CARDIAC A GUIDE FOR PATIENTS

©2018 St. Joseph’s Health WELCOME NOTES

Welcome to St. Joseph’s Hospital. We are honored that you have chosen St. Joseph’s Hospital for your cardiac surgery procedure and will do our absolute best to honor the trust you have placed in our exceptionally dedicated surgical team.

Performing the first open surgery in 1958, St. Joseph’s Health Hospital is a leader in cardiac care. A pioneer in prevention, detection, and the treatment of heart disease, St. Joseph’s performs more than 1,000 open heart procedures each year. Achieving excellence in cardiac surgery is truly a team effort. The cardiac surgery team includes the cardiac , cardiac anesthesiologist, assistants, nurse practitioners, respiratory therapists, , surgical techs, operating room, ; and step-down unit nurses, physical therapists, social workers, and case managers. Listed below are some highlights of the St. Joseph’s cardiac surgical program.

• Consistent clinical excellence over many years as evidenced by excellent results in New York State database over a 30-year period. • Top 5 among all New York State programs in terms of overall volume based on recent volume data. • Three star STS program (3 out of 3 stars) for overall quality, which places St. Joseph’s in the top 5-10% of all programs in the United States. The Society of Thoracic (STS) database is the largest clinical database in the world and the 3-star rating defines clinical excellence in cardiac surgery. • Extensive minimally invasive experience including robotic-assisted cardiac surgery, transcatheter aortic (TAVR), and catheter-based surgery. • One of the lowest readmission rates in New York State and the U.S. based on Medicare data.

Our team is dedicated to providing the highest level of cardiovascular care to the Upstate New York community. We will do our best to meet the needs of you and your family. Thank you again for choosing St. Joseph’s Hospital.

1 NOTES TABLE OF CONTENTS

TABLE OF CONTENTS

Part 1 Part 4 Meet Your Team Recovery After Hospital Discharge • Surgeons • Preparing for Discharge • Clinical Affiliates • Road Map to Recovery • Anesthesiologist • Monitoring Your Recovery • • When to Resume Usual Activities • Respiratory Therapist • When to Call • Physical Therapist • Dietitian Part 5 • Case Manager Cardiac Medications • Cardiac Rehabilitation Nurse Part 6 Part 2 Resources Preparing for Surgery • Cardiac Rehabilitation • Preoperative Appointment • Additional Nutritional Information • Preoperative Instructions • Skilled Nursing Facilities • Important Facts to Know Before Surgery • Cardiac Surgery Care Team Important Phone Numbers Part 3 • Map of Campus Recovering in the Hospital • Local Hotels • Care in the Cardiovascular Intensive • Website Links Care Unit (CVICU) • Understanding the Heart • Care in the Step Down Unit (D4) • Heart Disease and Treatment • • Glossary • Incision Care • What to Expect Each Day after Surgery • Frequently Asked Questions (FAQ) for Discharge

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Patient Pre-procedure Checklist

To help you prepare for your surgery and post-operative recovery, please use the following checklist.

Preadmission Testing Appointment: 104 Union Avenue Suite 905 Syracuse, New York Preoperative appointment for history and physical examination and testing.

Bring the following to your appointment: List of all prescriptions, herbal supplements, and over-the-counter medications that you are taking, including when you took the most recent dose of each . Prepare or update your Advance Directive. Insurance card Photo Identification

Notes:

Disability and family leave paperwork (if applicable) Obtain paperwork from employer and submit to surgeon’s office. Please allow 7 business days for completion of paperwork. PART 01 Notes: Post-operative appointments Post-operative evaluation and care is important for recovery after surgery. Following surgery, appointments with the surgeon, cardiologist and office are to be scheduled. Appointments with the surgeon’s office will be scheduled for you and may be found on your discharge paperwork. If an appointment is not noted, call the office to schedule. It is the patient’s responsibility to schedule follow up appointments with the cardiologist and primary care physician as advised on the discharge paperwork. Please review your discharge paperwork for further instructions. MEETING THE HEALTH CARE TEAM Take a list of questions with you when you visit your doctor. Bring a list of all medications that you are taking including name, dosage and frequency of medication.

Cardiac surgery appointment Cardiologist Primary Care Physician

3 54 RESOURCES MEETING THE HEALTH CARE TEAM

Pulse Oximeter –This is a machine that tells how Tricuspid Valve – The between the right much oxygen is in your blood. This percentage and the right . We will partner with you to best manage your heart health. of oxygen is known as oxygen saturation or “sat.” A dedicated team of professionals will provide care for you during A cord with a clip is attached to your finger, Ventricle – A lower (pumping) chamber of the heart. ear or toe. your hospitalization. Vital Signs – This includes taking your temperature, Stenosis – Narrowing or blockage of an or , pulse, and respirations (counting your Our cardiac anesthesiologists provide care for you in Our cardiac surgery program coordinator will work heart valve opening. breaths). Caregivers may also listen to your heart and the operating room. They are also trained in critical with the entire health care team to ensure the best lungs using a stethoscope. Your vital signs are taken care medicine and with your surgeon will manage possible experience. Swan-Ganz Catheter (PA Line) – A large and long so that your caregivers can see that you are making a your care in our cardiac surgery intensive care unit. intravenous catheter inserted through the neck used good recovery from surgery. We as a team look forward to caring for you and to monitor the blood pressure in the heart. The operating room staff is specially trained to your family. We stand by core principles of quality, care for you during your surgery. They include integrity, and compassion. We will make a sincere Thrombolysis – A process of dissolving clots that perfusionists who run the heart lung machine, commitment to delivering exceptional care and thank clog . surgical techs, and operating room nurses. The you for allowing us to serve you. cardiac surgery team also includes Physician Transesophageal Echocardiogram (TEE) – Assistants and Nurse Practitioners, who assist the An invasive type of echocardiographic procedure surgeon in the operating room and provide care for wherein a probe with an ultrasound transducer is you under the direction of the surgeon. The surgery placed into the esophagus via the mouth. team will round on you daily during your stay. They will discuss with you a plan of care and update you of any changes.

Physical therapists will evaluate you and begin an activity program while you are in the hospital. The respiratory therapist will provide care related to your ST. JOSEPH’S HOSPITAL individual needs. RANKED AMONG TOP IN

Registered nurses and licensed practical nurses NATION FOR HEART SURGERY will provide direct care for you throughout your stay. Following surgery you will be cared for in our St. Joseph’s Hospital is in dedicated cardiac surgery intensive care unit called a very elite class – which the CVICU and a step down unit called D4. includes only 15 hospitals out of more than 400 nationwide. After your surgery dietitians will be available for you to discuss any questions you may have concerning your diet. A cardiac rehabilitation nurse will visit you to discuss participation in a cardiac monitored exercise program during your recovery. Acknowledgements This booklet was created with the assistance of several St. Joseph’s Hospital Cardiac Surgery team members. Material from other cardiac surgery centers, including Hartford Hospital, Brigham and Women’s Hospital, and Johns Hopkins, was also utilized to help create this booklet. In addition patient educational material from the Society of Thoracic Surgeons and the book Heart 411 written by Drs. Marc Gillinov and Steven Nissen from the was also used in certain sections. Several illustrations were designed by Rose Zhou. We encourage our patients to take an active role in their heart health and seek out the valuable information listed in the Resources section of this booklet.

53 4 RESOURCES

Heart Monitor – This is a machine that allows Mitral Valve – The valve between the left atrium and your caregivers to view the tracing of your left ventricle. heartbeat on a TV type screen. Your heart is being watched to make sure your body is making a good Mitral Insufficiency (Regurgitation) – Inability recovery from surgery. of the mitral valve to close completely, resulting in leakage or backflow of blood into the top left (atria) High Blood Pressure (Hypertension) – A greater- chamber and the lungs. than-normal pressure of blood against the walls of the arteries. It may not make you sick, but over time Mitral Stenosis – Obstruction of the passage of it may cause wear and tear on the artery walls and blood across the mitral valve due to narrowing of may damage the heart, brain, eyes, and kidneys. The the opening, resulting in a decreased forward flow causes of high blood pressure are not completely of blood and accumulation of blood into the top left understood. Stress, high sodium diet, obesity, and (atria) chamber and the lungs. may contribute to or aggravate high blood pressure. In some cases the tendency for high blood – Heart muscle damage pressure runs in the family. brought about by a prolonged or persistent abrupt blockage of the blood vessels that supply the heart Implantable Cardioverter Defibrillator (ICD) – muscle (coronary arteries). Also known as a A special type of electronic device placed inside heart attack. the body to automatically terminate life-threatening abnormal heart rhythms. NG Tube – This is also called a nasogastric tube. This tube may be put in your nose and down into your Intra-aortic Balloon Pump – This is a circulatory stomach. The tube is attached to suction to keep your assist device commonly used in heart surgery to stomach empty. PART increase the supply of oxygen and blood flow to your heart when your heart is too weak to do its Oxygen by Mask or Nasal Prongs – You will normal work. receive extra oxygen through a mask or small prongs that enter your nostrils. Your caregivers will monitor IV Line – An intravenous line is a tube that is placed your vital signs to determine how much oxygen your 02 in your vein for giving or fluid. This tube body requires while you are in the hospital. can be capped or connected to tubing and fluid. Pacemaker – A device placed in the body to help Leaflets – The small flaps on the valves of the heart regulate your heart rhythm. This device sends out which serve as “doors,” allowing or preventing the electrical signals to keep the heart beating at a speed passage of blood. appropriate for your body’s needs.

LifeVest – A wearable defibrillator worn by patients – The condition of having an PREPARING FOR SURGERY at risk for sudden cardiac arrest. inside the lungs. Mechanical Valve – An artificial device implanted in Pulmonic valve – The heart valve between the right the heart to take the place of a natural valve. ventricle and the blood vessels that lead to the lungs (where blood is pumped to pick up oxygen).

