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*CLINICAL EXERCISE PHYSIOLOGY > EXAM2/CH15- Revascularization of the Heart > Flashcards

EXAM2/CH15- Revascularization of the Heart Flashcards

1
Q

clinical procedures (for revascularization of the heart) may be elected for what 3 reasons

A

-restore myocardial blood flow
-symptom relief
-improved morbidity + mortality

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2
Q

4 common procedure types for revascularization of the heart

A

-angiography
-percutaneous transluminal coronary angioplasty (PTCA)
-stent therapy
-coronary artery bypass surgery (CABG)

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3
Q

angiography

A

IMAGING technique

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4
Q

what procedure is PTCA usually paired with

A

stent therapy

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5
Q

what is the most invasive procedure for revascularization of the heart

A

CABG

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6
Q

how does a coronary angiography work

A

catheter is inserted in leg + guided up to the aorta ->
catheter tip stops at left coronary artery ->
contrast agent is injected into arteries + x-ray imaging shows stenosis in left coronary artery

-dye shows plaque buildup occurring in the vessels

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7
Q

is coronary angiography an interventional procedure

A

NO, imaging
-it is done so the surgeon knows where they must intervene

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8
Q

what is often the first line of intervention

A

PTCA

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9
Q

what is PTCA also known as

A

heart catheterization

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10
Q

where does cath go through in PTCA

A

-radial artery in arm
-femoral artery in leg

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11
Q

-plasty means

A

to redistribute

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12
Q

percutaneous transluminal coronary angioplasty (PTCA)

A

-insertion of catheter to site of coronary lesion
-compression, redistribution, or removal of plaque

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13
Q

various techniques of PTCA (3)

A

-balloon angioplasty
-atherectomy
-laser angioplasty

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14
Q

PTCA techniques

balloon angioplasty

A

balloon catheter inflated to stretch vessel + increase diameter
-as the balloon inflates, it pushes the plaque to the size of the vessel wall; opens up lumen to revascularize

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15
Q

-ectomy means

A

removal/cutting out

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16
Q

PTCA techniques

atherectomy

A

plaque removal using blade catheter
-catheter has a blade tip but also has a vacuum tip to capture the plaque being dislodged
-in this technique, we are CUTTING AWAY + actually removing the blood from the vessel

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17
Q

is atherectomy common

A

not as common
-because higher risk of something going wrong

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18
Q

PTCA techniques

laser angioplasty

A

beam used to vaporize plaque into water + gas
-emits beam to remove plaque by turning it into a vapor

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19
Q

is laser angioplasty common

A

not as common
-because ability to target a very small area with a laser is very hard

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20
Q

after a PTCA procedure (balloon angioplasty, atherectomy, laser angioplasty), what do they do

A

put a bandaid over incision site
-typically outpatient so patient is in + out in 1 day
-femoral artery causes patient to be sore in groin area

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21
Q

PTCA indications

A

1-2 vessel involvement
EF ~ 55%

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22
Q

PTCA success

A

~85-90%

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23
Q

who would we suggest a PTCA for

A

individuals that don’t have incredibly advanced plaque, but rather maybe only 1 area
-their heart must be relatively healthy, which we determine via ejection fraction (EF around 55%)

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24
Q

why do we use EF as an indication for PTCA

A

because if they have a bad EF, using a stent won’t make a drastic difference

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25
Q

stent therapy- revascularization

A

reduces acute closure + restenosis of coronary arteries after PTCA

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26
Q

stent therapy- old method

A

bare metal stents + dual antiplatelet meds

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27
Q

stent therapy- new method

A

steel mesh- drug eluting stent + improved antiplatelet meds
-coated in antiplatelet medication that directly targets the plaque buildup from the stent itself

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28
Q

what did the new method of stent therapy do

A

provided improvements in endothelial hyperplasia

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29
Q

endothelial hyperplasia

A

scarring around stent leading to partial or full restenosis
-buildup of scar tissue within the endothelium
-further contributes to the narrowing of the vessel but nowhere near degree of plaque buildup
-still something we need to address

30
Q

are stents a permanent fix

A

NO
-for most individuals they will work for around 2-3 years if they are adhering to medications + other instructions
-eventually the plaque will build up again + the stent will lose its effectiveness + we must go back in + remove the stent
-when you remove a stent, we INCREASE endothelial hyperplasia again

31
Q

what happens when you remove a stent

A

increases endothelial hyperplasia

32
Q

2 types of stents

A

-mesh/latticed
-coiled

33
Q

the future of stent therapy

A

-stents from biodegradable polymer resins
-will reduce the threat of endothelial hyperplasia + also late stent thrombosis

-biodegradable stents would get rid of one of the aspects leading to endothelial hyperplasia since we wouldn’t have to go back in + remove it
-billions have been spent to try + create this but no luck yet
-CURRENTLY no biodegradable stents in the market

34
Q

coronary artery bypass surgery (CABG)- revascularization

A

-uses venous graft from an arm or leg or an aterial graft
-creates bypass around damaged vessel

35
Q

who is involved in a CABG

A

typically 1 cardiothoracic surgeon + another surgeon working somewhere else in the body to extract a vessel (aka graft)

36
Q

where are vessels typically taken from in a CABG

A

-arm, leg, or mammary vessel
-we can use EITHER veins or arteriers

37
Q

which vessels are BEST for a CABG

A

mammary vessels
-most resistant to atherosclerosis

38
Q

CABG is reserved for which patients (4)

