Cardiac Surgical Procedures Flashcards
Difference between Cardioversion and Defibrillation
-Both aim to restore normal sinus rhythm/heartbeat & use an EKG monitor.
-Cardioversion is a non-emergency procedure & delivered at a specific point during the cardiac cycle (w/ the R wave)
Defibrillation characteristics
-Emergency, for V-Fib/V-Tach, no CO
-200-360 joules
-Pt unconscious
Cardioversion characteristics
-Elective procedure
-50-200 joules
-Synchronized w/ QRS
-Requires consent
-Pt aware and frequently sedated throughout procedure
What is a percutaneous procedure and some diff types of cardiac surgeries?
-Any procedure where access to inner organs/tissue is done via a needle puncture of the skin rather than an “open” approach
-Percutaneous transluminal angioplasty (PTA) ballooning, stenting, filter delivery, cardiac ablation
What is a cardiac ablation?
-tx for Arrhythmias
-Uses ESTIM to locate abnormal electrical activity & tissue causing it. Uses heat or cold via a catheter inserted in the Femoral A to destroy abnormal tissue causing arrhythmia
Cardiac Ablation PT Implications
-Hemodynamic Stability
-Bleeding at site of catheter insertion
What is a ballon angioplasty
-balloon placed & inflated to widen lumen of vessel to incr. blood flow to the heart.
-Stent is often placed
What is a atherectomy?
-Tx blocked arteries that CANNOT be tx with stents
-Catheter w/ sharp blade inserted into the artery to remove plaque from vessel. Lasers may be used also
What is a Coronary A stent?
Small, expandable tubes used to open up narrowed arteries (femoral, coronary, carotid). Stents can be drug eluding (block cell production) or bare metal (w/out coating/covering)
Results/Pros to Coronary A stent?
-reduce S&S (chest pain)
-incr. blood flow
-keep vessels open to prevent further issues (MI)
-Less invasive & discomfort
Stent Cons
-Does not fix underlying cause
-Pts may be place on aspirin or other antiplatelet drugs
2nd and 3rd Gen Stents
Covering delivers drug (anti-coagulant to prevent clotting) then stent becomes bare metal. However bare metal stents can lead to scaring of artery, leading to re-stenosis.
Restenosis usually occurs within ____ of placement
12 months
Coronary A Stent Procedure
1) Peripheral access route (groin, upper arm, wrist)
2) stent collapsed & moved to blockage area via XR w/ dye
3) Pts experience brief angina for 30 mins-2 hrs (1 hr common) when balloon is used to expand stent
4) Pts are d/c the day after PCI
Coronary A Stent Complications
-Vessel not big enough for stent
-Bleeding if arterial wall is perforated
-CVA if plaque/blood dislodged by catheter
-Clot formation
-Scar tissue/plaque build up→ restenosis
-Requires lift time anti-coagulation therapy
-arrhythmias
-Kidney damage or allergy from dye
T/F: Restenosis occurs more frequently in pts with DM.
True (think about etiology of diabetic heart failure)
Coronary A Stent PT Implications
-care with incision
-Consider Cardiac Rehab
-watch for S&S of CVA (BEFAST)
T/F: Stents always work.
false
What is CABG (Coronary A Bypass Graft) & what is it used for?
Invasive, surgical procedure
-To restore blood flow to obstructed coronary artery
-Relieve angina not ctrled by max dose of anti-HTN meds
-Prevent/relieve LV dysfunction
-Reduce risk of death
-single/double/triple/quad: LAD, RCA, L circumflex A, Post descending A
usually pts have 2 grafts
CABG Procedure/method
1) Median Sternotomy
2) Heart stopped & heart/lung machine to circulate blood to body
3) Use vascular graft sites: Saphenous Vein, Internal Mammary As, Radial A
4) New Highways formed creating a bypass to get blood around clogged vessel
How long do CABGs usually last?