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Glossary Preoperative Appointment • Your appointment in our Pre-Admission Testing (PAT) Office is designed to take care of Coronary – A blood clot in an artery Elastic Stockings – These tight elastic stockings all your medical testing needed before your surgery can take place. The visit normally which blocks the supply of blood to the heart muscle. keep blood from pooling in the legs and causing takes about two hours but can take longer if needed. Causes a heart attack. clots. They may also be called TED stockings. • The PAT Office is open Monday through Friday from 7:00 a.m. to 4:30 p.m. Your surgeon’s office will schedule your appointment. Consent Form – This is a legal piece of paper that Electrophysiological Study (EPS) – A procedure gives your surgeon permission to do surgery in which a catheter is inserted through the veins to • At your PAT appointment, you will undergo a physical examination and have blood work and other related procedures while you are in the the heart to study the electrical activity of the heart drawn. An EKG and chest x-ray will be taken. A Pulmonary function test and vascular hospital. It tells exactly what will be done to and to identify absence or presence of abnormal study of your veins may be completed. you, and what risks are possible. Be sure all your heart rhythms. If abnormal heart rhythms are present, • Medications and preparation for surgery will be discussed. questions have been answered before you sign the specific site of origin is identified and appropriate • You will be provided with patient education material including a website link this form. treatment is instituted. (http://cedu.sjhsyr.org) to view educational modules before your procedure.

Coumadin® – The commonly used trade name for the Monounsaturated Fats – Aid in lowering drug warfarin, an anti-coagulant (blood thinner) often blood cholesterol levels. They are liquid at room prescribed to reduce the chances of . temperature and originate only from plant and Preoperative Instructions vegetable sources. Examples: olive oil, canola oil, In the days before surgery, you will need to follow certain instructions, as detailed below. Deep Breathing and Coughing Exercises – peanut oil, and avocado. • The night before surgery, you will be asked to prep your skin. These breathing exercises help to prevent a lung • Infection is a potential risk with any surgery. infection after surgery. Deep breathing opens the Polyunsaturated Fats – Aid in lowering of blood airways going to your lungs. Coughing helps cholesterol levels. They are usually soft at room • To decrease bacteria we ask you to take a shower the night before surgery using special bring up sputum from your lungs. temperature and originate from plant and vegetable antibacterial soap called Chlorhexidine Gluconate solution. sources. Examples: cottonseed, soybean, corn and • If you cannot take a shower we ask you to clean your chest, arms, and legs with the Diabetes – Metabolic disease that prevents the body safflower oils. special soap we give you. from producing insulin (necessary to break down glucose) and regulating glucose levels in Saturated Fats – Raise blood cholesterol levels. • We ask that you remove all jewelry including piercings, necklaces, and rings. the blood Generally, they are solid at room temperature. They originate primarily from from animal sources, Diuretics – A medication commonly called a such as beef, veal, lamb, poultry, milk, butter, “water pill” that helps the body get rid of excess salt cheese and lard. and fluid. Skin Preparation Instructions for Bathing Fluid Restriction – This is the total amount of fluid Echocardiogram – A procedure which uses sound that you may take in a 24-hour period. It includes waves to: 1) evaluate the structures and functions of fluids that you drink by mouth and IV fluids. Fluid is THE EVENING BEFORE THE MORNING OF SURGERY the heart valves and heart muscle; and 2) measure the restricted after surgery because too much fluid can size of the heart’s pumping chambers (ventricles). be very stressful to the lungs. Thoroughly rinse your body with water from DO NOT SHOWER neck down Endotracheal tube – A tube inserted into the Foley Catheter – This is a tube that is placed in Do not shave your legs or chest for your lungs (via the mouth and throat) and attached to your bladder to drain your urine. When the catheter is Apply the Chlorhexidine Gluconate 4% solution surgery. Shaving with a razor blade can a respirator to supply oxygen when the lungs are taken out, you can urinate on your own. directly to the skin and wash gently with a increase your risk of infection. At the hospital unable to operate on their own. clean cloth while showering we will prepare your skin by removing hair with special clippers. Rinse thoroughly with warm water

51 6 PREPARING FOR SURGERY RESOURCES

Medications to Take the Prepare for Surgery on One Day Unit Evening Before Surgery • Your nurse will start an IV and apply oxygen. Breathing Treatments – Breathing treatments are Chest Tubes – These are tubes that are put into your • Your nurse will check your blood sugar level. • Your doctor will tell you what medications to take sometimes ordered to open your airways. chest during surgery. Chest tubes remove air, blood, the morning of surgery. If your doctor wants you to • We will have you remove any dentures, Medicine is slowly breathed in by mask or or fluid from around your lung, and are connected to take medication, take these medications with only eyeglasses, wigs, or hair pieces at this time. mouthpiece and often followed by Chest PT. a drainage container. sips of water. • You may wear hearing aids to the operating room • Take a rectal suppository prior to going to bed the but they will be removed before surgery. Cardiomyopathy – Enlargement and weakening of Chest X-ray – This is a picture of your lungs and night before surgery to assist in emptying the heart muscle which may have resulted from any heart. After surgery you may have a daily chest your bowels. Family Will Wait on Ground Floor one of various causes, i.e. long-standing heart X-ray taken either in your hospital room or in the disease, viral , toxic effects of alcohol or department. Caregivers may use the • Diabetic Medications – If you are a diabetic your Surgical Waiting Room during Surgery unknown causes. A dilated heart does not pump as X-ray to look for signs of infection, pneumonia or doctor will tell you what to take the day before • When you go to surgery your family will be well as it should. collapsed lungs. surgery and day of surgery. instructed to wait in our ground floor • Plan to have your evening meal no later than 6 surgical waiting room. – Works in place of heart Chordae – Tendon like cords which connect the PM. You may have a light snack and fluids after 6 • A surgical liaison will give your family updates and lungs during surgery to circulate blood to edges of heart valves to the papillary muscle PM. However, DO NOT eat or drink after midnight. about you and how you are doing. the body. thereby restricting how far the valve leaflets can open or close. • Surgery usually lasts 3-6 hours but this varies among patients. Your family should not be alarmed Catheter – A small plastic tube used to inject liquid Important Facts to Know if your surgery takes more or less time. (dye) into the coronary artery at the time of coronary Congestive Heart Failure – A condition in which angiogram or angioplasty/stent. the heart muscle is unable to effectively pump out Before Surgery • Once the surgery is completed, the surgeon blood to the rest of the body which results in will meet with your family and discuss your plan Cholesterol – A waxy substance with fat-like increase accumulation of blood in the heart Day of Surgery of care. properties present in animal tissues and, thus, in chambers and the lungs. • Most elective surgery patients are asked to come foods of animal origin such as meat, eggs and dairy to St. Joseph’s Hospital Health Center the day of Anesthesiologist Will Prep You for Surgery products. Saturated fats will also increase cholesterol Coronary Arteries – Vessels originating from the their surgery. You should expect a phone call the • Before entering the operating room, you will levels. In addition to food sources, cholesterol is main artery (), which runs on the surface of the night before giving you a time in which you should be taken to our pre-induction area. Here you manufactured by the body. Cholesterol in excess is heart, supplying blood to the heart muscle from arrive at the hospital. will meet your nurse and anesthesiologist. stored in the fatty deposits in the arterial wall the aorta. in . • Typically, early cases arrive by 5:30 a.m. and later Your operating room team will review medical Coronary Arteriography (cardiac cases by 7:30 a.m. We suggest you use valet information with you at this time. You will see your Low-Density Lipoproteins (LDL) – Special type of catheterization) – X-ray procedure in which dye is parking. Valet parking is available from surgeon and they will have you sign your consent cholesterol that, when high, increases the incidence injected to outline the coronary arteries, allowing the 5 a.m. - 9 p.m. Monday through Friday. for surgery. Any other questions/concerns that you of fatty deposits within arterial wall (increasing risk for physician to see blockages or abnormal narrowing in The cost is five dollars. If you wish not to use valet may have can be addressed at this time. coronary atherosclerosis). Called “bad cholesterol.” the artery. parking you can park your own car on the street • Our surgical team will then take you into the using a parking meter or you can park in the operating room where your surgery will be High-Density Lipoproteins (HDL) – A special (CAD) – A condition garage for a fee. performed. You can expect the operating room type of cholesterol that, when high, decreases in which a coronary artery is clogged by a buildup to be brightly lit, cool, and somewhat noisy. It’s • We will have you stop at the front desk, then you the incidence of fatty deposits within arterial wall of cholesterol and fatty deposits. Clogged arteries normal to be anxious about your surgery. Your and your family will be directed to go to the one (decreasing risk for coronary atherosclerosis). may potentially decrease delivery of oxygen-rich anesthesiologist will then give you an anesthetic day unit where the staff will review your medical Called “good cholesterol.” blood supply to the heart muscle and predispose to (medication) through your IV that will make you information and prepare you for surgery. development of heart attacks (myocardial infarction). sleepy, then your procedure will begin. You can Triglycerides – Another type of fat which, when be assured that before the operation begins you elevated, increases the risk for atherosclerosis. Coronary Artery Bypass Graft (CABG) – Acronym will be completely anesthetized and will feel no for Coronary Artery Bypass Graft surgery. Open heart pain. At the conclusion of the surgery you will be surgery used to bring new blood supply to the heart transported to the cardiovascular intensive care muscle by connecting pieces of a vein or artery to unit for recovery. reroute blood flow around the obstructed arteries. 7 50 RESOURCESPREPARING FOR SURGERY

Glossary

Ablation – A non-surgical procedure in which a – Refers to irregularities in heart catheter is inserted through the veins to the heart, rhythm with the heart beating either too fast and delivers an electrical energy to eliminate the (tachycardia) or too slow (bradycardia). The areas of the heart muscle or conduction system arrhythmias may reduce the pumping ability of that cause abnormal rapid and potentially the heart. life-threatening heart rhythms. Arteries – Vessels branching from the aorta – A bulge or in the walls of a which carry oxygen-rich blood to different parts blood vessel. of the body.

Anesthesiologist – The doctor responsible for Arterial Line – This tube is also called an “A-line,” monitoring your vital signs and general well being and is placed in an artery of the wrist. The line is and administering the medications that affect attached to tubing and is used to measure blood consciousness before and during your surgery. pressure or to draw blood tests.

