Valve surgery in the heart is a modern miracle. It’s risky, involving many precise steps. It’s amazing that anyone survives the operation! Here’s a step-by-step guide through a typical heart valve surgery as well as the post-op intensive care area.
This blog is part 3 of a five-part blog about heart surgery. It’s the longest of them, so you may wish to skim it. Here are all the segments in this blog:
1: Heart Surgery – Highly Likely for You or a Family Member
2: What Brings Us to the Operating Room Before Surgery
3: Valve Surgery Operation and the Intensive Care Unit
4: Life Beyond: Post Surgery Recovery
5: Heart Surgery Cost – Medicare Coverage and Hospital Staff
Step By Step Through Heart Surgery
Brain surgery is the popular epitome of highly skilled medicine. But at least the brain doesn’t have to have its motion arrested and then re-started. For sheer complexity, I think that heart valve surgery outranks it.
Hospital notes by my surgeon Dr Altshuler detail the steps involved in my mitral valve surgery:
Prepare for Heart Valve Surgery:
– Position intravenous tubes and bags.
– Sedate with anesthetic.
– Put into position for valve surgery, and restrain in place. The positioning included keeping my right arm stretched to one side to keep it out of the way of the surgical incision.
– Insert TEE sensor to image the heart so as to guide the valve surgery.
– Insert breathing tube with mechanical ventilator and supplemental oxygen.
– Also, insert urinary catheter to drain the bladder while I was unconscious.
Get Into the Body:
– Incision in the right groin to expose the femoral artery and vein.
– Insertion of catheters into artery, upper heart chamber and lung artery.
– 3.5 inch incision in the front right chest using electrocautery (an electrically heated wire or needle). Continue the incision through the layers of subcutaneous tissue (beneath the skin) and fascia (connective tissue).
– Place retractors to hold the ribs apart for access to the heart.
– In the pleural (lung) space, move the lung to one side.
– Open the pericardium (membrane enclosing the heart).
– Inject heparin to prevent blood clotting.
– Thread cannulae (thin tubes) through the femoral artery and vein, and connect to “cardiopulmonary bypass” (heart-lung machine).
Repair the Heart:
– Apply cross-clamp to close the aorta.
– Use Custodiol (a medication) and cold packs to arrest the heartbeat.
– Cut open the atrium while flooding the area with carbon dioxide gas.
– Remove the defective mitral valve.
– Choose an appropriate prosthetic valve and stitch it into place.
– Inject fluid into the ventricle to see that the new mitral valve properly closes.
– Close the atrium with two layers of sutures.
Re-Activate the Heart:
– Remove air from the heart, using echo (acoustic) imaging to confirm the air is gone.
– Install pacemaker wires on the right ventricle in case they are needed to stabilize the heartbeat later; bring the wires out of the body through a separate puncture.
– Remove the aortic clamp and allow blood to re-enter the heart.
– Place drainage tubes in the chest and in the pericardium.
– Gradually introduce epinephrine (adrenalin) to stimulate the heart.
Repair the Body:
– Remove the cardiopulmonary bypass tube from the vein and repair the vein with sutures.
– Inject protamine, another drug, to reverse the effects of the heparin.
– Remove the arterial bypass tube and repair the artery.
– Verify smooth blood flow through the femoral artery and vein using ultrasound.
– Use Vicryl (a dissolvable suture) to pull the ribs back together.
– Use various diameters of dissolvable suture to close the fascia, the subcutaneous layers and finally the skin.
This valve surgery involved continuous effort for six hours, and all the interior work had to be performed through one 3.5 inch incision! Fortunately, when the lung is inactive it deflates. When that happens, the heart comes very close to the surface. Therefore Dr Altshuler didn’t have to reach deeply into my chest to do his work.
This is probably more than you want to know about heart valve surgery. But if you thirst for more info, see the seven-minute YouTube video from the Cleveland Clinic. It shows a valve surgery operation much like mine, except that they repair rather than replace the mitral valve.
In the Cardiac ICU
After heart valve surgery, I awakened in the cardiac intensive care unit on the second floor of the hospital. I was tethered like Gulliver in Lilliput. I counted the following connections tying me down:
– An intravenous stand feeding IV bags of saline, electrolytes and antibiotics.
