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Getting Back in the Cockpit after Heart Surgery

For me, one of the really awesome things about being a cardiac surgeon has been that cardiac surgery is almost always a curative procedure. 

Patients who have these operations obviously appreciate that too. Although there are always exceptions, most patients can get back to pretty normal lives after their recovery. Our pals in the FAA don’t always see things the same way and, justifiably so, have some very strict rules and regulations on getting back in the cockpit after heart surgery.

Cardiac surgery can replace blocked arteries with wide-open new ones bringing needed blood to the heart muscle. We can fix or replace leaky valves that cause debilitating heart failure if not treated. If all else fails, we can even replace a bad heart with a mechanical one or a new one but that’s pretty dramatic. There’s no doubt these are big and invasive procedures and getting back to flying airplanes after having an operation like this is a huge step forward. Some of it has to do with the mechanics of having a chest incision and a heart repair and some of it deals with the effects of that surgery on your postoperative cardiac function and other parts of your physiology. From a surgeon’s point of view there are a number of issues to consider before clearing a postoperative (“post-op”) patient to return to their normal activities, especially flying airplanes.

“Open heart surgery” has lost a little of its specific meaning and taken on a different connotation now that many of the repairs to the heart can be done without an incision, instead using wires and balloons passed right through the skin (“percutaneously” in our lingo). Real “open” heart operations entail dividing the breastbone (sternum) down the middle to get direct surgical exposure for an open repair. That approach gives the incision its name “median sternotomy.” Having this kind of a surgical approach has a significant impact on post-procedure recovery and is an important factor in how the FAA will evaluate your post-op fitness to fly. I’m going to limit this review to the real “open” aspects of open-heart surgery, meaning through an incision and a direct repair. My aim here is not just to go over the FAA regulations that are all open source but also to shed some insight on how you might respond and recover to a major operation on your chest and how that can affect you down here and up in the air.

Before you return to full function there are numerous issues that need to be considered by you and your surgeon. Like I said above, open-heart surgery requires a big incision through the sternal bone. As the weeks go by after your procedure, the incision is likely to be painful, especially with motion like coughing and using your arms. If you use any kind of narcotic-based pain meds for this you can’t drive and certainly not fly with any of those chemicals in your system. There are several non-narcotic-based pain medications that are really effective such as Ketorolac that is marketed under the name Toradol. I’ve prescribed that medication a lot and it works great, but it’s a non-steroidal anti-inflammatory medication (NSAID) that has effects on platelet and kidney function. If you are on any anti-coagulation or have a low platelet count or an element of renal dysfunction you need to talk with your doc and likely avoid these types of medications.

I also advise my patients not to try to drive for about 6-8 weeks after having had a median sternotomy. Any motion across the healing bone can disrupt healing and also cause sudden jolts of pain. There is also a chance you may have some weakness and pain down your arms since your arm strength and mechanics are supported by their connection to the sternum and clavicles. Driving that might require turning the steering wheel quickly to avoid someone or something in your way may cause a significant sudden pain that is distracting and possibly impacts your arm motion and ability to avoid an accident. I tell my patients to think of their sternal incision like a broken leg, which they wouldn’t walk on for a few months after the fracture and has a cast application to support healing. You can also experience some numbness in your arms from the mechanics of the sternal incision that can impart pressure on the nerves in your neck. This is usually self-limited and goes away with time but it can also affect your handling of an airplane yoke or steering wheel.

Rarely there can be some neurocognitive changes after cardiac surgery. That used to be a lot more common when putting all of our patients on the heart-lung machine for every operation. We used to call it “pump head,” and it was thought to be related to the mechanics of artificial circulation and cerebral blood flow. Now that most straightforward coronary artery bypass graft (CABG) operations are done off pump, cognitive problems are a lot less common but still can impact valve patients. This is something that will be checked as part of your post-op evaluation by your cardiologists, surgeon and the AME.

Open-heart surgery can have effects on pulmonary function related to several different intra-operative and post-op factors. Former president Bill Clinton’s recovery from his CABG is a well-known example. Follow up pulmonary function testing (PFTs) may be required under some conditions that you will need to sort out with your docs before even going to an AME for clearance. Any compromise in your breathing clearly can impact your ability to fly at any altitude more than a few thousand feet off the ground.