Angina – A warning sign that the heart muscle is Atherosclerosis – Narrowing or blockage of not getting enough blood and oxygen. This may arteries (blood vessels) caused by build-up of fatty be manifested by one or more of the following: plaque made up of cholesterol and other materials a discomfort or a feeling of pressure, tightness, within the artery wall. squeezing, aching, pain, indigestion, fullness, heaviness or burning in the chest, arm, neck or jaw. Atria – The upper (filling) chambers of the heart

Anticoagulants – Medications that prolong the Bioprosthetic Valve – Also known as a tissue time it normally takes for the blood to clot. These valve, these come from animal (usually pig) or human medications ( and Coumadin) are often called (deceased) donors. “blood thinners.” Blood Pressure – A measurement of the force that Aorta – Main artery leading from the heart to the rest moving blood puts on the artery wall. It consists of of your body. two measurements: the systolic pressure, and the diastolic pressure. Aortic Valve – The valve that controls blood flow between the left ventricle of the heart and the aorta Diastolic Pressure – Pressure left in the arteries in (as blood exits the heart). between heartbeats. The “lower number” in a blood pressure reading. Aortic Insufficiency (Regurgitation)– Leakage or back-flow of blood from the aorta, across the aortic Systolic Pressure – Peak pressure in the arteries valve into the left ventricle. when the heart pumps out the blood to the body. The “top number” in a blood pressure reading. – Inability of the aortic valve to open completely, resulting in obstruction to the Blood Tests – You may need blood taken for tests. forward flow of blood from the left ventricle into This may be taken from a vein in your arm or the aorta. drawn from special IV lines. It will be tested to see how your body is handling your illness.

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PART 03

Permanent Pacemaker Insertion • The permanent pacemaker essentially takes over for the patient’s own diseased conduction system • The heart has its own electrical conduction system and allows the heart to beat normally. and a natural pacemaker called the sinus node that sends an electrical signal to stimulate the • A permanent pacemaker insertion involves RECOVERING IN THE HOSPITAL atrial and ventricular muscle to contract. placing very small catheters into the heart and connecting them to a small generator or battery • The heart’s conduction system can become placed just below the skin in the upper chest diseased, causing a very slow . In this (just below the collarbone). situation a pacemaker must be inserted.

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Cardiac Tumors • • Tumors can occur in the heart, but most -- Procedure where cardiologist uses a small Once your surgery is completed, you will be admitted to the Cardiovascular are benign catheter to create a on the inside of the • The most common type is called a myxoma and is heart to block AF electrical signals Intensive Care Unit for post-operative monitoring and care. found in the atrium • Surgical Ablation • Surgery is recommended to remove the tumor (Galaxy and Cryomaze Procedure) and can often be performed through a minimally -- Involves creating in a specific pattern in invasive approach the right and left atria. -- A clip is placed to close the left atrial The CVICU is located on the third floor in the surgical Who will be caring for you appendage (a sac-like structure that can tower, also known as D3 East. There you will receive contain blood clots), which reduces the care by a team of specially trained nurses. Their goal in the CVICU patient’s risk of stroke. is to help you recover as quickly as possible. • A designated surgeon will round and discuss your -- Can be performed in conjunction with another care daily with the members of the team, including procedure or as a stand-alone procedure for Care in the Cardiovascular a cardiac intensivist. This may or may not be the patients with symptomatic AF. Intensive Care Unit (CVICU) surgeon who performed your surgery. -- It is important to note that it takes about • You will stay in the cardiovascular intensive care • When you first arrive at the CVICU it will take the 6 months following the procedure to unit until the surgeon has decided it is safe for you nurses approximately one hour to get you settled. know for sure if the MAZE procedure has to transfer to the step-down unit. Each patient’s After that time your family will be allowed to visit. been successful. stay varies, however patients generally spend 24- The CVICU guidelines will be discussed with your 48 hours in this unit. -- A Pacemaker is sometimes necessary after a family at that time. surgical ablation. • When your doctor feels you are making sufficient • Family and patients should know that the critical progress in your recovery, you will be transferred Galaxy procedure care unit has open visiting hours. Family and from the CVICU to the post cardiac surgical unit or friends can visit any time of the day yet we step-down unit where you will remain until you are • Minimally invasive option for AF in which scars are Surgery encourage visitors to see their loved one based on discharged from the hospital. created on the outside of the left atrium by small • Atrial fibrillation (AF) is the most common irregular the patient’s request. This is a critical time for the radio frequency energy catheters. heart rhythm and can lead to dizziness, fainting patient to rest and recover. Immediate Post-operative Period and stroke. • Performed through very small incisions in the • Many of you will want your family to be kept patient’s right and left chest • It is routine for patients recovering from surgery • It is most common in older people with heart informed about your recovery, but due to patient to be surrounded by monitors and equipment. The disease or after cardiac surgery, but can also occur • Performed without placing on the heart-lung privacy laws (HIPPA regulations), our ability nurse caring for you can explain the equipment in otherwise young and healthy individuals. machine or stopping the heart to share information about your condition is limited. We recommend you appoint a family and answer any questions you may have. During your surgery many tubes will be placed while you Atrial Fibrillation Treatment Options Cryomaze procedure spokesperson whom we call with updates and they may call us for information. are asleep. • Medical • Procedure in which scars are created on the • It is common for patients to experience some inside of the left and right atrium by a catheter that • You and your family member will be asked to -- Medications that slow the heart rate and help confusion, which in some cases may last a few freezes the atrial tissue. complete a Disclosure form. This will provide the convert the rhythm to normal health care team with two contact names and days. This is often due to many factors, including • Procedure is performed either through a -- Blood thinners such as Coumadin that reduce numbers. The two people you have elected will be , pain medication, and the stress of sternotomy or through a small incision in the the risk of stroke given a pin number. This pin number allows the surgery. This can be scary for you and your family patient’s right chest and is performed on the health care team to give information about you but will go away with time. • heart-lung machine with the heart stopped. over the phone. We ask that only the designated -- Procedure which uses low dose of electric spokesperson call the unit for information. current to restore normal heart rhythm

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Mechanical Ventilator or Valve Sparing You will receive a red pillow Surgery (David procedure) (Breathing tube) with this surgery to support • A breathing tube will be placed for your surgery your chest and decrease your • Procedure in which the aortic wall is replaced and a ventilator will breathe for you. pain with coughing. with a graft and the patient’s own aortic valve is left in place • The breathing tube is usually removed 4-6 hours after your surgery. It is common to have • Typically performed for patients who have an about the breathing tube. We will guide you aortic aneurysm (ballooning of the artery) with • This red pillow means “STOP!” through the process when removing the tube, a normal aortic valve making sure to address any of your fears. Each -- DO NOT lift more than 5-10 pounds for at least patient varies and the breathing tube will be 2 months. removed when the cardiac surgery team feels -- DO NOT push or pull using your chest. you are ready. You are sleepy during this time and -- DO NOT raise your arms above your head. often will not remember the tube even being in. -- Following these sternal precautions is • After the tube is removed it is important for you extremely important. to cough and deep breathe. Coughing and deep • Aortic are often diagnosed by chance breathing is extremely important to your recovery. -- A bag of sugar weighs 5 pounds and a gallon when the patient undergoes a chest X-ray or CT You will be asked to exercise your lungs using an of milk weighs 8 pounds. scan for another problem. incentive spirometer. • As an aneurysm enlarges the risk of rupture Minimally Invasive • If you need instructions on how to use the increases. Because aortic rupture is life An incision on the side of the chest between the incentive spirometer, a respiratory therapist or threatening and often fatal, it is important that the ribs means the surgery was performed through a your nurse can help explain the proper use. patient be closely followed by a cardiac surgeon to minimally invasive approach. prevent this devastating event. -- We will give you a heart-shaped pillow to • Valve surgery is performed with an incision on the use to splint your incision when coughing to right side of the chest. Repair of Ascending, Arch, or Descending decrease any discomfort you may have. Aortic Aneurysm • Coronary bypass surgery is performed with an Repair of -- We ask you to perform coughing and deep incision on the left side of the chest. • Surgery is generally recommended when the • Aortic dissection is a life-threatening emergency breathing exercises 10 times every hour while aneurysm reaches 5 to 5.5 cm. where the aortic wall tears and requires emergent you are awake. • Repair of an ascending or aortic arch aneurysm medical and surgical treatment. Where is the location of involves removing the aneurysm completely and • Dissections are often associated with uncontrolled You will receive a green replacing it with a Dacron graft. high blood pressure or smoking and may occur in pillow following this surgery. your incision? • Performed through a conventional sternotomy a patient with an aneurysm. Sternotomy (breast bone dividing) approach. • Aortic dissections are classified into two types: Incision runs down the middle of your chest and Type A and Type B dissections. involves dividing the breastbone or sternum. • Descending aortic aneurysms can often be repaired using endovascular techniques -- Type A dissections start in the ascending aorta • The bone is wired together but this means you • This green pillow means there is no broken bone (stent grafts). and require emergent surgical repair to prevent have a broken bone and all broken bones require death from aortic rupture. 6 to 8 weeks to heal. -- You will recover faster and can use your arms more. -- Type B aortic dissections start in the • It is very common to have a small lump at the top descending aorta and can generally be of your incision. This will go away with time. -- Most patients are fully recovered in one month managed medically with blood pressure • Many patients will also have an incision in their • Notify your surgeon if you have an to metal control. Surgery in this group is reserved for groin. This is used for access to the heart lung or Nickel. The wires contain a small amount of those patients in whom medical management machine. This incision generally heals quickly Nickel, which could cause a reaction. In that case fails or have evidence of rupture. we can close the bone with Titanium plates. but it is common to have a small lump and some numbness around this incision for a few weeks.

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Mechanical valve • Advantage -- Very structurally durable, failure very rare • Disadvantage -- Patient has to take long-term Coumadin (also called Warfarin), which carries an increased risk of bleeding. 0 1 2 3 4 5 6 7 8 9 10 -- Make an audible clicking sound.

