Your Questions About Heart Surgery Answered

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy and information about diseases and treatment options. Enjoy!

Lars Svensson, MD, PhD:

I'm Lars Svensson. I'm Chairman of the Heart, Vascular & Thoracic Institute, and my interests are valve surgery and aortic surgery. So a number of you have asked questions about heart surgery, and I'm just going to look through some here on my iPhone.

“So what are the normal symptoms after surgery? When will I feel normal?” So typically after particularly a minimally invasive J-incision or even a full sternotomy, you should not be having much pain. Patients who have had both abdominal surgery and heart surgery usually say that abdominal surgery is much more painful as far as recovery and chest pain versus abdominal pain. And so you shouldn't be having too much pain and your medications typically will not be the powerful morphine or fentanyl-based medications. You'll be on mostly anti-inflammatories. As I said earlier, it takes about six weeks to get back to completely normal. When you leave, we expect you to be walking and potentially walking up steps, and I encourage patients to walk 45 minutes a day for five days a week, and that's very good exercise. If you're having trouble motivating yourself, then cardiac rehab is very helpful. And especially if you're a bit more frail cardiac rehab is also good to undertake after surgery, and that is sponsored also by Medicare if you are older than the age of 65.

“When can I resume activities, driving, mowing the lawn, golf, sports, and sex?” So from the point of view of driving, if you have a full sternotomy, the recommendations usually are six weeks. There's no strong medical reason for that. It's mainly from a legal point of view to protect you in case you get involved in an accident. As far as mowing the lawn and other exercise, etc. I would say just start off slowly. If you find you're hurting yourself, and for example playing golf or sports, start off with chipping. Don't suddenly go out there and start swinging again and trying to drive a ball 300 yards or whatever you're capable of doing. So just take it easy and take your time and ease yourself into it. Some of my professional NBA players, they've been back playing eight weeks after surgery. I don't particularly recommend that, but you can get back to a pretty active exercise and doing things about eight weeks after surgery. So your body will tell you if you're overdoing it. So do what you're comfortable with and just ease into life again, and you should be fine.

Another question here: “When can I have dental or other procedures before or after surgery?” So for most procedures, I recommend patients wait about six weeks. That allows you to heal up and let's say you need a prostate procedure or you need to have some lung procedure or something like that. I usually recommend orthopedic surgery, wait about six weeks. And by then you should be pretty healed up and your valve should be settled in and you shouldn't have any problems with having a procedure.

“Do I need antibiotics before?” That's a very good question. I always recommend patients have antibiotics before any procedures that potentially involve bacteria, so particularly dental procedures, procedures related to endoscopies, for example, or that type of procedure. Obviously if you're having say a bowel operation, then your surgeon will give you prophylactic antibiotics for that. And the reason is that if your valve was to get infected, that is a serious issue to deal with and we don't want you to have that happen.

“Can I get vaccines before and after surgery?” Yes. I don't have any particular strong feelings about vaccines, whether before or after surgery. After surgery, I'd encourage you to wait six weeks. And the thing about, let's say the vaccines for COVID, they don't prevent infections, but they prevent severe infections. So if people have had vaccinations and they've had those vaccinations, they're less likely to die. That's what the bottom line is. When it comes to flu vaccines, I strongly encourage that, particularly in older patients. And then the other vaccines, you should be taking those on a regular basis anyway.

“I need an MRI. Are my sternal wires, cut temporary pace wires, valve MRI safe?” So for sternal wires and the valves we use, including the mechanical valves as they are called, which are made mostly with carbon, those are safe for MRIs. When it comes to cut temporary pacemaker wires, that's a bit debated. Generally, most people prefer not to have an MRI done in patients who have had those. It also depends what kind of wires they are. Some wires can be a lot thicker, for example, the permanent pacing wires. And so you'd have to talk to your cardiologist and they would typically check with your radiologist.

“What is the best way to prepare for surgery?” That's a good question. What I encourage people is to keep on walking and exercising lightly. Now, if you have a very heavy regimen of doing weight lifting and squats and running and so on, I encourage people just to back off a bit because, as I mentioned, there is always the risk of a sudden death with aortic valve stenosis. I'm not quite so concerned in patients with leaking aortic valves. So just be cautious about what you do and also check with your cardiologist. The other thing is that in the week before surgery, avoid taking aspirin and vitamin E, and that's because those can cause some bleeding at the time of surgery. And if you are on any long-term anticoagulants like Plavix or Coumadin or any of those things, you'll be advised how to manage that and how to stop that. And potentially, for example, if you have a mechanical valve and you're on Coumadin, we will maybe bring you into hospital for a day or two and switch you to Heparin. That will vary from case to case and your surgeons will advise you about that.

