Intervention Cardiology and Cardiac Surgery Flashcards
(29 cards)
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.
2
Q
two types of stents
A
•Bare Metal Stents •Drug Eluting Stents
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
4
Q
Treatments for arrhythmias
A
- temporary epicardial pacer
- pacemaker
- Implantable cardioverter defibrillator (ICD)
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.
6
Q
Median sternotomy approach
A
- Coronary artery bypass graft CABG
* Valve Replacement or repair•Mitral (MVR) or Aortic (AVR)•Heart Transplant
7
Q
Thoracotomy approach
A
- Lobectomy
* Lung Transplant (Bilateral aka “Clamshell” for COPD)
8
Q
Transcatheter aortic valve replacement approach
A
accessed through femoral artery
9
Q
minimally invasive cardiac surgery approach
A
- CABG, valvular surgery
10
Q
Video assisted thoracic surgery approach
A
- lobectomy (lung cancer)
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
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.
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
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
15
Q
Disadvantages of LIMA
A
- Limited lengthof vessel
- May prolong surgery
- Risk of sternal wound failure
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
Complications cardiac post surgery
* 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
Impatient PT implications for Cardiac transplant
* 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
Sternal precautions
•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
Typical progression and goals
* 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
Usual discharge times
* PCI-1-2days
* Pacemaker 1-2days
* CABG 4-5days
* Valve Replacement: 2-3 days
* HTx: 1-2weeks
