Cardiac surgery and ptca

Cardiac surgery and ptca

1. Cardiac Surgery
Wejdan Khater, RN, PhD
NUR 415- Spring 2008
Jordan University of science and
technology

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Cardiac Management
•Invasive Interventions
include: PTCA,
Laser Angioplasty,
Directional
Atherectomy, Stent
Placement, & CABG

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Percutaneous Transluminal
Coronary Angioplasty
•A balloon tipped catheter is inserted into narrowed
coronary arteries and is inflated at the narrowed
areas in order to widen the artery and remove the
plaque.
–Stents: A device called a stent may be placed. A stent is
a latticed (network/web), metal scaffold that is placed
within the coronary artery to keep the vessel open.
•Patient is admitted in the same day of the
procedure.

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Percutaneous Transluminal
Coronary Angioplasty [PTCA]
Indications for PTCA:
–Alleviate angina pectoris
unrelieved by medical treatment
–Reduce the risk for MI
–Acute MI
–Persistent chest pain (angina)
•Pts with lesions >70% stenosis
placing large areas of heart
At risk for ischemia

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Percutaneous Transluminal
Coronary Angioplasty [PTCA]
Indications for PTCA:
–Patients with surgical risk
factors (elderly, poor LV Funx.,
sever underlying diseases).
–Blockage of one or more
coronary arteries (Multivessel occlusion)
–Residual obstruction in a
coronary artery during or after a heart attack
–Recurrent stenosis and graft
– closure of coronary disease for
patients underwent CABG.

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Percutaneous Transluminal
Coronary Angioplasty [PTCA]
•CONTRAINDICATIONS
•Patients with left main CAD.
•Mild stenosis less than 50%

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PTCA

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GOALS OF PTCA
•Improve blood flow to myocardium-”cracking”
the atheroma
•PTCA done in cardiac catherization lab.
–Several inflations & balloon sizes may be required to
achieve desired goal, usually defined as less <20%
residual stenosis
•Advantages of PTCA
–Performed under local anesthesia
–Provides alternative to surgery
–Eliminates recovery from thoracotomy surgery
–Pt is ambulatory within 24hrs
–LOS 1-3 Days vs 5-7 post CABG

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Pre-procedure preparations
•Lab tests
–Cardiac enzymes
–PT, PTT
–Electrolytes (K+)
–Creatinine & BUN
•Well hydrated patient before procedure

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Pre-Procedure Preparations
Preoperative Medications
–24 hours before the procedure:
–patient is placed on Aspirin 325 mg x 1/day
–Nitroglycerine and Ca++ blockers x 3/day is
prescribed to prevent vasospasm
–Hold anticoagulant drugs if taken (like warfarin).
–metformin (antidaibetic agent) should be
discontinued.

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Pre-Procedure Preparations
•Surgical standby
•Food and fluid are restricted 6 to 8 hours before the
test.
• health care provider should explain the procedure and
its risks.
•A witnessed, signed consent for the procedure is
required.
•Allergic history: to seafood, if the pt had a bad
reaction to contrast material in the past

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PTCA -Intra procedure
•The patient is anticoagulated with 5000-10000 U
of heparin bolus to prevent clot formation on the
catheter system.
–Bolus dose of heparin (2000-5000 U) may be needed to
maintain ACT (Activated Clotting Time) level of
250-300 seconds.
•Monitor patient anticoagulant status
–ACT is monitored at baseline, 5 minutes after heparin
bolus, and every 30 minutes after for the duration of the
procedure.

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PTCA -Intra procedure
•The nurse must recognize signs and
symptoms of contrast sensitivity, such as
urticaria, blushing, anxiety, nausea, and
laryngospasm.

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PTCA –post procedure
•Bed rest 4-6 hours after sheaths removed (sheaths
removed 3-4 hours after procedure).
•Maintain leg in strait position
•Avoid flexing or bending leg at hip level
•Avoid vigorous use of abdominal muscles
(coughing, sneezing).
•Monitor ECG, VS, LOC
•Neurovascular check below catheter insertion site
(color, sensation, pulses).

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PTCA –post procedure
•Monitor sheath insertion site for bleeding (apply 5
lb sand bag, suture, collagen plugs).
•Monitor for signs of angina (chest pain) recurs.
•If vasospasm occur, administer vasodilators
(nitro., isosorbide, nifidipine sublingual)
•Patient sent home with Aspirin, Ca++ blockers, &
lipolytic drugs
•Perform treadmill stress test 6 weeks after
procedure and compare to the one before the
PTCA. Repeat the test at 6 months and 1 year.

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COMPLICATIONS PTCA
•Hematoma at insertion site
•Pseudoaneurysms
•Embolism
•Hypersensitivity to Dye
•Re-stenosis, immediately or 3-6 mo’s
•Dysrhythmias
•Vessel rupture, need for emergent CABG
•Angina, MI, and Vasospasm
•Abrupt closure of dilated segment.
•Coronary artery dissection
•Travel of stent

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OTHER INTERVENTIONAL
CARDIAC PROCEDURES
•Laser Angioplasty-uses pulsed laser energy to
vaporize plaque & reopen blocked arteries
•Coronary Atherectomy-involves widening of artery
lumen by removing atherosclerotic plaque.
Directional catheter is a device that shaves the
plaque off vessel walls by means of a rotary cutting
head, retaining the fragments in the device’s
housing & removing them from vessel.

