Open Heart Surgery – A final note – when to call your doctor

December 8, 2009 by  
Filed under Education

After you get home you may feel a little nervous and worried about being on your own. Well, don’t sit and worry if you think something is not right about your health or healing. If you have any of the following signs of a or infection call your doctor, cardiologist or . Keep their numbers handy. If the signs tell you it’s an emergency and you are not able to reach your doctors, call 911 immediately.

Your stitches or staples will be removed within 10 to 14 days after . You should check your incision every day. Call you doctor if you have signs of infection listed below.

Warning signs of infection

  • red, hot and swollen incisions(s)
  • smelling discharge coming from an incision
  • a temperature over 100 degrees for a few days
  • chest congestion, coughing, and problems with breathing at rest

Warning signs of a heart attack

  • intense, steady pressure or burning pain in the center of your chest
  • pain that starts in the center of the chest and goes to a shoulder and arm (usually the left) or both shoulders and arms, back, neck and jaw
  • prolonged pain in the upper abdomen
  • nausea, vomiting, profuse sweating
  • shortness of breath, looking pale
  • dizziness, light-headedness or fainting
  • frequent angina attacks like you may have had before surgery
  • a sense of anxiety or doom

Warning signs of an emergency

  • your are bleeding a lot of bright red blood or you see blood clots
  • you have a sharp pain that does not go away with your pain medicine
  • your incision(s) opens
  • if you had leg surgery, your leg turns blue or you lose feeling in your leg
  • your fever goes up fast or is over 101 degrees
  • you have allergic reactions to medicines you are taking
Tags: Myocardial infarction, heart attack, ER, incision, heart surgery, cardiologist, surgeon, Surgery

Open Heart Surgery – On the road to recovery

December 8, 2009 by  
Filed under Education

Each patient’s recovery rate is different, especially after a coronary artery bypass surgery. How quickly you recover will depend in part on your physical health before surgery and how complex and extensive your heart surgery was. The first step in recovery is when you can breathe deeply and cough to clear your lungs. When you can do this, your breathing tube will be removed and replaced with an oxygen mask. This could happen as soon as the day after your surgery. Your doctor will then have you moved from the ICU to another area of the hospital. Your care will continue as follows:

  • you will continue to have electrocardiograms to record your heart rhythm
  • you will wear an oxygen mask as needed
  • you will continue to have blood tests
  • your fluid intake and output will be monitored
  • the nurses will help you with turning in bed, coughing and deep breathing exercises
  • you will start with ice chips and sips of fluid, then solid food

Taking part in your recovery

As you become more active, you will become more involved in your own recovery – even while you are still in the hospital. Here are some activities you can do:

  • eat right – healthy food helps you heal
  • keep your lungs free of fluid, which can lead to pneumonia, by practicing your deep breathing and coughing exercises
  • get out of bed as soon as you can so your muscles stay strong; start slowly sitting on the side of the bed, then the chair, then short walks, then longer walks
  • do the recommended leg exercises to keep your legs muscles strong
  • wear elastic or support stockings if your doctor ordered them
  • use a chair with a firm back when sitting with pillows on the chair arms; raise your feet to the same height if your legs or feet swell, but don’t cross your legs (this slows blood flow)

Because of your surgery and limited movement right after, fluid can build up in your lungs. This fluid can cause pneumonia and keep you keep you in the hospital. Therefore, it is very important that you take deep breaths and cough often. You may be given an incentive spirometer to help you breathe correctly. To ease the pain when you cough, support your chest incision with a pillow or your hands.

Good days and bad days

After the first few days when you’ve come through the worst of it, your emotions may get the best of you. Don’t be surprised if you have good days and bad days. You may cry more easily, have bad dreams, not be able to concentrate or just feel afraid or down. Some of this is related to stress, lack of sleep and the effects of the anesthesia and other medicines. It’s not pleasant, but it’s normal after what you’ve been through. Don’t pretend you feel OK when you don’t. Let your family and the hospital staff know. Both you and your family may benefit a lot by talking to a rehabilitation counselor.

Better days ahead

As you near the end of your hospital stay, you will become really anxious to return home. Your mental outlook will improve and your physical recovery may even speed up once you’re home. Family, familiar surroundings and peace and quiet can help a lot.