– A urinary catheter, which is a really annoying appendage.
– Three chest tubes, attached to a vacuum device that extracted excess fluid from my insides. These were removed on the second day, leaving me with three large bandages oozing clear fluid.
– Electrodes to monitor my heart function.
– Supplemental oxygen, provided through a nose clip.
– Balloon-like devices wrapped around my calves. These automatically tightened and relaxed, over and over, to keep me from getting blood clots lying in bed.
Even in the ICU, the nurses want you to get out of bed. I sat up in a large comfy chair during most of my waking hours. A couple of times a day, a nurse would help me take a walk. Walking was a complicated process since all my tubes had to come with me, attached to a rolling cart.
Feeling No Pain
Patients often experience pain after surgery, sometimes a great deal of pain. I’m happy to report that pain is not a necessary accompaniment of surgery. I had no pain after my prostate surgery, nor after I awoke following heart surgery. (As previously noted, I complained of “acute post op pain” while still under anesthetic and the docs gave me a pain-relieving medication.)
I cannot explain this. I have no trouble feeling pain if I cut myself or get a bug bite. I’m not like the Italian family that is unable to feel pain because of a gene mutation.
Perhaps my heart surgery was not painful because it was “mini” rather than open-chest. Perhaps I unconsciously suppressed pain feelings because they were not intense. Or perhaps Drs Telang and Altshuler have such superior surgical skill that they can “walk between raindrops” – that is, perform operations without traumatizing nearby nerve fibers.
Start What Stopped, and Vice Versa
A recurring theme in the ICU is to get things moving that are stationary, and to stop things that are moving but shouldn’t be. Here are a few patient recovery items that the ICU deals with:
After an extended dose of anesthetic, your digestive system shuts down. Getting the bowels moving again was one of the principal goals while in the ICU. When you keep eating food, it has to go somewhere, so eventually this returned to normal. In my case, it took 2 days in the ICU.
The urinary catheter is necessary during surgery because the patient is unconscious and can’t void. The doctors keep it in place for at least 24 hours afterwards in order to monitor exactly what your body is producing. Just before I left the ICU they removed the catheter and I could start returning to normal:
– The first part of normal is peeing again. This was not so easy, because the catheter irritates the urethra, which causes bleeding. Bleeding leads to blood clots and those block the urine flow. Most of the clots are soft and pass easily, but not all of them. I thought I would need a temporary catheter to start the urine again, but I was fortunate. With some effort I passed a few more clots and I could pee again.
– Once I was peeing, some blood and clots continued to accompany the urine. This was alarming, but the nurse assured me that bleeding is normal following removal of a catheter. And sure enough, the blood and clots disappeared in one week.
Breathing is another thing that has to get moving again after an operation such as heart valve surgery.
During valve surgery, the medical team kept me alive with a heart-lung machine, which provided oxygenated blood. In addition, the surgical team used a mechanical ventilator to assist my breathing. The ventilator provides pressurized air to the lungs for the “inhale” part of the cycle. The ventilator then reduces its pressure and the lungs relax to exhale.
Normally, we inhale by tightening the diaphragm muscle and the muscles between the ribs. Together, these increase the volume of the chest cavity, which draws air into the lungs. However, with the ventilator doing the work, during the operation I was not using these muscles.
Just as your arm and leg muscles atrophy if you aren’t using them, the same thing happens to the breathing muscles. It seems that my six hours of surgery plus overnight on the ventilator were long enough that my breathing system took a holiday.
To get my lungs back into shape after valve surgery, the hospital prescribed two exercises for me to carry out:
– Inhaling through a small portable device called an incentive spirometer, ten times per hour.
– Taking a deep breath, then coughing deeply, several times an hour. Fluid which comes up is spit out into a plastic cup.
– The nurses advise the patient to hug a pillow against the surgical incision while coughing. This alleviates any associated pain and reduces the chance of popping the incision open. The nurses gave me a charming small pillow for this purpose. It had been made by the cardio staff. Using the pillow is probably most important for patients who have had open-chest surgery. Cough pillows (or “heart pillows”) seem to be a tradition, although not everyone believes in their medical usefulness.
