You will have a checkup with the cardiologist about 7 to 10 days after you go home. During this visit, the cardiologist will discuss your recovery, make recommendations for improving your lifestyle, and fine-tune your medications if necessary.
By the sixth week after surgery, most people resume almost all of their regular activities. You can drive, travel, return to your normal sex life, go to movies, eat out, and even return to work. However, your healing will progress most smoothly if you don't let yourself get exhausted, and if you remember to rest when you are tired. You will notice that as your activity increases, your strength will increase too. Six weeks after discharge, you should be able to walk two to three miles in one hour.
Need To Know:

Activities to avoid
The bone in the middle of your chest (the sternum) was opened during surgery. This bone does not completely heal for at least 12 weeks. For that period of time, no extra stress should be put on it. Remember to avoid heavy lifting (no more than 5kg), playing golf, tennis or vigorous swimming. Light activities will aid the healing process.

Cardiac Rehabilitation
Your cardiologist will discuss beginning an exercise program. This will be one of the most important things that will keep your cardiovascular system healthy.
These programs teach the importance of exercise, how to get started, and how to know your limits. Some programs may also help you make changes in diet, quit smoking, or control stress.

Keeping Your Arteries Clear
Before bypass surgery, there are significant blockages in the coronary arteries . If preventive measures are not taken, the processes that caused those original blockages can occur in the new bypass vessels after surgery. So, it is important to reduce the risk factors for coronary artery disease that can be controlled. These include: smoking, high blood pressure, diabetes , high cholesterol , and a sedentary lifestyle.

Smoking
Smoking causes major damage to your cardiovascular system . The risk of renewed heart disease is even greater than the risk of lung cancer. Patients who continue to smoke after bypass surgery are likely to have their new arteries blocked sooner than those who do not smoke. That's why it's essential for patients who smoke to quit after their surgery.

Hypertension
Many patients have hypertension (high blood pressure) before surgery. It is essential to monitor your pressure carefully after surgery. Poor control of blood pressure after surgery can worsen blockages in your arteries and speed up changes in your bypass grafts.
Your doctors will help you work out a plan for controlling blood pressure with diet, and perhaps medication.

Diabetes
Diabetes increases the risk for coronary artery disease. Control of blood sugar after heart surgery is just as important as before surgery, to keep the bypass grafts open.

Cholesterol Control
Poor control of cholesterol after surgery increases the risk that your new bypass grafts will be blocked. If changes in diet and lifestyle are not successful in reducing the level of cholesterol, then medications may be necessary in addition to the changes in diet recommended by your doctors. Remember that all medications have side effects, so altering your diet is an ideal strategy to improve your lifelong health.

Sedentary Lifestyle
Moderate amounts of physical activity, including daily walks, swimming, or biking for fun can make big differences in how you feel and how your heart works. To become more physically active:
• Start slow. Begin by walking or being active just 15-30 minutes each day, and work up slowly from there.
• Find activities you enjoy doing. Physical activity seems easier when it's fun.
• Be active with a friend. Walking, biking, or other activities are great ways to spend time with people.

Stress
Learning about and controlling stress can help your recovery and make it easier to tackle other lifestyle changes. There are many ways that people reduce daily stress: Some have quiet hobbies, some meditate, and some are physically active. Do whatever works for you, or sign up for a stress-control class. Remember, everyone is exposed to stress. But how you handle it can either support or undermine your long-term health.

Diet
Improving eating habits can help reduce risk for heart disease. Here are some tips to reduce the saturated fat and cholesterol in your diet:
• Try lean meats like skinless chicken and fish instead of higher fat meats.
• Use lower-fat cooking methods, like boiling, broiling, baking, roasting, poaching, steaming, sauteing, stir-frying, or microwaving.
• Choose fat-free or 1% milk, and nonfat or low-fat yogurt and cheeses.
• Eat five or more servings of fruits or vegetables each day.
• Choose whole-grain cereals and breads.
Major dietary change is a challenge for anyone. But, by making gradual changes, you may find that you actually enjoy a healthy diet more.

