Pre-Surgery

What is CABG?
Arteries carry blood from the heart to the rest of the body. But sometimes arteries become blocked. When this happens, surgeons create a new channel to bypass the blockage. Doctors call it bypass graft surgery. It uses a working blood vessel from another part of the body – the graft – to channel blood around the blocked area.

Why do we perform CABG?
Coronary Artery Bypass Surgery is performed to improve blood supply to the heart. The ultimate aim of this operation is to improve patient’s quality of life by relieving angina in the vast majority of cases. It not only improves the patient’s symptoms like chest pain or occasional difficulty in breathing but also protects the heart against a potential risk of a massive heart attack. Our second objective is to prolong our patient’s life expectancy by performing this surgery.

Types of CABG?
There are 2 types: 1. Off-pump CABG 2. On-pump CABG

• Roughly, 70-80% of the CABG surgeries we perform are off-pump. This means we’ll be performing the surgery while the heart is still beating. In this type of CABG, the patient has a better chance of recovering earlier post-surgery.
• In on-pump CABG, we use our heart-lung machine which is controlled by an experienced perfusionist. In this type of CABG, your heart along with your lungs will be non-functional while performing surgery. The heart-lung machine will act the role of your heart and lungs.

How much does CABG cost?
We have 3 classifications for our fees:

• PKR 0-50,000 - for the poor & needy/zakat; for the unfortunate who are unable to fulfill their medical payments.
• PKR 100,000-150,000 - Standard Package; this is our most commonly used package, which will include everything excluding a private room, this package may also require you to purchase certain medical equipment required for surgery which could vary anywhere between an extra PKR 50,000-60,000.
• PKR 300,000 - Exclusive Package; this is the package where our team will facilitate you with a private room as well, and will include all expenses needed for surgical equipment.

**Prices may vary in the standard and exclusive packages at the time of surgery due to complications**

How much pain will I have after CABG?

• You will have some discomfort in the incision made to reach the heart. (It is made along the midline of the chest through the breast bone). Usually, there will be one or more incisions in the leg, if a vein was removed to use for the bypass. These incisions may also hurt. Medications will be given regularly to relieve pain.

Why have I developed CAD/CHD at such an early age?
There are several causes, some of the major ones may include:

• Smoking
• Diabetes
• Obesity
• Genetics

Post-Surgery

What are the best foods for me?

• No one food provides all the nutrients needed by the body. Each day eat a variety of fruits, vegetables, whole grains, meats, and dairy products. Try to avoid saturated fats and salty meals. The amount of sodium allowed in your diet is 2gm.
• If you are diabetic, then keep your blood sugar under strict control.
• If you are constipated, try drinking prune juice, using Metamucil, or taking a mild laxative such as milk of magnesia. (Milk of magnesia and Metamucil are available at most pharmacies).

Is exercise necessary for me?

• Yes. 2 exercises are of utmost importance, lung expansion exercises, as well as walking. Spirometery is an object used for lung expansion in which a patient will blow into a tube in order to lift 3 balls. This is usually done from the 2nd day after surgery onwards. Walking is important as to maintain good circulation of blood throughout your body, thus preventing any blood clots from forming. A 30 minute walk, 5 days a week is optimum.
• Start doing the same kind of exercises at home as you were doing in the hospital and increase gradually day by day.
• Do not lift anything heavier the 5kg, since this puts more stress on your incision. This means avoid carrying suitcases, groceries, or children for 6 weeks from the time of surgery.
• You may climb stairs but this requires more energy so take your time and go slowly. Rest if you need to.

Am I allowed to drive?

• Avoid driving a car for 4 to 6 weeks after surgery, since your reaction time will be slowed down due to weakness, fatigue, or medication. If you met an accident, there would be a chance of hitting the steering wheel and reinjuring the sternum.
• Let someone else do the driving, avoid long trips if possible. If not possible, then stop every 1-2 hours and walk around. Always wear your seatbelt.

Can I take a bath?

• Take a shower every day. If you feel weak, you maywant to place a chair in the shower until you feel stronger. Avoid extremely hot water, wash your incision gently with soap and water but do not scrub it.
• Somebody should be with you the first few days to help and look after you.

Why are my incisions sore/red/itchy/numb?

• our incision will improve gradually each week, during the first few weeks after surgery; however, you may notice some itching, redness, soreness, or numbness. Things like too little activity or sleeping in one position for too long can cause soreness. These things are not abnormal and gradually disappear. For relief and comfort, your doctor, will prescribe pain medication pills to take every 4-6 hours. These are to be taken only if you have pain. In addition, you should move your head and neck muscles normally and maintain good posture without letting your shoulders slump forward.

Can I continue doing house work?
Do not expect to resume total responsibility for household duties, care of the children, or meal preparation until after your 4-6 week medical checkup at the clinic.
But till then, you can still:

• Supervise the cooking
• Do some sewing
• Help to set the table
• Dust easily accessible furniture

Can I have sexual intercourse?

• If you feel good and rested, sex should be possible as before. But if you are tired and tensed, wait till you feel better.
• If you find that certain positions cause discomfort to the chest area, try different positions.

Is it safe to become pregnant?

