Improving physical condition after bypass surgery

[samway]

I had a triple-bypass and open-heart surgery, ten months ago after a  heart attack (in May 2010).  At first, I could barely walk, being terribly short of breath.  Thankfully, it was water on the lung, which was resolved after another 10 days in the hospital.  My age is 56.  I now have arrhythmia and an implanted defribillator.  

As an athlete all my life, I sought to resume my exercising.  First I had to walk,  then, walk and run.  Now, I can run a 3.3 mile course without stopping, in maybe about 45 minutes.  But I run very slowly and everyone passes me.  I have kind of plateaued for a couple of months.

Also, climibng steps is getting easier, but still poses challenges.  If I climb too many, I start gasping for breath and my heart beats hard and fast.  .

I asked the surgeon and my cardiologist why I am running so slowly.  They say that I may not run faster, but they are not sure.  I don't know if the reason is my weak heart, or that my lungs are still collapsed from the surgery, or that the rib cartilage has not healed from when I was sawed open.  Bottom line is that my chest feels tight and I still cannot take a full breath by any means.  

What is the reason for my slow pace and difficulty climbing steps?  Is it my heart, my lungs, my rib cage?

What are your exercising recommendations as to improving performance?

Do you know of Any advice or books you can recommend?  If you would be so kind, please pass it along.  Most of the literature out there for exercise after heart surgery, involves the period immediately after surgery, i.e. don't lift over 10 lbs over your head, etc.  

Thanks for helping me.

Warmest Regards,

[CCF HeartMD-1]

It is difficult for me to say exactly why your exercise pace is slow and why you get short of breath at the top of two flights of stairs.  I think it may be multifactorial.  Although if your heart is weak it could definitely be due to this.  I commend you though for continuing to exercise daily with jogging.  That is great and keep it up.  Do you know what your ejection fraction is (EF) which is something we measure by an echocardiogram.  I presume it must be low if they put in a debrillator in the setting of an arrythmia which I presume was ventricular tachycardia.  If your EF is low, I definitely think your shortness of breath and decreased exercise tolerance could be due to this.  If your EF is completely normal then i would be somewhat concerned by your symptoms because after 10 months you should be feeling pretty good.  I would then wonder could one of your grafts have gone down which can happen even in the first year after bypass surgery.  Have you had a stress test??

I really cannot give you more exercise recommendations before knowing more details about your case.  If there are no more details I think you need a further evaluation including echocardiogram, stress test and a chest x-ray to make sure the water around your lungs is gone.  Maybe you need a higher dose of diuretic if your heart is weak.  See these are details that are hard for me to figure out over the internet.  

Sorry if this answer hasn't help but I think both you and I need more information.  

[is_something_wrong]

Forgive me for commenting this. I'm not a healtcare professional but I remember my dad had open heart surgery (triple bypass) a year and a half ago. I helped him recover from his condition after surgery by daily exercise.

First, running 3,3 miles 10 months after open heart surgery isn't bad at all I think. What is an important difference between him and you is 1) he wasn't an athlete before surgery, his BMI was 33 and he was smoking (luckily he quit after surgery) but 2) he didn't have a heart attack, though it was close I suppose.

What your doctors need to consider, is what damage to the heart the heart attack caused. If you have arrhythmias and an ICD, I would suppose they found signs of heart damage. The cardiologist may easily measure this by echocardiography, a non-invasive test done in 15-30 minutes and you'll get the results immediately.

It is possible, even in the setting of heart failure, to improve the condition level. This should be done in careful cooperation with your doctor, however, but it may be a good idea to examine what damage your heart possibly suffered from the heart attack, and how good the heart is pumping today. I hope the cardiologist here will answer you soon, but if you get this comment before he/she answers you, it could be a good idea to describe which arrhythmia you suffer from. Atrial fibrillation? (common after heart surgery). Ventricular arrhythmias? Do your ICD fire often?

I wish you the best, and I hope your heart has/will recovered/recover well.

[samway]

Thank you for concern and your good information.  Since you asked:
1)  During My surgery, they had to pinch off an aneurysm at the bottom of my heart.  An aneurysm is dead heart tissue from the HA.  The aneurysm had to be isolated because blood was flowing too slowly in that area, raising the risk of a clot. So, I have a smaller heart now.   Also, they had to remove a thrombus through an incision in the heart .  A thrombus is a clot-in-waiting stuck to the wall of the heart.  If the thrombus should break loose, then it becomes a clot.  

