CV Surgical Procedures Flashcards
CABG - uses
emergent vs. urgent vs. elective
coronary artery bypass graft
used to reperfuse coronary arteries once occluded
emergent: MI/CVA using cardiac catheter w/ or w/o a stent for scaffolding
urgent: symptoms/testing determine there is a blockage eg angina
elective: blockage found on stress test/imaging but asymptomatic, surgery for prevention of MI
CABG indications
50% L main coronary a. stenosis
70% stenosis proximal LAD and proximal circumflex aa.
3 vessel disease in stable angina
3 vessel disease w proximal LAD stenosis and poor L ventricular function
1-2 vessel disease w large area at risk for stable angina pt
70% proximal LAD stenosis w EF below 50% or demonstrate ischemia
disabling angina
ischemia with nSTEMI not responding to medicine
poor LV fx with viable myocardium that can be saved
factors contributing to decision to perform CABG
tortuosity of arteries/location/type
inability to perform PTCA/catheter to resolve symptoms
pts with advanced kidney disease making PTCA contrast dye dangerous
pro/cons of CABG vs PTCA
long term outcome: CABG better, esp high risk pts, than PTCA or medicine
expense: PTCA cheaper initially
risk: CABG has lower CVA/MI risk but has higher morbidity due to surgical risks, lower long term mortality
CABG approaches
sternotomy: midline sternum to attach 1-4x bypass
ant. thoracotomy: cut into chest from anterior through ribs to access LAD
lat thoracotomy: cut into chest from side to access smaller vessels
minimally invasive/robotic
MSK implications of CABG approach
pt is in awkward shoulder position for prolonged time, overstretching some muscles likely causing soreness post op
off vs on pump
off pump is heart beating during the surgery and pt is not on bypass
on pump: heart is stopped and but on bypass to give surgeon more time
disadvantages of ONCAB
post operative cognitive decline, which is often short lived but delays discharge
disadvantages of OFCAB
specially trained surgeon
clots could form
arrhythmias
loss of perfusion -> kidney issues
higher mortality
common harvest sites for grafts
saphenous vein
left internal thoracic artery
radial artery
arteries are better than veins bc they are less likely to reocclude
surgical complications of thoracic surgery
15-20%
infection of site
pain
blood loss
pulmonary complications: atelectasis, pneumothorax, PE, pneumonia, failure, endotracheal tube complication, fluid overload
cardiac complications: decreased CO, arrhythmia, bleeding, ischemia/MI/stroke/DVT
indications for valve repairs/replacements
stenotic valve
incompetent valve
rated scale mild 1+ to 4+
repair higher survival rate than replacement
types of valve repairs and replacements
surgical: mod-severe, replace valve ring, total repair
mechanical: replacement w mechanism for younger patients
biotissue: transplant from animal or human
TAVR
transcatheter aortic valve replacement
post CABG medications
anti platelet - clots
beta blockers - slow HR, BP, O2 demand, reduce angina
nitrates
ACE inhibitors
lipid lowering
pain meds
sternal precautions
no consensus
keep arms below 90, lifting <5-10 lbs, no UE WB, no unilateral reaching
main concern is to avoid sternal dehiscence, instability, and infection
incidence and mortality of sternal complications
.04%-8% incidence
47% mortality
risk factors of sternal wound complications
primary:
BMI, COPD, BL mammary aa. grafts, DM, disability, smoking, prolonged surgery/ventilation, PVD, large breasts
secondary: osteoporosis
ICU stay, antibiotics, staples, renal fx, emergency surgery, ACE inhibitors, shock, etc etc
sternal instability scale
used to assess for sternal dehiscense, gently palpate during limb movements
0-3
0 clinically stable
1 minimal separation
2 partially separated
3 completely separated
ACSM guidelines for mvmt with sternal precautions
ROM within limits
lifting 1-3 lbs
limit motion by pulling on incision feeling or mild pain
Abdominal Aortic Aneurysm
dilation of abdominal aorta 50% larger due to weakened vessel wall
often asymptomatic, extremely high mortality when burst
palpable pulsatile mass often found incidentally on other imaging
most commonly btwn aortic bifurcation/renal arteries
risk factors for AAA
smoking
male
older
caucasian
atherosclerosis
family hx
other arterial aneurysms
PMH
aortic surgery
Are AAA symptomatic? How prevalant? mortality?
5-22% symptomatic when non-ruptured
80% mortality once ruptured
AAA symptoms
pain - back, flank, pelvis, groin, thigh
general malaise
AAA treatment
aneurysmectomy, endovascular repair
indications for a heart transplant
end stage heart disease/compromise
uncompensated HF not responding to any treatment med/surg
poor QoL
intractable angina, arrhythmias
absolute contraindications of heart transplant
malignancy
substance abuse
HIV+other infections
multi system disease active
irreversible renal/liver fx
severe COPD
fixed pulmonary HTN
cerebrovascular disease
Hepatitis
Relative contraindications to heart transplant
age 70+
active infections
peptic ulcer
severe DM
severe PVD
symptomatic carotid stenosis
uncorrected AAA
BMI 35+
pulmonary dysfunction
severe HTN
dementia
heterotopic heart transplantation
piggyback
native heart remains, donor connected to R/L atria
total heart transplantation
excise recipient atria for atrioventricular transplantation
biatrial technique of heart transplant
biatrial anastomoses where donor and recipient atrial cuffs sewn together
recipient SA node intact and donor heart SA node denervated
shows 2 p waves
PT considerations for heart transplantation
infection
aerobic endurance: pts feel good but have been deconditioned due to heart disease, hold back!
vitals/BP
denervated heart blunts HR, SV
requires prolonged warm up and cool down
RPE monitoring
monitor for s/s of rejection
Aspects of PT eval Heart transplantation
appearance of site, skin, edema, breathing, posture
MSK: thoracic mobility, transfers, core strength, balance
ADLs: fx, endurance, sts
frailty scale
s/s of heart transplantation rejection
low grade fever
myalgia
fatigue
hypetension rest, hypertension activity
decreased exercise tolerance
dyspnea
arrhythmia
fluid retention/weight gain
decreased urine output
pt capabilities after heart transplant for PT
aerobic power 1 year post op is 40-50% age norms
30-40% lower peak exercise
immunosuppressants affect MSK
PT priorities after cardiac surgery
pulmonary hygiene
vitals/manage activity tolerance
cognitive management
wound management
mobility
discharge planning
