Lecture 16: Cardiac and Surgical Conditions

Question 0

As a PT, what do you need to be considerate of when dealing with a patient with a pacemaker?

Answer 0

You must be monitoring BP and S&Ss to ensure the pacemaker is adapting to exercise

Question 1

What is a risk of having a pacemaker?

Answer 1

They can fail

Question 2

How can you tell if a pacemaker has failed?

Answer 2

If the patient’s heart rate is <40 bpm

Question 3

What 5-6 structures does the RCA (right coronary artery) supply?

Answer 3

1. Right ventricle
2. Right atria
3. Inferior wall of Left ventricle
4. Bundle branches
5. AV node
6. (If right dominant) SA node

Question 4

What does “Right dominant” heart mean and what is its prevalence?

Answer 4

The RCA (right coronary artery) supplies both the AV and SA node. Occurs in 55-75% of the population

Question 5

What does “Left dominant” heart mean and what is its prevalence?

Answer 5

The LCA (Left coronary artery) supplies the SA node instead of the RCA. Occurs in 24-45% of the population.

Question 6

What does the LAD (Left anterior descending artery) supply?

Answer 6

The anterior wall of the left ventricle

Question 7

What is known as “The widow maker”?

Answer 7

Occlusion of the LAD (left anterior descending artery) which will lead to death.

Question 8

What 2-4 structures does the LCX (Left circumflex artery) supply? (Include prevalence)

Answer 8

1. Left atria
2. Posterior and lateral walls of the left ventricle
3. SA node (45% of population)
4. AV node (10% of population)

Question 9

What is a CABG?

Answer 9

Coronary artery bipass graph: It is a graph of a vein or artery used to go around an occluded artery or vein.

Question 10

What is an indication for having a CABG?

Answer 10

Medication is inadequate to treat the problem

Question 11

What 5 vessels are typically used for a CABG?

Answer 11

1. Saphenous vein
2. Left internal mammary artery (LIMA)
3. Brachial artery
4. Radial artery
5. Gastric artery

Question 12

What 3 pieces of equipment may be hooked up to a patient who has undergone a median sternotomy?

Answer 12

1. Mediastinal tubes
2. External temporary pacing wires
3. Intra-aortic balloon pump

Question 13

When are temporary pacing wires usually removed?

Answer 13

Within 2 days of a median sternotomy

Question 14

What does an intra-aortic balloon pump do?

Answer 14

Assists the left ventricle

Question 15

What do we need to be cautious about with patients who have temporary pacing wires.

Answer 15

We cannot work with patients who have had temporary pacing wires removed in the past 4 hours.

Question 16

What are the 6 sternal precautions after a median sternotomy?

Answer 16

1. Do not push or pull for mobility
2. Do not push or lift > 5-10 lbs for 6-8 weeks
3. Do not hyperextend your shoulder
4. No trunk rotation for several weeks
5. No driving for several weeks
6. No unilateral shoulder flexion >90 degrees

Question 17

What is a PT consideration of patients with an intra-aortic balloon pump?

Answer 17

Do not flex the hip! It is inserted through the femoral artery. Ankle pumps all the way!!!

Question 18

What 4 interventions will we be using with median sternotomy patients and why?

Answer 18

1. Compressive socks - to reduce edema
2. Deep breathing and coughs - prone to atelectasis
3. Check incision site often - diabetics have poor healing, prone to dehiss
4. Ambulate or do ankle pumps - prone to DVTs

Question 19

How is a minimally invasive surgical procedure different from a median sternotomy?

Answer 19

1. Video thorascopy used
2. Shorter bypass
3. Incision is made through intercostal space
4. No cardiopulmonary bypass machine is needed.

Question 20

What are 3 kinds of graft replacements and what are they?

Answer 20

1. Prosthetic/mechanical - Artificial
2. Xeno graph - From animal
3. Homograph - From cadaver

Question 21

Which graph types does not require anti-coagulation and why?

