• When initially entered onto the Waiting List
  
• When attending a Pre-Admission Clinic
  
• Post-operative chat to prepare for discharge
  
• Followup phone calls/home visits
  
• Surgical review at week 6/52 after surgery.

Pre-Admission Clinic

Attendance of the pre-admission clinic is required in order that necessary investigations can be carried out prior to surgery.

The clinic reduces the amount of time a patient needs to spend in hospital before any operation and will serve to reduce any worries the patient may have about their forthcoming procedure.

Unfortunately, some of the departments that the patient may need to attend, can get very busy and it may be necessary to wait before being seen.
Overall the investigations should take about 3-4 hours to complete. Patients are normally sent for a chest X-ray and an electrocardiogram (ECG) and some blood samples wiil be taken from the patient. These tests are done to ensure the patient is healthy enough to undergo the surgical procedure. These tests are routine for any surgical procedure.

The doctors that meet the patient during clinic will be looking after the patient throughout the patients stay in hospital. They examine the patient and take a medical history. A nurse also asks about the patients home and family situation. This is done to discover what , if any, support the patient will need on discharge from hospital.
The nurse will also take nose and throat swabs, a urine sample and, if possible, a sample of sputum. This is to ensure the patient has no infections prior to surgery.

When attending clinic patients are asked to bring their medication with them
Also if undergoing a heart valve procedure patients are advised to have visited the dentist before admission, allowing sufficient time for any treatment to be completed.

Discharge Information after Heart Surgery

All patients are considered to be ready for discharge any time on or after the 4th Day Post Op - only of they are well enough, i.e. if the operation was performed on Monday the patient may be discharged the following Friday.

Activities
Patients should have exercised, walked and climbed the stairs before leaving hospital. Progress can be slow and it may be a couple of weeks before any progress will be noticeable - this is normal. Patients are advised to keep to their hospital routine i.e. get up, washed and dressed; eat meals ; potter around;rest. Exercise is as good as rest for recovering patients.
As a rule it is advisable not to bring the bed downstairs. Doing the stairs at least once a day is good exercise.

Alcohol
Excess should be avoided, particularly if taking pain killers. If patients are on anticoagulants - binging is not recommended. It is safer to drink the same amount daily i.e. two pints per day or equivalent in Spirits, than to save it all for the weekend.

Anticoagulant Clinic
If patients are on anticoagulants post-operatively, and are being controlled at the M.R.I., the anticoagulant clinic is in the Out-Patient Department in Suite A.

Sessions are as follows:-

Monday, Tuesday & Friday : 8.30am - 11.30am
Wednesday and Thursday 1pm to 3.30 pm.

An appointment will be given to the patient before discharge.
Patients should always carry their anticoagulant booklet with them, whether going to clinic or not.

Bathing and Showering

Bathing or showering is not essential everyday. If patients have problems getting in or out of the bath, then patients are advised to practice with clothes on and no water (shoes and socks off). It may be easier to kneel initially instead of getting right down then struggling to get up. Leave the water in the bath until stood up - buoyancy of the water helps. Bath aids can be provided - the liaison team would be happy to discuss this.

Cholesterol
The normal levels are between 3.5 and 6.9. Bypass patients ideally should keep their levels below 5.0. If a patient level is not known, a GP should be asked to measure this 3 months after surgery and again at a later date. It can take between 3 months and 2 years to rise to normal levels after surgery. Most patients have a routine test in hospital immediately prior to surgery and it takes about a week for the results to come through. If the cholesterol level is raised it can be reduced initially by a low fat diet and then by tablets if necessary. As a precaution, the immediate family of a patient are advised to have their cholesterol levels checked by the practice nurse or GP - except children under the age of 12.

Constipation

(a) It is common for patients who have been hospitalised to be constipated.
(b) Pain killers such as codeine i.e. (Co-dydramol, Kapake and Tylex) are usually the main cause.
(c) Patients who become constipated should not leave it for more than 1 day.
(d) Patients should consult a GP or chemist before taking laxatives.
(e) Otherwise consult your GP or chemist for advice about taking laxatives until you have
stopped taking strong painkillers.
(f) lf the pain is not too bad, take Paracetamol instead of Co-dydramol etc - particularly at
lunch and tea time.
(g) Don't hesitate in asking the liaison team for advice.
(h) Low fat, high fibre diet, potter around the every hour or so, and drink plenty.
All of these will help.
PS. lf you strain - too much pressure will be applied to the chest bone, which will delay healing.

Dental advice for Patients with New Heart Valve - either tissue prosthetic

1. Patients with natural teeth should visit the dentist every 6 months.
2. Go to the dentist immediately if you have any problems with your teeth, i.e. tooth ache etc.
3. Advise the dentist that you (a) have a new heart valve and (b) are on anticoagulants for either 3 months or for life.
4. Expect to have to take Amoxycillin (3 gms) one hour prior to any dental treatment, which may either break the skin or cause bleeding.
5. If you need a dental extraction, it will almost certainly have to be done in hospital.
6. A letter can be provided for your dentist by the liaison team.