Minimally Invasive Approaches

No Mild Moderate Severe Very Severe Worst Pain Port-Access Approach Symptoms Symptoms Symptoms Symptoms Symptoms Possible Picture showing completed tricuspid valve repair • or replacement surgery is (Used with permission from Medtronic) performed through a small incision between the ribs (mini-). Tricuspid Valve Replacement • The surgeon also makes a small incision In some cases (most commonly infection) the tricuspid in the groin to place the patient on the valve can’t be repaired and replacement is the only heart-lung machine. option. This is most commonly done with a tissue (pig) valve. • With this approach there is no broken bone that has to heal and the patient is generally fully Minimally Invasive Options recovered in one month. A tricuspid valve repair or replacement can be performed through a minimally invasive approach. Robotic-assisted Mitral Valve Repair This involves making a small incision between • The daVinci robot is added to the port-access the ribs on the right side of the chest called approach in selected patients with mitral valve a mini-thoracotomy. prolapse who need a complex mitral repair. • The benefits to the patient are similar to the Aortic Aneurysm Treatment Pain Management port-access approach in that patients have a Aneurysm Surgery • Managing your pain is important to your recovery. -- After surgery you will be given pain medication much faster return to full activity compared • The thoracic aorta is located in the chest area and to the conventional approach. We want you out of bed and walking as soon through an infusion. Once you are able to take is the major blood vessel taking blood away from as possible. medication by mouth, you will be given pain the heart and toward the other organs. pills. Prior to discharge to home, you will be Tricuspid Valve Surgery • You can expect to experience some pain after • A occurs when the aorta surgery but our goal is to make you as comfortable prescribed pain medication to use as needed. The tricuspid valve is located between the right enlarges to greater than 50 percent of the vessel’s as possible. If you feel uncomfortable tell your nurse • If you start to feel pain at any time, please ask atrium and the right ventricle. When the tricuspid normal diameter. or other health care provider. the nurse for pain medication. Pain medication valve becomes severely diseased and the patient • An aortic aneurysm can be caused by a is not given routinely. Do not wait until you are develops symptoms (most commonly (fluid • To help control your pain after surgery, you will be combination of many factors, including high blood very uncomfortable or until it is offered. The build-up) or fatigue) then surgery is recommended. asked to rate your pain on a scale of zero to ten. pressure, smoking, and genetic factors such as sooner you request pain medication, the better bicuspid aortic valve and Marfan’s syndrome. -- Zero means no pain at all and ten means the you will manage your pain. When your pain is well Tricuspid Valve Repair worst pain you have ever experienced. controlled, you will be able to exercise your lungs Most tricuspid valve disease is due to other by using the incentive spirometer, sleep better, valve problems and in most cases the valve can -- Once your pain treatment begins, your nurse eat better, increase your daily activity, and feel be repaired. will periodically reassess your pain to see how well your medication is working. better overall.

45 12 RECOVERING IN THE HOSPITAL RESOURCES

What to expect in the CVICU Chest Tubes Mitral Valve Disease Mitral Valve Surgery Heart Monitors and Temporary • You will have one to three tubes in your chest, • The mitral valve is located between the left atrium Mitral Valve Repair depending on your open heart surgery. These Pacing Wires and left ventricle and essentially separates the tubes drain blood and fluid from your chest cavity • Most patients with mitral valve disease are • During your entire stay you will be connected heart from the lungs. candidates for mitral valve repair. to a heart monitor. This allows the following surgery. Often these tubes are removed • Thin parachute-like structure composed of two and nurses to watch your heart and rhythm. 2-3 days after surgery. Your surgeon will decide • If the valve CAN be repaired, repair is preferable to leaflets attached to the ventricle by thin cords. It is important for us to monitor your heart when these chest tubes will be safely removed. replacement. after surgery. • The mitral valve can become diseased due to a • Advantage to the patient is improved quality of life, Bladder Catheter problem with either the leaflets or heart muscle. • The monitors also help your nurse watch the better heart function, and no need to take long- pressures in your heart and your heart rate. • A bladder catheter (also called Foley catheter) • Most common mitral valve problem is mitral term blood thinners. You will have ECG (electrocardiogram) wires is also placed in the operating room which will regurgitation (leakage) caused by mitral and special IVs in your wrist, neck or groin that drain the urine from your bladder. The catheter is valve prolapse. removed as quickly as possible to decrease the connect you to monitors. • Mitral regurgitation can also be caused by a chance of you getting an infection. Sometimes the cardiomyopathy (weakening of the heart muscle). • It is very common to have minor problems with catheter will remain in. Your surgeon will decide your heart rhythm after heart surgery. These when the catheter can be removed. • Mitral valve stenosis (narrowing) is caused mainly are usually rhythms called atrial flutter or atrial by rheumatic heart disease and is much less fibrillation where the top chamber beats faster Chest X-rays common today. than the bottom chamber. This can make you feel • Mitral valve surgery is recommended when anxious but is easily treated with medication. • Chest X-rays are taken in the CVICU, or in the imaging department following your surgery. You regurgitation or stenosis is severe and the patient • You will also be connected to a temporary pacer may expect chest X-rays at different times during develops symptoms (shortness of breath and box. Small pacing wires are placed on the surface your hospitalization stay. fatigue most commonly). of the heart during your surgery. The purpose of theses wires is to increase your heart rate if Circulation necessary after surgery. They are temporary and will be removed before you go home with little or • After surgery your circulation is compromised no discomfort. due to inactivity for an extended period of time. Picture showing completed mitral repair for mitral prolapse A soft foam dressing will be applied to your (Used with permission from Medtronic) buttock area to protect pressure points. This will prevent skin breakdown often caused from inactivity. Once your activity increases, the In some patients the mitral valve is severely diseased dressing will be removed. and a repair is not possible. In those patients, the • Circulation of your legs is also important to valve has to be replaced. prevent blood clots. Your doctor will order elastic stockings to wear. These stockings help blood flow Bioprosthetic valve (tissue: pig or cow) back to your heart and prevent blood from pooling • Advantage in the veins of your legs. The nursing staff will apply these stockings every morning and remove -- No long-term Coumadin them at bedtime. The morning after surgery the (a blood thinner) required nursing staff and physical therapist will assist you • Disadvantage in getting out of bed and sitting in a chair. -- Not as durable as mechanical valves. -- About a 10% chance the patient will need repeat surgery in 10 to 15 years.

13 44 RESOURCES RECOVERING IN THE HOSPITAL

Care in the Step-Down Unit (D4) Most patients are transferred to the post-cardiac Your surgeon has approved your transfer from the floor the day following their surgery. This may intensive care unit to be cared for on the step-down vary depending on your progress. unit. Here the remainder of your recovery will take • Once on the floor, the cardiac team will continue place until you are discharged to home. to see you daily to discuss your plan of care and discharge. The telemetry floor is also known as D4. D4 is located • The surgeon who performed your surgery may on the fourth floor in the surgical tower. Here you will not always be present during morning rounds, but be cared for by a team of specialty trained nurses, available if you should have any further questions and other members of your care team, including a that cannot be answered at that time. physical therapist, dietitian, cardiac rehabilitation nurse and case manager. Our goal is to prepare you • The Case Manager will also be involved in for a safe discharge. your care to facilitate and address your discharge needs.

Traditional Open-Heart Surgery Minimally Invasive Valve Surgery What to Expect Each Day After Surgery

(Picture used with permission from Edwards Lifesciences) • Be weighed every morning • Have your blood pressure, heart rate, oxygen level, and temperature checked • Get out of bed for each meal • Valve can be placed though other approaches if Minimally Invasive Approaches • Use your incentive spirometer 10 times every hour while you are awake the legs’ arteries are too small. EVERY DAY • Two basic approaches • Use your heart pillow to help you cough and breathe deeply • It is anticipated that this procedure will expand in -- Mini-thoracotomy (small incision between • Have your fluid intake and output monitored the future. the ribs) • See an increase in your activity level and tolerance

-- Mini-sternotomy (small upper partial • Sit in a chair for your meals breastbone dividing incision) approach • Walk in your room with assistance DAY 1 -- Both allow the patients to get back to full • Begin eating a heart-healthy diet activity faster compared to a conventional • Begin discharge planning with the care team and your family sternotomy approach. • Have your dressings changed or removed, if possible • Very commonly performed at St. Joseph’s • Have your Foley catheter removed • Take a shower Transcatheter • Walk in the halls 2 to 4 times per day with assistance (TAVR) DAYS 2 & 3 • Have your oxygen removed • New option for patients who are not candidates • Increase the amount of food you eat for a conventional or minimally invasive AVR • Begin discharge planning with the care team and your family • TAVR procedure involves the cardiologist and • Finalize discharge plans cardiac surgeon working as a team to place a new Example of a catheter valve currently used at St. Joseph’s Hospital valve via a catheter placed in the femoral artery • Walk in the halls 3 to 5 times per day (groin artery). The only incision for the patient is • Walk up and down stairs with staff assistance • Continue to increase your food intake to help the healing process a small groin incision. (Used with permission from Medtronic) DAYS 4 & 5 • Receive diet and medication instructions in preparation for discharge • Finalize discharge plans 43 14 RECOVERING IN THE HOSPITAL RESOURCES

Activity • St Joseph’s Hospital offers ROOM SERVICE, which allows you to call for each meal when you are • Early activity following heart surgery has been ready. In the Intensive Care Unit, your nurse will shown to improve the speed of recovery, help you order meals. Once on the D4 step-down decrease complication rate, and make patients unit, you will have a phone in your room and can feel better overall. call for yourself to order your meals. • Fatigue is very common after surgery so do not -- Choose food items with blue apples and red get discouraged. . The blue apples identify foods lower in • We encourage patients to get out of bed for meals. sodium and the red hearts identify foods lower in saturated fats. • We will provide assistive devices such as canes and walkers as needed. You will continue to increase • Other accommodations will be made if you have your daily activity by gradually increasing the time diabetes or have other dietary needs. in which you walk and the distance you walk. • If you have diabetes and are prescribed a • The goal for all cardiac surgery patients is to walk consistent carbohydrate diet, select a total of four three times a day and to sit in a chair for all meals. carbohydrate servings at each meal. The number in parentheses ( ) next to each food item is the -- The nurses and physical therapist will assist you in walking. number of carbohydrates servings in the food. • Good blood sugar control helps you heal, and -- We ask that you walk two times on the day shift (7 a.m. - 3:30 p.m.) and once on the evening avoid infections. shift (3 p.m. - 11:30 p.m.). • The representatives in the Nutritional Services Call Center will be able to assist you in making the -- You may walk more as tolerated. appropriate meal choices while you are in the hospital. Diet • It is very common to have a poor appetite and for Case Management food to not taste right after surgery but this will improve with time. • The case managers will round with the cardiac surgery team daily to discuss your plan of care and • After your surgery, eat three meals, or six smaller keep you updated of any changes. meals each day. • A case manager or discharge planner is a • Eating a balanced diet with adequate calories and registered nurse who serves as a resource for you protein will help your incisions to heal. and your family through support, and education • Select 1-2 high protein foods at each meal such as with clinical expertise. eggs, meats, poultry, fish, dairy products, • Case management is a collaborative process of and beans. planning, care coordination, and advocacy for • If you continue with a poor appetite and intake options and services to meet a patient and family’s your Physician or Registered Dietitian may health needs. suggest you try nutritional supplements to help • Your case manager will coordinate and manage all meet your protein and calorie needs for healing. of your anticipated discharge needs. • Following surgery most patients are started on a low-saturated fat, low-sodium diet.