Answer 21

Xeno graph and homograph - because dead tissue does not elicit an immune response.

Question 22

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?

Answer 22

Don’t let them cross their legs Post-op

Question 23

What is dehiscence?

Answer 23

When a patient splits open the skin over their median sternotomy

Question 24

What are two downfalls of prosthetic/mechanical valve replacements?

Answer 24

Requires lifetime anticoagulation medications | No contact sports because the valves can become dislodged

Question 25

What is a benefit for having a Xenograft?

Answer 25

No anti-coagulation medications are required because the tissue is dead (no antibody response)

Question 26

What is the benefit of using a homograft?

Answer 26

There is no anti-coagulation

Question 27

What is the Ross procedure used for?

Answer 27

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.

Question 28

There are (6) types of valve repair procedures. List them.

Answer 28

(1) Commissurotomy (2) Decalcification (3) Triangular resection of the mitral valve repair (4) Annuloplasty (5) Patched leaflets (6) Bicuspid aortic valve repair

Question 29

What is done during a commisurotomy?

Answer 29

A valve repair that separates fused valves, a catheter is used to physically push apart the fused valves

Question 30

What is done during a decalcification valve repair?

Answer 30

Removal of the calcified material on the valve

Question 31

What is done during a triangular resection mitral valve repair?

Answer 31

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

Question 32

What is done during an annuloplasty?

Answer 32

This procedure prevents regurgitation | A tissue or synthetic ring is sewed around a valve annulus which is too wide

Question 33

What is done with a patched leaflets valve repair?

Answer 33

This is when the surgeon repairs holes or tears with a synthetic patch or a pericardium patch

Question 34

What is done during the bicuspid aortic valve repair?

Answer 34

Normally the aortic valve should have 3 leaflets, so the bicuspid aortic valve (a congenital defect) will need to be reshaped.

Question 35

What are the PT implications of valve repair

Answer 35

(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

Question 36

What are temporary pacemakers ("pacing wires")?

Answer 36

Wires put in place during surgery and are taped down and then removed 1 to 2 days after surgery

Question 37

What does AICD stand for?

Answer 37

Automatic implantable cardiac defibrilator

Question 38

What is an AICD?

Answer 38

A device that provides a defibrillation if the patient has history of life threatening arrhythmias

Question 39

What should a patient with an AICD be educated on?

Answer 39

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.

Question 40

What does IABP stand for?

Answer 40

Intra-aortic Balloon pump

Question 41

What is IABP?

Answer 41

A temporary measure to augment stroke volume and maintain good BP

Question 42

How is the catheter ballon in the IABP placed into the aorta?

Answer 42

It is inserted through the femoral artery

Question 43

What happens to the balloon in the IABP during systole? During early diastole? During late diastole?

Answer 43

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

Question 44

What is the ratio of balloon inflation to heart beat for an IABP?

Answer 44

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

Question 45

When is an IABP used?

Answer 45

Used during/post-op cardiac surgery to maintain the BP | Or when the patient is waiting for heart transplant

Question 46

What are the PT implications if the patient is currently using IABP?

Answer 46

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

Question 47

What does VAD stand for?

Answer 47

Ventricular Assist device

Question 48

What is a VAD?

Answer 48

A mechanical pump used to bypass a failing ventricle (move blood straight to the aorta)

Question 49

What are the three types of VAD?

Answer 49

(1) RVAD - right ventricle --> aorta (2) LVAD - left ventricle --> aorta (3) BiVAD - both ventricles --> aorta

Question 50

What are the types of patients that may be using a VAD?

Answer 50

(1) Patients waiting for a heart transplant (2) Patients that are ineligible for heart transplants (because of other co-morbidities (3) Chronic cardiomyopathy patients

Question 51

What are the PT considerations with working with a patient who uses a VAD?

Answer 51

- 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

Question 52

If the patient is on an external VAD, Can the patient get out of bed?

Answer 52

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.