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cardiopulm > Intervention Cardiology and Cardiac Surgery > Flashcards

Intervention Cardiology and Cardiac Surgery Flashcards

1
Q

Percutaneous coronary intervention

A
  • Formerly known as coronary angioplasty with stenting
  • Non-surgical procedure that uses a catheter and balloon to place a stent to open up blood vessels in the heart that have been narrowed by plaque buildup.
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2
Q

two types of stents

A

•Bare Metal Stents •Drug Eluting Stents

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3
Q

endarterectomy

A

Surgical removal of part of the inner lining of an artery, any obstructive deposits
•(Usually atherosclerotic plaques)
•Most often performed in the carotid artery or femoral arteries

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4
Q

Treatments for arrhythmias

A
  • temporary epicardial pacer
  • pacemaker
  • Implantable cardioverter defibrillator (ICD)
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5
Q

Temporary epicardial pacer

A
  • Epicardial pacing wires common after open heart surgery wires exit through mediastinal incision.
  • Cardiac surgery makes myocardium irritable and prone to arrhythmia
  • Pacer is used to control heart rate due and rhythm.
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6
Q

Median sternotomy approach

A
  • Coronary artery bypass graft CABG

* Valve Replacement or repair•Mitral (MVR) or Aortic (AVR)•Heart Transplant

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7
Q

Thoracotomy approach

A
  • Lobectomy

* Lung Transplant (Bilateral aka “Clamshell” for COPD)

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8
Q

Transcatheter aortic valve replacement approach

A

accessed through femoral artery

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9
Q

minimally invasive cardiac surgery approach

A
  • CABG, valvular surgery
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10
Q

Video assisted thoracic surgery approach

A
  • lobectomy (lung cancer)
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11
Q

Median sternotomy

A
  • One of the most frequent accesses in cardio-thoracic surgery
  • Vertical inline incision is made along the sternum.
  • Chest wall is retracted Mediastinum exposed
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12
Q

Coronary artery bypass graft

A
  • First done 1967
  • 320,00 bypasses per year done in US
  • 1-2% mortality rate although 5-10% risk of MI during procedure
  • Graft vessels sewn to coronary arteries beyond blockage and attached to aorta
  • Triple, quadruple or quintuple bypasses are now routine
  • Most commonly used vessel for grafts is saphenous vein.
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13
Q

CABG procedure

A
  • CABG surgery takes ~4hours to complete.
  • Aorta is clamped off for about 60 minutes to allow bloodless field and allow bypasses to be connected to aorta.
  • Heart is stopped using a chilled K+ solution
  • Plastic tubes are placed in RA to channel venous blood out of the body for passage through heart lung machine
  • Body is supported by cardiopulmonary bypass for about 90 minutes.
  • Sternum is wired together with stainless steel and the chest incision is sewn closed.
  • Breathing tube removed shortly after surgery.
  • Chest tubes left in place to allow drainage of any remaining blood from the space around the heart (mediastinum)
  • Patients usually get out of bed and are transferred out of ICU day after surgery
  • ~25% of patients develop heart rhythm disturbances within the first 3-4d post-op.
  • Temporary a-fib related to surgical trauma to the heart.
  • Most resolve one month after surgery
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14
Q

Left Internal Mammary artery grafts

A
  • Gaining popularity especially for LAD - Proximal origin off left subclavian maintained and distal end is separated from the chest wall,
  • Remain open longer (90% in 10yrs) - compared to 66% of vein grafts, - also maintain endothelial function
  • Internal mammary arteries generally not used for emergency CABG surgery
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15
Q

Disadvantages of LIMA

A
  • Limited lengthof vessel
  • May prolong surgery
  • Risk of sternal wound failure
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16
Q

Intra-aortic balloon pump

A
  • Most common circulatory assist device in critically ill patients with cardiac disease - (HF usually).
  • Improves ventricular performance of a failing heart by facilitating an increase in myocardial oxygen supply and a decrease in myocardial oxygen demand
  • Inflates at the onset of diastole, increasing diastolic pressure and thus increases in coronary blood flow and which improves myocardial oxygen supply.
  • Deflates just before systole, thus reducing LV afterload, which decreases demand and improves cardiac output.
17
Q

Cardiac transplantation (HTx)

A
  • End-stage heart failure
  • Cardiomyopathy (48%)
  • CAD (44%)
  • Congenital
  • Valvulardefect
  • Retransplant
  • Other
18
Q

