Dr. Bobby Yanagawa – Heart Sisters

by Carolyn Thomas ♥ @HeartSisters

Unless they’re undergoing minimally-invasive cardiac surgery, most heart patients facing open heart surgery may in fact hear a range of responses to “how long will it take?” because of the added complexity of getting their sternum (or breastbone, the long flat bone in the centre of the chest) cracked open right down the middle.

This procedure is called a sternotomy. As you can imagine, a cracked-open bone takes longer to heal afterwards than a simple soft tissue incision does.

But how long? Cleveland Clinic cardiologists suggest this:

“You’ll do most of your healing – about 80 per cent – in the first 6-8 weeks after surgery”. Complete recovery can take about one full year.”

But when University of Toronto cardiac surgeon Dr. Bobby Yanagawa pondered the same question online recently, he received a surprisingly wide range of answers from other physicians in response to this post on Twitter (10/8/2020):

“As cardiac surgeons who see patients at a 6-week follow-up appointment, we don’t really have a good sense of how long it takes to recover from a sternotomy.

“I used to say three months, but now I say 3-6 months. I suspect a survey of patients will reveal that it takes much longer for complete recovery.

“Is a survey needed?”

Here’s just a sampling of dozens of responses from cardiac surgeons and other docs to Dr. Yanagawa’s Tweet:

7. “Maybe the definition of ‘recover’ varies. Patient expectations: pain-free, baseline function. Doctor expectations: good healing, improving function. Since people will heal variously, might be good to align expectations e.g. “At three months, we hope to see _____”

8. “Some bypass surgery patients complain of pump head (dizziness and fatigue) up to 10 weeks post-op. I agree we need a survey to see what’s going on with them.”

9. “It will also depend on the care provided after hospital discharge. If the patients are sent home straight after surgery, the recovery seems to take forever. If they go to recovery centres with physiotherapy, dietitians and an overall holistic recovery approach, then recovery is shorter!”

10. “There are so many variables in recovery after cardiac surgery. Cardiac rehabilitation enhances recovery. It’s imperative to get people moving and back to their baseline as soon as possible.”

And even some responses from cardiac surgery patients themselves:

11. “I had a mini-sternotomy with wires at age 52, and while I had minimal pain afterwards, I had complications at six months (pleural and pericardial effusion). I didn’t feel close to ‘normal’ for a solid year, then two years before I felt like myself. Depressing when they tell you it will take 6-8 weeks!”

12. “I am nine months post-op; from the get-go I have been dealing with clicking, instability and pain. I found out it was a sternal non-union (a persistent fracture of the sternum after three months without signs of healing). “Now trying physiotherapy in hopes to avoid another sternotomy. Long story short: yeah, I’d say it takes longer than three months to recover.” NOTE: read more about how non-invasive pulsed ultrasound therapy has been successfully used in the U.K. to treat sternal non-union).

And these two comments from the When-Doctors-Become-Patients world, in which doctors have open heart surgery:

13. “I followed up on a surgical colleague post-op – shocked at how long and difficult the recovery was.”

14. “I’m an interventional cardiologist who needed a sternotomy at a young age. After three months, I felt ‘okay’ enough to work. But just barely. I couldn’t imagine true physical labor at that point.”

This small one-day snapshot of varying responses to a sternotomy healing question (with answers essentially ranging from six weeks to one year) may seem puzzling to some patients.

That’s an impossibly wide range of possibly correct answers.

And few if any of the answers even mentioned the psychosocial recuperation impact of being diagnosed with a heart condition serious enough to require profoundly invasive cardiac surgery. See also: When Are Cardiologists Going to Start Talking About Depression?

Given this reality, I commend Dr. Yanagawa’s open call for feedback, acknowledging that his own post-op advice to patients has dramatically changed from three months to now 3-6 months – and additionally suggesting a survey of patients.

But instead of asking other cardiac surgeons what they’re telling patients, how about instead asking patients what their lived experience has been like?

As the University of Calgary’s Dr. Doreen Rabi answered that tweet:

“It is so important to include patients in defining what ‘recovery’ really means. I have heard repeatedly when I speak with patients that they ‘don’t trust’ their body for two years after a cardiac event/surgery. Anecdotal for sure, but compellingly consistent.”

Last year, a systematic review of studies on patient-centred adult cardiac surgery recovery published in the Journal of the American Heart Association reported, in a remarkably under-stated conclusion, that “the evidence base for post-operative patient‐reported outcome measures needs to be strengthened.”(1) TRANSLATION: The studies they found were small, mostly done in single centres, 71 per cent male and 88 per cent white.

So in answer to the original question: “Is a survey needed?”, we might be tempted to say, What took you so long?”

The promising news is that such surveys do exist, and some heart patients themselves have already been asked.

In 2016, for example, Dr. Sari Holmes and her team at the University of Maryland in Baltimore published a study using a heart patient survey called C-SPEQ –“Cardiac Surgery Patient Expectations Questionnaire”.(2) Although prediction of poor outcomes or longer recovery time after open heart surgery is most often focused on physical and surgical factors, these researchers suggested that the wide variation in these predictions may also be affected by psychosocial aspects that are not typically even considered by cardiologists.

In this study, the higher the patients’ pre-surgery C-SPEQ survey scores, the greater their rate of depression and perceived stress, and the longer their recovery time.

The study’s conclusion:

“Negative pre-surgery expectations have a detrimental impact on both recovery and quality of life following that surgery. Pre-surgical education might better prepare patients, reduce negative expectations, and improve psychosocial outcomes after cardiac surgery.”

What else might help speed up sternotomy recovery?

♥ Cardiac rehabilitation for almost all heart patients is recommended in current practice guidelines of all cardiovascular societies worldwide as a Class I recommendation (which means that a procedure/treatment should be performed/administered). Studies have shown that completing a course of rehab classes can significantly lower your cardiac risk. Most cardiac rehab programs this year have had to move online due to COVID-19. Ask your cardiologist about participating in a virtual rehab program like this series of exercises developed by Vancouver Coastal Health for their heart patients.

♥ “Keep Your Move In The Tube” is a recovery concept developed by a Texas-based team of physical therapists, occupational therapists and cardiac rehabilitation specialists to help prevent sternal wound complications.(3) They claim that the common “Don’t lift more than 5 pounds” hospital post-op warning to new heart surgery patients is the opposite of what they need to hear. Instead, this team teaches recovering hospital patients to safely move or lift (e.g. getting out of bed) that involves keeping elbows tucked into the sides (as if inside an imaginary “tube”) while lifting, pushing or pulling – with the goal of faster recovery. This concept is also expanding to other hospitals (including in Alberta, Canada).

♥ What you can do ahead of time: You may assume that your recovery will start as soon as you’re safely out of surgery. But a key predictor of speedy healing is often how healthy you are before that day. So if your surgery is scheduled (i.e. not an emergency procedure), you may have some time between now and your surgery date to work on issues like smoking or other steps you can take to become as healthy as possible.

And for cardiac surgeons who, like Dr. Yanagawa, are wondering how to answer that “how long does it take?” question from patients, consider surgeon Dr. Lisa Brown’s suggestion. Here’s how this researcher and Assistant Professor of Thoracic Surgery at the University of California-Davis responded to Dr. Yanagawa’s original Tweet: