Lecture 16: Cardiac and Surgical Conditions Flashcards
As a PT, what do you need to be considerate of when dealing with a patient with a pacemaker?
You must be monitoring BP and S&Ss to ensure the pacemaker is adapting to exercise
What is a risk of having a pacemaker?
They can fail
How can you tell if a pacemaker has failed?
If the patient’s heart rate is <40 bpm
What 5-6 structures does the RCA (right coronary artery) supply?
- Right ventricle
- Right atria
- Inferior wall of Left ventricle
- Bundle branches
- AV node
- (If right dominant) SA node
What does “Right dominant” heart mean and what is its prevalence?
The RCA (right coronary artery) supplies both the AV and SA node. Occurs in 55-75% of the population
What does “Left dominant” heart mean and what is its prevalence?
The LCA (Left coronary artery) supplies the SA node instead of the RCA. Occurs in 24-45% of the population.
What does the LAD (Left anterior descending artery) supply?
The anterior wall of the left ventricle
What is known as “The widow maker”?
Occlusion of the LAD (left anterior descending artery) which will lead to death.
What 2-4 structures does the LCX (Left circumflex artery) supply? (Include prevalence)
- Left atria
- Posterior and lateral walls of the left ventricle
- SA node (45% of population)
- AV node (10% of population)
What is a CABG?
Coronary artery bipass graph: It is a graph of a vein or artery used to go around an occluded artery or vein.
What is an indication for having a CABG?
Medication is inadequate to treat the problem
What 5 vessels are typically used for a CABG?
- Saphenous vein
- Left internal mammary artery (LIMA)
- Brachial artery
- Radial artery
- Gastric artery
What 3 pieces of equipment may be hooked up to a patient who has undergone a median sternotomy?
- Mediastinal tubes
- External temporary pacing wires
- Intra-aortic balloon pump
When are temporary pacing wires usually removed?
Within 2 days of a median sternotomy
What does an intra-aortic balloon pump do?
Assists the left ventricle
What do we need to be cautious about with patients who have temporary pacing wires.
We cannot work with patients who have had temporary pacing wires removed in the past 4 hours.
What are the 6 sternal precautions after a median sternotomy?
- Do not push or pull for mobility
- Do not push or lift > 5-10 lbs for 6-8 weeks
- Do not hyperextend your shoulder
- No trunk rotation for several weeks
- No driving for several weeks
- No unilateral shoulder flexion >90 degrees
What is a PT consideration of patients with an intra-aortic balloon pump?
Do not flex the hip! It is inserted through the femoral artery. Ankle pumps all the way!!!
What 4 interventions will we be using with median sternotomy patients and why?
- Compressive socks - to reduce edema
- Deep breathing and coughs - prone to atelectasis
- Check incision site often - diabetics have poor healing, prone to dehiss
- Ambulate or do ankle pumps - prone to DVTs
How is a minimally invasive surgical procedure different from a median sternotomy?
- Video thorascopy used
- Shorter bypass
- Incision is made through intercostal space
- No cardiopulmonary bypass machine is needed.
What are 3 kinds of graft replacements and what are they?
- Prosthetic/mechanical - Artificial
- Xeno graph - From animal
- Homograph - From cadaver
Which graph types does not require anti-coagulation and why?
Xeno graph and homograph - because dead tissue does not elicit an immune response.
If the saphenous vein was used in a CABG procedure, what is an additional precaution that both you and the patient must be aware of?
Don’t let them cross their legs Post-op
What is dehiscence?
When a patient splits open the skin over their median sternotomy
What are two downfalls of prosthetic/mechanical valve replacements?
Requires lifetime anticoagulation medications
No contact sports because the valves can become dislodged
What is a benefit for having a Xenograft?
No anti-coagulation medications are required because the tissue is dead (no antibody response)
What is the benefit of using a homograft?
There is no anti-coagulation
What is the Ross procedure used for?