Indications for cardiac transplant

A
  • Cardiogenic shock requiring continuous inotropic support or mechanical support
  • Persistent NYHA functional class IV symptoms refractory to treatment
  • Intractable angina
  • Intractable life-threatening arrhythmias
  • Congenital heart disease with NYHA III/IV symptoms refractory to treatment
19
Q

Absolute contraindications of cardiac transplant

A
  • Irreversible Pulmonary vascular resistance
  • Malignancy
  • Active infection
  • HIV/AIDS
20
Q

Relative contraindications of cardiac transplant

A
  • Age>65*
  • Poorly Controlled DM with organ damage/failure
  • Psychosocial impairment that jeopardizes transplanted heart
  • Arnold Palmer and VA Example
  • Cigarette smoking
  • Unreliable Caregivers
21
Q

Donor allocation system

A

•Supervised by United Network of Organ Sharing (UNOS)
- Private organization designed to ensure equitable distribution of organs

  • Organ Procurement and Transplantation Network (OPTN)
  • Divided into 11 regions
  • Prioritization based on •Severity of illness
  • Geographic Distance from Donor
  • Patient time on wait list
22
Q

cardiac transplant procedure

A

•Median sternotomy •Cardiopulmonary bypass

23
Q

Physiological changes post transplant

A
  • Transplanted heart is denervated
  • Higher resting HR (90-110bpm)
  • Absence of direct neural regulation of HR/SV
  • HR and SV controlled via circulating catecholamines and muscle pump
  • Absence of chest pain
24
Q

Exercise capacity post transplant

A
  • 56% of patient exercise capacity is <70% of predicted normal
  • Only 13% achieve >90% predicted normal
  • Contributing Factors
  • Transition from type 1 to type 2 fibers - Especially for patients with previous long standing HF
  • Neuro-hormonal changes from long standing HF resulting in elevated TPR
  • Side effects of corticosteroids and immunosuppressive therapy
25
Q

Complications cardiac post surgery

A
  • DVT and/or Venothrombus embolism
  • Intra or Peri-operative MI
  • Pericarditis
  • Infection
  • Sternotomy Failure
  • Pulmonary Complications
  • Reduced bowl motility
  • Deconditioning
  • Neurocognitive decline
  • Chest wall pain and mobility issues
26
Q

Impatient PT implications for Cardiac transplant

A
  • Getting patient moving, - Reduces risk of deconditioning, pulmonary complications (atelectasis and pneumonia), bed sores and DVT,
  • Goals- Determine stability for ambulation, transfers, stairs, ADLs, assistive device needs, tolerance to activity, return to PLOF or as close possible
  • Discharge Plans - Always ask patient if they live alone/family, floors in home, steps to needs, can patient establish self of 1st floor bathroom) may need to talk to family.
27
Q

Sternal precautions

A

•No traction forces on sternum for 6-8 weeks, - Longer if osteoporosis or on steroid medication•No shoulder flexion or abduction >90deg***
•Lifting restriction 8-10 lbs6wk, then 30lb for 3mo
•Minimal or no push/pull. This means
- Use log rolling to get out of bed, get to edge of chair before standing, use momentum and rocking, look up
•If sternal tissue fails, use rectus or pectoral flaps-severe ROM restriction of 20deg flex and abd, no lifting, push or pull
•Monitor incision: 30% mortality of skin opens and becomes infected
•Encourage splinting chest with pillow when coughing
•Avoid valsalva
•No driving due to medications initially, then need to avoid air bag for 4-6wks

28
Q

Typical progression and goals

A
  • Post op day 0 pt transfers to chair with RN in AM
  • Post op day 1 pt transfers from sit to stand, gets to doorway, pre gait- Afternoon ambulation
  • Post op day 2-3 chest tubes d/c, cardiac pacer d/c - Pt must be supine for either and remain still for 1hr with pacer d/c) - Stairs assessment - Independent ambulation assessment
  • Consider using a standardized assessment, - 5meter Gait Speed, 6MWT, 2MST, Dynamic Gait Index, POMA
29
Q

Usual discharge times

A
  • PCI-1-2days
  • Pacemaker 1-2days
  • CABG 4-5days
  • Valve Replacement: 2-3 days
  • HTx: 1-2weeks

cardiopulm (14 decks)

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