SURGERY FOR HEART FAILURE

Generally heart failure is considered as totally a medical problem as the risks with surgery are high. However in selected patients, who are resistant to medical therapy, cardiac surgery can make medical treatment easier, improving quality of life to the patient. And there are surgeries like heart transplantation which have been proven to increase the longevity of these patients. Basically surgeries in these patients are:

- Those that identify and remove the primary insult that resulted in heart failure
- those that try to surgically reverse remodel the ventricle,
- using assist devices
- heart transplantation and
- Sometimes combination of the procedures.
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Surgeries for removing the primary insult:

These include operations for coronary artery disease and valve diseases that resulted in heart failure and significant left ventricular dysfunction.

Coronary artery bypass surgery: Myocardial ischemia is probably the most important cause of heart failure and is associated with a 30% - 50% annual mortality. However reduced ventricular function may be reversible with ischemia. Restoration of function with correction of ischemia may take some time, on occasion, months. Identifying the presence of such hibernation is probably best achieved with labelled (F18 deoxyglucose uptake) positron emission tomographic (PET) metabolic studies. If it shows viable myocardium >20% of left ventricular mass, evidence is stronger. Viable myocardium can also be demonstrated by dobuatmine stressed echo and its characteristic bi-phasic response to increasing levels of inotrope. There is an initial improvement in contractility followed by a fall off in function as dobutamine levels reach values of 25 – 40g/Kg/min. Magnetic Resonance imaging (MRI) is showing promise too by revealing scar or viable muscle. Sometimes even 2D echo may give some suggestion of viability through the thickness of myocardium and subendocardial thickening. However one has to consider the clinical condition, evidence for significant viable myocardium and the high risks involved in these patients before advising surgery. Sometimes bypass surgery may have to be combined with mitral valve repair surgery or with left ventricular remodelling surgery.

Valve surgery: In India rheumatic heart disease still contributes to significant proportion of heart diseases. Today advances in surgery allow most valve disease patients with left ventricular dysfunction to be operated successfully although prognosis is still reduced in such patients. However surgery is likely to reduce number of hospital admissions with heart failure and improve their quality of life. Aortic stenosis patients with low gradient and low ejection fraction without inotropic reserve and mitral incompetence patients with ejection fraction of <30% in whom mitral subvalvar apparatus cannot be preserved constitute the small group in whom valve replacement surgery should probably not be performed.


Surgical procedures to improve cardiac output by reducing left ventricular size (“La Place surgery”):

Many modalities are being tried in the world today that aims at reducing an enlarged ventricular volume and reversing the forces that are driving further ventricular remodelling. Some of these are
(i) The Myo-splint.
ii) The CorCap® or Acorn device
iii) Left ventricular aneurysmectomy.
(iv) Mitral valve repair for secondary regurgitation.

One of the more accepted modalities is left ventricular aneurysmectomy when there is a left ventricular aneurysm causing heart failure. Dyskinetic segment of ventricle is removed reducing ventricular diameter and so reducing ventricular wall tension. However the segment removed here is scar and not ventricular muscle. The aim is to restore a more “normal” ventricular geometry increasing the efficiency of ventricular contraction..




Surgical strategies to re-power the failing heart:
These include surgeries like implanting ventricular assist devices and heart transplantation.

Ventricular assist devices (VAD): The intention here is to off-load the failing heart. This is achieved by the unloading of blood from the ventricle and delivering into the arterial tree (pulmonary for right ventricular assist or RVAD and systemic for left or LVAD). Both ventricles may be supported simultaneously with BIVADs. Total excision of a failing heart is occasionally undertaken followed by replacement with an artificial heart (Cardiowest, Abiocor).
Generally a potential VAD candidate presents with severe, refractory heart failure with deterioration despite intensive medical therapy. A VAD is selected and may be temporary or long–term. Some are designed for per cutaneous insertion into the systemic arterial tree lying across the aortic valve (Impella). More usually VADs are inserted via a sternotomy. Patients are often mortally ill with multi-system dysfunction. Bleeding, control of vascular resistance and multi-organ failure are early problems soon replaced by risks of infection and thrombo-embolism. Mostly these are used as bridge to transplantation in individuals who are on inotropes with haemodynamic instability and waiting for a suitable heart donor.. Interestingly some patients (often those with a short but aggressive history of failure or myocarditis) recover so that the VAD can be removed and heart transplantation avoided.

Heart Transplantation: Despite many advances in the management of chronic heart failure, many patients continue to progress to advanced end-stage heart failure. For those that are suitable, heart transplantation is the only proven therapy to offer improved survival and quality of life. Current survival for heart transplantation approaches 80-90% survival and 50-60% at 10 years. In addition to improving the longevity of life, it is associated with a marked increase in quality of life despite the need to take life long immunosuppressive medication and follow-up. In India now there are centres working to develop this transplantation facility.