Diet

All patients will benefit from a healthy diet which is low in fat and high in white meat, fish and fibre. We do have a dietician who visits the ward and we can supply booklets if you are interested.

Do's

When deciding if you should attempt a certain task, ask yourself these questions:

A) Do I really want to do it. lf the answer is yes - proceed to (B). If the answer is no - forget it, until you feel up to it.
B) Do l feel I can cope with it? If the answer is yes - proceed to (C).
C) Go ahead and have a try, so long as you stop as soon as you feel that you are pushing yourself rather than enjoying yourself. Always try a little at first. lf you find you have overdone it, don't push yourself - just stop. Your progress should always be slow, steady and gradual. Always give into tiredness, weariness and lethargy. If you find you have a "good'' day followed by a "bad'' day you have probably overdone it. Try to avoid that when possible.

You can begin cycling, yoga etc. approximately four weeks after discharge, so long as you find it relaxing rather than strenuous and build it up slowly, steadily and gradually. You should be able to undertake most light household and gardening activities by about the third or fourth week post discharge. Ask at your 6 week post op check if you can start swimming.

Don't's

However - No digging the garden, No mowing the lawn, No lifting anything heavier than 2lbs in weight, No vacuuming, No ironing, No cleaning the windows or the bath, or anything which you find strenuous for at least six to to eight weeks, or until you feel you can cope. This restriction is to enable the breast bone to knit together. If it should start clicking or clunking once you have been discharged from hospital, please ring the liaison team for advice - Try to avoid it happening by moving like a "tin soldier'' and moving both arms equally.

Driving

About 6-8 weeks after operation. Do not drive before your post operative check-up unless it exceeds eight weeks. Your chest bone has been broken and it takes approximately 8- 12 weeks to heal properly. It is advisable to inform your Insurance Company of your heart surgery - however they may increase your premium. If you have any difficulty with car insurance please feel free to contact us. You do not need to inform the D.V.L.A. about any heart operations except pacemakers.

Emotions

Emotions may be up and down initially particularly if you are a man. If you feel like crying, do so. Don't hold it back. If you have a lump in your throat and tears in your eyes at the slightest provocation. You are only human and it is a normal reaction after heart surgery. You may find you run on quite a short fuse, immediately after you go home. Once again it is normal. If you can, talk about it. Although you have had to suffer the physical pain and all that major surgery entails, it is very important not to forget how those at home have also suffered, but in a different way. It is equally as frustrating, tiring and lonely. It is important for your partner also to have a break during the day, instead of pushing himself or herself too far.

Good and Bad Days
It is normal to have good and bad days. The good days are to remind you that you can feel normal. The bad days are to remind you that it takes approximately three months to recover from heart surgery and not two weeks. If you do too much on a good day, it will be followed by one or two bad days, learn to pace yourself. If you wake up one morning and feel that you could cope with anything. Don't! Just do a little more than on the previous day.

Heart rhythm

You may be very aware of your heart beating - particularly when you go to bed.You may have to changepositions for it to go away. It is normal. If it gets worseand happens more frequently see your GP. The heart is working more efficiently and usually you beta blockers have been stopped after surgery.

Holidays
As a general rule, most people are able to enjoy a holiday either abroad or in this country approximately 8-12 weeks after surgery. Under normal circumstances you should then be able to fly.

PS. lf you have any problems obtaining insurance, ask the cardiac liaison team for advice.

Numbness
Is relatively normal down the leg scar from the knee to the ankle. The superficial nerves may have been cut during the operation - it could take up to 2 years for the nerves to regrow

Out Patient Appointment

You will be pent an appointment through the post, approximately 4 - 8 weeks after discharge, for a post operative check.

The clinics are as follows :-

Pain

We normally send the patient home with 3-4 days supply of strong painkillers either Kapake or Codydramol. Please make sure you also have some Paracetamol at home. Don't hesitate to get a repeat prescription for painkillers; you may need to take 8 per day for pain, discomfort or soreness, or just not being able to get to sleep at night, for up to 6 weeks. Don't hesitate to take them in the middle of the night if necessary. It is quite normal for the pain to get worse when you go home. The pain can be anywhere between your neck and your ankle. It is caused by using different muscles to get in and out and on and off. No doubt, your furniture will be different from that in the hospital. Please take painkillers if you need them. Don't be a martyr. The pain will eventually disappear, but may take longer if your posture is affected by the pain.

Pain from I.M.A grafts

lf either your left internal mammary artery (LIMA) or your right internal mammary artery (RIMA) or both internal mammary arteries (BIMA) have been used as a graft - expect more pain over the 6-8 week period after surgery. The site is approximately one inch away from the sternal scar running parallel with the scar down the chest. If BIMA the pain is seldom the same on each side of the chest. One is usually more painful than the other. It can feel like a burning sensation or a stabbing sensation. Take adequate painkillers - lf it is difficult to control - ask your GP for something stronger, anti- inflammatory tablets may be appropriate.

Patients who were on Ace Inhibitors pre-op i.e. Captopril, Enalapril, Ramapril, Lisinopril.

1.If treatment is not prescribed on discharge, it is because, it is not required at this stage.
2. If you start to feel weary and short of breath, consult your GP. Your breathing should not deteriorate after discharge.
3. If you restart these tablets, initially it is at a much lower dose.

