Managing the Open Heart Surgery Scar

Working in Cardiac Rehabilitation a common issue for patients who have had open heart surgery is  that their scar is very tender.  Many patients scars are so sensitive they don’t like  feel of the weight of their shirt to be rubbing against the scar. I would like to present you with some information as to how to manage the scar and give you some tips to ease any discomfort you feel. Physically you may not remember the pain from your surgery but your body does. It can over respond to certain stimuli and give signals of pain which may seem for no reason. The body has to learn what is good sensations again and what is bad. It’s normal to feel discomfort in the form of numbness, deep itchiness, tightness, or a burning sensation during healing.

The skin forms a scab over a wound within three to four days following an injury. By day ten the scab usually shrinks and sloughs off. The body then begins to form collagen fibers to strengthen the surgical incision site. Scar tissue remodeling occurs as you start to stretch and pull on it. The stretching of the scar tissue helps to align the collagen fibers to allow them to return to normal. This realignment of the collagen fibers makes the tissue better able to tolerate the forces that are placed on it during the day.  It takes damaged tissue approximately between three months to over a year before it returns to full strength.  Scar tissue management involves early and consistently exercise, massage of  scar tissue to decrease the possibility of developing any long-term concerns.

Scar Traits
While the degree of scar formation varies from person to person, there are some distinguishing characteristics:

•  Becomes hard and non-pliable
•  Bands of fibers form  on or below the surface
•  Skin tightens or shortens. This is called a  contracture and  may limit range of motion, leading to postural changes.
•  Becomes dry and reopens to form a wound if not managed properly.
• Scar tissue has no melanin in it and will burn, be aware in summer to apply sunscreen or keep covered with a shirt.

Long-Term Effects
The scar tissue acts almost like glue, adhering the skin to the layers of fascia, and muscle. Normally these  different layers are able to glide smoothly, however the scar tissue inhibits this and may set the stage for the following problems include:

· Nerve impingement
· Pain
· Numbness
· Limited range of motion and flexibility
· Postural misalignment

Two Phases

A scar’s healing progression consists of two phases, immature and mature.

· Immature – Immediately after a wound heals, the scar is immature. During this period it may be painful, itchy or sensitive as nerve endings within the tissue heal. While it is typically red in appearance, most scars fade to normal flesh color with maturation. Exercise, massage and heat application will have the greatest positive effect on an immature scar.

· Mature – Depending on the size and depth of the wound, scar tissue will cease production 3 to 18 months following wound healing. When scar tissue is no longer produced, the scar is considered mature. It takes a more disciplined and vigorrous approach to scar tissue management when the scar is mature.

 Techniques

As soon as the wound is knitted,  you no longer have steri strips or staples and no  open areas or scabs you can begin massage techniques. Initially begin while in the shower, soap the area as this works as a lubricant and prevents infection if the wound has small openings that may not be visible The heat from the water helps the pliability and flexibility of the scar. During the initial immature stages of wound recovery, it is imperative that a gentle approach be taken. The following techniques can improve scar tissue:

• Manual Lymph Drainage helps lymphatic circulation and drainage around the injured area. Gentle, circular, draining motions within the scar itself or a gentle stretch to the skin above and below the scar, first in a straight line and then in a circular motion. Placing the fingers above the scar, then making gentle circular pumping motions on the scar also helps drain congested lymph fluid.Drainage techniques should not hurt or make the scar redden.
• Myofascial Release helps ease constriction of the affected tissue. To stretch the skin next to the scar, place two or three fingers at the beginning of the scar and stretch the skin above the scar in a parallel direction. Then move the fingers a quarter of an inch further along the scar and repeat the stretch of the adjacent tissue, working your way along the scar. An alternative method is to follow the same pattern of finger movements using a circular motion instead of straight stretches. Work your way along the scar in a clockwise and counterclockwise fashion.
•  Deep Transverse Friction can prevent adhesion formation and rupture unwanted adhesions. With your hand on opposite sides of the scar gently push the scar to the left, then to the right. Repeat along the entire distance of the scar .This deep tissue technique can make the scar much more pliable.

•  Stretching aids in increasing range of motion.  Scar tissue will lengthen after being stretched, especially if the stretch is sustained for several seconds and is combined with massage. However, be cautious not to over stretch the scar. Some stretching is good, but if you overstretch it it can make the scar wider. Remember gentle!

Cautions

•  Do not continue if your actions cause  significant pain or increase tissue redness.
•  Never perform massage on any open lesions.