Before you leave the hospital, you will receive instructions from your cardiac health care team about a number of things. These include :

  • how to care for your incision(s)
  • your new heart-healthy diet
  • a list of physical activities you can do during the next 6-12 weeks
  • recommended exercises
  • a list of special equipment, medicines or supplies you will need
  • the date of your first follow-up visit

Once you’re at home, pace yourself. Follow your doctor’s instructions. Be aware of how you feel during everyday activities. You will be able to tell when you can increase the amount or level of activity. When you are tired, rest. When you’re hungry, eat – but eat heart healthy foods.

Congratulations! You’re on your way. There are better days ahead!

A final note – when to call your doctor

After you get home you may feel a little nervous and worried about being on your own. Well, don’t sit and worry if you think something is not right about your health or healing. If you have any of the following signs of a or infection call your doctor, cardiologist or . Keep their numbers handy. If the signs tell you it’s an emergency and you are not able to reach your doctors, call 911 immediately.

Your stitches or staples will be removed within 10 to 14 days after surgery. You should check your incision every day. Call you doctor if you have signs of infection.

Warning signs of infection

  • red, hot and swollen incisions(s)
  • smelling discharge coming from an incision
  • a temperature over 100 degrees for a few days
  • chest congestion, coughing, and problems with breathing at rest

Warning signs of a heart attack

  • intense, steady pressure or burning pain in the center of your chest
  • pain that starts in the center of the chest and goes to a shoulder and arm (usually the left) or both shoulders and arms, back, neck and jaw
  • prolonged pain in the upper abdomen
  • nausea, vomiting, profuse sweating
  • shortness of breath, looking pale
  • dizziness, light-headedness or fainting
  • frequent angina attacks like you may have had before surgery
  • a sense of anxiety or doom

Warning signs of an emergency

  • your are bleeding a lot of bright red blood or you see blood clots
  • you have a sharp pain that does not go away with your pain medicine
  • your incision(s) opens
  • if you had leg surgery, your leg turns blue or you lose feeling in your leg
  • your fever goes up fast or is over 101 degrees
  • you have allergic reactions to medicines you are taking
Tags: Cough CPR, surgeon, heart surgery, rehabilitation counselor, heart attack, chest incision, Surgery

Open Heart Surgery – Being admitted to the hospital for open heart surgery

December 8, 2009 by  
Filed under Education

You will usually be admitted to the hospital the day before your surgery. Simply check in at the hospital admissions desk. The hospital should have a record of your pre-admission tests and forms that you completed. Read more

Tags: General anaesthesia, open heart surgery, Intensive-care medicine, Surgery, Anesthesiologist, Cardiac surgery, surgeon, Anesthesia, Intensive-care unit

Open Heart Surgery – Getting Ready for open heart surgery

December 8, 2009 by  
Filed under Education

Usually, can be scheduled days or weeks in advance. It will depend upon how serious your heart condition is, your schedule and the ‘s schedule. If you have a week or two before surgery, use this time wisely. Check with your surgeon about:

  • exercise – Should you start, stop or continue exercises?
  • diet – Should you change your diet in any way?
  • weight – Would it help your recovery to lose or gain a few pounds?
  • smoking – If you smoke, can your doctor recommend a stop smoking program?
  • medicines – What medicines should you start, stop or continue taking? Remember to ask about all medicines that you take regularly or occasionally, including prescription and over-the-counter medicines.

Also, be sure to:

  • rest, relax – Take good care of your physical and mental health. Don’t overdo things. And make sure you plan some enjoyable activities to relax your mind and give your spirits a lift.
  • report health changes – Tell your doctor if you have any signs of infection, like chills, fever, coughing, runny nose, within a week of your scheduled surgery. If an infection continues, surgery may have to be rescheduled.

A special note about smoking

Not only is smoking bad for your health, but it could affect your recovery. Since most hospitals are “smoke free”, you will have to quit smoking when you go into the hospital. This means you will be going through nicotine withdrawal when your body is trying to recover from surgery. So, do yourself a big favor. Quit smoking now, and your mind and body will be able to focus on healing, not withdrawal.

Making arrangements for surgery

Whether you’re having major surgery or minor surgery, you should always have a family member or friend with you. Even when you are going for the pre-admission tests (explained later), it’s a good idea to have someone with you. He or she can listen and take notes for you – or simply hold your hand if that’s what you need! So give your family or friend plenty of notice about your upcoming tests and surgery. Also, now is a good time to make a list of any medicines you are taking and any allergies to medicines, food, etc. that you may have. Take this list with you when you go to the hospital so you don’t forget anything.