The waiting period after heart surgery to get FAA clearance for first- or second-class medical airman recertification is at least 6 months. The BasicMed rule requires no waiting period for third-class applicants, but most patients aren’t ready for a post-op stress test for at least a couple months after the surgery. These times can easily be extended depending on your postoperative recovery. There are some sound reasons to start at this point for the evaluation process, since that’s a good estimate of the time to get over the effects of the surgery, heal inside and out, and make sure that your heart function is back to normal.

With regard to the specifics of those regulations covering applicants for medical certificate reissuance after heart surgery, the FAA requires your AME to defer the application to the FAA for consideration of an “Authorization for Special Issuance of a Medical Certificate.” Your application, depending upon class of medical certificate sought, will have to pass through the Federal Air Surgeon’s (FAS) Cardiology Panel or FAS Cardiology Consultant. The FAA divides procedures for coronary heart disease (CHD) into 4 broad categories (depending on how it’s treated) when evaluating reissuance of medical certification. The link to their regulations is here but we’ll stick to the open surgery again. Your AME is going to need to see an extensive postoperative work-up with all of your medical records (inpatient and outpatient) pertaining to the event, including all labs, tests, study results and op reports. You will also need to provide a current status report from the treating cardiologist or surgeon. In FAA vocabulary that’s a “complete cardiovascular evaluation (CVE).” The minimum work-up for third-class special issuance includes a maximal level stress test (Maximum Level Bruce Protocol Stress Test (GXT)), labs for cholesterol, triglycerides, and fasting glucose, in addition to that detailed CVE. For first and unlimited second-class, and even an occasional complicated third-class case, the FAA policy requires a nuclear exercise perfusion scan and a more expensive and invasive 6-month post-event cardiac catheterization (angiogram). The regulations for returning to flight after open valve repair or replacement are similar to CABG surgery and linked here. The difference is that you are unlikely to need a cardiac catheterization again but it still requires a special issuance.

Additional required documentation for unlimited first- and second-class airmen can be further restricted and special issuance guidelines for your AME are linked here. “Limited medical certificate” refers to a second-class certificate with a functional limitation such as “Not Valid for Carrying Passengers for Compensation or Hire,” “Not Valid for Pilot in Command, Valid Only When Serving as a Pilot Member of a Fully Qualified Two-Pilot Crew.” It all depends on the results of your post-op testing.

Anticoagulation, so-called “blood thinners” like warfarin (Coumadin) or one of the newer medications (Xarelto, Eliquis, Arixtra) are prescribed to some post-op heart surgery patients. I’m not sure why they are called blood thinners since they have nothing to do with how thick or thin your blood actually is; they prevent your blood from clotting. These medications are prescribed after valve surgery depending on what type of valve hardware that was used in your repair or replacement, and there are numerous issues that determine how long you will be on this medication. In addition to indications for valve surgery, anticoagulants might also be prescribed for a variety of postoperative conditions like a change in your heart rhythm (the most common is atrial fibrillation). The FAA has specific regulations on pilots who use anticoagulants and monitoring of the medication. Also you will be at a high risk for bleeding even after a minor injury that can limit your activities.

If you do have atrial fibrillation (A-fib) there are still more FAA hoops to jump through linked here that could impact your clearance and capacity to fly an airplane. Lots of pilots get back in the air with A-fib as long as the rate is well controlled and proven with a 24-hour Holter EKG monitor. It also requires a special issuance authorization that is reviewed annually. Beta-blockers and calcium channel blockers are among the most commonly used medications to control these rhythm changes and also postoperative blood pressure. They can have side effects like fatigue and cognitive haziness that you need to be careful about and will also prompt further evaluation by the FAA.

There’s nothing good about getting sick and needing a big operation, but if you have to have one, cardiac surgery is among the better procedures. It fixes the problem and gives you a great chance for a normal healthy life after your recovery. Lots of pilots return to flight after these procedures but you are going to have to jump through a lot of hoops to get there. Be persistent; you’ll get back in the air and be safer and healthier for it.

Kenneth Stahl, MD, FACS

Kenneth Stahl, MD, FACS is an expert in adapting principles of aviation safety to the healthcare industry for patient safety. He also writes and teaches pilot safety principles and error avoidance. He is triple board-certified in cardiac surgery, trauma surgery, surgical critical care and general surgery and holds an active ATP certification and a 20-year member of the AOPA. Dr. Stahl practices surgery full-time and is Healthcare Division President for Convergent Performance, an industry leader in teamwork, checklist and accountability training and consulting. He can be reached at [email protected]

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