Cardiac Interventions Flashcards
what is electrical cardioversion?
a procedure aimed at restoring normal sinus rhythm
done electrically or pharmacologically
PT implications for electrical cardioversion
ie. how long before you can work with them?
withhold care for 24 hours or until the pt can tolerate activity
Briefly compare/contrast cardioversion and defibrillation
- Cardioversion
- elective procedure
- pt awake & frequently sedated
- synchronized with QRS
- 50-200 joules
- consent required
- Defibrillation
- emergency procedure
- V-Fib/V-Tach
- no CO
- begin w/200 joules (up to 360)
- pt unconscious
what are coronary artery stents?
small expandable tubes used to open up narrowed arteries including coronary arteries, femoral artery, and carotid
what is the procedure of inserting a stent called?
PCI
percutaneous coronary intervention
what other procedures are included in the umbrella term PCI? (3)
- angioplasty
- atherectomy
- stenting
what are the results of coronary artery stent placement? (3)
- reduced symptoms (like chest pain)
- increased blood flow
- helps keep vessels open and prevent subsequent problems/MIs
after the placement of a stent what are patients placed on?
- aspirin → for life
- antiplatelet drugs → pt dependent
what are stents usually made of?
metal mesh
two types: drug-eluting stent and bare metal stent
what is a drug-eluting stent?
a stent that slow releases a drug to block cell proliferation
Describe the procedure for stent placement
what might the patient experience briefly?
what is considered sucessful?
- light sedation (valium, versed, or morphine)
- peripheral access route thread a catheter to the location of blockage
- Balloon expanded to fit the stent in place
- pt may experience brief angina
- considered successful if lumen is open after catheter is withdrawn
how long does the procedure take to place a stent? How long are pts in the hospital?
- lasts 30 minute - 2 hours
- most pts are D/C home the day after PCI
List risks/complications of coronary artery stents (8)
- Bleeding if arterial wall is perforated
- CVA → if plaque is dislodged by catheter
- clot formation
- restenosis
- scar tissue or plaque can also form in the area of the stent
- requires anti-coagulation therapy → bleeding risk
- arrhytmias
- kidney damage from dye
- allergy to dye
T/F: Stents are safe under MRI
TRUE
most if not all are safe up to 3 Tesla and made of nonferromagnetic materials
T/F: stents treat the underlying cause of angina
FALSE
only one area of a narrowed artery and not the underlying condition
arteries can narrow and new blockages can occur
Coronary stent prognosis (5)
- stents tend to damage the artery wall and increase risk of secondary obstruction
- 60% of all stented coronary stents require restenting
- PCI was no better at relieving angina symptoms than OMT
- appear to increase postoperative bleeding, MIs, and CVAs compared to no trx
- pts recieving stents go back to their bad habit afterwards
coronary artery stent implications for PT
- care with incision site/bleeding
- cardiac rehab candidate
describe a balloon angioplasty
- tiny balloon is deflated and guided through the artery to the blockage
- inflated to widen the opening and increase blood flow to the heart
- stent often placed during procedure
what is an atherectomy?
- catheter with sharp blade attached
- inserted into artery
- sharp blade removes plaque from a blood vessel
- used to treat blockages in arteries that are not easily treated with stents
- risk for an embolus from dislodged debris
Benefits of an atherectomy (6)
- minimally invasive procedure
- short recovery time
- small incision
- less pain
- less scaring
- reduced blood loss
list surgical treatments for cardiac diseases
- CABG
- off pump CABG
- Minimally invasive CABG
- Valve replacement/repair
- Cardiac Ablation
- Aortic Aneurysm Repair
- Intra-aortic balloon pump
what is a CABG?
Coronary Artery Bypass Graft
- is a surgical procedure used to restore normal blood flow to an obstructed coronary artery
List reasons for CABGs (3)
- to relieve angina unsatisfactorily controlled by max tolerated anti-ischemic meds
- prevent or relieve left ventricular dysfunction
- reduce the risk of death
list vascular donor sites for CABGs (3)
- saphenous vein
- internal mammary arteries
- radial artery
what is an off pump CABG?
