Open Heart Surgery

My 100 hour Mitral Valve Repair

(Part 2: Screening, Surgery & Hospital Stay)


Surgery (-1 Day): Screening (Pre-Op Exam):

The day before the surgery, I had to go to the surgeon's office for a pre-op exam. Not sure if that is the right term for it, but basically he and his staff wanted to make sure I was in otherwise good health. My vitals were checked and a chest X-ray was taken (presumably so the surgeon could get a better idea of what he had to work with and to plan his surgical strategy). There was also an ultrasonic image taken of the carotid artery (to check for stiffness, an indicator of overall coronary artery disease). Earlier, the tape from my TEE and CDROM from the Angiogram were submitted. Bottom line, the surgeon wanted to know what he would have to work with and on the day of the surgery.

Finally, after all that was done, I had my first meeting with the primary surgeon that would be repairing (hopefully) my mitral valve (to be more specific, the anterior leaflet of my mitral valve). Keeping in mind this was less than 24 hours before the surgery, my mind was pretty much preoccupied with upcoming events; I am sure that there were many more things discussed than I can't remember now. One of the items I do remember was the discussion about which replacement valve I would prefer should he find he couldn't repair mine. The options were basically a mechanical valve, with the advantage that it would probably last the rest of my life, and the disadvantage that it mandated anticoagulant therapy for the duration, and the organic or "pig valve". While the organic valve didn't require that anticoagulants be taken, it had the disadvantage that it had a typical useful life of ten or so years, at which time it would have to be replaced. The surgeon's recommendation was the organic valve. First of all, he said there was significant risk in the long-term usage of anticoagulant drugs, and second he reasoned that in ten to twelve years time, organic valves and the surgical techniques for their repair or replacement will have advanced to the point, that the next surgery would probably be the last that would be necessary and done by far less invasive techniques than are available today. I was sold and told him to go with the organic valve if required. I also quickly added that saving (repairing) my own valve was obviously my first choice.

The second thing I remember was his comment that there was calcium deposits in the area surrounding the mitral valve opening, which he said would make the surgery more difficult. I think he said it would be something like trying to sew a cement block, but that well could have been my own simplification or over reaction to what he actually said.


Note...

While in the hospital, every few hours a nurse would stop by to take my vitals, ask me how I was feeling, and to rate my pain on a scale from 0 to 10, where (0) was a total absence of pain and (10) was... well, the worst imaginable. The form used in the hospital had five faces from a "happy face" to a "crying face" which were used as a graphical representation of the pain. When doing the research for this page I discovered that, of all things, the "face pain scale" was copyrighted. Not wanting to invoke the wrath of the copyright holder, I decided to work out my own graphical representation, shown to the left of this frame (my apologies to Celsius and Fahrenheit).

While I have a pretty good handle on what was (0) pain, I wasn't sure what to use as a reference for the (10) end of the scale. Pain of course is relative, and is different for everyone. Some people have a high pain threshold (lucky them) while others a low pain threshold (like yours truly). What I ended up doing is dynamically adjust my scale throughout my hospital stay; i.e. whatever was my worst pain to that moment, was considered (10) on my scale and everything else was adjusted accordingly.

I should add that my hospital (10) was certainly not the worst pain I've ever experienced. I'd say that honor goes to a root canal I had. Let me tell you friends there is no pain quite as bad as having an endodontist tap dance on an exposed nerve some 2" from your brain! To put the hospital experience in perspective, if I were to rate my root canal as a (10), I'd have to say the worst pain I experienced in the hospital was no more than a (6).


Morning of the Surgery...

I had to arrive at the hospital at 5:00 AM the day of the surgery, which means I was up and out of bed sometime around 4:00 AM! As far as I can remember, the last time I started my day at four was when I had a paper route many, many years ago. In a way, I guess it was a good thing since I was still too numb to fully realize what was in store.

Once arriving at the hospital I was shown to the prep area. The first event of the day was a fellow coming in to shave my body from neck to toe, literally. As I understand it, the idea is to have the entire body prep'd, just in case the surgeon finds it necessary to make additional incisions, harvest arteries for a bypass, etc.