2)The fluid has been removed and verified bu x-rays several different times to make sure it did not return.  

3)  A nuclear stress test was done 1.5 months ago, results were in the very good range.

4)  An Eco was done maybe 3 months ago and my EF was about 40, up from about 32 right after surgery.  A normal EF reading is 55 to 65, I think.  

I have both types of arrythmia, atrial figrillation and ventricular tachycardia.  

Yes, my ICD jsut fired on me for the second time.  I was running up the steepest hill in Prospect Park and it went off at the top of the hill.  I was running better than ever, but still slowly, and was trying to push the pace a little.  I went iin today to  see the electrophysiologist who implanted the devce.  After analyzing data from the ICD, He said my heart rate had climbed to 210 beatsa minute.  The heart rate become unregulated after a bout of afib at the same time, he said.  He adjusted my device to prevent it from happening.

I had to tell him that I had stopped taking my meds for a couple of weeks.  I guess I am tired of the side effects and am afraid to take them long-term.  He told me I should start re-taking the Amiodorane, Coreg, Cozaar,  Coumadin, Aspirin, and Lipitor,  I will listen to him.  Also, he said to cut back on the pace of the workouts for two weeks while my body gets reacclimated to the Amiodarone.  He reiterated that he wants to do an ablation on me to try kill hte arrythmia.  

I am holding off for a while because I lost my insurance coverage and am busy with school and things.  

I noticed that palpitations increased during exercise after I stopped the meds.  This is not good.  

Also, I notice that I sweat profusely during exercise, and at other times.  My pillow at night sometimes gets soaked with sweat.  During the day, the back of my head is wet from sweat.  Another heart patient said this is a temporary by-product of the surgery.  Please advise.

Another long-tem concern of mine is how to prevent this from happening again.  The surgeon told my sister after surgery that he could tell I took care of myself, when he cut me open.  But that did not prevent me from having a heart attack.  At the time of the HA, I was about 15 to 20 pounds overweight.  

There is a family history.  My brother had a quadruple bypass over a year ago.  My father had a stroke and stents.    

At the time of the HA, my diet was pretty good, but it could be better.  I am looking at the Mediterranean diet, and a vegan diet.  There is an excess of sodium in my diet that could be removed, especially if I cook more thiings. Some of the excess weight is gone, with more to follow hopefully.    

How does one rid the arteries of fatty buildup so it never gets to a critical level?  As it was described to me, a cardio CatScan can measure the percentage of blockage of all key artieries around the heart.  Is this corect?  Maybe I can take one of these tests regularly.  

Thank you once again for your caring remarks.

Regards,  Sam

[samway]

Thank you for your concern and sharing your father's experience.

Yes, my ICD fired on me again.  I discuss it in my comment to the doctor.  There is  added extra detail in my comment to the doctor  for your benefit, since you are not a doctor.

yes, I have taken about six Echo's, since the time of the HA.  Yes, I have both arrhythmias (dsicussed above).

I am glad to hear that your father is taking care of himself.  One of my roommates in the hospital after surgery did not take care of himself.   He did not watch his diet and he smoked.  He had numerous bypasses and stents already. He needed three more bypasses.  There was only one problem, he only had one good vein left for grafting.  So, the doctors advised him to do a single bypass and leave the other two blockages alone.  I hope your father is never in that position.

Regards,  Sam      

[samway]

If I may, one more question please.

Why is my cardiologist so concerned that my Coumadin level high enough?  The coumadin test is the highlight of my visits.  He gets very worried that it is not high enough and keeps wanting to up the dose.  I don't like to take the Coumadin, because I'll be sitting on the subway and all of a sudden my elbows start bleeding.  

Tnanks again.  

[is_something_wrong]

Hello,

It wouldn't be right if I answered all your questions. The cardiologist at this forum should answer you.

But generally, heart surgery often causes atrial fibrillation and heart attacks often cause ventricular tachycardia. Heart attacks often leaves scars in the heart, and under certain circumstances, electrical impulses aren't conducted simultanously through the heart, which may make an impulse "loop" around the scar or nearby tissue, so-called re-entry. If this happens in the main chambers, which it usually will after a heart attack, you get ventricular tachycardia.