Desensitisation

Scars may become senitive to touch and feel ‘tingly’ if the surrounding nerves have been effected. Desensitisation is the process of teaching the scar to accept many different textures without feeling uncomfortable. Start with using the softest smoothest cloth you can find, silk or satin. Begin with gently rubbing over the scar for two minutes. Initially this will drive you crazy, and two minutes can feel like an hour. Then progress to adding two more minutes with  more abrasive cloths such as a cotton t-shirt, or terry cloth wash cloth. This helps to teach the skin the difference between the sensation of touch. It sounds a bit crazy but can make a big difference. Do this consistently for one to three months.

Signs and symptoms of Infection

Contact your physician right away if you have any of the following symptoms. Infection is serious and can tunnel under the skin requiring further surgery to treat it. Don’t try home treatment get in right away!

• Hot Incision: An infected incision may feel hot to the touch. This happens as the body sends infection fighting blood cells to the site of infection.
• Swelling/Hardening of the Incision: An infected incision may begin to harden as the tissue underneath are inflamed. The incision itself may begin to appear swollen or puffy as well.
• Redness: An incision that gets red, or has red streaks radiating from it to the surrounding skin may be infected. Some redness is normal at the incision site, but it should decrease over time, rather than becoming more red as the incision heals.
• Drainage From the Incision: Foul-smelling drainage or pus may begin to appear on an infected incision. It can range in color from blood-tinged to green, white or yellow. The drainage from an infected wound may also be thick, and in rare cases, chunky.
• Pain: Your pain should slowly and steadily diminish as you heal. If your pain level at the surgery site increases for no apparent reason, you may be developing an infection in the wound. It is normal for increased pain if you “overdo it” with activity or you decrease your pain medication, but a significant and unexplained increase in pain should be discussed with your surgeon.

Sometimes the body will reject a suture or spit a stitch, in this case it often appears like a pimple on the scar. There may be a small amount of the stitching material coming out. If this occurs call your surgeon’s office. It can usually be handled very easily in the office however in some cases may require antibiotics.

My Little Heart

This heart of mine has been with me my entire life.  It beat for me before I even had

awareness, while my brain was only a rudimentary organ with

 little, but the basic body functions. It raced the day I was born and drew my first

breath. It swelled when I saw my mother leaning over my crib. It beat

strong and steady as I played and grew.

. 
It fell in love and was broken as a teenager and was filled to capacity

as I held my baby son in my arms. My heart was there, every second of my life.

It did its job and allowed me to do mine. I rarely even thought about it.
Then one day, it began to fail. It would race, it would skip and it would

flutter uselessly as my vision dimmed and the world tilted precariously. I could

no longer keep up with the schedule I set for myself. It was letting me

down and I was angry. I didn’t like it very much. It was like an old friend

that betrays your confidence and you can never trust them again.
There were hospitalizations, there were too many doctor visits to count,

yet still my heart continued to let me down at such a wonderful point in my life.

The medical field was baffled and it seemed they were insinuating that

this was somehow all my fault, like I didn’t WANT to get well. Oh, but I did. I

would look at my husband and son sleeping at night and pry that I would

be there in the morning to see them awake just one more time. My heart

and I were losing hope.
Finally, after many trial and errors with medications, some of

which left me vomiting for hours or unable to find the energy

to pull up my socks, they

implanted a pacemaker/defibrillator. I remember wakening from

the surgery, feeling like they had stuffed something the size of a Chevrolet

under the skin just below my shoulder. It hurt to move, but I turned my

head to see my husband sitting beside my bed. The pain etched in his face

was so much greater than any pain I felt from the surgery. I suddenly

realized what a toll all this had taken on him. I blamed my heart and

hated it for what it had done.

We went home the next day and I tried to pick up the scrambled pieces

of my life. I still felt terrible and each time the pacemaker corrected, I

retched to the point of vomiting. If I rode in the car and the road was

bumpy, my heart raced uncontrollably. I couldn’t listen to my hard

rock music too loud or the pacemaker kept tune with the beat.

Was this the improvement I was hoping for?

When I went back for the 6 week check on my ICD, they finally realized

that something was wrong. Two of the wires had not implanted properly.

One was coiled next to a valve and the other had slipped so it was

triggering my diaphragm along with my heart.
Back into surgery I went. I was really angry now, not at the doctors, not at

the situation, but at my heart. I didn’t sleep at all that night for the anger

that I felt within me. Morning came and as soon as I walked down the hall,

I knew this was different. I actually did feel better. With several adjustments

over the next few months, I began to feel like I was going to live. More

importantly

 I WANTED to live.
I call February 11, my rebirthday, that is the day that they implanted

the ICD, but my true rebirthday came weeks later when I decided that

the rest of my life was going to be different than before. I chose to get

everything I could out of every day. Carpe Dieum doesn’t even come close

to what I do every morning. Not only did I start living my life to the fullest,

but dragged everyone else with me. Some weren’t very willing, some even

dropped by the wayside, but I was too busy living to go back and sit with them.
What started with cardiac rehabilitation, moved through aerobics,

hula hoops, belly dance, tai chi, and now kung Fu and Karate. I never sit still.