Next step was to shower with a special antibacterial soap (I had to used the same stuff at home the night before). After that, it was a clean surgical gown and I was good to go. Perhaps a strange expression for someone that was about to undergo two-plus hours of open heart surgery, but I think that, after three months of anxiety and anticipation, it was a relief to know it was almost over with.

Once back in bed, the nurse gave me something to help me relax. This is a bit of an understatement, since I don't remember much of anything after that. Seems like someone came by and said it was time to go, but to be honest I don't remember being wheeled out or entering the operating room.

When I had the Cardioversion, I was wide awake for the gurney ride to the Cath Lab. Once there I remember the surroundings, remember meeting the anesthesiologist, remember him talking to me as the anesthesia took hold, and remember waking up, still in the Cath Lab. None of this with the Open Heart Surgery. If I'm given a choice the next time I am in the hospital, I think I'll go with the "see nothing, feel nothing" approach used this time during my surgery.


After the Surgery - First Memory...

I wish I could tell you what happened next. I remember hearing a voice off in the distance saying (shouting?) breathe... that's good, now breathe for me again... and again... Next thing I remember is what had to be the worst pain of the entire time in the hospital; at least I think it was. I was sort of in a fog and really not sure about much of anything. I don't remember seeing anything, but the next thing I heard was something about we're going to suction out your lungs or something to that effect. Again there was a sharp pain. As you can see this was to be the (10) for my pain scale. Fortunately it only lasted a few seconds and then it was over. It wasn't until later that I learned that pain was when they removed the ventilator tubes from my lungs and suctioned out fluids that had accumulated (not necessarily in that order). Of course I didn't know it then, but that was as bad as it was ever going to get. I guess what amazed me most was how they were able to time it so precisely: not quite awake enough to panic or resist, but yet alert enough to respond to verbal instructions. Bless them for that! Whatever they did, my guess it is best done before you are fully aware of what is going on.


After the Surgery - Fully Awake...

My wife tells me I was fully awake around 5:00 PM Twelve hours had passed since I arrived at the hospital. Considering what I had been through during those twelve hours, I was amazed how well I felt. It was over and I was on my way to full recovery! Absolutely amazing.

There was some discomfort, but certainly not bad. I'd give it a (2) on my pain scale. The nurses, bless their hearts, frequently asked if I was in any pain, it there was anything they could do to make me more comfortable, etc. They would stop by often to take my vital signs, administer medications and take blood samples. This was done via the IV tubes, so there were no needle sticks, in fact no sensation at all.

The "call button" was rather interesting. Here I was in a state-of-the-art medical facility, with the latest and greatest everything, and the nurse comes in with a little mechanical bell like you might ring at the bakery for service. I asked about this and she said that they have never had one fail or break and never needed to call engineering to fix one. Hmmmm, I guess in some cases, simple is better.

Their was even a ring code: One ring for "Please stop buy when you have a chance." and three or more rings for "HELP!". Fortunately the few times I used my bell were "One Ringers", though I could hear that others on the floor weren't so fortunate.


 

 

 

Surgery (+ 1 Day): The Day of Pain and Nausea...

What I am assuming was the next day (1) had to be the worst of the four plus days spent in the hospital. One of the nurses called the day after surgery the "Day of Pain & Nausea". I'd say that pretty much sums it up. Fortunately there were very effective medications for both. In a relatively short time, I was feeling better, though was sure aware when the medication started to wear off again. The key, is to keep the nurses informed as to how you were feeling and to notify them as soon as things change.(2)

Apparently when you are on the ventilator and when you've spent a long time flat on your back relatively motionless, fluids tend to build up in the lungs. If there is too much accumulation there is the danger of infection, pneumonia, etc. They could stick a tube down your throat and into your lungs and vacuum out the fluid, but take my word for it, you don't want this. The other option is to cough up the mucus, just as you would if you had a bad cold. To assist you with this they give you the tools shown to the left (the names I used are my own creation; I have no idea what they are really called). The "Exhaler" provides a controlled resistance as you exhale. The idea being my increasing the pressure in your lungs, you cause the alveoli (the terminal air sacs of the lungs) to expand. The "Inhaler" measures lung capacity, but unlike the tests your may have had at your doctor's office, this is done while inhaling rather than exhaling. Difficult to see in this small photograph, but there is a scale on the left that indicates lung capacity in milliliters. The hospital's "Respiratory Therapist" teaches you how to use the equipment, and also sets your "goal" (based on height I believe). My goal was 3500 ml and the indicator on the side was set at that number as a reminder. I'm not sure if the therapist said this or I imagined it, but I got the feeling that I wouldn't be allowed to go home until my goal was achieved. FYI, the first time I tried it I was lucky to pull 1500 ml; I had a long way to go...

