Complications can occur during or after any surgery. Before recommending a surgical procedure, the potential for postoperative complications is evaluated thoroughly by the medical staff.
In elective cases (i.e. when there is sufficient time to plan and prepare the surgical procedure), the preoperative surgical consultation is carried out also for the sake of this purpose: seeing the patient personally enables the surgeon to have an idea about his conditions and his strengths and energy store. This clinical evaluation, together with “technical” information drawn from medical exams, allows to better evaluate the surgical risk.
We distinguish between technical and general complications.
Technical complications are mostly dependent on the conditions as presented on the surgical site: the quality of tissues, the individual anatomy, the real extension of the illness or the complexity of the technical move. To limit as much as possible any complications of this kind, an underway change of strategy or surgical technique is sometimes necessary.
I won’t dwell too much on this, as the possible technical complications are most of all linked to the specific surgery and will be discussed and explained during the meeting with the surgeon.
More than anything, the general complications have to do with the body’s reaction’s to the surgical intervention. The body does not perceive surgery as a positive action, but as an aggression, a lesion to its entireness. And to be honest, it’s not wrong! Incision, tissue divarication, handling the insides of the body…. The defence mechanisms that are activated on hormonal and immunological level make the body react in several ways and some of them can be rather harsh, too.
One of the more visible ones are a general swelling (water retention) of the body, due to the altered permeability of the blood vessels and to the liquids shifting from the blood to the tissues. The tissues full of liquids suffer a worsening of their functionality and their ability to defend themselves. Strangely enough, the body is now more vulnerable.
The weaker and more fragile the patient at the beginning, the more difficult it is for him to get out of the vulnerable phase.
Besides the complications discussed below, it must be kept in mind that dealing with heart surgery, the heart is the primary organ that needs to react well and with it the whole body. The less the heart is damaged, the better the chances to overcome the operation without major difficulties. Sometimes it is necessary to help the heart by means of potent drugs given directly and continuously in the vein, sometimes (rarely thank God) even this is not enough: the needed assistance to the heart is provided by special assist devices inserted in the vascular system, which can be balloon catheters synchronised to the cardiac rhythm or extracorporeal pumps connected to the heart. I won’t get into details now, the whole subject will be discussed more thoroughly in a future post.
The most important general postoperative complications are:
- postoperative bleeding
Postoperative bleeding has been a fact from the very beginning of surgery. Tissues bleed when they are cut. The hemostatic techniques (i.e. sealing of small blood vessels to stop the bleeding) have clearly improved over the years. However, there are some adverse conditions that make hemostasis rather difficult: drugs reducing the body’s capability of blood clotting are given before and during surgery, such as anti-platelet drugs (blood cells that can be the onset of a clot that can provoke the heart attack – such as Aspirin, Plavix, Effient, Brilique), anti-clotting drugs given during the operation (i.e. heparin).
Part of their effect can be neutralised pharmacologically after the surgery to obtain a good balance between coagulation (needed to seal blood vessels) and anti-coagulation (needed to maintain a good blood fluidity to avoid thrombosis).
Prevailing of anti-coagulation and / or tissues or sutures giving way will increase blood loss, that will be drained through tubes inserted during the operation .
Should the correction of clotting through transfusion of coagulation factors, platelets and administration of suited drugs not result in a decisive improvement, a surgical revision must be carried out (rarely more than one).
The postoperative bleeding is a complication that mostly occurs within the first few hours from surgery: the more time passes by the less the patient will bleed.
This is one of the most hated complications. It is usually due to a clot or a detached tissue particle that travelling with the blood flow occludes a brain artery causing the area supplied by it to starve of oxygen. It can occur both during surgery (handling of tissues, heart and large vessels, unstable balance between coagulation and anti-coagulation, changes of blood flow characteristics, etc.) and after surgery. Heart rhythm diseases, particularly atrial fibrillation (i.e. very irregular heart beat) can also cause a stroke.
A large part of the surgical strategy and technique is thought out just so to avoid any strokes. We, as medical and nurse team, loathe this nearly as much as the patient and his family do.
Generally speaking, the risk of stroke in heart surgery rates at approx. 1 – 2%. It is important to point out that the age of the patient is significant: patients aged over 75 have 10 times more chance to get a stroke.
It is only possible to detect a stroke a few hours after surgery, when the patient is awake. In fact, it is just when the patient is awake that he can be asked to execute easy tasks, i.e. move arms and legs, grip hands and answer questions. This preliminary exam help us have a first rough impression of the brain’s functions after surgery. Should some limb weaknesses be detected or an abnormal awakening occur, a brain CT scan and a neurologic evaluation will be carried out, enabling the medical team to understand the extent and repercussions of the problem.
Many times these deficits revert on their own accord within a couple of days, some other times they will revert rather slowly (weeks / months) leaving residual deficits of varying importance. Physiotherapy and functional re-education are of the utmost importance to improve and restore the damaged functionality.