Patients who had Treatment for High Blood Pressure Before Surgery .

1. If treatment is not prescribed on discharge it is because it is not required at this stage.
2. Please ask your GP or Practice Nurse to check your Blood Pressure once a week or fortnight.
3. If your Blood Pressure rises, they may recommence treatment.

Patients who were on Tablets Before Surgery

1. If treatment is not prescribed on discharge, it is because it is not required at this stage.
2. If you start to feel more breathless and both of your ankles begin to swell please consult your GP. It is normal for the leg, which has been operated on, to swell, but the other leg should not be unduly swollen.
3. You may need to go back onto water tablets if your GP recommends it.

Periods

For all female patients who are still having regular periods - anything is possible during your in-patient stay and after discharge. Allow at least 4-6 weeks before expecting your cycle to return to normal. lf your periods are prolonged and heavy it may be advisable to get your iron level tested by your GP. Any patient who has recently started Warfarin may be particularly prone to heavy periods.

Rehabilitation

This can be arranged at a hospital near you, in most cases. Please ask the physiotherapist or one of the Liaison Team for further details.

Return to Work

Approximately three months after the date of operation. Most people should be able to return to their previous occupations, although avoid excessive overtime. The time needed to prepare for return to heavy work will obviously be rather longer than for a desk job, i.e. nearer four months after surgery.

Seat Belts

On discharge from hospital, seat belts should be worn. You would not qualify for a seat belt exemption. lf uncomfortable put a cushion between your chest and the seat belt.

Sensitive Chest

Most common 2-6 weeks post op. It is not sore, but clothes etc. cause friction and is most uncomfortable. It will eventually settle when the nerve endings have calmed down. Try cling film over the affected area - this may help.

Sex

You may resume when you feel fit enough. Not too energetic at first. Remember your chest bone has been broken and won't be properly healed until 8-12 weeks. Ensure you are the passive partner to begin with. lf you want any further advice, please ask one of the liaison team.

Sleep and Rest

At night time, don't be surprised if your sleep pattern is unsettled. Expect to waken every 2-3 hours for the first one to two weeks. Take pain killers in the middle of the night if necessary. Don't be frightened of lying on your side. It may hurt when you wake up but it won't harm you. Cuddle a pillow if necessary.

It would be preferable for the patient not to be in a smoky atmosphere. Smoke is an irritant and will make the patient cough, which will then hurt. lf either the patient or any members of the family want to give up smoking please ask the liaison team for advice. Videos can be lent to anybody who is interested.

Stockings / advice about legs

You may be asked to wear surgical stockings after your operation. Please discuss these with the cardiac liaison team. If your leg / legs swell up after the operation (those which have a scar), try to keep them up when you are resting (the higher they are above your bottom, the quicker the swelling will go down).

Visitors

If not restricted at the beginning you may suffer the following day. Suggest 15-30 minutes per session for the first 1-2 weeks. After that you will benefit greatly from the company.

Walking

When you start walking outside (which can be as soon as you get home or after 1-2 weeks as preferred) start off by walking to your front gate and back (approximately 10 yards- metres), then go to the next door house and back and so on. Always making sure you get home safely. lf you are not tired when you
return home, perhaps you could walk a little further next time. lf you struggle to get back don't walk so far next time. For those of you who are dog owners, walking with the dog is good exercise but please don't hold the lead for at least 6 weeks.

Wounds

Any problems - either contact your GP, District Nurse or the liaison team. Patients should not be expected to do their own dressings. Typically - if the leg does not heal immediately it may take weeks - please don't lose heart. It will be right eventually.

Worries

One of the Cardio Thoracic Liaison team will visit you prior to discharge and arrange to keep in touch on the phone for as long as is necessary. A home visit can be arranged if there are any problems. There will be somebody in the office each day on 061 276 4393 from 9 - 5. Please leave a message if necessary on the megaphone. You can also bleep one of the team by ringing 061 276 1234 then ask the switchboard to bleep the Cardiothoracic Liaison Team.

Don't hesitate to ring your GP about any immediate or urgent problems.

Massage your scar
Massaging the scar is encouraged, whenever possible. This will help to promote blood supply and soften and fade scars. Creams such as Lanolin or Nivea can be used. Use sparingly and massage 1 cm of the scar at a time using a circular motion. it is not the cream doing the work, it is the pressure of the massage. If possible do three times a day.

How to use Novogel

• Ensure scar is clean and free from talc/creams etc.
  
• Cut the gel to the size of the scar, whilst it is still covered with the plastic and lycra covering.
  
• Remove the clear backing (keep it for later) and apply the gel to the scar so the gel is in contact with the scar and the lycra dressing is facing upwards.
  
• For extra support apply the gauze dressing over the gel and secure with tape.
  
• Wear the gel for as long as possible, i.e. 24 hours a day.
  
• Remove when bathing /showering - discard the gauze and tape and carefully place the gel back in its protective covering (i.e. lycra and plastic) and keep safe, until ready to use it again.
  
• The gel must not come into contact with water. Each piece of gel will last between 10 and 14 days.