Unfortunately there are two things wrong with this scenario:

  1. Keep in mind that, at this stage, your rib cage is held together with string. When you inhale, your chest expands and... Well let's just say your body is none too happy about it; i.e. it smarts a bit!
  2. When you breath deeply with your lungs full of gunk, it makes you cough (the whole idea of this exercise). In the beginning, coughing feels like someone hit you in the chest with a pick ax. It gets easier with time, but I can assure you you'll never forget that first cough after surgery!

The sequence goes something like this...

  • Exhale (30 times per session)
  • Inhale (10 times per session)
  • Cough (typically once per deep inhale)
  • Ouch! (PC substitution for deleted expletive)

You might be wondering what the "heart pillow" is for. Well... you know how small children will latch on to a stuffed animal and it becomes their best buddy? Same thing. This small pillow will become your best buddy while you are in the hospital and for some time after. You are instructed to clasp the pillow tightly to your chest when you feel you are going to cough; doing so helps stabilize the sternum (breastbone) and makes the pain almost tolerable. To this day I walk around the house clutching my little pillow like a security blanket; Linus at age 60!(3)


(1)Time spent in the ICU (Intensive Care Unit) is rather surreal. There are no windows, the lights are on around the clock and doctors, nurses, and patients are constantly coming and going. I couldn't see a clock from my bed so I had no idea how much time was passing, or even if it was day or night. About the only cues I had were the particular meal that was being severed at the time. Well that, and I figured it was most likely the doctors were there in the morning, rather than late at night; the nurses were always there, working twelve hours shifts.

(2)Pain and nausea are extremely subjective and as far as I know, they cannot be monitored directly. The nurses must depend on you to tell them how you are feeling. You don't get anywhere with the "grin and bear" it approach. Chances are if you tell the nurse what's bothering you she can fix it or at least make it a heck of a lot better.

(3) R.I.P. Charles Schulz


Soapbox time again (sorry)...

This has absolutely nothing to do with the thread of this page, but I wanted to cover this while it was still fresh in my mind. Today I went back to the surgeon's office for my 30 day follow-up exam. While there, I asked the nurse if she could explain to me exactly what sort of problems were found during my surgery (I had been told the surgeon had a very tough go of it and I wanted to know why). The nurse reviewed the surgeons notes and told me that, where most MVR (Mitral Valve Repair) patients had one or rarely two problems with the valve, I had three! She proceeded to tell me about the problems found and ended by saying that most (if not all) other surgeons would have simply removed the valve and replaced it with an organic (pig) valve. As mentioned in the Preparation page, organic valves wear out; i.e. had the surgeon taken the easier path, I'd be back in the hospital in another 10 years or so going through all of this again. Had the surgeon installed a mechanical valve, I'd have to be on anticoagulant therapy for the rest on my life and have to live with the associated risks. Quite literally, the decisions made and the skill and perseverance manifested by the surgeon that day in the operating room, determined the quality and quantity of the rest of my life.

Hopefully my real-life, firsthand experience will drive home the importance for finding the very best talent available. Choosing your surgeon will be one of the most important decisions you'll ever have to make. Remember, you'll have to live with the consequences of that decision for the rest of your life!


Surgery (+ 2 Days): Secondary ICU

The hospital I was in had two levels of ICU (Intensive Care Unit). The primary ICU was the area where they took you directly after surgery. As mentioned earlier, this place probably has the highest nurse-to-patient ratio in the hospital. It is nonstop 24 hours a day. I can't even begin to guess how many hours sleep I got while there (not including prior to coming out of the anesthesia). With no way to tell day from night, no clocks, and nurses coming and going all the time to take samples, check readings, and administering medication, it was like one very long day.

