Cardiac Surgery & Long-Term Ventricular Assist Devices

Question 1

VAD/BiVAD/RVAD - letter before VAD - which ventricle assist - Bi - for both
The ventricular assist device (VAD) is designed to support or replace a failing natural heart with flow assistance.
Used in patients who have advanced heart failure (getting worse with CHF: stage IV or LV damaged somehow - viral infection and low EF, huge MI and pumping ability of LV little), as a bridge to transplant, destination therapy, bridge to recovery
Not qualify for heart transplant - beyond age or had cancer - place this and end of road - higher quality of life for longer
Not expect get better soon
VADs - bridge to transplant
Waiting for health heart transplanted and may not make it - die before available
Keep healthy enough when heart is available
Diff products out there - may look diff - difference usually inside body; outside - see drive line coming out
Advanced Heart Failure
Bridge to Heart Transplant
Destination Therapy
Bridge to Recovery
Nursing management pts with VAD

Answer 1

Long-term ventricular assist devices

Question 2

Advanced heart failure patients may need an LVAD when medications and other treatments for heart failure become no longer effective. An LVAD can help manage or reduce a variety of heart failure symptoms, such as:
Shortness of breath
Fatigue
Limited exercise capacity
Leg swelling that gets worse over time
Kidney and/or liver malfunction
An LVAD may be necessary to address recurrent admissions to the hospital due to heart failure. Even a single admission to the hospital because of heart failure symptoms is associated with reduced longevity.

Answer 2

Advanced Heart Failure

Question 3

Waiting for a heart transplant may take anywhere from weeks, month, or even years. An LVAD implantation may be a good choice to address getting sicker while waiting for a new heart. If signs and symptoms indicate that a weakened heart is threatening the function of other vital organs, it may be time to discuss an LVAD with your doctor.

Answer 3

Bridge to Heart Transplant

Question 4

If a patient is not a candidate for heart transplantation due to age or other considerations, an LVAD implantation can prolong and improve their life. The risks and benefits of having an LVAD will be carefully discussed with your doctor and the decision to proceed is considered based on personal history and preferences.

Answer 4

Destination Therapy

Question 5

An LVAD is sometimes used when a patient’s heart is expected to recover its function, but cannot do so safely with medications alone. Some of these scenarios include heart failure resulting from complications of cardiac surgery, inflammatory conditions of the heart that are expected to get better, or, sometimes, heart failure after having a baby.
Our team places a strong emphasis on giving every patient an opportunity to recover their heart function. We have developed a state-of-the-art protocol that is designed to give our patients the best chance of recovery.
A minority of patients are able to recover their heart function to the point where the LVAD is no longer necessary and can be removed. When that occurs, testing is performed to ensure the LVAD can be removed safely.

Answer 5

Bridge to Recovery

Question 6

Nurse Monitor for hemodynamic changes related to the device -
Anticoagulation
Assess for complications r/t the device
Emergency care/Resuscitation of Patients Who Arrest After Cardiac Surgery

Answer 6

Nursing management pts with VAD

Question 7

PA Catheters not required because VAD display shows pump flow (indicator CO); PA catheter not give more information - may have sig pulm HTN or high risk for RV failing and PA catheter give additional info on right side of heart
Done with assessment and info from LVAD
Preload
Afterload
Maintain mean arterial blood pressure <100

Answer 7

Nurse Monitor for hemodynamic changes related to the device -

Question 8

All about volume
Device: RV primary means of LVAD filling - maintain RV func
Ensure this or volume going to RV so get to LV and LVAD to be pumped out
Contribute to BP
Maintaining euvolemia
Hypovolemia - treated aggressively

Answer 8

Preload

Question 9

Care taken to manage the afterload
Measured with SVR - directly impedes LVAD flow
Increase afterload - decrease output of LVAD - need make sure is not too constricted or dilated - vascular tone in sys; increases how aortic valves open and closes
Contribute to BP

Answer 9

Afterload

Question 10

Follow protocol on where keep
BP hard get
No palpable pulse
Doppler mean BP
Not doppler systolic and diastolic

Answer 10

Maintain mean arterial blood pressure <100

Question 11

Upmost importance
Not make out of biologic tissue and body’s response is to fight = sending cells to get rid of it - not happen: get fibrin coating and components of VAD - blood clots and pump running - alarms of low flow (outlet smaller because coated with blood or fibrin sheath) - blood dislodged (ischemic event)
Very imp - Follow protocol for antiplatelet and anticoagulation administration