15 42 RESOURCES

Endoscopic Saphenous Vein Harvest • Advantage • Minimally invasive approach in which surgeons -- No long-term Coumadin (a blood thinner) use an endoscope (thin surgical tube with a light, required camera, and instrument on the end) to dissect • Disadvantage the vein carefully through a small incision below -- Not as durable as mechanical valves. the knee. -- About a 10% chance the patient will need • Standard approach at St. Joseph’s repeat surgery in 10 to 15 years.

Heart Valve Disease Mechanical Valve and Treatment • Advantage Aortic Valve Disease -- Very structurally durable, failure very rare • Aortic valve separates the left ventricle from the • Disadvantage aorta, has three thin leaflets, and is the final valve -- Patient has to take long-term Coumadin blood flows through as it exits the heart. (also called Warfarin), which carries an • Can become either stenotic (tight) or increased risk of bleeding. insufficient (leak). -- Make an audible clicking sound. • Aortic valve disease can be either congenital (present at birth) or acquired (develops over time). • Most common congenital problem is a bicuspid (two leaflet) aortic valve • Most common acquired problem is called calcific aortic stenosis. • Surgery is required when the valve becomes severely diseased and the patient develops symptoms (commonly angina, syncope (passing Bovine (Cow) Pericardial Valve out), and shortness of breath)

Aortic Valve Surgery Aortic Valve Replacement (AVR) Aortic valve replacement involves removing the patient’s diseased valve and replacing it with one of the options below. Conventional replacement involves placing the patient on the heart lung machine.

Bioprosthetic Valve (Tissue Valve: Pig or Cow) Mechanical Valve • Tissue valve most commonly from a pig or cow.

• Very common: 90% of all valves replaced in U.S. (Used with permission from Edwards Lifesciences and Medtronic)

41 16 RECOVERING IN THE HOSPITAL RESOURCES

Cardiac Rehabilitation What if I am too weak to resume my Factors You Can’t Change • Arteries (left internal mammary artery (LIMA)) and normal activities? • Family History veins (saphenous vein from the leg) are used to • A Cardiac Rehabilitation Nurse will visit you in bypass the blocked coronary arteries and improve You will be evaluated by a physical therapist the hospital. • Gender the blood supply to the heart muscle. following your surgery to assess your ability to • Cardiac rehabilitation has many long-term benefits • Age move. If they determine that you are too weak • Most durable CAD Treatment Option and we encourage every patient to attend. to resume your normal activities safely they will • Diabetes • CABG surgery is usually performed with the heart • Patients generally begin cardiac rehabilitation recommend you go to a short-term rehabilitation stopped which requires placing the patient on the once cleared by their surgeon and cardiologist, facility in your area to gain strength. Or you may Other Factors to Consider heart-lung machine or cardiopulmonary bypass about 6-8 weeks after surgery. benefit from having a physical therapist come to • Inflammatory diseases your home for several visits. (rheumatoid arthritis, psoriasis, lupus) Minimally Invasive Options Frequently Asked Questions • Gum disease Off-pump Coronary Artery Bypass How do I arrange for homecare services? (FAQs) For Discharge • Air pollution Grafting (OPCAB) The RN case manager will perform an assessment of Your discharge process begins on admission to the • Procedure where bypass surgery is performed your homecare needs following your surgery. They • Sleep apnea hospital. The team will ask you questions about on a beating heart without the use of will work with you and your insurance plan to identify how you care for yourself on admission so we can • Emotional stress cardiopulmonary bypass (the heart-lung machine) anticipate possible needs after your surgery. a homecare agency that your plan participates with. The case manager will review any copayments CAD Treatment Options • Conventional CABG is the gold standard, but required by you and complete all required paperwork the OPCAB technique may benefit selected When will someone from the hospital • Lifestyle Changes meet with me to discuss my and referrals. high-risk patients discharge plan? -- Quiting Smoking Robotic-assisted Coronary Bypass Grafting What is short-term rehabilitation? -- Low Fat Diet A case manager will also meet with you the day • A minimally invasive option where a single or after your procedure to review, update, and finalize Short-term rehabilitation is a program located in -- Regular Exercise a separate skilled nursing facility that provides double vessel bypass is performed your hospital discharge plan to ensure a safe return -- Reduce Stress to home. supportive services from professional personnel that • The daVinci surgical robot is used to dissect the include registered nurses, licensed practical nurses, • Medical Therapy left internal mammary artery (LIMA) off the inside How do I contact my case manager if I physical therapists, occupational therapists, speech • Stents, also called Percutaneous of the chest. The LIMA is then connected to the pathologists, and certified nursing assistance. They have a discharge related question? Coronary Intervention (PCI) target coronary artery through a small incision will assist you with daily designed to help (mini-thoracotomy) between the ribs. • Coronary Artery Bypass Grafting (CABG) You can contact the Hospital case management you return to your previous activity level. You stay • Shorter time in hospital and faster recovery time department at (315) 448-5678. Please feel free overnight at the facility, in a shared room, receiving all compared to conventional CABG to leave a message during the evening or medications, meals, and therapies at the facility. weekend hours. Coronary Artery Bypass Grafting (CABG) Hybrid Surgery How do I pay for short-term Will I be able to go home after rehabilitation? Combining robotic-assisted coronary bypass with my surgery? The case manager will review your insurance plan for stenting of other coronary arteries. That will depend upon how well you are able to move short-term rehabilitation benefits with you. You will • Involves the cardiac surgeon and cardiologist after your surgery. A physical therapist will assess you be given a choice of several skilled nursing facilities working as a team to treat the patient’s coronary after your surgery and determine whether you are to choose from. Your short-term rehabilitation artery disease in the most minimally invasive appropriate to go home or need a brief stay at short- benefits are determined by your insurance plan. way possible. Private insurance and managed Medicare plans have term rehabilitation facility to gain strength. • The cardiac surgeon performs a robotic-assisted varying copay amounts. Medicaid has no copayment single-vessel coronary bypass and the cardiologist Will I need someone to take care of responsibility. Medicare patients not enrolled in places a stent to treat the disease in the other me at home? a managed care plan will receive full payment of coronary arteries. Our goal is for you to have a safe discharge. Our team rehabilitation services day 0 to day 20. Days 21 to 100 have a copayment. • St. Joseph’s hospital is one of the few centers in will assess your individual needs and work with you Upstate New York that offers this procedure. and your family to develop a safe discharge plan. 17 40 RESOURCES RECOVERING IN THE HOSPITAL

Understanding the Heart • The heart has its own internal pacemaker called the sinoatrial (SA) node, which sends an electrical Heart Facts signal to the atrium (top chamber) causing it • The women’s heart weighs about 8 ounces and a to contract. man’s about 10 ounces. • The signal continues through the atrioventricular • The heart is a little larger than your fist and sits in (AV) node and into the ventricle (bottom chamber) the chest between the lungs. causing it to contract and force blood out. • The heart pumps about 5 quarts of blood each minute and about 2,000 gallons per day Heart Disease and Treatment throughout the body. Coronary Artery Disease (CAD) • The heart beats about 100,000 times each day and and Treatment about 2.5 billion times over a 70 year lifetime. • Coronary artery disease or atherosclerosis occurs • The first hearts specialists emerged after World when fat and cholesterol deposits build up on the War I and modern cardiac surgery first began in inside of the coronary arteries. the late 1960s. • The fatty deposits continue to thicken and enlarge Coronary Artery Anatomy throughout a person’s life. Called atherosclerosis, this thickening narrows the arteries and can • Two main coronary arteries (left and right) supply decrease or block blood flow to the heart. blood to the heart muscle. • When a clot forms, a heart attack may occur. • The left has two large branches called the left anterior descending (LAD) and circumflex arteries. • The term three vessel coronary disease refers to the right coronary and two left side branches (LAD and circumflex) How long do patients typically stay at Who can help me with my disability and short-term rehabilitation? family leave paperwork? Heart Conduction System Typically at least one week, but your stay will depend Our office can assist you with filling out these forms. upon your progress.