These exercises served to restore lung capacity, and to eliminate fluid that built up while I was on a medical ventilator during valve surgery.
4. Fluid Drainage:
During valve surgery Dr Altshuler installed three “chest tubes.” Two tubes were on the right side of my chest, and one on the left. The tubes would drain serum and blood accumulating in my body cavity and around my lungs. Each chest tube had a perforated section about 9” long which resided inside me. The external portion of the tube was about 6” long. A vacuum system kept it empty of fluid.
For many patients, the chest tubes are very painful. However, they didn’t bother me unless I lay down on my side. That position put pressure on the tube or tubes on that side of my chest. Although they didn’t hurt, I wanted the tubes out so that I could get disconnected from the vacuum pump and start healing.
The nurses regularly measured the volume of fluids I produced. At night each chest tube would drain 200 ml of clear fluid, about one cupful. Eventually the volume declined enough that the nurse could remove the tubes.
There were substantial holes left behind, of course. The nurse covered these with immense gauze pads that had to be changed several times a day. Sometimes the gauze was not enough to hold back the drainage, as described below.
An Embarrassing Walk Through the ICU
In the ICU I felt rather weak following valve surgery. Nevertheless, the nurses wanted me to stay out of the bed. I sat up in a large comfy chair during most of my waking hours. A couple of times a day, a nurse would help me take a walk. As previously mentioned, all my tubes came along, attached to a rolling cart.
On my second or third walk, the nurse and I made a full loop of the floor plus a couple of side hallways. This felt like an excellent accomplishment. However, then my largest chest bandage started leaking. The flow kept increasing and soon there was a path of clear fluid drizzling behind me.
I felt pretty embarrassed, but there wasn’t anything I could do about it. I pressed my hand on the bandage but neither my hand nor the bandage could slow down the flow.
The nurse and I immediately headed back to my room, leaving a slick trail down the middle of the corridor behind me. The nurse called the “environmental team,” which quickly arrived to clean and sterilize the floor. Naturally they do not want one patient’s precious bodily fluids to contaminate another patient, or the staff either!
There’s No Sleep for the (Wicked?) Patient
I can usually sleep anytime and anywhere. I sleep especially easily right after lunch. Unfortunately, I also get v-e-r-y s-l-e-e-p-y in a meeting if I am not participating in the dialogue.
Long ago in California I took a test to see whether I had narcolepsy. The doctor decreed that my condition didn’t qualify as narcolepsy since I did not spontaneously fall asleep mid-morning. Nevertheless, my body really enjoys any opportunity to snooze.
Despite my natural talent for going to sleep, I found sleep difficult in the ICU. Not only did staff members frequently wake me up for tests but in addition, many tubes tied me down. My usual side-sleeping position was impossible because I had chest tubes on both sides of my body that complained when lay on them. Eventually I found a back-sleeping position with upper body and knees elevated that let me sleep comfortably between interruptions.
Back to the Fifth Floor
November 9 – 10 – 11 – 12: The morning of the 9th I finally persuaded the doctors to remove the coudé catheter. This occurred just before I moved to the post-recovery area.
The afternoon of the 9th I moved to the post-ICU section, returning to the fifth floor. My room was just down the hall from where I stayed prior to surgery. Every room in this post-ICU section is private and the nurses are specially trained. Of course, the nurses and nurse assistants encouraged me to keep walking around, several times a day.
Walking was considerably more convenient, now that my only tethers were IVs. The chest tube pumps and the catheter bags had been left down on Two. Therefore I could walk without a nurse coming along, just by pushing the IV stand ahead of me.
Walking and More Walking
And walk I did, as often as possible. I had no interest in lying in bed or mindlessly staring at a TV. Among the choices available, walking counted as pretty good entertainment. However, I didn’t have much time for exercise. Nurses and doctors kept me quite busy with tests, blood draws and consultations. I did have time for a few worthy activities: (1) visiting with family members who stopped by; (2) keeping notes on my hospital stay, which I e-mailed to Nola daily and which totaled 27 pages by the day I returned home; (3) attaining level 2260 in Candy Crush(!).