Aortic valve replacement. The patient’s pulmonary valve is moved to the aortic valve position and a xenograft is placed into the pulmonary valve position.
There are (6) types of valve repair procedures. List them.
(1) Commissurotomy
(2) Decalcification
(3) Triangular resection of the mitral valve repair
(4) Annuloplasty
(5) Patched leaflets
(6) Bicuspid aortic valve repair
What is done during a commisurotomy?
A valve repair that separates fused valves, a catheter is used to physically push apart the fused valves
What is done during a decalcification valve repair?
Removal of the calcified material on the valve
What is done during a triangular resection mitral valve repair?
This is to repair a floppy mitral valve
A portion of this floppy valve is removed and the leaflet is sown together to make the valve smaller and be able to close better
What is done during an annuloplasty?
This procedure prevents regurgitation
A tissue or synthetic ring is sewed around a valve annulus which is too wide
What is done with a patched leaflets valve repair?
This is when the surgeon repairs holes or tears with a synthetic patch or a pericardium patch
What is done during the bicuspid aortic valve repair?
Normally the aortic valve should have 3 leaflets, so the bicuspid aortic valve (a congenital defect) will need to be reshaped.
What are the PT implications of valve repair
(1) Risk for atelectasis because these procedures use a medial sternotomy
(2) The longer the length of the surgery, the greater the risk is for atelectasis
(3) INR needs to be between 2 to 3 for these patients
(4) Valve replacement patients (all cardiac surgery patients) are at increased risk for orthostatic hypotension
What are temporary pacemakers (“pacing wires”)?
Wires put in place during surgery and are taped down and then removed 1 to 2 days after surgery
What does AICD stand for?
Automatic implantable cardiac defibrilator
What is an AICD?
A device that provides a defibrillation if the patient has history of life threatening arrhythmias
What should a patient with an AICD be educated on?
If the patient feels a pounding or fluttering in his/her chest, they need to sit down - otherwise they will fall down
The ICD will provide an automatic defibrillation and it feels like a horse kicking them in the chest.
What does IABP stand for?
Intra-aortic Balloon pump
What is IABP?
A temporary measure to augment stroke volume and maintain good BP
How is the catheter ballon in the IABP placed into the aorta?
It is inserted through the femoral artery
What happens to the balloon in the IABP during systole? During early diastole? During late diastole?
During systole: balloon collapses
During early diastole: the balloon is inflating
During late diastole: the balloon is fully inflated and then immediately deflates for systole
> This will create a negative pressure pulling the blood out of the ventricle > reducing afterload
What is the ratio of balloon inflation to heart beat for an IABP?
May be 1:1 to 1:8
1:1 would be the initial setting and then the patient could be weaned off the IABP slowly by reducing the ratio to 1:8
When is an IABP used?
Used during/post-op cardiac surgery to maintain the BP
Or when the patient is waiting for heart transplant
What are the PT implications if the patient is currently using IABP?
No hip flexion (bed is flat) > that means no sitting
Utilize ankle pumps and side rolls
Monitor vital signs just in case the device fails
What does VAD stand for?
Ventricular Assist device
What is a VAD?
A mechanical pump used to bypass a failing ventricle (move blood straight to the aorta)
What are the three types of VAD?
(1) RVAD - right ventricle –> aorta
(2) LVAD - left ventricle –> aorta
(3) BiVAD - both ventricles –> aorta
What are the types of patients that may be using a VAD?
(1) Patients waiting for a heart transplant
(2) Patients that are ineligible for heart transplants (because of other co-morbidities
(3) Chronic cardiomyopathy patients
What are the PT considerations with working with a patient who uses a VAD?
- Pumping is happening continuously (there will be a mean BP, not a SBP/DBP)
- Look for S&S of inadequate blood flow: faint, dizzy, pale
- VAD can be internal or external
If the patient is on an external VAD, Can the patient get out of bed?
Most likely not, it depends on the patient’s stability. You can still perform bed exercises with this patient, just be very careful not to pull external lines.