15 years, w/ repeat CABGs if pt had one done in 40s-50s
Off Pump CABG characteristics
-Performed w/out stopping heart (no need for a machine)
-Limited to 1-2 bypasses
-Pros: reduce risk of post-op complications: inflammation, infection, & arrhythmias, reduced recovery time
Minimally Invasive CABG procedures
-Thoraco or subxiphoid incision to L chest cavity
-Internal Mammary A is mobilized from L chest wall & sewn to LAD in front of heart
-No machine used
-Pros: minimal invasive & quicker recovery
CABG Complications
1) Postperfusion Syndrome (Pumphead): Transient neurocog impairment that includes reduced ability to follow commands, confusion, & communication difficulty
2) Cardiogenic Shock
3) Nonunion of sternum/infection (common)
4) Acute renal failure d/t embolism/hypoperfusion
5) CVA
6) Pneumothorax/collapsed lung
7) Hemothorax (blood b/w chest wall & lungs)
8) Pericardial tamponade
9) arrthymias
Cardiogenic Shock: what is it? meds for it? implications for PT?
-Heart can’t pump enough blood/O2 to vital organs
-Meds: NE (vasoconstrictor) & Dopamine (incr. cardiac contractility)
-PT Implications: monitor vitals and check w/ nursing before session
What is a Cardiac Tamponade?
MEDICAL EMERGENCY
-Reduced cardiac function d/t fluid accumulation in pericardial space reducing EDV/ventricular filling & decr. SV
Signs of Cardiac Tamponade
-Beck’s Triangle: Hypotension, Muffled heart sounds, Swollen/Bulging Neck Veins
-Dyspnea/tachypnea, tachycardia
Strict Sternal Precautions can help prevent sternal wound complications. What are some Sternal Wound Complications to look out for?
-Sternal dehiscence
-Sternectomy (removal of infected bone)
-Pectoralis Flaps (used to cover area of sternal removal)
-Donor Sites: rectus abdominus, lats, internal mammary A
Sternal Wound/CABG PT Implications
Less chest wall stability
-Aerobic exercise training (walking, stairs, recumbent stepper), balance, stretch/strength, gait, power/endurance
-Family edu
-Device/equipment use
-Infection ctrl
-Sternal Precautions & ROM restrictions
CABG Sternal Precautions
“Move Within the Tube” (including BILAT overhead reaching)
-AVOID for 12 Wks: unilat shld flex/abd >90 degr., full WB thru UE (PWB required for gait), pushing/pulling or lifting >5lbs, no driving or…
sitting behind airbag (4wks)
-Encourage UE AROM as tolerated for functional mobility
CABG Harvest Site PT Considerations
-Protect site, reducing infection/pain/edema
-WBAT, no ROM restrictions w/ norm healing
-Elevation, compression, & AROM of involved LE while seated & in bed
-Monitor for S&S of infection
Types of Valve surgeries
1) Annuloplasty: rim (annulus) on mitral or tricuspid valves
2) Valve Repair
3) Valve Replacement:
-Mechanical = highly durable, can last a lifetime, requires lifelong anti-coagulation
-Tissue/Biologic = human/pig/cow tissue, 10-20 yr durability, no lifelong anti-coagulation required more useful for elder/frail pts
Valve Replacement PT Implication
Refer to CABG PT implications, may involve median sternotomy
Transcatheter Aortic Valve Replacement (TAVR): What is it, what population is it useful for, & PT implications?
-Valve replacement via femoral A, transapical (L ant. thoracotomy to heart apex), & transaortic (upper hemisternotomy or R ant. thoracotomy to get to aorta)
-For pts who are high risk or cannot undergo open heart surgery for AVR
PT Implications: Minimally invasive, no restrictions/precautions, watch for complications (infection, kidney disease, CVA, etc)
Pacemakers (PPM): What is it and the procedures/method for it?