- a CABG performed on a beating heart
- limited to 1-2 lesion bypasses
- decreased post op complications and recovery times
describe a minimally invasive CABG
- minithoracotomy or subxiphoid incision into the L chest cavity
- the internal mammary artery is mobilized from the L chest wall and is sewn to the artery in the front of the heart (LAD)
List some CABG complications (9)
- postperfusion syndrome (pumphead)
- cardiogenic shock
- nonunion of the sternum/infection
- acute renal failure due to embolism or hypoperfusion
- stroke
- pneumothorax
- hemothorax
- pericardial tamponade
- arrhythmias
what is cardiogenic shock?
heart cannot pump enough blood and oxygen to vital organs (impact MAP)
- MAP is too low to adequately perfuse the organs
- serious medical emergency → often follows an MI
- 50%
what is cardiac tamponade?
reduced cardiac function secondary to fluid accumulation in the pericardial cavity
restrictive cardiac disease
requires Beck’s Triad
list the components of Beck’s Triad
- hypotension
- muffled heart sounds
- bulging neck veins
what are some potential sternal wound complications?
What is a sternectomy?
What are pectoralis flaps?
- sternal dehiscence
- sternectomy → partial or torn debridement of sternum to remove infected bone
- pectoralis flaps → pectoralis muscle used to cover area where sternum removed
CABG Post-op complications
- LE
- edema
- extravasation → fluid leakage out of harvest site
- inflammation and ecchymosis
- Clotting
- Mortalitiy → rate ~2%
what types of things increase mortality risk in post-op CABG pts? (5)
- age > 70
- female
- low EF
- history of stroke, MI, or heart surgery
- DM or HTN
List sternal precautions
- no pushing or pulling
- no lifting more than 5 lbs
- no lifting one arm overhead
- can lift both at the same time
- no reaching behind your back
- encourage unilateral UE active ROM tolerated to facilitate functional mobility gains
- avoid full weight bearing through UE
- no driving and no sitting in passenger seat behind an airbag for 4 weeks
Sternal precautions PT implications
- log rolling for bed mobility
- avoid activities that may cause excessive Valsalva
- encourage chest splinting w/pillow when coughing
- avoid lifting, pushing, and pulling greater than 10 lbs for 3 months
what does “keep your move in the tube” mean?
another method of describing sternal precautions
CABG harvest site considerations
- incisions at the harvest site often present as impaired integumentary and contributes to incisional pain, infection, and edema
- protection incision sites
- WBAT for pts with LE or UE harvest sites
- no ROM restrictions given normal healing
- provide thigh-high compression garments to those with LE harvest site
- elevate involved extremity while seated and in bed
- AROM to prevent edema
- monitor for signs of infection
- rubor
- purulent discharge
- acute pain
what is a pericardial window?
what are restrictions/precautions?
surgical procedure performed on the sac around the heart
used to drain symptomatic pericardial effusions
usually small subxiphoid incisions
no restriction/precautions
list the types of valve surgeries (4)
- annloplasty
- valve repair
- valve replacement
- mechanical: metal or synthetic material
- tissue: pig or cow tissue
- transcatheter aortic valve replacement (TAVR)
describe an annuloplasty
- tightens or replaces the rim (annulus) of the mitral or tricuspid valve
- can get torn when valve prolapases
describe the pros/cons of a mechanical valve replacement
- high durable, can last a lifetime
- require lifelong anticoagulation to decrease risk for thromboembolism
describe the pros/cons of a tissue valve replacement
- durability is 10-20 years
- no lifelong anticoagulation required
describe a transcatheter aortic valve replacement
where are the 3 access points?
who is it used for?
what are the restrictions?
- Access
- transfemoral
- transapical → anterior thoractomy to get to apex of heart
- transaortic → upper hemisternotomy or R anterior thoracotomy to get to aorta
- minimall invasive
- useful for pts who are at high risk or who cannot undergo open heart surgery for AVR
- typically no restrictions, no sternal precautions
what are pacemakers?
a tool that creates artificail action potentials to maintain appropriate cardiac conduction/rhythm
where are pacemakers typically placed?
how many weeks for incision healing and firm adhesion?