Answer 11

Anticoagulation

Question 12

Bleeding - big tube and big pieces equipment in arterial vasculature - on anticoags and antiplatelet therapy; either from VAD or GI bleed
Infection - tube going in body; lines treated like central line - sterile technique during dressing change; assess for s&s of infection - gooey discharge, red around insertion site, high temp
Thromboembolism, stroke - blood dislodged and moving here
Respiratory failure - cardiac event and respiratory follows if not take care of cardiac
Arrhythmias - managing can be hard; most pts already have implanted defibrillator (pacemaker with ICD) - reprogrammed before VAD put in; external defibrillator pads in place for first couple day just in case; kept in NSR when possible; may impair unassisted ventricle (LVAD - impair RV) and decrease flow to VAD
Device failure - pump failure very rare - usually have this and easily fixed; most likely obstruction of inlet or outflow cannula: thrombus (harder fix), kinked cannula - figure out what alarm for; suction event

Answer 12

Assess for complications r/t the device

Question 13

Did sternotomy approach
Do NOT initiate chest compressions. - chest will not handle it; sternum cut in half and wires holding it together not secure - can break easily if sternum not healed - can cause more harm
There are special guidelines for the resuscitation of patients who have cardiac arrest after cardiac surgery
VF or pulseless VT
Asystole or extreme bradycardia (30s)
Pulseless electrical activity
Although there are several special caveats with this patient population, the importance of early emergency resternotomy (within 5 minutes) is a major focus of the recommendations.
Know what unit does and policy in case of code blue with this population
Cardioversion and defibrillation should be performed for the same indications as other patients - follow ACLS protocols
Still need care even tho LVAD
LVAD assist device - not fully mechanical heart - heart has to be doing something and if into cardiac arrest
Do NOT do chest compressions - Compressions risk cannula dislodgement, which may result in life-threatening hemorrhage - pushing on sternum - risk cannula to be dislodged from ventricle: life-threatening hemorrhage
All VADs do not do anything for electrical of the heart; only mechanical - can shock them; cannot do chest compressions

Answer 13

Emergency care/Resuscitation of Patients Who Arrest After Cardiac Surgery

Question 14

Three sequential attempts at defibrillation before external cardiac massage
Start with defib to get out
Need do chest compressions - not option - do external cardiac massage - get into chest externally and massage the heart with the hand

Answer 14

VF or pulseless VT

Question 15

Attempt to pace if wires are available before external cardiac massage
Hook up to pacer box because should have pacing wires
If not crack chest and do cardiac massage

Answer 15

Asystole or extreme bradycardia (30s)

Question 16

Any rhythm but no pulse - go through all Hs and Ts and reverse ASAP
If K, treat
Pain control, sensitive to narcotics reverse
Quickly assess for and treat reversible
If treatable cause not identified - emergency resternotomy. - crack it open and do sternotomy again and massage the heart

Answer 16

Pulseless electrical activity

Question 17

Coronary artery bypass graft surgery
Valvular surgery

Answer 17

Cardiac surgery

Question 18

Coronary arteries are surgically revascularized.
Done by cardiothoracic surgeon
Cut sternum - access heart
Minimally invasive - thoractomy approproach
Heart access: vein or artery harvest (most common saphenous vein in leg)
A saphenous vein, radial artery, or internal mammary artery (bypass left anterior descending artery - no posterior arteries) are commonly used to bypass a blockage in a coronary artery
Can have lot lot bypasses
Aka CAB

Answer 18

Coronary artery bypass graft surgery

Question 19

Any of 4 valves can be replaced: usually stenotic - higher pressure to open; or regurgent - something happening with leafs - something wrong where not closing - may have had papillary muscle rupture and leaflets remaining open and age not close all way
Some point pathological - get HF from incompetent valves
Mechanical Valves
Tissue valves
Went from 100% surgical and now to cardiac cath lab
Starr-Edwards ball and cage valve - no longer used; incident of getting clots during them and huge strokes very high; not on market
Went from mechanical, to bioprostethic - combo of biological and mechanical, then to transcather (end percutaneous insertion) - nice option who not survive open heart surgery
Surgical aortic valve replacement
Transcatheter aortic valve replacement