Given the inadequasies of medical infrastrutuer and its accessiblity to the growing number of patients suffering from heart diseases requiring angioplasties and bypass surgeries i would wholeheartedly support chelation treatment provided it is well supervised and monitored.It shud not become a tool in the hands of quacks to explot the vulnerable patints.Beside i do have some of my patients recovering to a significant extent their functional ability.and self confidence.If one cannot offer any other defiinite solution then this could one option. Any comments?

Carotid reconstruction was first performed by Eastcott et al. at St. Mary's Hospital, London, in 1954. However, it took nearly four decades until trial evidence became available to show that carotid endarterectomy was better than best medical treatment in patients with amaurosis fugax or hemispheric symptoms, transient ischaemic attacks, or stroke who had made a good recovery and whose symptoms were caused by severe carotid bifurcation stenosis (>70% with the North American Symptomatic Carotid Endarterectomy Trial [NASCET] method or >80% with the European Carotid Surgery Trial [ECST] method). The two-year risk of stroke in the medical arm of NASCET was 26% compared with 9% in those who underwent endarterectomy. Subsequently, the NASCET trialists reported that endarterectomy reduces the five-year risk of stroke in moderate stenosis (50%–69%) from 22.2% to 15.7%. A recent meta-analysis of the NASCET and ECST trials showed that benefit from surgery was greatest in men, patients aged 75 years or older, and those randomised within two weeks after their last ischaemic event, and fell rapidly with increasing delay.
Surgery is usually performed at six weeks if there is good recovery, but there is a tendency to perform it earlier in patients with transient ischaemic attacks or strokes with good recovery when CT brain scan shows no infarct. Surgery reduces the risk of stroke by 50% even if the event occurred more than six months previously, as shown by the Medical Research Council Asymptomatic Carotid Surgery Trial .
While recovering from stroke and awaiting carotid endarterectomy, aspirin even at a low dose of 75 mg daily reduces the risk of recurrence. .

What are vascular diseases and Vascular Surgery

“A surgeon's skills are measured by the way he handles the blood vessels”

These prophetic words of the great American surgeon William Halstead ushered in the era of one of the most skilful surgical specialties – Peripheral Vascular Surgery. This field has rapidly evolved over the last hundred years, with major advances occurring during the II World war and the Korean war. Endovascular interventions in the form of angioplasty and stenting have added an exciting new dimension for treatment of vascular diseases in the last two decades.

Vascular bypass operations in the leg preceded “heart bypass” operations by many years!

Vascular and Endovascular Surgery is a highly specialized field that deals with all the blood vessels in the body except those in the heart and the brain. Arteries that carry oxygenated blood from the heart to various organs and veins that return deoxygenated blood back to the heart, are the two main forms of blood vessels whose diseases are addressed by vascular surgeon. They are the life-lines of various body parts.The expression of vascular problems in different parts of the body is quite variable and this makes the specialty a complex, challenging field. A vascular surgeon is truly a “vascular specialist” since his expertise encompasses not only surgery, but also newer minimally invasive endovascular procedures (angioplasty, stenting) and vascular medicines. Hence vascular surgery remains one of the few “holistic” medical fields today which delivers complete, seamless care to patients with vascular disease.

How much is the problem?

What would be the magnitude of peripheral arterial disease of the legs in India? Since there are no specific data, we could extrapolate the available data to Indian population and the numbers thus obtained are quite staggering:

• Among 42 million diabetics – about 1000 per million will develop Critical Limb Ischemia, which usually means if some vascular procedure is not done they will lose the leg, which also makes them high risk for heart attack or stroke. If untreated this amounts to 42,000 amputations per year!
• Among rest of the population – about 500 per million (about 4,85,000) will develop critical limb ischemia needing a vascular correction or amputation!!
• In rest of the population about 38,00,000 (about 380 per 1,00,000 population) will develop peripheral vascular disease – these are the patients whose future vascular events can brought down significantly if proper medical care is given.

Venous diseases are far more common and include varicose veins, venous ulcers and deep vein thrombosis. All these problems affect a person’s quality of life and deep vein thrombosis is potentially life-threatening.