I don’t have time.

I’m absolutely, irrevocably in love with life.

For the most part, my heart lets me do pretty much what I want.

It reminds me that it is there and not exactly able to do all the things I want.

There are times, it actually lets me down, like when we were running relays in

Kenpo class and I passed out. Oh I was really pissed at my heart that night.

It has humiliated me.

There are days when I just don’t have the energy I’d like to. I just can

do everything I want. That’s when I really hate my heart. I blame it for holding

me back, like the albatross around my neck.

In the past year or so, I have embarked on a new journey of introspection.

I became a Buddhist and began meditating. I started searching out other ways

of managing my health in addition to Western medicine and exercise.

Acupuncture was probably the biggest surprise. I went for treatment on my

shoulder, hoping to delay surgery on the bone spurs in my joint.

My practicitioner was vaguely aware of my heart problem and placed a few needles

that she thought might be beneficial. I’m not sure it did a lot for my shoulder,

but as I lay on the table listening to soft flute music, I realized that my

pacemaker had gone into sleep mode. Good heavens,

it doesn’t even do that when I’m ASLEEP!
I felt wonderful, I felt relaxed. I went to Kung Fu that night and felt

as if I could do anything. (unfortunately, I discovered that I STILL was

unable to do the flying butterfly kick, but I’m working on it).

I knew that for me, acupuncture was going to be a routine

part of my self-care.
One thing with acupuncture, when you are laying there, feeling like

a pincushion and staring at the cieling, you have a lot of time to think.

And think I did. I would meditate while lying on the table. It was warm,

it was cozy, my mind would drift and thoughts and emotions would drift

through my head. I would dutifully address each of them and let them go.

Then one day that gentle little meditative voice whispered in my ear.”

How can you show compassion to others if you cannot feel it for yourself?”
Whoa, that thought wasn’t even addressed, the notion was tossed out like

an old cat food can. The next week it was back. “You have to love yourself, to

love others”
“Nope! Get out of my head please. I don’t want to think about that.”
“Forgive yourself. Forgive your body. Fill yourself with love.”
Each time, I angrily pulsed away the thoughts. I really didn’t want

to love my body. It wasn’t what I wanted. Elle McPherson’s body?

That I could love.

And what the hell did I have to forgive anyway?

What had I ever done to my body or it to me?
Then one particular day, when I went in for an extra treatment because my

heart was not behaving in the manner I thought it should. (In other words,

it wasn’t operating on a 20 year old athlete level) An new voice chimed in.
“I’m trying. I’m doing the best that I can.” I know this sounds insane and

could get me committed in at least 4 countries, but I knew it was my heart

talking to me. It was attempting to tell me that it was trying to meet my

expectations. It wasn’t the traitor that I viewed it as. It loved me and was doing

its damndest to keep up with me.
To say I was flooded with emotion is an understatement. Tears rolled down

my cheeks and soaked the pillow as I realized what I had been expecting of my

body. My heart had gotten sick and was broken and fixed the best it could be.

Even with its limitations, it pumped and pushed and beat every second of

every day. It kept me alive to run , to play, to love and I treated it with distain.

My heart had not failed me. I had failed it.                                                                                                                                                                
That day, I embraced my heart. I saw it as this wonderful brave ally,

who stood by me in sickness and in health. I saw how hard it worked

to allow me to see my dreams. I thanked it for allowing me to have

these extra years, to see my son married, to kiss my husband under

the stars, to learn to live again.

I loved it for its courage and perseverance. I gave it peace.
We came out of that room a team, that day. It, promising to do its best

and I, promising to listen more closely to what it needed. Just like any couple,

we have our little disagreements, like that skydiving thing, but we’re

working on it.
How many of us, as heart survivors, have forgiven our hearts?

Who among us still carries the anger and resentment of failure?

Who treats our hearts as a mere organ and not the center of our beings?

I live because my heart beats. I love because my heart beats. I hold all the

compassion for the world, because I now have compassion for myself.

I love this little heart of mine.

What Activities are Safe after Heart Problem?

