the main vessel leaving the heart) and a point along the coronary artery, beyond the narrowed area. In most cases at least one of the grafts is used from an artery inside the chest called the internal mammary artery. Blood vessels from the legs and sometimes from the arms are used for the other grafts.

The most common way of doing bypass surgery is for the surgeon to make an incision (cut) down the middle of the breastbone. However some operations can be performed through a smaller wound, so the breastbone does not need to be cut. This is called minimally invasive surgery. In most cases a heart-lung bypass machine is used to circulate the blood around the body while the surgeon operates on the heart. However some surgeons can carry out coronary bypass surgery without this machine. This is called beating heart surgery.

How successful is bypass surgery?
This operation is generally very successful. Most people who have a bypass operation find that they get excellent relief from their angina and their quality of life is greatly improved. However the operation does not cure the atheroma (fatty plaques), so angina may return in the future if the atheroma begins to build up again inside the grafts.

What are the risks?
The risk of a serious complication or of dying following the surgery varies from one person to another. On average 1-2 people in every 100 people will either have a stroke or die in hospital after having a bypass operation for the first time.

How long will it take to recover from the surgery?
After the operation most people are sitting out of bed a day or two afterwards and return home in about a week. On average, it takes most people about 2-3 months to recover fully from the operation, but this can vary greatly depending on your individual condition and how old you are.

Getting ready to go home
On the last or second to last day before you leave hospital, the medical and nursing staff need to do several things.

Having your stitches out
Different types of stitches are used for skin wounds. Some dissolve naturally and do not need to be removed. If the surgeon uses stitches which don’t dissolve, or clips, a nurse will remove these about 8 to 10 days after the operation.

There may also be some stitches around the site of the chest drains. The nurses will remove these about five or six days after the operation. If you have had an operation on a heart valve, the surgeon may have added ‘pacing wires’ during the operation. A nurse or doctor will remove these three or four days after your operation.

Discharge from the incision (cut) area
While you are recovering, it is very common for a small amount of fluid to leak from part of the chest where the incision (cut) was made. If you have had a vein graft from your leg or arm, there might be fluid from where the cut was made there too. This fluid may be blood-stained. If there is just a small amount of discharge, a doctor or nurse will put a small dry dressing on it.

Final check-up
Before you leave the hospital, the ward doctor will give you a thorough check-up and will repeat some of the tests you had before your operation. Your surgeon, or another senior member of the team,will talk to you before you leave the ward. They will make sure that all your questions have been answered and that you understand what to do, and what not to do,when you go home.

How long will it take me to recover?
Most patients find that it takes between two and three months to make a full recovery after the operation. Obviously the recovery time varies greatly depending on how severe the heart disease was, and the type of operation. Older people or those who were particularly unwell before surgery may take longer to recover than younger and fitter people.

The first few days
For the first two or three days at home, it is best to take things easy. Do about the same amount of moving around and exercise indoors as you did with your physiotherapists in your last few days in hospital. Make sure you have enough rest. When you are sitting, sit with your feet up on a stool, but make sure your legs are supported. Set aside specific rest times in the morning and afternoon and stick to them. Make sure that you rest properly by going to lie down rather than dozing in a chair. Remember to get into a routine for taking your medicines. You may find it helps to write a list of the medicines you need to take and how often you need to take them.

The first four to six weeks
After two or three days of reasonable rest you can begin to do more activity. Steady exercise, particularly walking, is ideal. Set yourself realistic goals. It is best to ask your physiotherapist how much activity you should do. Different people will be able to do different amounts. Your physiotherapist will give you advice about how to gradually increase the amount of exercise you do between the time you leave hospital and when you start your rehabilitation programme about four to eight weeks after surgery. He or she will also tell you how to measure and keep a record of how much exercise you’re doing.

Avoid doing activities:
• after a large meal
• when it is very hot or very cold
• when it is very humid, or
• when you are in high altitudes.
All these put added strain on your heart.