Heart rhythm disorders occur frequently after open heart surgery. Sometimes the heart beats too slowly, e.g. with around 40 – 50 beats per minute or even less. The treatment consists in the electrical stimulation of the heart by means of an external pacemaker. During surgery, temporary electrodes are placed on the surface of the heart exactly for this purpose. When the normal rhythm is re-established these cables are simply pulled out of the thorax (a painless procedure). In rare cases (it depends also from the type of surgery) the normal rhythm cannot be reliably re-established. Then the rhythm-specialists are consulted. They evaluate the indication for the implantation of a permanent pacemaker, a rather simple procedure carried out in local anesthesia.
The heart beat can suddenly become far too fast and irregular, which can upset and worry the patient. It is a rather frequent postoperative arrhythmia (it occurs to 30-50% of all patients after open heart surgery) and it is called “atrial fibrillation”. It has to be taken care of quickly for various reasons.
The normal heart beat is a requisite for a coordinated contraction between the antichambers (the technical term is “atrium”) and the main chambers of the heart, a key for an efficient blood transport in the circulatory system. When the antichambers fibrillate they do not contract efficiently, the contraction chain is in disarray and cardiac output can decrease. Besides this, the stagnation of blood in the antichambers can cause the formation of clots which then can embolize in the body.
The drug therapy is first administered initially by infusion (endovenously) and then orally. More than half of the arrhythmias change back to a normal rhythm within 24-48 hours. Should the arrhythmia persist and several other elements in the individual medical history are favourable, an “electric cardioversion” can be done. It is a short electric shock (under total anaesthesia lasting a few seconds) that interrupts the antichambers’ electrical disorder, allowing the normal rhythm to prevail.
For more complex arrhythmias cardiology specialists will be consulted, who will then take care of the patient and his drug therapy.
Wound infections (as postoperative bleeding) have also been present since the beginning of surgery. Sterilization of surgical instruments, surgical disinfection of hands and patient, caps and surgical masks, sterile white coats, laminar air flow in operating rooms are all results of the never ending fight against infections on the surgical site.
Despite enormous progresses the problem has not been entirely solved, yet. The surgical incision is the most critical entrance for germs. The skin has been cut and germs coming from the deepest skin layers can invade the wound. This always happens and it’s the reason why the wound is disinfected several times during surgery when it’s still open.
Why do we still get infections then?
There are various factors that decide if by a simple germ presence an infection can develop: first of all is the wound’s blood supply. A good blood supply also brings some “cleaning” to the wound (thanks to white blood cells), that normally manage to get rid of the intruder. As such, tissues that are no longer well supplied with blood are more at risk. The patient’s own defence must be strong: a weak body can be at risk.
Another known risk can be explained in this context: diabetes mellitus. Diabetes weakens the white blood cells’ effectiveness in their role of wound healers and intruder killers.
A good surgical practice with adequate and gentle tissue handling, is another fundamental factor.
Particularities of the surgery (e.g. its extension, complexity and time needed), as well as of the patient himself, can affect the wound healing. Germs themselves change, meaning that they develop defence mechanisms that make them more resistant to antibiotics. All these are rather complex and interconnected issues, I’m sure it can be understood if I won’t dwell on it.
What happens when a wound gets infected?
The first reaction would be a surgical revision, i.e. re-opening of the wound, taking a sample to identify the germ and its sensitivity to antibiotics and the surgical cleaning of the wound. Once cleaned, the wound will remain open and won’t be sutured just yet. It can either be treated with frequent medications or with a special sponge that allows the wound to be totally covered and at the same time a non-stop suction is applied (VAC system). This can stimulate regeneration and tissue growth in a shorter period of time. When the microbiology samples are negative and the tissue growth satisfactory, the wound will be closed again (either in stages or completely).
I won’t be dealing with complex infections in this post. In these cases, detailed and frequent meetings with patient and family are very important.
The list of possible complications does not, I’m afraid, finish here. There are many more, less common but also more complex and difficult to understand. As mentioned several times, to be in touch with the responsible heart surgeon is paramount, most of all in case of adverse developments.
It is in everybody’s interest and first and foremost in the patient’s interest that any possible problems that can occur during this journey are handled as a team.
When talking about possible complications It is also important not to be pessimistic and to not fall into vicious circles of negative thoughts. Avoiding complications is one of the main objectives of the medical team! Besides posing the correct indication for the surgery, the larger part of thoughts and preparation to the surgery is dedicated to this target: acknowledging the elements that could induce to complications and carry out the surgery accordingly. In fact, the percentage of complications is very low (around 2%), despite the constant increase of the surgeries’ complexity and the patients’ age.
Thanks to a good preparation, to the vast experience and to the technical and technological evolution, we can nowadays offer and carry out heart surgeries to those patients that just a few years ago were not eligible for surgery. It is important to see the final goal, i.e. the improvement of the patient’s quality of life.
Nobody wants to undergo any surgery! However, should the operation be necessary to improve the symptoms, the quality of life or to avoid a serious health problem, it is then for the best to proceed consciously but with a positive attitude! Believe me, it really helps!