• Pregnancy should be avoided until recovery from surgery is complete. Since pregnancy puts an added stress on all your body systems, you should wait at least a year. In some cases, it should be avoided forever. Because certain contraceptives are not advised for heart patients, and because pregnancy is not advised, for some patients, all family planning matters should be discussed with your physician before you leave the hospital.

What happens if I forget to take my medicine?

• If you forget to take a pill, do not take two the next time. Your medications are especially for you and may be harmful for someone else, do not offer them to anyone.
• Do not increase, decrease, or stop the amount of your medications without your physician’s advice.

Can my medicine produce an allergic reaction?

• Yes, they can. Symptoms like rashes, fever jaundice, severe bruising, vomiting, and diarrhea are some of the possible reactions.
• Contact your local physician if you develop any of these.

Can I smoke?

• You should not use tobacco in any form. This includes chewing tobacco, smoking cigarettes, cigars, pipes or sheesha. Avoid smoke filled areas. Studies have shown that smoking increases the heart rate, narrows the blood vessels, raises the blood pressure, scars the lungs, and causes spasms of the coronary arteries.
• Even if you have smoked for years, quitting now will still be beneficial to your heart.

Can I fast?

• You cannot fast soon after surgery. You will be able to do it, after a relatively longer period of time when full recovery has been achieved and everything is under control.
• Fasting in itself is not dangerous, but each case should be dealt with in a case-to-case basis. This is particularly important in relation to the time schedule for taking your medication. It will have to be altered when the patient is fasting and therefore it is advisable to consult the physician before initiating the fasting.

How to maintain your lipid-profile?

• Dietary control is very important, foods high in HDL (good cholesterol) such as fish, nuts, and garlic should be taken more regularly, however foods high in LDL (bad cholesterol) such as fast food/junk food should be avoided.
• You should get a lipid profile done every 3 months to ensure proper care is being taken. Cholesterol in your blood should always be between 150-200mg/dl.

FAQ’s Valvular Disease

What is INR?

• INR stands for international normalized ratio. The INR provides some information about a person’s blood’s tendency to clot (which is often described as how “thin” or “thick” their blood is).
• The INR comes from the conversion of another value, the prothrombin time (PT). Prothrombin time is the time it takes for blood to clot in a test tube. A high or low PT can suggest bleeding or clotting tendencies. Most often, the PT is checked to monitor a person’s response to blood thinners such as warfarin (Coumadin).
• The problem with prothrombin time testing is that several manufacturers produce and sell slightly different PT tests to laboratories. The same person’s blood might have different results if tested on two different companies’ PT tests.
• To solve this problem, the international normalized ratio (INR) was created. By entering a PT result into a math formula, it yields the INR. The international normalized ratio means one lab’s test results can be compared to another’s with high accuracy.
• A normal INR is approximately 1.0. People taking the blood thinner warfarin typically have a target INR of anywhere between 2.0 to 3.0. People with an INR higher than 1.0 who aren’t taking warfarin may have a medical condition that needs further evaluation. A low INR is rarely significant

What may affect my INR test results?

• Certain foods rich in Vitamin K and any medicines you take may affect your results, especially if you take warfarin, heparin, or other anti-clotting drugs or are being treated for liver disease with vitamin K. It is very important to follow your healthcare provider's instructions for having this test.

What foods should I avoid?

• Don’t eat foods that are rich in saturated and trans fats, sugar, salt, and refined grains, such as white bread. Also avoid leafy green vegetables and green tea as well as herbal tea, as they contain significant amounts of vitamin K which can cause bleeding disorders and other complications. Instead, eat a variety of fruits and vegetables (other than the leafy green ones), whole grains, and proteins, such as lean meats, fish and nuts.

Can I use any pain killers while I’m already taking Warfarin?

• Taking non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin for pain relief when you are on anticoagulant therapy can increase your risk for serious bleeding.
• Some popular brand names of NSAID’s include: ibuprofen and aspirin (some brand names are Advil, Aleve, Bufferin, Excedrin, Motrin and Nuprin).
• Luckily, there are alternatives. Your doctor can advise you on over-the counter painkillers that may be safe to use if you are on Coumadin or anticoagulation therapy. Pain relievers that contain acetaminophen, such as Tylenol, may be a better choice. (Although these should not be taken in excess)
• NSAIDs and anticoagulants don’t mix, even in the short-term. Major bleeding events occurred just over one week after patients took an anti-inflammatory drug, and sometimes after just a single dose.

Why do I hear a clicking sound in my sternum/breast bone?

• A clicking, popping or cracking noise originating from the sternum (breastbone) is usually associated with the joints between the breastbone and ribs. However, there is no need to panic as this is quite normal in patients who’ve undergone open-heart surgery. It will fade over time.
• The exact mechanism of popping or cracking of any joint is not known. It may be due to the ‘snapping’ of ligaments or tendons, gas bubbles released from the joint fluid (cavitation) or partial dislocation (sublaxation).

What is an ideal lipid profile?

Do I have to keep a check on my INR although I have a tissue valve?

• Only for the first 3 months as you’ll be taking Warfarin (anti-coagulant) for the first 3 months as well.

Is it safe to get an MRI if I have a valve implant?

• Consult your doctor about having an MRI if you have a stent or artificial heart valve, or if you have had open-heart surgery recently.