On the second day after surgery I was moved to the secondary ICU. This room was quieter with less activity and they actually dimmed the lights at night (at least I guess it was night). This room was the transition room between ICU and the cardiac ward. You'd think that with this new found quiet and at least some indication as to when it was night, I'd have slept like a log. No such luck...

On the wall was an EKG constantly monitoring my heart. The nurse set it to sound a (loud) alarm, whenever my heart-rate dropped below 50. Yes, you guessed it, every time I started to drift off to sleep, my heart rate would drop below 50, the alarm would go off and I'd be wide awake. To make matters worse, every time the alarm went off the nurse would come running. The first few times were comforting (i.e. it was nice to know they were there should anything go wrong), but it didn't take long to go from comforting to annoying. All I wanted to do was sleep!

To make matters worse, each time the nurse came in she would warn that if there was much more of this, I would have to go back into surgery and have a pacemaker installed. Let me tell you, the thing you most don't want to hear after going through open heart surgery is that you may have to right back into for more work. In addition, I absolutely did not want a pacemaker. I tried to explain to the nurse that, prior to the surgery I had been on Beta Blockers and my heart rate was often below 50, but to no avail.

My mind was racing trying to figure out how I was going to avoid the pacemaker. It was then I looked over my shoulder and noticed that I could just make out the EKG monitor behind me. I then started moving whatever body parts I could in the hopes I could get my heart rate up. I tossed and turned, moved my arms up and down, held my breath, breathed faster, everything I could think of. With all the wires and tubes there was a limit as to what I could do, but fortunately it was enough. By keeping this up all night I was able to keep the alarm from sounding, the nurse from coming in, and hopefully eliminate the need for the pacemaker. Of course it meant no sleep, but I figured that was a small price to pay. Fortunately I only had to spend one night here.


Lessons Learned...

It wasn't until much later that I learned that this particular nurse had her own agenda, and just because she said I was a pacemaker candidate, didn't necessarily make it so; i.e. perhaps I lost a night's sleep for nothing.

Another example, I asked one of the ICU nurses for a glass of water (apparently the ventilator does a number on your throat). She gave it to me, but with a warning... She said if I drink too much water, the diuretics they were giving me wouldn't do their job which was to help my body get rid of accumulated fluids. Not knowing better, I lay there in absolute misery afraid to drink water. Gosh if the diuretics didn't work, toxins would build up, urine output would be low, and I'd probably never be allowed to go home. Yes, pretty dumb I know, but this was my first prolonged stay in a hospital and I wasn't sure what was what(1). Later, when the surgeon's PA (Physician's Assistant) came by and ask how I was doing, I complained about being so thirsty. He said there was no reason at all that I couldn't drink as much water as I wanted to.

I guess the bottom line is that nurses are people too. Certainly each has his or her own ideas as to the way things should be done. In addition, they take care of a lot of patients of a lot of different doctors and I would guess each doctor provides slightly different instructions as to how their patients are to be cared for. So what did I learn? Basically that you must be proactive. If something doesn't seem right to you or is making you uncomfortable, ask questions, speak to other sources, etc. If I am ever in this situation again, I will work my way up the chain of authority (for want of a better word) from floor nurse to nursing supervisor, to the PA's, to the surgeon himself if need be. Hospitals are busy places with a lot of patients to care for. Of course they want your stay to be as comfortable and pain free as is possible, but don't expect them to do all the work. You have your part to play just as they do. Nurses aren't mind readers, nor is it likely they are infallible. The person that knows the most about how your are doing and what your needs are... is you; speak up!


(1) As a side story, one time in ICU I decided to try to get from the chair back into bed on my own. As luck would have it, I must have caught or stepped on the tube from the Foley catheter to the urine collection bag. Fortunately, the coupler pulled apart rather than the catheter being pulled out (knowing how it feels when they remove the deflated catheter, I can only imagine how terrible it would be to pull it out while it is still fully inflated (the catheter, not me). Anyway, when the nurse came in to clean up the mess, I asked him to try to estimate how much urine had spilled, and put that on my chart. This gives you some idea how desperate I was to get the "numbers" necessary for an early discharge.


