Lecture 3 - Cardiac Surgery Flashcards
what is Percutantous Transluminal Coronary Angioplasty (PTCA)?
Elective procedure or used in acute treatment of MI, in conjunction with thrombolytic therapy
Procedure successful if 40-50% reduction in stenosis with clinical improvement of symptoms
Complications: acute occlusion due to spasm, clot, collapse, corona dissection, MI, bleeding
Contraindications: absence of significant atherosclerotic lesion, multivessel diffuse disease (only do it if a few arteries are diseased), or where L coronary artery involved (since acute occlusion of LCA g L ventricular dysfunction)
PTCA results in improved myocardial blood flow and relief of angina
Restenosis occurs in -25-50% of individuals, usually within 2-6 months after PTCA
Is not a surgical procedure! It is invasive but not surgical
Can’t be fully blocked otherwise it won’t be able to get the catheter through
what is directional coronary atherectomy?
Procedure not really used much.
what is lazer angioplasty?
Procedure not really used much.
what are coronary stents?
Question: “What happens when you deflate the Balloon and the artery collapses?”
“Bailout Procedure” – for the complication of abrupt closure of a coronary vessel immediately after Balloon deflation during PTCA.
-Because before sometimes vein would collapse after doing the procedure!
-
- Stent is around the balloon and both are inserted – stent stays in!
- VERY important to have anti-coagulation bc with any foreign body, incr risk of clots
what is a coronary artery bipass graft?
When deciding which vessels to bypass, a reduction in diameter of 50% is considered critical (equivalent to 75% reduction in area). This relieves angina in the large majority of patients and most operations are for symptom benefit.
Criteria :
- LCA occlusion > 50%
- severe triple vessel disease
- two-vessel disease with L ventricle dysfunction
- chronic stable angina unresponsive to medical there
- unstable angina
- emergency (after acute MI)
- if symptomatic – SOB, angina, cp, syncope
Diagnostic Tests:
Coronary arteriography: contrast material injected into coronary circulation, allows visualization of coronary lesions and estimation of obstruction
Usually in charts we see it written as: Cardiac Cath (Catheterization) or Angio (Angiogram).
Ventriculogram: visualization of L ventricle dysfunction (ejection fraction), akinesis (immobile segments of ventricle wall), dyskinesis (paradoxical motion), valve defects, septal defects.
Usually in charts we see this as an Echo (Echocardiogram), which shows the integrity of the valves (shows ejection fraction too).
Shows us for example Stenosis, Regurgitation, Insufficiency.
*note they do not remove the diseased artery, they just bypass it!
what happens during surgery for a coronary bipass graft?
ASYSTOLE – Heart stops beating.
Cardioplegia - a Hyperkalemic solution is used on the beating heart to create Asystole.
CBP – Cardiopulmonary Bypass Pump – Cannulated Right Atrium and Aorta is connected to an external pumping and oxygenating system. Therefore the heart remains still while the other vital organs are oxygenated and perfused. Venous Cannula is inserted in the Right Atrium (which removes oxygen poor blood from the patient) and delivers it to the CBP (External Pumping and Oxygenating system / Heart Lung Machine). Then returns the oxygenated blood via the arterial cannulae in the aorta and to the rest of the body. So basically, by routing the blood to an External Pumping and Oxygenating system the heart may come to a standstill to facilitate surgical intervention while perfusing vital organs.
The heart is stopped during the surgery – have the pump that acts as a pumping machine so that problems don’t occur
This machine has to go on before they stop the heart and have to work on it – they stop the heart by cooling it, then electrically rewarm the heart and once it is working again they stop the CBP machine
what is an octopus?
This is another procedure where the Bypass is performed on a “Beating Heart”.
Why is it called an “Octopus”? – it suctions (sucks) like an octopus part of the heart to isolate it and stabilize it while the rest of the heart is still beating.
The device is called the Octopus Tissue Stabilizer which is intended to stabilize the heart.
The Octopus uses suction to position the heart, isolate an area and limit the motion in that area during the anastomosis of the coronary vessel.
what are the benefits to an octopus?
Don’t have to use CBP – good bc any time you use another machine, you have chance of issues/complications
Can only use this surgery if you have only a few vessels to bipass (and the artery is totally clogged, otherwise you can use the stent)
Quicker post-op recovery bc no leg issues
describe valve repair/replacement and when it’s indicated
Complication:
AV heart block, infections, arrhythmias.