A

-unsuccessful PTCA
-patients who are no longer candidates for angioplasty but still have target vessels offering preservation of left ventricular systolic function
-multivessel disease no amenable to angioplasty or stenting
-technically difficult vessel lesions (ex: on the curve of a vessel or in a distal location not readily amenable to angioplasty or stenting)

39
Q

what % of PTCAs are unsuccessful

A

10-15%

40
Q

sternotomy

A

cutting down the middle of the sternum

41
Q

benefit of sternotomy

A

provides full access to heart

42
Q

right anterior thoracotomy

A

access to heart through one of the ribs

43
Q

mini-sternotomy

A

only cutting top/bottom half of the sternum to gain access to the heart

44
Q

when would a right anterior thoracotomy or mini-sternotomy be used

A

only if the surgeon is confident exactly where it is, how advanced, etc.
-most cardiothoracic surgeons will go with the full sternotomy in the case of if the condition was more advanced than they thought, it is better to have access to everything

45
Q

protocol for CABG

A

-patient is given general anesthesia; ensures they will be asleep + pain free through the entire surgery
-surgeon makes 8-10 inch cut in the chest
-surgeon cuts through all or part of the patient’s breastbone to expose the heart
-once the heart is visible, the patient may be connected to a heart-lung bypass machine; the machine moves blood away from the heart so that the surgeon can operate; some newer procedures do not use this machine
-surgeon uses a healthy vein or artery to make a new path around the blocked artery
-surgeon closes breastbone with wire, leaving the wire inside the body; over time, the sternum will fuse back together
-the original cut is stitched up

46
Q

how many surgeons working concurrently during CABG

A

2

47
Q

is the heart stopped during CABG

A

yes- necessary because it will be hard for surgeon to work on the heart while it is actively beating
-they will shock the heart to make it stop + hook patient up to a heart-lung bypass to keep them alive while the heart is not actively beating
-this is how an individual can be in surgery for a long time without the rest of their tissue becoming necrotic

48
Q

what securements are used in CABG to attach the vessel

A

staples + stitches
-these securements will become more permanent as these tissues fuse together

49
Q

success rate of a revascularization procedure is predicted by which 3 things

A

-age
-other existing comorbidities
-severity + location of the lesion

50
Q

as age increases, what does this mean for recovery

A

decreased chance at good recovery

51
Q

how does severity + location of the lesion affect success rate

A

the bypass might not work due to increased severity

52
Q

does everyone that needs a bypass get one

A

no
-due to risk factors + how invasive the procedure is

53
Q

restenosis

A

reduction in the diameter of the vessel lumen after angioplasty

54
Q

what is the #1 concern after bypass surgery

A

restenosis
(aka continued narrowing of the vessel)

55
Q

how long do stents last

A

2-3 years
-because the antiplatelet drug wears off

56
Q

predictors of restenosis after PTCA

A

-degree of residual stenosis after PTCA
-diameter of the parent vessel
-number of diseased vessels
-degree of reduction of the stenosis
-presence or type of coronary dissection
-presence of documented variant angina
-presence of comorbid disease (ex: diabetes, hyperlipidemia)
-optimal medical therapy + adherence

57
Q

predictors of restenosis after stent

A

-lesion eccentricity
-diameter of the parent vessel
-type of vessel stented (artery vs. vein)
-location of stent in vessel
-presence of multiple stents
-recurrence of unstable angina
-presence of comorbid disease (ex: diabetes, hyperlipidemia)
-optimal medical therapy + adherence

58
Q

lesion eccentricity definition

A

greater expansiveness of the lesion
-it goes further into depths of the vessel wall or farther length

LESION ECCENTRICITY IS A PREDICTOR OF RESTENOSIS IN STENTS

59
Q

exercise prescription after these procedures

A

-mobilization in hospital ASAP
-cardiac rehab begins ASAP
-educational focus on medications, home activities, + follow-up appointments

60
Q

after hospital discharge, what 3 things should exercise focus on

A

-improved cardiac performance at rest + during exercise
-improved exercise capacity (aerobic + strength)
-improved angina-free exercise tolerance, much of which is attributable to peripheral muscular adaptations

61
Q

after hospital discharge, which type of exercise is the main focus

A

aerobic exercise

62
Q

what is the primary concern after a PTCA

A

restenosis

63
Q

ExRx special considerations after a PTCA

A

-assess for signs/symptoms indicative of angina
-initiate outpatient program as soon as they are discharged from the hospital or outpatient surgery facility

64
Q

is cardiac rehab only prescribed for individuals that had surgery

A

no
-also for patients at risk of MI

65
Q

ExRx special considerations after a CABG

A

-incisional healing
-sternal stability if open heart CABG
-soreness/stiffness in chest/back
-hypovolemia
-low hemoglobin concentrations

66
Q

special considerations after a CABG- hypovolemia

A

blood volume loss post-surgery
(causes decreased cardiac output)

67
Q

ExRx special considerations after a CABG- can exercise directly impact sternum

A

NO exercise should have direct impact on the sternum for these patients

68
Q

ExRx special considerations after a CABG- everytime you breathe in…

A

puts pressure on your chest + causes pain

69
Q

ExRx special considerations after a CABG- good movements to implement

A

shoulder circles/shoulders back to stretch the pec muscles

70
Q

why do cardiac patients hunch over

A

because good posture pulls on chest muscles

71
Q

hypovolemia leads to

A

-fatigue
-lightheadedness

72
Q

special considerations after a CABG- low hemoglobin concentrations

A

caused from blood loss during surgery

*CLINICAL EXERCISE PHYSIOLOGY (18 decks)

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