Initially your doctors and nurses give you activity guidelines for early discharge from the hospital. Within a few days or weeks however, you start to ask can I do this? Or you do something and a family member suddenly yells “You can’t do that. It’s not safe!!”  So what is safe?  Well it is very individual, based on your health. In Cardiac Rehabilitation one of the ways we advise people is through use MET levels.

MET levels refer to how much energy your body needs to do a particular activity. At rest your body uses approximately one MET. The physiology world knows this means your are using about 3.5 millilitres of oxygen per kilogram of body weight per minute to allow all your organs to have enough energy to operate.

If your body isn’t conditioned to high levels of activity then you could get into trouble. You want to gradually build up. An example I use is if your body is conditioned only to a 3-4 MET level, and you plan to go and shovel wet heavy snow – which requires approximately 10 or METS then this activity is potentially dangerous, as your heart may not be able to meet these demands.    Determine what is the activity you would like to do. Is it raking leaves, biking hills, carrying heavy loads up the stairs, lifting a ladder etc? Below are a few charts to help you see what the MET requirements are for typical activities. Then gradually increase your exercise activity until you are able to get to that MET level and sustain it for a period of time.

So how do you determine what MET level you can do?  Some exercise equipment will tell you what level you are at. Often you need to enter your weight into the machine to properly calculate. The charts below are helpful for estimating the MET requirements for activity.

Healing the Broken Heart

Healing the broken heart was shared with me by a patient I have known and worked with for years. She is a Women Heart advocate and an inspiring voice to heart disease.
What have you done for your heart today? Have you exercised? Did you eat oatmeal instead of pop tarts for breakfast? Did you take your beta blockers, ace inhibitors, diuretics, supplements or any of the host of pills they give us after our hearts to pot? Maybe you took your blood pressure and (God forbid) weighed yourself. Most of us have been around the block several times at our age. We know what we are supposed to be doing to keep our hearts healthy and functioning.
Well, let me tell you what I did for my heart today. I kissed my husband. I scratched the cat’s tummy till she purred. I smiled at an old man in the grocery store till he winked back. I went to my Tai Chi class, not for exercise, but for the pure joy of movement and good conversation. I came here to talk to you. These are all things I do for my heart.
I had my first heart attack at 45, second at 48, my third was at 51 and then my heart began to fail. The first two attacks were fairly mild and since no obvious reason could be found for them, I simply went on with my life as usual. Each time they offered cardiac rehabilitation, but I felt I didn’t have time for it. I was active, why go to a gym?
Then at 51, I didn’t recover as quickly. My heart never settled back into a normal rhythm and was weak. Within a few days I was passing out in the grocery store. Once, while running the vacuum, My heart went into a rhythm that could no longer sustain life and I went out. I don’t remember falling, but I did. I woke up on the floor, lying across the Hoover with a lump on my head and a bruise, already starting to purple across my chest. I am probably the only woman you will meet who was saved by a vacuum cleaner.
I was so lucky. The doctor believed that when I fell, my chest hitting the vacuum jarred my heart back to beating. The problem was, I didn’t feel very lucky. Within days, I was in the hospital again having a pace maker-defibrillator installed, my ejection fraction, even with the assist of the device was down around 20 percent . I thought life was over and was heartbroken.
This time I was not given a choice about cardiac rehab. I was going on my own or my family would drag me down there. My first day was humiliating. I was the youngest person in the room who did not work there and one of only two women. Ten minutes on the treadmill exhausted me, but I went back two days later. And two days after that and two days after that. That was five years ago next week. I’m still going.
The ICD, the handful of daily meds the structured exercise all started to work. My body was coming back. Even though I was told repeatedly that the exercise was good and would help my heart, I should not expect it to improve my ejection fraction. My heart remained broken. Every time I thought of my family going on without me, my heart ached. When I thought of the grandchildren I might never see, my heart was emptied of all joy. That year, when I put away the Christmas decorations (which by the way, neither of the men in the house had thought to do when I had the attack), I labeled each box carefully so that the next wife would know where they were supposed to be put up.
This is when I realized that there are two sides to every heart. The physical heart and the heart spirit. The Tao Te Ching and Zen practices teach that there are three distinct parts to every human being. The intellectual mind, the body and the spirit. For a person to be fully functional and live a happy life all three of these areas must be cared for and cultivated. The Judeo-Christians have a similar belief, only they refer to the spirit portion as the soul. Other cultures refer to this as the heart. We have all heard people say, “listen to your heart, loving with all your heart and of course, my heart is broken.”
The doctors, the medications, even cardiac rehab all work to take care of the physical heart. It heals, it becomes stronger and many of us live better than we did before our heart events. But the spirit heart is seldom addressed. It is perfectly normal to experience depression after a heart attack or surgery. In fact it is part of the stages of recovery. Your mind, body and soul have been through a great shock. You know your life will be different; you may even be a little embarrassed by the fact that your heart “failed you”.
Stop.
Stop and take a look at that inner heart. The spirit heart, the heart of your soul. What makes it sing? What lifts it up and makes it soar. Find that which fills your heart with joy and lights up the darkest night. It may be as complicated as going back to school to learn something you always wanted to. It may be relearning to ice skate after 23 years. It may be as simple as kissing your husband of flirting with an old man at the grocery store.
A woman’s heart is a tender thing. She is the heart of her household and she carries the hearts of all her family in hers. If her heart is healthy, she does not suffer alone. Take time to heal this inner heart and make it strong and shinning again.
Now, back to my story. Within two years of my rebirthday (that’s the day they implanted the ICD and I began to live again) my ejection fraction was nearly normal and I had lost 70 pounds. No one can tell me why my heart improved so much. There is no scientific explanation. My doctor shrugs his shoulders and says I should be very grateful. It was a fluke. It’s not a fluke, it’s a combination of hard work, medication and bionics, the support of my family and friends and a heart no longer broken.
Five years later, here I am. I wore out the first pacemaker and am my second. I come to cardiac rehab, teach an aerobic class, ice skate, study Tai Chi, and belly dance. Recently, I have taken my soul on a journey into Eastern religion and philosophy. Life is good. It is filled with activity and joy. I plan on using both sides of my heart as long as I can.
Now, what are YOU going to do for your heart today?