Valve is a foreign body leading to increased risk of clotting.
Patients are started on anticoagulant drugs before surgery and must continue taking them permanently.
- Will be on anti-coagulents for life!
when and how is a heart transplant done?
Patient selection crucial due to complex post-operative management
Selection criteria vary in different centers, however usually:
- patient < 65 years
- no donor-specific antibodies
- no irreversible hepatic or renal dysfunction
- no active infection or peptic ulcer disease
- no advanced peripheral or cerebral vascular disease
Also, patients should be emotionally stable, compliant with medical regimen, and have a strong psychosocial support system.
Major post-operative complications are rejection and infection.
Immunosuppressive drugs used to minimize rejection. Protective isolation used to minimize infection.
Cardiac rehabilitation is an important component of post-operative management.
Problem is not the surgery, but these types of patients typically very weak before surgery – that is why recovery period if longer
*looking at rejection and infection as the more important risks after this type of surgery!
Nerves have been removed as well – so make sure to warm up a bit more the pt before exercise and cool down, bc heart is denervated
what are important considerations WRT angiograp reports?
Cx = circumflex,
- 4 blocked arteries
- Therefore 4 bipasses = a complete revascularization
- Might go in for 4 bipasses, but surgon goes in and finds more so come out with 4+ bipasses
- Chest pain – even if they still have 2 arteries blocked and they have chest pain (angina), alert the nurse and NO PHYSIO!
- How do you know if it is incisional or angina?
- Ask is it like a pain from before the surgery or new pain from after
- Is it like the pain from your leg or a different pain?
what are important considerations WRT cardiopulmonary bipass time?
CPT/CBT = the time they are on the pump (ie the one when the heart isnt beating) (can typically be only 50 minutes, but add valves to it and can be 2 hours on pump)
what are
Important considerations
% EF/LVEF: Ejection Fraction/Left Ventricular Ejection Fraction?
EF = how strong is the heart, can we mobilize the pt?
what is an Intra Aortic Balloon Pump (IABP)? what is it used for?
No one gets this unless something happens!
IABP rests below the Ascending Aortic Arch and above the levels of the kidneys.
It is attached to the console at the foot of the bed which monitors the ECG. This console shuttles helium in and out of the IABP resulting in inflation/deflation which is synchronized with cardiac systole and diastole.
This is invasive and only seen in ICU!
When you see this machine – it is not good, cannot go up on the floor with it – helps them to recover until they can be moved up
*For that millisecond blood is forced to go to the outside of heart (ie coronary arteries) to help the heart come out of its weak state
IABP (Intra Aortic Balloon Pump) PT implications?
When it is removed, just don’t do anything that day – always see nurse first if you have this type of patient!
describe A-fib (course and fine)
Quick & Easy way to know if patient is in AFIB is by looking at the EGG monitor - check to see if there are uneven spaces between each QRS complex - short followed by long time intervals between the QRS intervals.
PT implications for a-fib?
Always ask the nurse!
Chronic = proceed more cautiously
Acute – put back to bed, get nurse
describe ventricular tachycardia and PT implocations
Medical emergency!
describe V-FIB and PT implications
Medical emergency! no PT!
what pt treatment would you suggest considering each HR? now each one but in v-fib?
<50
50-60
60-100
100-110
110-120
120-130
130-140
>140
If the Patient is in AFIB (Atrial Fibrillation) , follow the same guidelines as above for NSR but 1) Check with Nurse, 2) check to see if ACUTE/CHRONIC and 3) proceed with more caution !!!!!
Pts less than 60 – usually waiting for a pacemaker !
Telemetry = a small walky-talky thing so pt can be monitored and will ring alarm if something happens and nurse comes
50-60 – ambulation, walking, etc can do, sitting in chair, yes – chose to walk past the nursing station so you can see on the monitor what their HR is etc
More than 140 = NO treatment!
Now for the whole chart but in afib – same thing but with even more caution!
what do PTs do post op day 1 and 2 for cardiac surgeries?
Day 1 = 1 day after surgery – usually home 4-5 days after surgery!
Give them the “baby” for their surgery pain
Part of the education – reassure them that it isnt going to open up
*always check with nurse first!!
Mediastinal drains, chest tubes, check
How far do I walk with them? As tolerated!
what pt treatment do you do post-op day 3-5?
Transplants might take longer like said before in prev slides bc they are more deconditioned
what are the goals of cardiac rehab?