Pre-admission procedures

A few days before surgery you will need to have certain tests. Your surgeon’s office staff will tell you where to go and which tests you will need. If you have had any of these tests recently, ask your surgeon if a copy of your test results will do in place of redoing the tests. You may need:

  • a chest x-ray to see how well your lungs work
  • an electrocardiogram (ECG) and/or an echocardiogram (ECHO) that shows how your heart is working
  • blood tests that show chemistry and blood counts
  • a urine analysis

There will be paperwork to complete. You will be asked:

  • to fill out insurance forms, or provide authorization forms from your insurance company; make sure you bring your insurance card(s)
  • if you brought written orders from your doctor or lab test results
  • the name, address and telephone number of someone to contact in case of emergency

You will be told about your rights for advanced directives (your options for life support if that’s needed) and asked for a copy of your living will and health care power-of-attorney. You must sign a surgical consent form. This is a legal paper that says your surgeon has told you about your surgery and any risks you are taking. By signing this form you are saying that you agree to have the surgery and know the risks involved. Ask your doctor about any concerns you have before you sign this form.

Blood transfusion

Surgical methods today reduce much of the blood loss during surgery. However, you may need a blood transfusion. If so, your blood will be matched carefully with blood that has been carefully tested. The blood you receive can come from:

  • a blood bank – this blood supply is from the American Red Cross and is safer today than it has ever been
  • a designated donor – this can be a family member who has the same type of blood that you do
  • you (autologous blood donation) – you will donate blood at a local blood bank or hospital

Ask your surgeon which would be best for you. If you donate blood, you must do it in plenty of time for surgery. Also, be sure to eat and drink as directed if you decide to donate blood.

Tags: Transfusion medicine, Allergies, heart surgery, Hematology, Blood donation, major surgery

Open Heart Surgery – Your visit with the heart surgeon

December 8, 2009 by  
Filed under Education

Your heart will explain the results of your tests and why surgery is being recommended. He will also explain the surgical procedure and the results you can expect. He will tell you about the risks of having or not having the surgery, the benefits of having the surgery and any options you have in place of surgery. You must consider the balance of the risks you will be taking and the benefits you will receive. Don’t be afraid of offending the surgeon or embarrassing yourself by asking questions about anything you don’t understand. Remember, the more you know, the more you will become confident about your decision. The following is a list of questions to help you get started.

Questions to ask

These are basic questions to ask your surgeon. If you think of others, write them down and bring them with you to your visit. Go over the list with your spouse and family. Ask if they have other questions they would like to have answered. Before you leave the surgeon???s office, try to get all your questions answered. Be sure you understand everything clearly. If you think of questions after you leave, write them down and call your surgeon back.

  • How will the surgery improve my condition?
  • Tell me again what will happen during the surgery?
  • Will I need blood transfusions?
  • How long will the surgery last?
  • How long will I be in the intensive care unit (ICU or CCU)?
  • How much pain should I expect and how will it be controlled?
  • What will the scar look like?
  • What are the possible complications of surgery, and how likely are they to happen?
  • Can I recover completely from this surgery? If so, how long will it take?
  • How long will I be in the hospital?
  • How long will my recovery take after I am home?
  • What will I be able to do and not do during recovery?
  • Will I need special equipment when I get home?
  • When can I return to work?
  • If I choose not to have surgery, will I get worse or remain the same?
  • Is there an alternative treatment that does not involve surgery?
  • How long do I have to decide?
  • If I decide to have the surgery, how soon should I have it?

Making your decision

Once you have the information you need to consider all your options, you may be surprised that the best decision for you is becoming pretty clear. That doesn’t mean that it’s an easy decision to make, but at least it will be one you will feel good about and will know what to expect as a result of your decision.

Tags: surgeon, Surgery, Nursing, open heart surgery, heart surgeon, Evaluation methods

Open Heart Surgery

December 8, 2009 by  
Filed under Education

A Patient and Family Guide

The thought of having can be pretty scary. You may be most afraid of what you don’t know about it. Like -

  • How should you prepare?
  • What exactly will happen during surgery?
  • How long will it take?
  • What will your recovery from surgery be like?
  • How long will it be before you fully recover?
  • Will you ever be the same again?
  • When can I return to work?
  • When can I return to sex after heart surgery?