 

Surgery (+3 Days): Moving Day - Out of ICU and into CSU

After a rather uncomfortable night, it was time to move again, this time out of ICU and up to the CSU (Cardiac Surveillance Unit). This area of the hospital is equipped with remote EKG monitoring equipment. You are equipped with a small EKG transmitter and it broadcasts your heart's activity to the nurses station via several antennas located throughout the area. The big advantage is that you can be mobile, no longer tethered to the bed with a hardwired EKG.

The real high point of this day was getting the various tubes removed. The PA and a floor nurse came in that afternoon and removed the two drain tubes from my chest, the Foley catheter, and the IV. Just after surgery there where to IV lines running to either side of my neck. As I remember, one of those was removed the first day. Now they were removing most of what remained. One of the remaining IV lines was removed, leaving behind a short catheter. This would be used throughout the balance of my hospital stay to inject medications and take blood samples. Certainly a much better system than having them constantly sticking needles in your arm. Injections through the neck catheter were completely painless, but occasionally there would be a slight discomfort when they took blood samples. The wires for the temporary pacemaker were also left in place, just in case it was required.

All-in-all the tube removal process was relatively painless. Certainly not what I expected. The drain tubes in my chest were rather large, perhaps as much as 3/8" (~1 cm) O.D. I was sure it would hurt like heck when these were pulled out, but fortunately that wasn't the case. More of a strange sensation rather than a pain. Removing the Foley catheter wasn't painful per se, but the sensation is one you will have to experience for yourself to fully appreciate.

The real blessing of having most of the plumbing removed was being able to finally move around without dragging the collection bottles behind me. May not sound like much, but it is a true milestone, second only to waking up in the ICU after the surgery and realizing it is all over and you're OK!

The balance of this day was rather uneventful. I was still a bit weak, but able to walk short distances. I was able to use the bathroom (finally!) and brush my teeth for the first time in three days (something I always considered a chore, but now was a true joy). Having the accumulated tastes of three days worth of hospital food in your mouth is not one of life's better moments.


I should note that the above pain ratings do not include what I call the "Tape Factor" or "TF". The TF is the pain caused by ripping off the tape used to secure the tubes, wires, etc. to your body and is proportional to the amount of it used. Nurses, bless their hearts, will tape anything to anything. They have rolls of the stuff hanging from their stethoscopes and their belts, a few rolls in their pockets, and, just to be sure they don't run out, each room seems to have a dozen roll backup supply sitting on the shelf. I had more tape on my body than King Tut.

The tape nurses use has very special characteristics. Not only does it adhere like epoxy, but it also has a built-in hair detector. Should there be a single hair remaining anywhere on your body, the tape will find it. Oh yes, I should correct a previous statement. I said that they shave you from your neck to your toes, but I forgot to mention that they don't shave your arms. Guess what part of your body ends up with the most tape on it?


Surgery (+4 Days): The last day!

This was my last full day in the hospital. Early that morning, they removed the remaining IV and temporary pacemaker wires. As far as I was concerned I was ready to go home. I felt great and and could see no reason to remain in the hospital, but was told it's best to stick around awhile longer to make sure there was no adverse reaction to removing the last bit of hardware.

I spent most of the day walking the halls and hanging around the nurse's station looking at the EKG monitors and other gadgets at their disposal. I'd walk for 30 minutes or so, stop by my room for a short rest, then I was back on my feet again. Unfortunately I was restricted to walking in a rather limited area since I had to stay in range of the wireless EKG monitoring equipment.


Going Home!

Early the next morning I was released from the hospital, just about 100 hours after I checked in; truly amazing considering what I had been through. As per hospital rules, they had to summon a wheelchair to take me down to the car, but the way I felt I could have just as well flown. I felt fantastic. The few minutes I had to wait for the wheelchair to arrive seemed to drag on for an eternity. Don't get me wrong, the treatment I received in the hospital was first rate, as were the doctors, nurses and support staff that took care of me during my stay. Be that as it may, as the old saying goes: "There's no place like home" and that's where I wanted to be. As Julius Caesar said: "Veni, Vidi, Vici (I came, I saw, I conquered )"; now it was time to go!


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Page Updated: 25-Apr-2005