Causative factors
1. Smoking
2. Diabetes mellitus
3. High cholesterol
4. Lack of exercise
5. Obesity
6. Thrombophilia: tendency for blood to clot easily.
7. Heredity
8. Aging

Symptoms of vascular disease

Majority of vascular patients have one or more of the following three symptoms:

1. Painful extremity
2. Swollen extremity
3. Ulcerated extremity
Other problems include arterial aneurysms (dilated arteries) that have a potential for rupture, renovascular hypertension that is correctible, mesenteric ischemia that reduces blood supply to the intestines and has a higher fatality that heart attack, carotid artery stenosis that affects blood supply to the brain and results in paralytic attack which is preventable!
There has been an exponential increase of vascular problems in India due to unabated smoking and rapid increase in diabetic population (42 million or 4.2 crores), crossing all economic barriers. Peripheral vascular disease affects mostly the legs, which initially causes pain in the calf muscles while walking. The walking distance progressively reduces and if ignored will result in severe pain in the toes even at rest and eventually will result in gangrene of the toes and the foot, which might necessitate amputation. This “leg attack” is more dangerous than heart attack as it can endanger the limb and life of the patient. But this can be easily treated in the initial stages with appropriate medicines and simple life style modification programs. Unfortunately, these patients rarely reach a qualified vascular surgeon at this stage. One of the main reasons being lack of awareness among the public and also among many of the doctors about the vascular diseases and the role of vascular surgeon. There are only about 50 vascular surgeons in India, which results in these patients seen by other specialists, resulting in delayed referral to a vascular surgeon. In fact majority of these patients are not seen by vascular surgeon at all resulting in unnecessary limb and life loss. Even when a patient presents relatively late to a vascular surgeon, most of the limbs can be salvaged with a high success and low complication rate by vascular bypass or minimally invasive endovascular procedures like angioplasty and stenting if needed.

Blocked arteries in the leg mirrors rest of the body. Early diagnosis by good clinical examination and simple tests in patients with risks (smokers, diabetics, those over 50 years) will detect the disease even before they become symptomatic. It is well established now decreased blood flow in the legs is the biggest indicator of future hear attacks, strokes and amputation of legs or in other words the blocked arteries in the legs indicate a wide spread vascular disease in the body. When a patient has blocked arteries in the heart (cause of heart attack) it indicates that there is 30% chance that he/she has vascular disease else where, but a blocked artery in the leg indicates 60 to70% chance of diffuse vascular disease. Hence it is recommended in these risks groups should be examined peripheral arterial disease in the legs and if they do, they should be started on good medical treatment and life style modification program, which would markedly decrease the chance of future heart attacks, stroke or amputations.


Since poorly diagnosed and untreated vascular disease can lead to major limb and life threatening problems, it is of paramount importance that public and the medical profession is aware of early symptoms and the diagnostic methods. Early diagnoses and proper therapy will not only control the disease, but will markedly decrease the future complications and results in improved quality of life.

Vascular surgeon plays a pivotal role in diagnosing and treating these diseases, as our medical education imparts very little knowledge about vascular diseases to other specialties. Hence it is mandatory that any body suspected of these problems be evaluated by a vascular surgeon.

Patients with diabetic foot problems, which are the number one cause of admission in diabetic patients in India, usually are treated by vascular surgeon. These are of epidemic proportions, causing life and limb loss, though they can be easily prevented with proper foot care. Vascular surgeon plays a pivotal role in caring for the diabetic foot problems whether they are related to vasculopathy or neuropathy.

Vascular surgeon’s field is wide since it covers major portion of the human body. The next most important disease treated is stroke prevention surgery. Majority of strokes occur because of the narrowing of a blood vessel, called carotid artery, in the neck which carries blood to the brain. If diagnosed in time and treated with a highly successful surgical procedure called “Carotid Endarterectomy”, the chances of stroke is markedly reduced. In few, highly selected patients vascular surgeon may opt to perform “angioplasty and stenting”, but these cannot be applied to all patients at present, but might change in future. Again, it important to have these patients evaluated by a vascular surgeon, for proper diagnosis and treatment.

Vascular surgeons also deals with blood vessels in the upper limbs, those inside the abdomen supplying vital organs like the kidneys, liver intestines etc. Diseases of the veins, simplest of which is the varicose veins, also come under the purview of vascular surgeon.


Dr. P C Gupta, MS, FICA
Senior Consultant & Chief,
Vascular & Endovascular Surgery

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