This information will answer many questions for you and your family and hopefully put some of your fears to rest. But it can’t answer all of the questions that you might have about your own heart problem and the treatment of it. Always rely on your doctor and your healthcare team for that.

If your heart problem was discovered by your primary care doctor, he has probably referred you to a heart specialist, called a cardiologist. Following an exam and many tests, the cardiologist has recommended surgery to treat your heart problem. The cardiologist then referred you to a heart . This booklet will let you know what to expect during your visit with the surgeon. And it will explain what will take place before, during, and after your heart surgery. If you have already met with the surgeon, review the first part of this booklet to make sure you understand everything you need and want to know before making a final decision about having the surgery. Remember, peace of mind is very important to your good health. Your doctors want you to have all of the facts so you can make the decision which is best for you.

Tags: Cardiac surgery, Surgery, heart surgery, cardiologist, Cardiac surgeon, surgeon, heart surgeon, heart specialist

Heart Stents and Angioplasty

August 22, 2009 by  
Filed under Education

The purpose of the following information is to help you understand coronary artery disease () and the treatment of it using a coronary stent. If you have any questions about the following information, write them down and discuss them with your doctor, , or nurse.

About one third of all Americans develops some form of heart disease. Heart disease is caused by atherosclerosis. Atherosclerosis is a thickening of the inside lining of the blood vessels. This thickening results from the deposit of fatty substances such as cholesterol. As the inside of the blood vessels thicken there is less room for the blood to pass through the arteries. Percutaneous transluminal coronary angioplasty (PTCA or angioplasty) is a procedure that is commonly performed on people with heart disease. This procedure is done to open up the blood vessel to allow the blood to pass through more easily.

PTCA means:
Percutaneous – performed through the skin
Transluminal – through the inside opening of a vessel
Coronary – relating to arteries or veins of the heart
Angioplasty – a procedure to open blood vessels

The common name for PCTA is angioplasty.

How does heart disease affect your body?
Your heart is a muscle that needs a constant flow of oxygen-and-nutrient-rich blood to keep it healthy and functioning properly. Blood reaches your heart through two main coronary blood vessels (arteries). There is also a network of blood vessels covers the surface of the heart and supplies blood to the heart. Fatty deposits and cholesterol can form in your arteries. This results in a narrowing of the arteries. This narrowing is called atherosclerosis.

If your coronary arteries, which supply blood to your heart muscle, become too narrow, they cannot provide your heart with enough oxygenated blood. When your heart beats faster because of physical activity or psychological stress it needs more oxygen and nutrients. Your narrowed or sometimes blocked arteries cannot provide enough blood to the heart. This lack of oxygen can show up as angina (heart pain). In cases of prolonged pain you could have a heart attack.

So you can see, it is very important to diagnose and treat heart disease. You should know that you are at greater risk for heart disease if you:

  • are male
  • currently have high blood pressure or diabetes
  • are a smoker
  • are overweight
  • have a close relative with heart disease

One of the most common test for finding out if you have heart disease is the stress test (exercise electrocardiogram). You may also hear this test called an exercise treadmill test. This test measures changes in the electrical activity of your heart muscle as you do controlled exercise. The stress test may show if there has been damage to the heart. If the stress test is found to be abnormal, your doctor may want you to have a cardiac catheterization. A cardiac catheterization is the most definitive test for finding heart disease. During the catheterization, a special dye is injected into the coronary arteries. Your doctor will be able to see the dye in the arteries on x-ray pictures shown on a monitor. The x-rays will show any narrowing or blockage in the arteries. After catheterization your doctor will know how much heart disease you have. Your doctor will also know if you need a stent.

What is Angioplasty?
Angioplasty is a surgical procedure that opens blood vessels that have narrowed due to deposits of plaque. Angioplasty is done in a cardiac catheritization laboratory (cath lab). The cath lab is an x-ray room with a sterile environment much like that of an operating room. The surgeon makes a small cut usually in the arm or groin. Then a catheter with a tiny balloon on the end is placed into a blood vessel. The doctor then moves the catheter up through the body and into the coronary artery. During this process the doctor will watch the progress of the catheter on x-ray monitors. Once the catheter is placed across the blockage, the doctor slowly inflates the tiny balloon. As the balloon inflates it presses the fatty deposits (called atherosclerotic plaque) against the wall of the blood vessel. By compressing the plaque the inside (diameter) of the blood vessel gets bigger. This bigger vessel makes the blood flow more easily.