Heart Rhythm Monitors

One of the benefits of attending a formal hospital based cardiac rehabilitation program is that most of the time your heart rhythm is monitored as you wear a telemetry monitor. With today’s advanced technology you can monitor your own heart rhythm at  home. There are many portable handheld monitors which you can capture a picture of your heart rhythm save it and bring it with you to your followup physician appointment. It is good to record this at rest, with peak exercise and if you are symptomatic. Below is a link to such a device.  Now don’t get sticker shock…this can be the co-pay amount of just one week’s visits to a cardiac rehabilitation program, and you get to keep this!  http://www.newegg.com/Product/Product.aspx?Item=9SIA0AV05N5764&nm_mc=OTC-Froogle6&cm_mmc=OTC-Froogle6-_-Cardio+Equipment-_-Omron-_-9SIA0AV05N5764

Beta Blockers

I bet you were discharged out of the hospital on several new medications. I am not a pharmacist but can certainly talk about the common medications for heart disease and their side effects. It is important to understand what medications you take and what they are supposed to do, as well as what potential problematic side effects to be watchful for.

Beta Blockers – Beta blockers work by reducing the heart rate and causing the heart to beat less forcefully. They also relax blood vessels, which lowers blood pressure and allows blood to travel more easily to all areas of the body.

Common Beta Blockers: Atenolol, Proprandalol, Metoprolol, Bisoprolol, Carvedilol

Side effects:

• A slow heart rate  – this is what they are supposed to do slow the heart rate but sometimes it slows too much. Heart rates in the low 40’s or less should be reported to you physician.  When sleeping usually your heart usually beats even slower so rates in the 20-30’s are a problem
• Low blood pressure- again this is what beta blockers are supposed to do, but if your blood pressure is less than 80/40 or you don’t feel well at the level you are at report to your doctor as soon as possible.
• Fatigue – It takes about 30 days for your body to get used to this medication. If you are so fatigued that you cannot perform your daily functions contact your doctor.
• Cold hands and feet
• Dizziness – Get up from seated positions slowly, wiggle your legs before standing if you have been seated for a long length of time

• Lightheadedness or fainting, which can be a sign of dangerously low blood pressure. Again get up slow from bending over, seated positions and do a good cooldown with exercise to prevent this side effect.
• Worsening of asthma – if you have asthma make sure your doctor aware as this medication can make it worse.
• Depression
• Signs of heart failure, such as rapid weight gain, swelling of the hands and feet, and shortness of breath

• Sexual problems erectile dysfunction is very common and low sex drive. Don’t be afraid to mention this to your physician.
• Masking of the signs and symptoms of low blood sugar. If you have diabetes measure blood sugar frequently before and after exercise.
• Exercise intolerance sometime the heart rate is so blunted from this medication that it cannot rise enough to pump blood to the exercising muscles we call this chronotropic incompetence. You should see your heart rates rise 10-20 points while exercising or more. If you feel like you can’t progress your exercise intensity without feeling fatigue, weak or short of breath this may be the cause.