It should be a good sign that your EF is improved from 32 to 40%. Other parts of the heart are strengthened to keep up the pumping abilities. A normal EF can vary greatly, in different people and different settings, and there are also a possibility of errors when the cardiologist measure it. My EF was measured first at 60%, second time at 80%. Normal is from what I know 50-70%. Some say 55-75%, some say 55-65%, some say 50-65%.

I really hope they are able to ablate your ventricular tachycardia. But luckily you have an ICD now.

You don't have to be overweight or smoking, or generally have an unhealthy life style to get a heart attack. Some of us have elevated cholesterol levels even with a really healthy lifestyle. Some of us have elevated blood pressure and some of us are just unlucky. In my country, there were two cases of CAD among the elite football players, one of them, age 38 got angina pectoris, he was captain of the best Norwegian team, and no one understood why he got shortness of breath and chest pain during the matches. Another one got a heart attack at age 29. But, of course, an unhealthy lifestyle increases the risk.

I won't comment the medications or specific advice to prevent this from happening again. The cardiologist will do that. I can only hope you will be OK and give you my best wishes.

[samway]

Thank you for your comments and your impeccable English.

I need to understand more about the arrythmia - the causes, etc.  The EP told me that 65% the first ablation procedure is not fully effective.  Then, a second one is required.

Since the operation, generally more sleep has been required.  It seems like all I did for the first three months was sleep.  Also, Right now, I seem to be sleeping too much, nine or ten hours.  It may something else causing excessive sleep, perhaps.  Did your father sleep a lot also?

Yes, there seems to be several interpretations of the data in calculating the ejection fraction.  My cardiologist said the EF on the printout was too high, during my last two echocardiograms.  

Also, he was pessimistic that it would increase a whole lot more, based on his experience.  How has your father's EF recovered since his surgery.  

What can you tell me about reducing stress?  Your bio says you experienced stress.  My friends say I have a high-stress personality.

Warmest regards,  Sam  

[is_something_wrong]

Hello.

Thanks a lot for your kind words.

I continue the discussion here, I'm not sure if it's allowed because this is a doctor forum, if it's illegal I apologize.

First, my fathers EF: I don't know what it was before surgery (at that time I didn't know what EF was I think) but one month ago it was 65-70%. But he didn't have a heart attack, only angina pectoris. This disease doesn't decrease EF at rest, only during activity, where the heart doesn't get enough blood and can't contract sufficiently. With a heart attack, there is some damage to the heart and there are important questions, such as 1) how well does the damage heal, and 2) how well does the rest of the heart (with time) compensate for the damage. The fact that your EF is increasing should be a good sign and a sign of progress, but I'm not able to say this for sure, your doctor should.

The EF itself is a poor measurement for condition levels. Athletes may have an EF of 50%. Another important factor is how well the heart is able to fill up with blood. In the setting of (left) ventricular hypertrophy, enlarged heart muscle, the EF can be amazingly high, but the walls aren't able to relax and the output of blood is still low. This is known as diastolic dysfunction or diastolic heart failure. Low EF = Systolic dysfunction.

Other factors count as well, such as lung function, O2 uptake from muscles, and so on.

Exercise is good for the heart (in your case you should discuss with your doctor what you can and can't do). Exercise will 1) increase wall thickness and 2) increase inner chamber dimensions. Hypertension alone will only increase 1) and high heart rate for a long time alone will only increase 2). The 1) alone can cause diastolic failure and 2) alone can cause systolic failure, if you see the point. Exercise strengthens the heart completely. But as I said, you need to cooperate with your doctor. It's important to understand that what happened is serious and you need time to recover.

It's normal get reactions after major surgery. In my fathers case, he immediately quit smoking and started to live healthy. Others can get depressed or give up. It's important that you get the help you need to recover from this.

I've probably said way more than I should, here. I can't stress enough that medical advice should only be given by a MD, this is just thoughts from a community member like yourself. But I really hope you will recover and if you have other questions, or just want to talk, don't hesitate to follow up or send me a message.

[samway]

Thanks for your information on EF readings, the value of exercise, and attitude after surgery, as it relates to heart disease.  I will continue to consult my doctors and read books on the subject.  All the best.  Sam