- Usually inserted under the skin in the L infraclavicular pocket, with leads inserted into the R side of the heart via the L subclavian vein to the superior vena cava
- device leads are attached via passive (tined) or active (screw) fixation into the myocadium
- 4-6 weeks needed to allow incision healing and firm adhesion of pacemaker leads
general indications for pacemakers (3)
- SA node disorder
- AV node disorders
- Supraventriclar tachycardia
Pacemaker implications for PT
- keep the involved UE in a standing sling for 24 hours
- no theraeutic exercise to involved shoulders for 4-6 weeks
- involved UE may be used functionally but limit shoulder flexion and abduction to 90 for 4-6 weeks, then may use functionally as tolerated
- no lifting greater than 5 lbs with involved UE for 4-6 weeks
- no driving until after follow up visit with electrocardiologist
what is an ICD?
Implantable Cardioverter Defribillator
- small battery-powered electrical impulse generator capable of cardioversion, defibrillation and pacing of the heart
- is programmed to detect cardiac arrhytmia and correct it by delivering a jolt of electricity
- ICDs constantly monitor the rate and rhythm of the heart
- often permanent safeguards against sudden abnormalities
ICD implications for PT
- know that the patient has one
- almost all forms of physical activity can be performed by patients with an ICD
- no sports which might damage the device
- no excessive strain on the shoulder, arm or torso where the ICD is implanted
Exercises to avoid in ICD pts
ones that cause the clavicle to be pulled down towards the ribs
such as lifting weights with the arms, on the ICD site, while standing
what is cardiac ablation
used to treat conduction defects/heart rhythm problems
briefly describe the procedure for cardiac ablation
- catheter is inserted into a cardiac chamber
- electrodes at the tip of the catheter gather data, allowing the mapping of the heart
- data pinpoints the location of the faulty electrical site
- that site or those sites are then destroyed (cold/heat)
why is a rupture aneuysm bad?
it can lead to bleeding and subsequent hypovolemic shock, leading to death
it can also be a site for clot formation
describe abdominal aortic aneurysm repair
- open repair
- large abdominal incision in the abdomen to expose aorta
- endovascular aneurysm repair
- minmally invasive
- small groin incisions
what is an IABP?
Intra-Aortic Ballon Pump
- a mechanical device that increases coronary perfusion
- increased O2 availability to the heart
Indications for IABP
- failure to wean from cardiopulmonary bypass
- HF
- support during high-risk percutaneous transluminal coronary (balloon) angioplasty, rotoblator procedure, and coronary stent placement
- cardiogenic shock
- acute heart attack
- cardiogenic shock
- ventricular arrhythmias
- post cardiac surgery
describe the mechanism of action of an IABP
- the balloon deflates during ventricular systole
- the balloon inflates during ventricular diastole
- increases coronary artery perfusion pressure
- increases diastolic BP by 15-30% and increases SBP
IABP Implications for PT
- patients are typically hemodynamically unstable and inapproriate for therapeutic exercise programs
- protection of the catheters integrity most important
- movement and activity should be limited to avoid disruption of the catheter, balloon rupture, or incision site infection
- therapeutic exercise to the uninvolved extremitites
- avoid hip flexion >70 degrees on affected
- minimize extreme joint range of motion
what is a LVAD?
Left Ventricular Assist Device
- pump that we use for pts who have reached end-stage HF
- LVAD is battery-operated, mechanical pump
- helps the LV pump blood to the rest of the body
- may remain implanted for years
Indications for LVAD
- Bridge to transplantation
- Bridge to candidacy
- Destination therapy
- Bridge to recovery
LVAD: PT considerations
- often have multi-organ involvement
- devices prevent pts from increasing CO
- often also have RV dysfunction
- may have chronotropic incompetence
- may have impaired pulmonary function
- may have skeletal myopathy, endothelial dysfunction and anemia
- at rest the device provides most of the CO, whereas during exercise the contribution is variable
- these are complex pts with limited ability to respond to CV demands of exercise