How do I get transportation to short-term rehabilitation? You will be transported by wheelchair van or stretcher van. You will be responsible for payment of this transportation as insurance plans do not cover this expense with the exception of Medicaid. The case manager will work with the transportation companies on your behalf to set up your transportation. Many companies require you to pay What Causes Coronary Artery Disease? at the time of service, but some will bill you later. These private transportation companies are not • Smoking affiliated with the hospital. If you want your family to • High Fat and Cholesterol Diet transport you to rehabilitation, please discuss this • The heart has a conduction or electrical system, • High Blood Pressure with your case manager. which causes the heart to beat. • Lack of Exercise

39 18 Coronary Artery Anatomy • Two main coronary arteries (left and right) supply blood to the heart muscle. • The left has two large branches called the left anterior descending (LAD) and circumflex arteries. • The term three vessel coronary disease refers to the right coronary and two left side branches (LAD and circumflex)

PART 04

RECOVERY AFTER HOSPITAL DISCHARGE

19 RECOVERY AFTER HOSPITAL DISCHARGE

Understanding the Heart Preparing for Discharge Road Map to Recovery • Average length of stay in the hospital is 5-7 days Incision Care Heart Anatomy following surgery but depends on what type of • Your incisions will be closed with dissolvable surgery was performed. Your length of stay will stitches covered by a layer of glue. There will • The normal heart has four chambers (right and left atriums, right and left ventricles) also vary depending on your recovery. be no staples. and four valves (Tricuspid, Mitral, Aortic and Pulmonic) • The team will be assessing you daily to be sure • No matter what type of incision you have, your you are meeting the milestones necessary to incision sites are easy to care for. discharge. The case manager will check in with • Monitoring your incision after surgery is important. you to see if there are any other resources you We will ask you to look at your incision daily. might need prior to discharge. -- Watch for signs and symptoms of infection. • In order for you to be discharged from the hospital Call your surgeon if you have a temperature you must: Eat, drink, move your bowels and above 101 degrees; if you have redness or urinate, walk, and have your pain under control. swelling; yellow or thick drainage (pus) from If you cannot do these things you will not be your incisions. discharged from the hospital. • Wash your incisions daily with mild soap and warm • Once your surgeon feels you are ready to be water. Continue to use the soap given from the discharged, the nurse will review your discharge hospital until it is gone. Avoid vigorous scrubbing. instructions including diet, activity and follow-up appointments with your cardiologist, primary care • It is very common to experience numbness around physician, and surgeon. the incision. This will improve with time. • The pharmacist will also visit and review any new • Because incisions sunburn easily, be sure to medications you have been started on while in the protect them from overexposure to sunlight hospital and answer any questions you during the first year after surgery. The scar will might have. pigment more (be darker) if exposed to the sun. Do not apply any lotions, creams, oils, or powders • We will also schedule your follow-up appointment to your incisions unless prescribed by your with your surgeon. We will notify you of any cardiac surgeon. appointments you will need to make with your primary doctor and cardiologist. • Please leave your incision open to air. There is no need for any dressings at home unless there is drainage. Itching and tightness and/or numbness along the incision is normal. A lump at the top of You can anticipate checkout your chest incision is normal and will go down in a time on the day of discharge to couple of months. be before 11:00 a.m. Leg Incision

• Please make plans to have a ride ready so your If your surgery involved taking a bypass from your leg, discharge is not delayed. follow these guidelines: • If you are going to short-term rehabilitation, we • Avoid crossing your legs because this will arrange transportation for you to the facility. impairs circulation. • Your discharge will be the final step in your care • Avoid sitting in one position or standing for while in the hospital. Should you have questions or prolonged periods of time. concerns, do not hesitate to ask any member of the • Elevate your leg whenever possible when sitting. health care team. Your care is important to us.

20 RECOVERY AFTER HOSPITAL DISCHARGE RESOURCES

• Check your leg daily for swelling. The swelling • Activity is important to your recovery. Should you Local Hotels should decrease when you elevate your leg, but it have any further questions about your restrictions, might recur when you stand again. please ask a member of the cardiac surgery team For updated hotel list and pricing search “Syracuse, NY” in the website www.hotels.com. • If you continue to have leg swelling or it becomes for recommendations. worse, notify your doctor. • Unless your doctor tells you differently, you can • If elastic stockings (TED Hose) were prescribed climb stairs. Sarah House Ronald McDonald House for you, wear the elastic stockings during the day $ Heart–Healthy Nutrition 130 Roberts Ave 1027 E Genesee St while up for at least three weeks after discharge. Syracuse, NY 13207 Syracuse, NY 13210 A Low Sodium, Low Saturated Fat diet is The stockings will help decrease swelling in $15 PER NIGHT (315) 475-1747 (315) 476-1027 your legs. 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If your post-exercise pulse rate is more www.eatright.org Hampton Inn Residence Inn than 30 beats faster than your resting pulse rate 417 7th North St Downtown The Craftsman Inn you have exercised too hard. You will need to Liverpool, NY 13088 300 West Fayette St 7300 E. Genesee St modify your activity. (315) 479-9900 Syracuse, NY 13202 Fayetteville, NY 13066 (315) 422-4864 (315) 637-8000

21 38 RESOURCES RECOVERY AFTER HOSPITAL DISCHARGE

What should I eat? Sleep A Mediterranean Diet has been shown to promote • It is very common to have trouble sleeping for a heart health. few weeks. This will improve with time. It is OK to • Eat more fresh fruits, vegetables, beans, nuts, sleep on your side as long as you don’t lift greater seeds, legumes, whole grains, olive oil, poultry than 5-10 pounds for 2 months following surgery. without the skin, fish, low-fat dairy. • Eat more omega-3 fats (heart-healthy fats) and Emotions foods that have omega-3s include salmon, tuna, • A cardiac surgical procedure is stressful to both mackerel, and sardines. the body and the mind. • Aim to eat fish twice a week. • is very common following cardiac • Eat more fiber. surgery and you can be reassured that it almost always improves with time. • Aim for 20-30g of fiber per day. • It is also very common to have periods of • Foods high in fiber include oats, beans, fruits, confusion and short-term memory loss. This will vegetables, and whole grains. also improve with time. • Aim for 5 cups of fruits and vegetables per day. Cough NOTE: If you would like more information about changing your diet, please CAMPUS MAP ask your nurse or health care provider for the Registered Dietitian to come • It is very common to experience a cough following speak with you. cardiac surgery but this will resolve with time. Sex • This is most commonly due to the breathing tube but can also be due to medication called an ACE • You can resume sexual relations when you feel inhibitor (see medication section). Website Links comfortable. For many people this is about two to four weeks after discharge unless instructed • It is important to use your pillow to stabilize your Cardiac Surgery Patient The International Society for Government Website for differently by your doctor. You should avoid any chest when you cough. Education Website Minimally Invasive Information on Vitamin K positions that place stress on your chest or http://cedu.sjhsyr.org Containing Foods arms. Please ask your nurse for more detailed Showers www.ismics.org ods.od.nih.gov/factsheets/ information, if needed. Society of Thoracic Surgeons VitaminK-Consumer/ • You can take showers after your pacing wires www.sts.org American College of are out. Avoid direct pressure of water on your www.acc.org More Detailed Information Driving incision. Avoid bathing until your incisions are The Patient Guide to Heart, Lung, on Coumadin • You can ride as a passenger in a car at any time. completely healed. and Esophageal Surgery Transcatheter Aortic Valve www.coumadin.com Avoid driving three to six weeks after surgery. www.ctsurgerypatients.org/ Replacement (TAVR) This time period is recommended to allow your Dress adult-heart-disease Educational Site New York State Department breastbone (sternum) to heal. Check with your www.tavrbyedwards.com of Health Smoking • Wear comfortable, loose-fitting clothes that do not The Cardiothoracic Surgery Cessation Website surgeon if you want to drive sooner. put pressure on your incisions. Network Mended Hearts Organization www.nysmokefree.com www.ctsnet.org www.mendedhearts.org Flying Work Academy of Nutrition • The minimum time before it is safe to fly after • Most patients will begin to feel like returning American Association for Website for Patients Created and Dietetics heart surgery is generally 2 to 3 weeks but you Thoracic Surgery by Adam Pick, A Heart www.eatright.org to light work six to 12 weeks after surgery. For should check with your surgeon before taking www.aats.org Surgery Patient jobs requiring heavy lifting such as construction any trip. www.heartvalvesurgery.com work we recommend not returning to work for a American Heart Association minimum of 3 months following surgery. Check www.heart.org with your surgeon before returning to work.

37 22 RECOVERY AFTER HOSPITAL DISCHARGE RESOURCES

Monitoring Your Recovery Daily Checklist: First Month After Returning Home Important Numbers – Your Cardiac Surgery Care Team

Record weight Check Incision (dry, weeping, Record use of incentive CARDIOVASCULAR SURGEONS OFFICE (same time each day) or red, clicking with movement) spirometer (5 uses per day) 104 Union Ave., Suite 1002, Syracuse Check legs for swelling Record temperature Note walking duration Dr. Nazem (315) 423-7192 Dr. Lutz (315) 423-7192 Dr. Zhou (315) 423-7192 When to Resume Usual Activities 104 Union Ave., Suite 1008, Syracuse Dr. Marvasti (315) 422-4442 FIRST 6 WEEKS AFTER 6 WEEKS AFTER 3 MONTHS CARDIAC SURGERY PROGRAM COORDINATOR Kelly LaRocca (315) 448-5655 • Light housekeeping (dusting, • Continue activities of first 6 • Continue activities of 1-3 CARDIAC SURGERY UNITS setting the table, washing weeks (but you may be able to months (but you may be able to Cardiovascular Intensive Care Unit (CVICU) dishes, folding clothes) tolerate more) tolerate more) D3 East CVICU (315) 726-6600 • Light gardening (potting • Return to work part-time if your • Heavy housework plants, trimming flowers) job does not require lifting, and (scrubbing floors) CVICU Manager (315) 448-5453 returning is approved by your Step-Down/Telemetry • Needlework, reading surgeon • Heavy gardening (shoveling snow, digging) D4 Cardiovascular Unit (315) 726-6240 • Cooking meals • Heavy housework (vacuuming, D4 Manager (315) 448-5751 sweeping, laundry) • Sports: football, soccer, • Climbing stairs softball, baseball, tennis, GENERAL INFORMATION • Heavy gardening (mowing lawn, bowling, golfing, • Small mechanical jobs raking leaves) swimming, water skiing, Hospital Operator (315) 448-5111 • Shopping skydiving, hunting Admitting Office (315) 448-5230 • Ironing • Attending sports events, • Jogging, bicycling, Patient Billing (315) 448-3555 church, movies, and restaurants • Business or recreational travel weight-lifting, push-ups Surgical Waiting Room (315) 448-6125 • Fishing, boating • Passenger in car • Motorcycle riding OTHER SERVICES • Light aerobics (no weights) • Walking treadmill, Preadmission Testing (315) 703-5108 stationary bike • Walking dog on leash Case Management/Discharge Planning (315) 448-5678 • Playing cards/games • Driving a small car or truck Patient Experience Office (315) 448-5559 Social Work Services (315) 448-5175 Spiritual Care Office (315) 448-5116

Keep in mind that all of these activities need to be in the 10-pound weight limit or less until 6 weeks after surgery.

23 36 RESOURCES RECOVERY AFTER HOSPITAL DISCHARGE

Skilled Nursing Facilities (continued) When to Call ** preferred facilities • It’s important to know that when you go home we are only a phone call away. • Unless there is a life-threatening emergency we ask that you CALL FIRST. Susquehanna Nursing & Jefferson County United Helpers Maplewood Rehabilitation Center Nursing Home -- There is always a nurse or nurse practitioner in our office during working 282 Riverside Drive Carthage Area Hospital 205 State St Rd hours and there is always a surgeon on call during nights, weekends, and Johnson City, NY 13790 1001 West Street Road Canton, NY 13617 holidays to answer questions and guide you. Carthage, NY 13619 • The following guide will help decide when to go to the Emergency Room or United Methodist Home Tompkins County Call the Office (See Phone list on page 37). 863 Front Street River Hospital Beechtree Care Center • Sometimes a patient will need to be readmitted to the hospital within the first Binghamton, NY 13905 4 Fuller Street 318 South Albany Street few weeks after surgery. Alexandria Bay, NY 13607 Ithaca, NY 14850 Vestal Park Rehabilitation -- If possible, we prefer that you come to back to St. Joseph’s Hospital. Center Samaritan Keep Nursing Cayuga Ridge Extended Care -- If you are readmitted to an outside hospital we ask that the doctors caring 860 Old Vestal Road Home 1229 Trumansburg Road for you call us so we can help them care for you. Vestal, NY 13850 133 Pratt St Ithaca, NY 14850 Watertown, NY 13601 Willow Point Nursing Home Groton Community Health 3700 Old Vestal Road Samaritan Summit Village Care Center Vestal, NY 13850 22691 Campus Dr 120 Sykes Street Watertown, NY 13601 Groton, NY 13073 Fulton County The Country Manor Oak Hill Manor Nursing Home Fulton Center 1045 West Street 602 Hudson Street 847 Co Hwy 122 Carthage, NY 13619 Ithaca, NY 14850 Call 911 or go to Emergency Call Your Surgeons Office for the Gloversville, NY 12078 Room if you Experience Following Urgent Problems St. Lawrence County Madison County Herkimer County • Severe chest pain (Angina) similar • Extreme fatigue to before surgery Highland Nursing Home The Grand Rehab at • Elevated temperature more than 101.0° Alpine Rehabilitation Center 182 Highland Road Chittenango • Heart Rate > 150 beats per minute F or 38.0° C 2 times within 755 East Monroe Street Massena, NY 13662 331 Russell Street with shortness of breath 24 hours Little Falls, NY 13365 Chittenango, NY 13037 • Fainting spells • Persistent bleeding or oozing Riverledge • Sudden severe headache from incisions Folts Center 8101 St Highways 68 Community Memorial • Sharp pain when taking a breath 104 North Washington Street Ogdensburg, NY 13669 Hospital • Sudden numbness or weakness in Herkimer, NY 13350 150 Broad Street arms or legs • Skin rash St Joseph’s Home Hamilton, NY 13346 • Shortness of breath not relieved • Weight gain of more than 2 pounds Mohawk Valley Health 950 Linden Street by rest within 24 hrs Crouse Community Center Care Center Ogdensburg, NY 13669 • Severe abdominal pain • Worsening ankle swelling or leg pain 99 Sixth Avenue 101 South Street • Coughing up bright red blood • Urinary tract infection: frequency, Ilion, NY 13357 St Regis Nursing Home Morrisville, NY 13408 burning, or blood with urination 89 Grove Street • Bright red stool Valley Health Services Massena, NY 13662 Oneida Healthcare • Pain in calf that becomes worse 690 West Germain Street 323 Genesee Street with movement Herkimer, NY 13350 Oneida, NY 13421

35 24 RESOURCES

Skilled Nursing Facilities (continued) ** preferred facilities

Harding Nursing Home Cortland County Finger Lakes Center 220 Tower Street for Living Waterville, NY 13480 Cortland Park 20 Park Ave 193 Clinton Ave Auburn, NY 13021 Heritage Health Care Center Cortland, NY 13045 1657 Sunset Ave Howd Nursing Home Utica, NY 13502 Cortland Regional 7 Keeler Ave 134 Homer Ave Moravia, NY 13118 Katherine Luther Home Cortland, NY 13045 110 Utica Road The Commons on Clinton, NY 13323 Crown Center St. Anthony Street 28 Kellogg Road 3 St. Anthony Street Presbyterian Home for CNY Cortland, NY 13045 Auburn, NY 13021 4290 Middle Settlement Road New Hartford, NY 13413 Chenango County Broome County

The Grand One Terrace Heights Absolut Center for Nursing & 801 North James Street 1 Terrace Heights Rehabilitation at Endicott Rome, NY 13440 New Berlin, NY 13411 301 Nantucket Drive Endicott, NY 13760 Rome Hospital Chenango Memorial Hospital 1500 North James Street 179 North Broad Street Bridgewater Center for Rome, NY 13440 Norwich, NY 13815 Rehabilitation & Nursing PART 159-163 Front Street St Joseph Nursing Home Norwich Rehabilitation Binghamton, NY 13905 2535 Genesee Street Center Utica, NY 13501 88 Calvary Drive Good Shepard Village Norwich, NY 13815 at Endwell 05 St Luke’s Home 14 Village Drive 1650 Champlin Ave Valley View Manor Endwell, NY 13760 Utica, NY 13501 Nursing Home 40 Park Street Good Shepard-Fairview Sunset Nursing & Norwich, NY 13815 Home Rehabilitation Center 80 Fairview Avenue 232 Academy Street Cayuga County Binghamton, NY 13904 Boonville, NY 13309 Auburn Nursing Home Ideal Senior Living Center The Pines at Utica Center for CARDIAC MEDICATIONS 85 Thornton Ave 601 High Ave Nursing & Rehabilitation Auburn, NY 13021 Endicott, NY 13760 1800 Butterfield Ave Utica, NY 13501 James G Johnston Memorial Nursing Home 286 Deyo Hill Road Johnson City, NY 13790 25 34 RESOURCES CARDIAC MEDICATIONS

Skilled Nursing Facilities ** preferred facilities Medications are an essential part of your treatment.

Onondaga County Menorah Park Pontiac Nursing Home During your stay, you may be started on various cardiac medications. Before leaving the 4101 East Genesee Street 303 East River Road hospital, you will be given a list of medications to be taken at home. Knowing the names, dose, Loretto** Syracuse, NY 13214 Oswego, NY 13126 purpose, and of your medication, is very important. 700 East Brighton Ave (315) 446-9111 (315) 343-1800 Syracuse, NY 13205 (315) 413-3401 Sunnyside Care Center Seneca Hill Manor 7000 Collamer Road 20 Manor Drive Iroquois** East Syracuse, NY 13057 Oswego, NY 13126 Table of Common Cardiac Medications 4600 Southwood Heights Drive (315) 656-7218 (315) 349-5302 Jamesville, NY 13078 MEDICATION EXAMPLES PURPOSE POSSIBLE SIDE EFFECTS (315) 469-1300 Syracuse Home Association St. Lukes Nursing Home 7740 Meigs Road 299 East River Road The Cottages at Garden Baldwinsville, NY 13207 Oswego, NY 13126 Antibiotics • Cefazolin (Kefzol/Ancef) • Reduce Risk of Infection • Allergic Reaction Grove** (315) 638-2521 (315) 342-3166 Vancomycin 5460 Meltzer Drive Cicero, NY 13039 Van Duyn Oneida County Beta Blockers • Metoprolol • Lower Heart Rate • Fatigue (315) 413-3066 5075 West Seneca Turnpike (Lopressor or Toprol XL) • Lower Blood Pressure • Dizziness Syracuse, NY 13215 Bethany Garden • Atenolol (Tenormin) Central Park Rehabilitation (315) 449-6000 800 West Chestnut Street • Carvedilol (Coreg) & Nursing Center Rome, NY 13440 116 East Castle Street Veterans Administration Antiplatelet Agents • Aspirin • Prevent Blood Clots • Bleeding Syracuse, NY 13205 Rehabilitation Betsy Ross • Plavix (315) 475-1641 800 Irving Avenue Health Related Facility Syracuse, NY 13210 1 Elsie Street Statins • Pravastatin (Pravachol) • Reduce Cholesterol • Muscle Weakness Community General Hospital (315) 425-2686 Rome, NY 13440 • Simvistatin (Zocor) Levels • Elevated Liver 4900 Broad Rd • Rosuvastatin (Crestor) Enzymes Syracuse, NY 13215 Charles T Sitrin Nursing Oswego County • Atorvastatin (Lipitor) (315) 492-5231 Home Seneca Hill Manor** 2050 Tilden Avenue, Box 1000 ACE Inhibitors • Lisinopril (Zestril/ • Lower Blood Pressure • Dizziness, Dry Cough The Crossings (Minoa) 20 Manor Drive New Hartford, NY 13413 Prinivil) • Treat Heart Failure • Kidney Damage 217 East Avenue Oswego, NY 13216 • Enalapril (Vasotec) Minoa, NY 13116 (315) 349-5302 Colonial Park Rehabilitation ((315) 656-7277 & Nursing Center • Ramipril (Altace) Michaud Residential 950 Floyd Avenue Elderwood 453 Park Street Rome, NY 13440 Angiotensin receptor • Losartan (Cozaar) • Lower Blood Pressure • Dizziness 4800 Bear Road Fulton, NY 13069 blockers (ARB) • Olmesartan (Benicar), • Treat Heart Failure • Kidney Damage Liverpool, NY 13088 (315) 592-2009 Eastern Star Home & • Irbesartan (Avapro) (315) 457-9946 Infirmary • Valsartan (Diovan) Morning Star 8290 State Route 69 James Square 17 Sunrise Drive Oriskany, NY 13424 Nitrates • Nitroglycerin • Treat Chest Pain • Headache 918 James Street Oswego, NY 13126 • Isosorbide mononitrate • Lower Blood Pressure • Dizziness Syracuse, NY 13203 (315) 342-4790 Focus Rehabilitation & (Imdur) • Treat Heart Failure (315) 474-1561 Nursing Center at Utica 1445 Kemble Street Utica, NY 13501 33 26 CARDIAC MEDICATIONS RESOURCES