Day 1 – need to start thinking about discharge right away! Where will they go after, etc
who are the candidates for cardiac rehab?
Anticiagulation therapy (have to disconnect it to do stairs) – this is the concern with slowing down discharge for these pts
what are common post-op complications?
Temponant = bleeding in mediastinum – medical emergency, have to go back to OR to fix it
* Showed a “path to home” chart for patient – very simple
describe risk reduction practices
Doing a bipass doesn’t alter the disease process – it is not a cure (just improves symptoms, and therefore QOL)
The bipasses can get clogged to – then need to come back again and there are no more veins (need to use radial – in wrist etc)
what is a ventricular assisted device and what types are there?
3 types:
1) THORATEC
2) Thoratec Extracorporeal Biventricular
3) Novacor: Left Ventricular Assisted System (LVAS)
When is a VAD used?
A VAD is used to assist the pumping action of a severely weakened heart
It may be used when medical therapy has failed and the patient is hospitalized with end-stage systolic heart failure, until a donor heart becomes available.
The VAD may be used for long-term destination therapy in those patients with end-stage heart failure who are not candidates for transplant.
So they are already moveing before for when they get surgery – for pple with end stage heart failure
describe the thoratec VAD
Ventricular Device is outside the Body.
Offers partial or total circulatory assistance when the natural heart is unable to maintain adequate circulation to perfuse vital organs.
describe the Thoratec Extracorporeal Biventricular VAD
This is outside the body
Eventually this gets replaced with a lighter one
Most important not to kink the wires
describe the novacore VAD
Novacor is implanted inside the body. (in the abdomen)
Binder bc device is heave, have to be very cautious
what are sternal precautions?
Wound assessment should include assessing for the presence of infection, inadequate healing, and determining the stability of would closure. Would infection is suspected if there is foul smelling, and/or discolored drainage. Some serosanguinous drainage may be present. Determining the presence of a sternal “click” quickly assesses sternal stability.
To assess stability, the practioner should place 2 fingers on either side of the incision or place the stethoscope over the top of the incision. You then ask the patient to take a deep breath or cough gently. With an unstable sternum, you should feel both sides of the wound rise and fall together and no click/rubbing noise should be auscultated via the stethoscope.
If there is any asymmetry via palpation of if a loud click is heard, the would is considered unstable and caution should be exercise with UE activities.
**no lift push pull anything heavy for 6 weeks – no driving 6 weeks either!
cardiac rehab definition and how many phases?
what is the goal of phase 1 cardiac rehab?
who are the candidates for the cardica rehab program? when does phase 1 start? what 3 sections are included in phase 1?
what is the 5-day treatment progression post cardiac surgery? what day is key?
Post op day 2 is the key day
describe the BORG scale
Borg is a sweedish physiologist
This is a modified borg* – borg is 1-10? Check
Know how to explain the borg scale to the pt
- Show the scale – the harder the activity, the harder the activity, the worse you will feel
- Example, in the first part, you are walking very short distance with a smile, this next section, you get tired and lost your smile - we want you to always have a smile - we are not training for a marathon here – tell them this
describe Impairment of Pulmonary Function Post-Op Cardiac Surgery - what diminishes pulmonary function and what are the results of this?
Can cause atelectesis and shunting (bc alveolar collapse)
Cilliary cant clear secretions
Pain = impaired cough reflex
describe lung volumes before compared to after surgery
Lung volumes much smaller – just because of surgery itself!
describe how one can get an atelectesis post-surgery
Everyone will have decreased breath sounds in lower lungs - expect that
contradicting evidence wrt post op complications and atelectesis
Just bc you have atelect – does not mean your gonna get a pneumonia
It Is ok for them to be discharged even if they don’t have perfect lungs! - tell them to still do deep breathing at home and they will continue to get better on their own
what is the key to preventing post-op complications?
Just breathing exercises alone does not make a difference!
what are the benefits of ambulation?
Early mobs = Offsetts the orthostatic hypotension
describe the importance of mobility post-op day 2
how has weekend Coverage at the RVH changed? results of this change?
describe phase 2 of cardiac rehab
what are the benefits of rehab?
A)Improved Quality of Life
B)Decrease in Depression
C)Improved Cardiopulmonary Function
D)Improved Graft Patency
*Patency = how well the vein graft took
whats out there presently in terms of cardio rehab and where do we go from there?