However, in about half of all successful angioplasty procedures, the plaque builds up again, causing the inside of the vessel to become smaller, or more narrow. This new build up is known as restenosis. To help reduce the chances of new build up and that narrowing will happen again, your surgeon may suggest placing a coronary stent inside the artery.

A coronary stent is a small device that provides support for a blood vessel. The stent is a small, stainless steel tube that is placed in your blood vessel. Stents can look like mesh or a small spiral wire (spring). The stent is inserted into the artery by using a balloon catheter after angioplasty. Once in the artery, the surgeon inflates the balloon. As the balloon inflates the stent expands and presses against the artery wall. The balloon is then deflated and removed. However, the stent remains expanded inside the artery and keeps the artery open.

The stent is now a permanent implant that remains in your artery and will help hold the artery open. Since is holds the blood vessel open it also improves blood flow. The improved blood flow should relieve your symptoms of heart disease.

Getting ready for angioplasty and the stent procedure
For several days before the procedure, you will be asked to take aspirin and other medicine given to you by your doctor. Be sure to tell your doctor if you cannot take aspirin for any reason. It is also important to tell your doctor if you are presently taking any medication or if you have any drug allergies. The night before you have the procedure, you will not be allowed to eat or drink anything after midnight. Before the procedure begins, women will have a urinary catheter inserted into the bladder. Men may have an outside catheter applied. The urinary catheter will reduce the need for moving on and off a bedpan after the procedure. This will minimize stress to the puncture site. Other preoperative instructions will be given to you by your doctor or nurse. You should follow all instructions very carefully.

It is not necessary that you be put to sleep during the procedure. However, you may be given a mild drug to help you relax. The discomfort you feel should be fairly minimal and tolerable. If you need additional pain relief it can be given to you during the procedure. But your doctor will want you to remain as alert as possible so you can follow instructions from him. For example, he will tell you to breathe deeply when x-rays are being taken. Being able to do what the doctor says will improve the quality of the x-ray pictures.

During the angioplasty and stent procedure
Your procedure will be done in a room that is has special instruments. It will also have a special x-ray machine that has a monitor. The monitor looks like a TV screen and is called a fluoroscope. After you are brought into the room, you will be moved to the x-ray table. You will be covered with a sterile sheet. The place where the catheter is to be placed, usually the inside of your upper leg, will be washed with a special germ killing solution. A local pain killer will be injected at the site. The pain killer may sting for a few seconds. Then, a small tube called a sheath will be inserted into the vessel. A smaller plastic tube called a guiding catheter will be passed through the sheath until it gets to the vessels of the heart. A special dye will be injected through the guiding catheter. The dye will show up on the special monitor. The dye allows your doctor to see the veins and arteries in your body.

The monitor also allows the doctor to see the balloon catheter as it is moved forward through the blood vessel and into the right position. Next, a guidewire will be inserted through the guiding catheter and moved forward to the diseased vessel. Then the balloon catheter will be attached to the guidewire. The balloon will be moved to the site where the vessel is narrowed or blocked. After the balloon catheter has reached the area to be treated the catheter is pulled back a little. This will expose the first balloon. This balloon does not have the stent attached. Then the balloon will be inflated. As the balloon inflates it applies pressure to the plaque in the vessel. This pressure compresses the plaque and opens the artery. The artery stays open because the plaque is a waxy material and will hold its shape. Once the artery opens up the blood flow increases.

Your doctor will ask you to be very still during this procedure. For the most part you will be comfortable. However, you may experience a feeling of pressure when the balloon is inflated. This feeling is normal and will go away quickly.

Once the artery is opened the first balloon catheter will be taken out. The stent will be mounted on the end of a second balloon catheter. The stent is directed to the area that was previously blocked. The balloon and stent are carefully positioned in the correct spot. The balloon will be inflated causing the stent to expand. One or more stents may be expanded in the vessel. The number of stents you will need depends on the amount of heart disease you have. After all stents are in place, the balloon catheter will then be deflated and removed. The stent remains in place permanently and keeps the coronary artery open. The balloon angioplasty and stent implantation procedure usually lasts between 45 and 90 minutes.