FOOD GROUPS RECOMMENDED FOODS FOODS TO AVOID Table of Common Cardiac Medications (continued) Fruits and • Fresh, frozen, or canned vegetables • Fried fruits or vegetables MEDICATION EXAMPLES PURPOSE POSSIBLE SIDE EFFECTS Vegetables without added fat or salt • Fruits or vegetables prepared with • Fresh, frozen, canned, or dried fruit butter, cheese or cream sauce • When using canned products, rinse • Canned vegetables (unless no salt Calcium Channel • Amlodipine (Norvasc) • Lower Heart Rate • Dizziness under water first added or low sodium) Blockers • Diltiazem (Cardizem CD • Lower Blood Pressure • Fatigue, Flushing • Frozen vegetables with sauces or Cartia XT) • Sauerkraut and pickled vegetables • Canned or dried soups (unless they Narcotics • Fentanyl (Duragesic) • Control Pain • Drowsiness are low sodium or salt free) • Hydrocodone- • Constipation • French fries and onion rings acetaminophen (Lortab, Norco) Grains • Whole grain bread, rolls, pitas • Quick breads prepared with • Oxycodone- • Low-sodium crackers, pretzels baking soda acetaminophen and chips • Bread crumbs or stuffing mix from (Percocet) • Shredded or puffed wheat, a store puffed rice • High-fat bakery products such as Anti-Arrhythmic • Amiodarone (Pacerone) • Control and Prevent • Dizziness • Cooked cereals — regular or quick doughnuts, biscuits, croissants, • Sotalol (Betapace) Irregular Heartbeat • Slow Heart Rate such as oatmeal Danish pastries, pies, cookies • Thyroid or Lung • Brown rice problems (rare) • Whole grain pasta

Diuretics • Furosemide (Lasix) • Remove Excess Fluid • Increased Urination Fats, Oils, and Nuts • Olive oil • Butter • Lower Blood Pressure • Muscle Cramps • Canola oil • Stick margarine • Treat Heart Failure • Low Potassium Level • Soybean oil • Shortening • Flaxseed oil • Partially hydrogenated oils Aldosterone Antagonist • Spironolactone • Remove Excess Fluid • High Potassium • Walnuts • Tropical oils (coconut, palm, (Aldactone) • Lower Blood Pressure • Increased Urination • Almonds palm kernel oils) • Treat Heart Failure • Ground flaxseed • Salted nuts

Diabetic Medications • Insulin glargine (Lantus) • Control Blood Sugar • Low Blood Sugar Condiments • Fresh or dried herbs • Salt, sea salt, garlic salt • Insulin lispro (Humalog) • Reduce Risk of Infection • Spices without added salt • Seasoning mixes containing salt • Insulin regular • Bouillon cubes (Humulin R) • Catsup • Barbecue sauce • Worcestershire sauce Anticoagulants • Heparin (IV form) • Prevent and Treat • Bleeding • Soy sauce • Warfarin (Coumadin) Blood Clots • Miso • Dabigatran (Pradaxa) • Reduce Stroke Risk • Salsa • Rivaroxaban (Xarelto) • Pickles, olives, relish

Alcohol • Check with your doctor. Generally, do not have more than one drink per day (1 drink=5 ounces (oz) wine, 12 oz beer, or 1-½ oz liquor) 27 32 RESOURCESCARDIAC MEDICATIONS CARDIAC MEDICATIONS

Long-term Exercise Goals (After completion of Phase 2) Additional Medication Services How Much? Information • Our pharmacists will review your current • At least 30 minutes per day Coumadin (Warfarin) medications at your pre-admission testing appointment. Some of your medications may • 5 days per week The Big 5 Things YOU Can Do • Blood thinner used for patients with mechanical be stopped or changed for your surgery. After heart valves, atrial fibrillation (rapid heartbeat), surgery, your daily medications may change. What Type? to Prevent Heart Disease and blood clots We will review your list of medications again Don’t Smoke • Aerobic • Requires frequent blood test monitoring prior to discharge. Exercise -- Brisk walking at a minimum • Dose of medication is adjusted based on blood • A pharmacist in the cardiovascular intensive -- Vigorous exercise that causes you to break a Healthy Diet (Mediterranean) test results care unit (CVICU) will round with the cardiac sweat if you can surgery team Monday thru Friday and review Check your blood pressure • Foods rich in Vitamin K can block action of your medications daily. -- Heart rate monitor is generally unnecessary Coumadin (Warfarin) Have your cholesterol levels checked • Once you are transferred out of the intensive • Warm-up -- Examples of Vitamin K rich foods: beef liver, care unit to the step-down unit, the pharmacist pork liver, green tea, alfalfa, asparagus, -- Before each exercise session: movement on D4 will review your medications daily. Upon broccoli, brussel sprouts, cabbage, cauliflower, based, like a light jog discharge from the hospital, a pharmacist will collard greens, kale lettuce, spinach, turnip, meet with you and review your medications and • Cool-down and stretching greens, watercress understanding of any new medications prescribed -- After completing the workout -- Important to eat a consistent diet while in the hospital. • Can interact with many medications • Please note: Over-the-counter medications • Takes several days to reach desired level of action (OTC) will be included on your list of Additional Nutrition Information medications to take at discharge. It will be your responsibility to pick up these over- FOOD GROUPS RECOMMENDED FOODS FOODS TO AVOID Vitamins and Supplements the-counter medications in addition to your • Vitamins and supplements are over-the-counter prescriptions at your local pharmacy. Milk • Nonfat (skim) or low-fat (1% fat) milk • Whole Milk medications • Fat-free and low-fat cheeses with less • 2% Fat Milk -- They cause biological changes than 150mg sodium per serving • Whole milk yogurt or ice cream • Hard cheese, low-fat cheddar • Cream -- They can interact with other medicines or mozzarella • Half & half -- “All natural” does not guarantee safety • Low-fat cottage cheese • Cream cheese • Do not take a supplement without telling your (check the sodium!) • Sour cream doctor, especially if you take a blood thinner • Processed cheese such as Coumadin Meat and Other • Lean cuts of beef and pork (loin, • Higher-fat cuts of meats (ribs, t-bone • Do not count on supplements to lower Protein Foods leg, round, extra-lean hamburger), steak, regular hamburger) your cholesterol skinless poultry, fish • Bacon -- A healthy diet, exercise, and if necessary a • Venison and other wild game • Sausage statin (cholesterol lowering) medication are • Nuts and nut butters • Cold cuts, such as salami or bologna safer and more effective • Corned beef • Organ meets (liver) • Folic acid, Vitamin C, and Iron are medications • Poultry with skin that will be prescribed for discharge • Fried meat, poultry, and fish

31 28 RESOURCES

Cardiac Rehabilitation • Don’t exercise immediately after eating. It’s best to wait at least an hour. Cardiac Rehabilitation is a program that includes exercise, education, and counseling. • Breathe deeply and regularly during exercise. Don’t hold your breath. Cardiac Rehabilitation Phase 1 • Avoid activities that involve excessive or heavy (1-4 weeks) pulling, pushing, lifting or strain. • Begins in the hospital and continues immediately upon discharge to home or Cardiac Rehabilitation Phase 2 short-term rehabilitation. (1 to 2 months later) • The goal is for you to take 3 walks a day while you • A referral form will be given to you by your nurse are in the hospital. As your strength increases, the when you are discharged. length and time of these walks will also increase. • Generally starts 6-8 weeks following • The walking that you do in the hospital will your surgery. continue once you are discharged. • If you start within 2 months after your surgery you • Begin walking slowly to warm up. Gradually will have to avoid lifting more than 5-10 pounds increase your pace and walk for the duration until you reach the 2 month mark. indicated below. Gradually slow your walking pace • The goal of this program is to continue to build to cool down. your strength and endurance while monitoring • As your strength increases, slowly increase the your heart so that you are exercising safely. amount of walking you do over the next several • Studies have shown that people who have had weeks. When Level 1 begins to feel too easy, open heart surgery and attend an outpatient progress to Level 2 and so on. cardiac rehabilitation program have a 25% less -- LEVEL 1: Walk 10 minutes continuously chance of complications. 3 times a day. • You will be asked to assess your risk factors for the PART -- LEVEL 2: Walk 15 minutes continuously development of coronary artery disease. 2 times a day. • Please take a moment to look these over to -- LEVEL 3: Walk 20 minutes continuously identify what your risk factors may be. 2 times a day. • Risk factors within your control: 06 -- LEVEL 4: Walk 30 minutes continuously -- Smoking 1 time a day. -- Blood sugar control if you are a diabetic • DO NOT use any exercise equipment at home, -- Cholesterol levels no treadmills or bicycles. We do not want you to fall and hurt your chest incision. Keep your feet on -- Obesity the ground. -- Blood Pressure • If you exercise outdoors: -- Stress -- Avoid weather extremes like heat (above 78 -- Sedentary lifestyle degrees) and humidity, cold (below 25 degrees) RESOURCES -- Our cardiac rehabilitation nurse will meet with and wind. you after your surgery to discuss your specific -- Choose a walking route that is safe and risk factors and lifestyle changes that can be relatively flat. made to further prevent heart disease. -- Let someone know where you will be walking and when you will be back.

-- If you can’t go outside, walk inside your house. 29 An alternative is mall walking. 30