Getting into the fresh air and doing your deep breathing exercises will help you get better and will help lift your spirits.As you begin to walk and exercise more, you may feel uncomfortable around your chest, neck, shoulders or back. Don’t worry. This is a natural part of the rehabilitation process as the muscles and bones around the chest continue to heal after the operation. Make sure that your pain is controlled as this will help you to gradually increase your activity level. You may also feel a bit short of breath as you begin to exercise. This will also improve as the days pass.

How soon can I go back to work?
Many people who have heart surgery go back to their previous jobs. How soon you can return to work depends on the kind of work you do. As a general rule, people who do light jobs can think about returning to work any time from about two months after the operation. People who have heavy manual jobs may not be able to go back to work for at least three months after the operation. That’s the time needed for the muscles, bones and joints of the chest wall to heal.

Housework and gardening
You can do light housework, or light gardening, once you feel fit and able. However, for the first three months after the operation, you should not do any heavy work or heavy digging involving your arms and shoulders.

Sex
Use the same common-sense approach to having sex again as you do to building up your general physical activities. Most doctors suggest waiting for about four weeks after the operation before having sex again. You will need to find a position which is comfortable for you, remembering not to stress your chest wound or restrict your breathing. It will also help if you and your partner are relaxed about having sex again. Don’t worry if early attempts are not successful or seem difficult. You will soon be able to get back to your normal routines.

How can I reduce my risk of further coronary heart disease?
The major risk factors for coronary heart disease that you can do something about are:
• physical inactivity
• high blood pressure
• high blood cholesterol
• smoking,and
• being overweight or obese.

Drinking too much alcohol and having too much salt can also increase the risk of coronary heart disease. Your risk of further coronary heart disease will depend on how many of the above risk factors you have, and how strong each individual risk factor is. Knowing about your risk factors may encourage you to deal with them and help you feel more in control of your heart disease.

Control high blood pressure
High blood pressure increases the risk of a heart attack and of strokes, and over time it can cause the heart muscle to become less efficient. If you have high blood pressure, even a small reduction in blood pressure can lower your risk of having a heart attack.

If you have high blood pressure, it is essential to control it. If you already have coronary heart disease, your target is to have a blood pressure below 140/85. If you have diabetes, your target is below 130/80. Some people can control their blood pressure by losing weight, doing more physical activity and cutting down on alcohol and salt. However, many people need to take medicines too.

Watch your cholesterol
A healthy diet will help. This means cutting down on fats in general, especially saturated fats,which are found mostly in meat and dairy products. Researchers have found that reducing the amount of saturated fat you eat can help you reduce your risk of dying from coronary heart disease. Many people with coronary heart disease also need drugs to get their blood cholesterol down to a level which brings the greatest benefit.

Eat plenty of fruit and vegetables
People who eat at least five portions of fruit and vegetables a day are less likely to have heart disease. We do not know exactly why, but it is thought to be due to the antioxidant vitamins they contain. However, there is not yet enough evidence that taking vitamin tablets has the same effect. Even if you already have coronary heart disease, it is still helpful to eat plenty of fruit and vegetables. They can include fresh, frozen, dried or canned fruits and vegetables, and also salads.

Fish and fish oils
Eating oily fish regularly can help to reduce the risk of coronary heart disease and improve the chances of survival after a heart attack. The oil in fish that has this effect is called ‘omega-3’.Try to eat oily fish about twice a week.

Control your weight
It is important to control your weight, not just to help your heart but also for your general fitness. Keeping close to the recommended weight for your height will help you keep your blood pressure down and reduce the workload of your heart. If your doctors think that you are very overweight, they will ask the hospital dietitian to give you advice on how to lose weight. If you have any questions once you get home about what or how much you should be eating, ask your doctor.

Control diabetes
Men with diabetes have about three times the risk of a heart attack compared with those without diabetes. Women with diabetes have about five times the risk of heart attack. It is very important to make sure you control your blood sugar. Doing more physical activity, controlling your weight and taking your medicines regularly will all help.

 
      Doctor Tips
Angina is an uncomfortable feeling or pain in the chest.
   
It usually feels like a heaviness or tightness.
      For healthcare professional
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