cardiac interventions Flashcards
Electrical Cardioversion
- procedure aimed at restoring normal sinus rhythm
- done electrically or pharmacology
- withhold care 24 hr or until pt can tolerate
What part of the heart cycle is cardioversion synchronized with?
QRS cycle
What are coronary artery stents?
small, expandable tubes used to open up narrowed arteries
What arteries are stents commonly used for?
CA, femoral artery, carotid
Procedure using CA stents
Percutaneous coronary Intervention (PCI)
Results of PCI trx
- reduces chest p!
- increase blood flow
- helps keep blood vessels open and prevent future MI
What are CA stenets usually made of
metal mesh:
- drug-eluting stent
- bare metal stent
T/F: CA stents are permenant, less invasive, and cause less discomfort
True
T/F CA stent patients are placed on antiplatelet drugs for life and aspirin (patient dependent)
False
aspirin = life
antiplatelet = pt dependent
Describe the CA procedure
- occur under sedation
- peripheral access route - collapsed
- moved into area of blockage - expanded -
- successful if lumen opens after catheter is withdrawn
pt experiences brief angina when balloon used to expand stent is inflated
How long does a CA stent procedure last
30 min- 2 hrs
1 hr is typical
When are CA stent pts discharged home?
day after PCI
CA stent risks/complications
- bleeding if arterial wall perforated
- CVA if plaque or blood clot gets dislodged by catheter
- clot formation
- scar tissue or plaque can form in area of stent (restenosis)
- require anti-coagulation therapy
- arrhythmias
- kidney damage from dye
Stents and MRI
- most/all CA stents are safe up to 3 Tesla
- Most made from nonferromagnetic material
- MRI staff must know pt has stent, make & model
CA stent implications for PT
- Care w/incision site or bleeding
2. Cardiac rehab is nurse driven
Balloon Angioplasty
- tiny balloon deflated and guided through artery to blockage
- inflated to widen opening and increase flow to heart
- stent often placed during procedure
Atherectomy
- catheter w/ sharp blade attached
- inserted into artery
- sharp blade removes plaque from blood vessel
- used to treat blockages in arteries not easily treated w/stents
CABG used to:
- restore normal blood flow to obstructed CA
- relieve uncontrolled angina
- prevent/relieve LV dysfunction
- Reduce risk of death
CABG types
Single, double, triple, quadruple
- LAD
- RCA
- LCX
- post descending artert
CABG graft sites
saphenous vein
internal mammary arteries
radial artert
Off pump CABG
- allows procedure to be done on breathing
- limited to 1-2 lesion bypasses
- decreased post op complications / recovery time
Minimally Invasive CABG
- Minithoracotomy or supxiphoid incision into the L chest cavity.
- internal mammary artery is mobilized from L chest wall and sewn to artery in front of heart
CABG complications
- Postperfusion syndrome
- cardiogenic shock
- nonunion of sternum/infection
- acute renal failure due to embolism of hypoperfusion
- CVA
- penumothorax
- hemothorax
- pericardial tamonade
- arrhythmias
CABG:
Postperfusion Syndrome
- transient neurocog impairment associated w/CABG
- longer the bypass time, higher the incidence
CABG:
Upper back, neck, and upper shoulder p!
- MSK from positioning
- completely supine in Sx and positioned poorly in recliner/bed
CABG:
implications for PT
- cognitive confusion
- personality change
- communication / participation limitations
cardiogenic shock
- heart can’t pump enough blood and O2 to vital organs
- Common meds:
levophed
dopamine
dobutamine
Cardiogenic Shock:
levophed
vasoconstrictor used for hypotension
Cardiogenic Shock:
dopamine and dobutamine
improve cardiac contractility
cardiac tamponade
reduced cardiac function to fluid accumulation in pericardial cavity
pericardial tamponade:
Beck’s Triad
- hypotension in arteries
- muffled heart sounds
- swollen or bulging neck veins
Effects of pericardial tamponade
- reduced diastolic expansion
- lower EDV
- dec SV
Sternal wound complications
- sternal dehiscence
- sternectomy
- pectoralis flaps
Sternal wound complications:
implications for PT
- strict sternal precautions and ROM restrictions
- less chest wall stability
- changing biomechanics of pecs
CABG post op complications
- LE edema
- LE extravasation
- LE inflammation and ecchymosis
- clotting
- Mortality
Extravasation
fluid leakage out of the harvest site
CABG:
inflammation and ecchymosis trx
- thigh length compression stockings
- elevation of limb
- early and frequent slow walking
CABG mortality
1.7%
30 day mortality = 2.1 %
What are risk factors for CABG mortality?
- age >70
- female
- low EF
- history of CVA, MI, or heart sx
- presence of diabetes or HTN
all of the above increases 30 day mortality
CABG:
Sternal Precautions
- follow for 12 weeks
- avoid unilateral shoulder FLX/ABD >90 deg
- avoid full WB through UEs
- no driving and no sitting in passenger seat behind airbag 4 weeks
T/F: following a CABG you should encourage bilateral UE AROM as tolerated to facilitate functional mobility gains and reduce risk of shoulder ROM impairments and muscle changes
False
unilateral AROM
when do UE WB sternal precautions get broken during PT?
Gait training must be at least PWB for ambulation
CABG sternal precautions:
implications for PT
- avoid excessive valsalva
- encourage chest splinting w/pillow when coughing
- avoid lifting, pushing, and pulling > 10 lb for 3 months
CABG: Harvest Site Considerations
- incisions at harvest site - impaired integ, incisional p!, infection, edema
- Protection of this site allows healing of skin and dec p!