“What advice do you have for recovery?” As I mentioned, walk 45 minutes a day, five times a week. And initially that's going to be around your home. Then increasingly say, go to the shopping malls and then hopefully if there's good weather, get out and walk and build up your strength again.

 So a couple of other questions. Connective tissue disorders. “What are connected tissue disorders?” So the building structure of your body, the musculoskeletal structure is made up of bones and then ligaments and support muscles and structures that hold those bones together. So when it comes to the heart and the aorta, the aorta has some elasticity to it, and that's because it's got elastic fibers. So it's like when you blow into a balloon, you blow the balloon up and you let the air out it, it comes down in size again. So with every beat, your heart pumps blood into the aorta, it expands, and then it contracts because of that elasticity. So there's some rebound from the elasticity. But obviously you cannot be having an aorta that's too elastic. You have to have something that restricts it from overstretching, and that connective tissue collagen stops it from excessively stretching. Now, what happens with connective tissue diseases, connective tissue disorders, is there's either loss of elastic tissue or the collagen tissues. And so that affects not only your aorta, your aortic valve, to some extent your heart, but it can affect the support for your joints. For example, people get curved spines or other things, hernias, associated with the connective tissue disorders. So if you come to see me for a connective tissue disorder, I will ask you questions about that. And in patients who have enlarged aortic roots, in particular, about 50% have inherited connective tissue disorder. So how do they affect the heart? Well, the effect is mainly on the valves and the aorta, but the heart muscle can also be weakened by connective tissue disorder. And also the lungs can be affected, so people can develop early emphysema because of loss of elastic tissue in the lungs.

“Should my families receive genetic testing?” That's a very good question. What we like to do in patients who have connective tissue disorders is to have the index person, in other words a person who presents with what is potentially a connective tissue disorder, tested for a genetic mutation, and you can have that done at home. If you come here we can also offer a free test that is done as an outpatient for a connective tissue disorder, and we look for 298 mutations that may be affecting your aorta. Or for that matter, other inherited heart diseases like cardiomyopathies or cholesterol issues or inherited heart rhythm problems.

“What surgeries may I need?” So for most patients who present to us with enlarged aortic root, we do the re-implantation operation where we free up the valve, put it in that tube graft and hook up the coronary arteries. We published a paper a while ago of 214 of our patients that had a connective tissue disorder, either Marfan syndrome or Lowes-Dietz syndrome or Ehlers-Danlos. And in that population, there were no deaths with the re-implantation operation and the freedom from re-operation was 97% at 10 years and 95% at 15 years. So really good results despite our early concerns about how durable that operation would be. So I highly recommend that in patients who have aortic root aneurysms and a connective tissue disorder. Unfortunately, a lot of patients develop aortic dissection related to connective tissue disorders, and that's the great danger with the connective tissue disorders. And when that happens, unfortunately, 40% of patients die immediately when that happens. And then the risk of death is about 1-3% per hour until people get to surgery.

And when you arrive at a hospital to be treated for that, the outcomes are very dependent on the individual hospital and how many of those type of operations they do to try and rescue. So that's acute aortic dissection surgery. And what is done at that operation is very dependent on the findings, but essentially the aortic root and the ascending aorta in most patients need to be replaced in patients who have connective tissue disorder. Not everybody has a connective tissue disorder that develops acute dissection, but the operation is dependent on what needs to be done. And then unfortunately, those patients also have to be followed over time for potentially developing aneurysms somewhere else.

All right, “who should I see?” So we set up patients here to see one of our cardiologists who also deals with the inherited connective tissue disorders when they have aneurysms of the aortic root, and then typically they'll see me also. Now if it's somebody with a cardiomyopathy, then it's a different team who deals with that and the other inherited disorders.

“What is a multidisciplinary approach?” Well, as I just mentioned, we work together with our cardiologist colleagues or vascular surgeons or bring in any other person who's needed to consult on what the best approach is for individual patients. All of us are on a salary, and so we are here to do the best for you as a team, and we work very closely and discuss the options about what will be best for you and what procedure is best for you. Whether that's replacing your aortic valve with a open min invasive J-incision, or a TAVR, or repairing your valve using a re-implantation operation that is discussed or we work together in figuring out what is the best option for you.

So I hope you find this review of what we do helpful. Thank you for listening.

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