Answer 19

Valvular surgery

Question 20

Nonbiologic tissue
Durable
Ideal for younger patients - have a valve for a long time
Downside: pt on anticoagulation for rest of life - foreign object in body and blood sticks to it and blood clots become thromboembolism - high risk for stroke/embolic event
Not in someone who has hx GI bleed, horrendously noncompliant with medication regimens - not compliant with anticoag - risk for deadly embolus
Made from combinations of metal alloys, pyrolytic carbon, Dacron, and Teflon and have rigid occluding devices
Require anticoagulation to reduce the incidence of thromboembolism
Durable
Ideal for younger patients

Answer 20

Mechanical Valves

Question 21

Flexible
Not as durable
Tend to calcify like normal valve
Big benefits: no anticoagulation - body not seen as foreign object: normal tissue
More for older patients - going to have valve not very long where get calcified; cannot take warfarin because of hx
Constructed from animal or human cardiac tissue and have flexible occluding mechanisms.
Anticoagulation NOT required
Not as durable – tend to calcify

Answer 21

Tissue valves

Question 22

Established 1952
Gold standard
Requires open-heart surgery
For mechanical and bioprosthetic valves

Answer 22

Surgical aortic valve replacement

Question 23

Established in 2002
Minimally invasive
Fast recovery
For bioprosthetic valves

Answer 23

Transcatheter aortic valve replacement

Question 24

Postoperative management
Mechanical Complications
Temperature regulation
Control Bleeding
Chest tube
Cardiac tamponade
Pulmonary care
Neuro complications
Infection
Acute Kidney Injury

Answer 24

Cardiac surgery - postoperative management

Question 25

Same if CAB or valve repair - post open heart surgery
Primary focus - maintaining CO - support func so have adequate end-organ perfusion
Cardiovascular support: Support cardiac function and low-output state; look at:

Answer 25

Postoperative management

Question 26

Heart rate - come out with epicardial pacemaker wires to where if HR below 60 - this kick in so normal HR; not all bradycardic; if tachycardic - IV beta blockers: esmalol or Ca Channel blocker - diltazem
Preload - all about volume; most common cause low: bleeding, fluid shifts, vascular dilation - systemic inflammatory response from surgery; volume resuscitation may be necessary postop; surgeons or intensivists start with crystalloid: NS or LR; cont have low and giving crystalloids - move to colloids: head of starch or albumin - given to pull extravascular fluid into vasculature; fail: blood products; bleeding badly: blood products
Afterload - cold and vasoconstricted (BP up) - nitroprusside or nitroglycerin - to open them up; as warms up arteries less constricted - BP drops - take vasodilators off - watch BP and afterload; hope settles down in normal range; if keep dilating: start vasoconstrictors - norepi or vasopressin - when giving these esp if CABG is artery itself as artery can constrict
Contractility - how heart muscle itself is contracting to get LV beat; CO low - + inotrope: dopamine or Dobutamine or epi drip or norepi; may require short-term mechanical circ support - new valve and to cath lab for impella device or intraaortic balloon until LV recovered - takes awhile for it to recover after being messed with

Answer 26

Cardiovascular support: Support cardiac function and low-output state; look at:

Question 27

Cardiac tamponade (presents self: muffled heart tones, hypotension, pulseless paradoxis), hematomas (surgical site or positioned on table weird), vasospasm of a coronary artery graft (present self as MI: ST elevation), prosthetic valve paravalvular regurgitation, and systolic anterior motion of the mitral valve.

Answer 27

Cardiac: - Mechanical Complications

Question 28

Pneumothorax, hemothorax, and endotracheal tube malposition - out surgery intubated - can be pulled out or pushed in
In thorax and spreading rib cage - can get blood in space

Answer 28

Noncardiac: - Mechanical Complications

Question 29

Prevent hypothermia - depressed myocardium, vasoconstriction, ventricular dysrhythmias
Warms quickly: are amplified: depressed myocardium, vasoconstriction, ventricular dysrhythmias
Regulate temp - maintain CO
Rewarm slowly after surgery
Do as safe as possible
Hypothermia can cause depressed myocardial contractility, vasoconstriction, and ventricular dysrhythmias