- WBAT for pts w/ extremity harvest sites considered appropriate
- No ROM restrictions given normal healing
CABG harvest site: Implications for PT
- providing thigh-high compression garments (LE)
- elevation of involved extremety seated and in bed
- AROM-edema reduction
- monitor for signs of infection (rubor, purulent discharge, acute p!)
Pericardial Window
surgical procedure performed on sac around heart
- used to drain symptomatic pericardiac effusions
- usually small subxiphoid incision
- no restrictions / precautions
Types of valve surgeries
- annuloplasty
- valve repair
- valve replacement
Annuloplasty
replaces rim of mitral or tricuspid valves
- can get torn when valve prolapses
Valve Repair: Mechanical / synthetic material
- highly durable, can last a liftetime
- require lifelong anticoagulation
Valve Repair: Tissue
- human/pig/cow
- durability 10-20 yrs
- no lifelong anticoagulation
Valve Replacement:
Implication for PT
similar to CABG
Transcatheter Aortic Valve Replacement (TAVR)
- Access
- transfemoral
- transapical
- transaortic - Minimally invasive
- useful for high risk pts for open heart sx
- typically no restrictions or sternal precautions
TAVR:
Transfemoral
femoral artery
TAVR:
Transapical
L ant. thoracotomy to apex of heart
TAVR:
Transaortic
upper hemisteronotomy or R anterior thoracotomy to get to aorta
Pacemakers
- creates artificial AP to maintain cardiac conduction/rhythm
Where are pacemakers usually inserted under the skin
- L infraclavicular pocket
- leads inserted into R heart via L subclavian to SVC
Pacemaker leads are attached via either _ or _ fixation into myocardium
passive (tined)
active (screw)
Pacemaker: time needed to allow incision healing and firm adhesion of leads
4-6 weeks
Pacemaker Implications for PT
- Keep involved UE in standard sling 24 hrs
- No therex to involved shoulder 4-6 weeks
- involved shoulder: limit FLX/ABD to 90 deg 4-6 weeks
- no lifting greater than 5 lbs w/involved UE 4-6 weeks
- No driving until after f/u visit w/electrocardiologist
Implantable Cardioverter Defibrillator (ICD)
Small battery powered electrical impulse generator capable of cardioversion, defibrillation, and pacing of the heart
ICD programmed to detect:
cardiac arrhythmia. Corrects it by delivering electricity jolt
T/F: ICDs constantly monitor rate and rhythm of the heart
True
ICD: Implications for PT
- know if pt has one
- almost all forms of activity can be performed
- No sports which might damage device
- no excessive strain on shoulder, arm, torse of ICD implant
ICD: Exercises to avoid
one that cause clavicle to pull down:
- lifting weights w/arm while standing
Cardiac ablation
- used to treat conduction defects/heart rhythm problems
2. non-invasive
Cardiac ablation: Procedure
- catheter inserted into cardiac chamber
- electrodes at tip of catheter gather data/mapping
- data pinpoints location of faulty electrical site
- site(s) destroyed (cold/heat)
Aortic Aneurysm:
Clinical Presentation
- older males, often asymptomatic at time of rupture
- abdominal fullness or pulsation
- palpable pulsatile mass present
- abdominal bruit
Aortic Aneurysm:
Size
- measured by US
2. Repair sx indicated by aorta >4 cm in diameter
Aortic Aneurysm Screening
- May present as LBP
- Understand pt history
- non-mechanical pattern of LBP
- Not responding to trx for LBP
- Abdominal palpation and auscultation
- Males > 65 y.o
- Cigarettes
- Hx of HTN, CAD
Abdominal Aortic Aneurysm Open Repair
Large abdominal incision to expose aorta
Abdominal Aortic Aneurysm:
Endovascular aneurysm repair
- minimally invasive
2. small groin incisions
Intra-Aortic Balloon Pump
Mechanical device that increases coronary perfusion
- increased O2 availability in heart
IABP indications for use
- failure to wean from cardiopulm bypass
- HF
- cardiogenic shock
- acute MI
- cardiogenic shock
- ventricular arrhythmias
- post cardiac sx
- Support during high- risk percutaneous transluminal coronary angioplasty; rotoblator procedures; coronary stent placement
IABP MOA
- balloon deflates during ventricular systole
- balloon inflates during ventricular diastole
- increases CA perfusion pressure
IABP: Increases diastolic BP by:
15-30%
also increases SBP
IABP: inflation triggered by
- EKG
- BP
- pacemaker
- pre-set internal rate
IABP: When heart contracts:
balloon deflates.
allows heart to pump more blood using less energy
T/F: IABP is a long term treatment
False
short term
IABP: implications for PT
- patients typically hemodynamically unstable (inappropriate for therex)
- Protection of catheter most important
- therex to uninvolved extremities
- avoid hip FLX > 70 deg on affected side
- minimize extreme joint ROM
LV assist device
pump used at end-stage HF
LVAD indications
- bridge to transplantation (primary use)
- bridge to candidacy
- destination therapy (final intervention)
- bridge to recovery (temp support)
LVAD: PT considerations
- often has multi-organ involvement
- prevent pts from increasing CO
- often also have RV dysfunction
- May have chronotropic incompetence
- may have impaired pulm function
- may have skeletal myopathy, endothelial dysfunction, anemia.
- at rest device provides most of CO. During exercise=variable
- no guidelines for exercise interventions. limited data
LVAD implications for PT
- infection concerns
- issues w/mobility
- may begin PT post op day 1
- weak, slow progression
LVAD issues w/mobility
- sternal precautions
- cannula and drive line displacement during mobility
- prevent obstruction of blood flow during mobility
Most LVAD pts become NYHA I or II in:
6 months