Recovering in the hospital
After the procedure, you will usually be returned to an intermediate cardiac care unit or a medical cardiac care unit. If the sheath is still in place, it will be removed. Pressure will be applied to the puncture site until the bleeding has stopped. The nurses will watch your heart rhythm and blood pressure very closely. From time to time they will also check your puncture site for bleeding. After a short recovery period, you will be returned to your room. You may eat and drink. Your family will be allowed to visit. Be sure to drink all of the fluids that are given to you. The fluids will help to flush the special dye through your kidneys and out of your body.

For the first few days after receiving your stent, your activities will be restricted. You will be told that you must lie flat until the day after your procedure. You will not be allowed to bend the leg that has the puncture site. A soft restraint may be placed around your ankle. Don’t panic. This is only a gentle reminder that you are not to move or bend that leg. You must also take medication that will keep the blood flowing smoothly through your stent. Your blood will be tested frequently to see how quickly a clot will form. This is called the “clotting time”. By monitoring the clotting time the medication dosage can be regulated. Within a few days, your doctor will allow you to gradually increase your activities.

When you go home
Most people who have angioplasty and a stent implant usually stay in the hospital for three to eight days. When the doctor thinks you are ready, you will be discharged to the care of your family doctor. If you have any discomfort, pain, or bleeding of any kind after you get home, you should contact your family doctor or hospital right away.

At first, your doctor will want you to come see him often so he can watch and record your progress. After about six months, your doctor may ask you to have a follow-up stress test or cardiac catheterization. Eventually you will be able to return to your normal activities. Be sure to ask your doctor before you do anything that is physically strenuous.

Your stent will not limit your daily activities in any way. However, you should tell any doctor who treats you in the future that you have a coronary stent. A small wallet-sized card that has additional information about your stent will be given to you by the doctor who implants your stent or the nurse. Remember to keep your stent implant card with you at all times.

Special Medication
When you get home, you will be instructed to take special medication. Your doctor may also want you to make some lifestyle changes. It takes about 4 weeks for the lining of the vessel to grow over the stent. Once the vessel grows over the stent it will become a permanent part of the vessel wall. Until the blood vessel covers the stent you will be treated with anticoagulants (blood thinners). You will also take an antiplatelet drug. This drug will prevent blood clots from adhering to the surface of your stent until it is covered by your blood vessel. You will be asked to take the following medications for at least one month (the time it takes the blood vessel to grow over the stent). You may have to these drugs longer:

  • aspirin for preventing blood clots
  • an anticoagulant which also prevents blood clots
  • special medication for preventing blood clots

It is very important that you follow the medication regimen exactly as you are told. Do not stop taking any of the prescribed medications unless you are instructed to do so only by the physician who implanted your stent. If you have any side effects from the drugs, such as nausea, vomiting, or rash, you must notify your doctor immediately.

Diet and exercise
Your doctor will probably prescribe a controlled exercise program along with lifestyle changes. If you smoke, you will be encouraged to stop. If your cholesterol is high, you will be taught and encouraged to eat a healthier diet.

In addition to following the dietary suggestions from your doctor or dietitian, you should avoid eating too many foods that are high in vitamin K. These foods will decrease the effectiveness of the oral blood thinner that your are taking.

The action of a blood thinner can also be affected by antibiotics, some non-prescription medications, vitamins, a change in your eating habits, and especially alcohol consumption. As long as you are taking the anticoagulant, your doctor will probably do a weekly blood test to see how fast your blood is clotting. In the meantime, you should let your doctor know about any lifestyle changes that you make during this time. You should avoid having any dental work while you are taking a blood thinner. If emergency dental work is needed, be sure to tell your dentist that you are taking a blood thinner. You should carefully read over the information packet about the blood thinner given to you by your physician or nurse.

A final word
Because heart disease has been called a “silent disease”, you should have regular periodic examinations to check your progress. Always keep appointments with your doctor. You can reduce your risk of further heart disease by making healthy lifestyle choices.

Keep in mind thousands of people who have heart disease are leading healthy, productive lives after having coronary angioplasty and stent implantation. So can you!

Tags: angioplasty, ptca, surgeon, heart disease, heart stent

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