Answer 29

Temperature regulation

Question 30

Assess how much bleeding; how dressing looks like; see where blood is
Assess color, quality, consistency of drainage from tubes
Assess mediastinal tube drainage - tubes: chest tube by the heart; inserted below sternum and in pericardial space; drain blood and fluid around heart
Maintain: SBP 90 – 100 mm Hg - cannot tolerate higher BP - affect anastomosis site - bleeding occur because tension and stretches it
Medications used to treat/control post-op bleeding
Aminocaproic acid (Amicar)
Desmopressin acetate (DDAVP)

Answer 30

Control Bleeding

Question 31

Maintain patency - not knock collection chamber over
Assess drainage color, consistency, and amount

Answer 31

Chest tube

Question 32

Assess for this
Blood accumulates in the mediastinal space
Assessment: ↓cardiac output, ↓ blood pressure, jugular venous distention, pulsus paradoxus, muffled heart sounds, sudden cessation of chest tube drainage
Life threatening
Interventions
Not do pericardial centesis - surgeon does Emergency sternotomy (open sternum) in the critical care unit
Return to the operating room for surgical evacuation of the clot - Fresh blood and blood coagulated; need do clot evac out of pericardial space

Answer 32

Cardiac tamponade

Question 33

Mechanical ventilation
Focus on getting off ventilator ASAP
Dangling on side of bed at 4 hours then extubated with 6 hours
Early extubating once the patient is hemodynamic stable, bleeding is controlled, normothermia, and can follow commands
Hemodynamically stable: no bleeding, temp, follow commands - do extubate
Supplemental oxygen after extubation
Early ambulation: 1st dangle on the side of bed, then up to a chair, then walk around the unit.
Prevent pulm complications: atelectasis: pneumonia
Teach pt about sternal precautions when changing position: brace with pillow, Heart hugger sternum support device - devices purpose: patient’s arms are up and sternum support until heals; not pushing: pressure on upper chest and those wires break and heart falling out chest cavity

Answer 33

Pulmonary care

Question 34

Heart not pumping no end organ perfusion
Brain not like low CO and low flow - assess them and do baseline assessment before surgery
Decreased cerebral perfusion or microemboli or hypoxia from pump - not used to having lower BP; having high BP for long time
Caused by: Decreased cerebral perfusion, cerebral microemboli, hypoxia, and the systemic inflammatory response.
Neuro assessment before (baseline) and after - chart trends

Answer 34

Neuro complications

Question 35

Ensure Sternal wound - dressing changes appropriately, clean wound, look for signs of redness or abnormal discharge; sternal wound then heart - bacteria go to inside heart - Infective endocarditis and valve repair: valve has vegetation on it
Graft harvest site (leg or arm) - open wounds
Hospital-acquired infections - pressure ulcers, DVT, pneumonia - assess and prevent

Answer 35

Infection

Question 36

Diuresis given for fluid retention - giving lots loop diuretics
Monitor urine output and serum creatinine levels

Answer 36

Acute Kidney Injury

Question 37

Mechanical valve - pt younger and no issue with anticoag therapy
Look at age
If any contraindications for anticoag therapy

Answer 37

The nurse is caring for a 35 year old who had a valve replacement due to a congenital valve disorder.
Which kind of valve would the patient be a candidate for?

Question 38

Yes
Hemodynamically stable
Bleeding under control

Answer 38

The nurse is assessing the patient for readiness to extubate. The patient is awake and follows commands. Vital signs: BP 105/74, HR 81, RR 18, temp 98.7, SpO2 98. The sternal dressing is dry and intact. Mediastinal drainage 20 ml over the last hour.
Is this patient ready to extubate?

Question 39

Postpone extubation - not longer meet criteria - uncontrolled bleeding
Notify surgeon - assess pt
Sudden output - position change or active bleeding: for surgeon to decide

Answer 39

Orders are received to extubate. The nurse raises the head of the bed, suctions the patient (subglottal (above balloon ET tube to not cause suction) and close system (bronchial tree) - best chance of extubating and staying extubated), and tells the patient what is going to happen. Before respiratory therapy gets to the room, the nurse notices a sudden output of 60 mls of bloody drainage in the mediastinal tube.
Take couple breaths to feel like not struggling during extubation
What should the nurse do next?

Question 40

Bleeding: amicor or DDAVP
Bleeding: blood products and crystalloids for volume

Answer 40

What medication should the nurse anticipate giving?