-Creates artificial AP to maintain proper cardiac rhythm/conduction. (Tx for SA/AV node disorder & arrhythmias)
-Inserted under skin in L infraclavicular pocket w/ leads inserted into R side of heart via L subclavian vein to superior vena cava. Device will be passive (tined) or active (screw) into myocaridium
PPM healing timeline
4-6 wks
PPM PT Implications
-Involved UE in sling for 24
-F/B 4-6 Wk Restrictions: no shld flex/abd >90 degr., no lifting >5lbs and…
no driving (cardiologist must approve)
Implantable Cardioverter Defibrillator (ICD): What is it and what’s it used for?
-Battery-powered & capable of cardioversion, defibrillation, & pacing of heart
-Detects arrhythmia and corrects it
-Permanent safeguards against sudden abnormalities
ICD PT Implications
-Know if pt has one (duh)
-No excessive strain on shld, arm, or torso where ICD is
-No sports
-Avoid exercises that cause clavicle depression on ICD site (i.e. lifting weight w/ involved UE while standing)
A ruptured aortic aneurysm can lead to…
bleeding f/b hypovolemic shock leading to death
Clinical Presentation of AA
-Can occur anywhere but usually abd aorta b/w renal A & aortic bifurcation
-Common in older males - Asymptomatic until they rupture, smoker, HTN, CAD
-S&S: non-mechanical LBP that doesn’t respond to tx, abd fullness/pulsation, palpable pulsatile mass, abdominal bruit (abnormal sound)
Surgical Repair of AA is indicated when the aorta is ____ in diameter.
> 4cm
Procedure for open surgery repair of AA.
-Tube placed inside AA and sutured into place, blood flows through graft
Procedure for Endovascular Stent-Graft Repair
Vessel is cut open at the thigh and graft is inserted & graft is threaded up to bulging area. Tube is NOT sewn into place, blood flows through graft.
Intraaortic Balloon Pump (IABP): What is it and Indications for use
-Device that incr. coronary perfusion/incr. O2 availability to heart
-Indications: HF, cardiogenic shock, acute MI, ventricular arrhythmias, post cardiac surgery, failure to wean from CP bypass, support during high-risk coronary PTA or stent placement
IABP Procedure
1) balloon mounted on catheter inserted into aorta through femoral A (or axillary A)
-Balloon Deflates during V systole
-Balloon Inflates during V diastole
2) Coronary A perfusion pressure, diastole BP, and SBP are all increased
3) Assists with increasing O2 rich blood output & CO
IABP PT Implications
Pts are hemodynamically unstable & inappropriate for TE
Protection of catheter’s integrity most important
-Avoid hip flex >70 degr. on involved LE
-TE to UNINOLVED extremities
-Limit extreme joint ROM
Left Ventricular Assist Device (LVAD): What is it and Indications for use
Pump that helps LV pump blood to rest of body, for pts with END-STAGE HF
1) Bridge to transplantation (main usage)
2) Bridge to candidacy: allows time for pt to become eligible for transplant
3) Destination Therapy: Pt’s final intervention for HF
4) Bridge to Recovery: temporary support for pt w/ acute HF
T/F: LVAD is temporary needs to be replaced annually.
False - may remain implanted for years
LVAD PT Considerations
-Pts typically very sick: multi-organ involved, RV dysfunction, impaired resp., skeletal myopathy, anemia
-Devices prevent incr. CO during exercise & may have chronotropic incompetence (EKG abnormality)
-Limited data supports exercise is good to pt
LVAD PT issues w/ mobility to be concerned about
-Sternal precautions
-Line displacement during mobility
-Prevent blood flow obstruction: caution w/ supine to sitting, sitting w/ poor posture, transition to standing
Pts are weak and debilitated, slow progressive, & most become NYHA HF class 1 or 2 w/in 6 months
T/F: PT may begin for pts 1 week post-LVAD.
False, PT may being post-op day 1