A physical therapist arrived and made sure I could handle stairs. He provided a wooden three-steps-up-and-down-with-railing device for practice. With him watching, I walked up and down the hospital emergency stairs. He also gave me a page of basic stretching exercises for me to do when sitting up and when in bed. I added those stretches plus the stairways to my regular routine of walks.
I would need to negotiate stairs when I went home, so the hospital wanted to know I could go up and down stairs by myself before letting me go. Heart valve surgery patients who don’t pass this test may be sent to a rehab facility rather than to their own homes.
Recovery Is a Rocky Road
Passing clots in my urine was not the only annoying thing about post-surgery recovery. I had a lot of fluid retention, especially in my legs. The nurses starting giving me shots of Lasix, a powerful diuretic.
After the fluid left my legs, some of it settled in my private parts. Having a man’s genitals swell up may sound desirable, but in this case the fluid was mostly on one side. I thought the lopsided result was picturesque but far from attractive.
I complained about this state of affairs to a nurse. She said, “Oh, that amount of swelling is nothing. We had a man in here whose scrotum swelled to the size of a baseball! You have much less fluid than that, so don’t worry about it.”
A male nurse suggested that it might help if I kept my “package” elevated when in bed. Gravity did the trick, and my parts returned to normal in a couple of days.
Freedom At Last!
November 13, Monday: Today the hospital will discharge me, hooray! The nurses scheduled my discharge for 9:00 a.m. However 9:00 a.m. came and went, and the schedule kept slipping.
One reason for the delay was a rare human error. As usual, the phlebotomists had taken blood draws for all twelve post-ICU cardio patients at 6:00 a.m. The results of these tests were critical to my schedule because both the cardio and infection teams had to review this data before approving me for release.
Usually, the lab results were posted in the computer within an hour or two of the blood draw. The nurse kept checking but the results never appeared. Finally, late in the morning it became clear that none of the post-ICU patients had any test results. Investigation showed that all the blood draws from these patients had simply disappeared on their way to the lab.
Oops, Not So Fast
There was a rush to re-take blood just before noon and hurry along the lab results. Later I learned that the cart with the blood samples had been misplaced somewhere in the hospital. By the time someone discovered the cart the blood, sitting at room temperature, had begun to clot. Since clotting blood is useless for the lab tests, that required a new set of blood draws for all these patients.
Another critical item: the medical teams had to talk and agree on my follow-up medications and antibiotics. It turned out that the antibiotics would require me to do home infusion. So then the care manager had to schedule a nurse to come to my home the very next morning to provide supplies and train me.
After all these steps were taken, the hospital released me at 7:00 p.m., ten hours after the original plan. My family members kindly came to fetch me, saving me riding home in a taxi.
A Plethora of IVs
In the hospital, you’re gonna have intravenous medication. In fact, you’re probably gonna have multiple IVs:
– IV #1: If you come in through the emergency room, they always put the IV into a vein at the elbow. This allows them good access if you’re having a stroke and need immediate IV medication.
– IV #2: However, once you’re admitted to the hospital the ER’s IV is a nuisance, because every little motion of your arm rings an alarm indicating blockage in your IV. Therefore, you will probably get a new IV in the forearm.
– IV #3: The IVs wear out if you’re in the hospital as long as I was. They get partially blocked, the skin gets inflamed in that area, the veins get irritated by some of the IV fluids, and so forth. So the nurses installed a second IV at a different spot on my forearm.
– IV #4: Recovering from endocarditis would require daily or twice-daily antibiotic infusions for six weeks. Therefore, I needed a more permanent IV that would not cause problems during that time. For these infusions the nurses installed a PICC line in my upper right arm. PICC, which stands for “peripherally inserted central catheter,” is appropriate when IV medication continues for more than two weeks.
In this blog, I finally made it out of the hospital after my valve surgery. However, there were many steps to take before my life would get back to normal. These are described in the following part of this blog: “Life Beyond: Post Surgery Recovery.”
Image Credits: Photos by Art Chester