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CURRENT INTERVENTIONAL
CARDIAC PROCEDURES
•Intracoronary Stents
Used to prop or support the
arterial wall. Used to keep
vessels open.
Anticoagulant &
antiplatelet meds given to
reduce risk for thrombus
formation at site

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Stent

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Stent

25. Coronary Artery Revascularization
Bypass: CABG Procedure
CANDIDATES FOR CABG
PRE-OP, INTRA -OP,
& POST-OP CARE
COMPLICATIONS

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What is Open Heart Surgery? It isn’t just CABG
•Valve replacement
•VSD
•Ascending Thoracic Aneurysm Repair
•Left Ventricular aneurysm repair
•Surgery to relieve hypertrophy in CMPs
•All need to be on the Cardio-pulmonary
pump in the OR

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WHAT IS CABG
•Coronary artery bypass
graft is the surgical
technique which uses
saphenous leg veins as
grafts (SVG) or the
internal mammary
(LIMA or RIMA)
gastroepiploic/radial
arteries as grafts to
bypass obstructed
portions of a coronary
artery

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WHAT IS CABG
Standard surgical
coronary
revascularisation
Requires :
2.CPB
3.Aortic cross
clamping
4.Global cardioplegia
arrest

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WHO NEEDS CABG?? CONDITIONS THAT NEED
CORONARY REVASCULARIZATION :
–Stable angina but meds not controlling pain, pt has
¯function
–Non-successful PTCA with evolving MI
–Unstable angina
–A positive exercise tolerance test [treadmill], & lesions or
blockage that cannot be treated by PTCA
–Exercise induced ventricular arrhythmias due to
myocardial ischemia
–A Left Main Coronary lesion or blockage of more than
60% (50%)
•Single or double vessel disease with type B or C lesions

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WHO NEEDS CABG?? CONDITIONS THAT NEED
CORONARY REVASCULARIZATION :
•Three vessel CAD (70% stenosis) with
depressed left ventricular function or two vessel
CAD with proximal LAD involvement. In
randomized trials, patients with three vessel and
depressed LV function showed survival benefit
with CABG compared to medical tx. Operative
mortality increases when EF is less than 30%.
• Other: post infarct angina, thrombosis after
PTCA

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AHA/AC AHA/ACC Definition of Classes for Various Conditions C Definition of
C AHA/ACC Definition of Classes for
Various Conditions
•Class I--Conditions for which there is evidence and/or
general agreement that a given procedure or
treatment is useful and effective.
•Class II--Conditions for which there is conflicting
evidence and/or a divergence of opinion about the
usefulness or efficacy of a procedure.
•Class IIa--The weight of evidence/opinion is in favor
of usefulness/efficacy.
•Class IIb--Usefulness/efficacy is less well established
by evidence/opinion.
•Class III--Conditions for which there is evidence and/
or general agreement that the procedure/treatment is
not useful/effective and, in some cases, may be
harmful.

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ACC/AHA Guidelines for Coronary
Artery Bypass Graft Surgery
In Asymptomatic or Mild Angina
Class I
1. Significant left main coronary artery stenosis.
2. Left main equivalent: significant ( 70%) stenosis of the
proximal LAD and proximal left circumflex artery.
3. Three-vessel disease. (Survival benefit is greater in
patients with abnormal LV function; e.g., EF <0.50.)
Class IIa
Proximal LAD stenosis with 1- or 2-vessel disease.*
Class IIb
One- or 2-vessel disease not involving the proximal
LAD.

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EMERGENCY VS ELECTIVE CABG
•The outcomes of the CABG are very
dependent on the pre-op conditions!!
•Emergency cases come from the cath lab
with death of tissue & many anticoagulants
on board
•Elective cases come from home NPO &
prepared

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RISK FACTORS FOR CABG
•Age :pts over 70 are at a slightly higher risk for
complications
•Gender – women have a slightly higher risk
•Previous heart surgery – puts a person at higher risk
•Having another serious medical condition such as
diabetes, peripheral vascular disease, kidney disease
or lung disease
•Current Hemodynamic status
•Concurrent medical conditions especially DM &
COPD

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CABG
•Native vessels
–Saphenous vein
–Internal mammary artery
•Off–pump CABG
In many ways, off- pump bypass (or op – CABG ) is similar to
conventional bypass surgery .
The main difference lies in the fact that a heart – lung machine is
not used to employ cardiopulmonary bypass during the operation .
•Transmyocardial laser revascularization

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Pre-operative
•ECG
•Laboratory (CBC, BUN, ABGs, PT, PTT)
•Preop. Teaching
•Familiarize patient to the ICU by touring
the ICU unit
•Place A-line, Foley cath., thermodilution
pulmonary artery.

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PRE-OP NURSING CARE
•Teaching:
–what this procedure will do for the patient’s
pathology- it is not a cure
–cough, deep breath, splint incision
–what the all the tubes do: chest, swan, Foley, ET,
leads
–wound care- legs and sternum, possible
complications of osteomyelitis of the sternum

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PRE-OP NURSING CARE
•Teaching:
•Meds: effects of Nitro, dopamine, dobutamine &
pain meds
•Anticipate mood changes or depression, anxiety, &
forgetfulness *new push to do CABG off the pump
•Pre-op risk factor modification
•Need for continuation of cardiotonic meds to
prevent ischemia prior CABG
•Re-hydration may be necessary, if on chronic
diuretics

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TEACHING NEEDS OF THE “REDO”
•It is a common misconception that patients
who have already had CABG and need a
“redo” do not need pre-op education- “they
already know what will come.”
•Recent nursing research shows these patients have
the same learning needs as the first timers. These
same patients had a special interest in knowing
who the health care workers were & what they
would be doing for the patient

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INTRA-OPERATIVE CARE
•Anticipate potential
problems with:
•Myocardial ischemia
due to
–induction of
anesthesia
–pre-op anxiety
–cross clamp of the
aorta for valve repair
–hypothermia

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Vessel Patency
1. internal mammary artery graft 90% patency at
10 years
2. saphenous vein graft 50% patency at
10 years
3. PTCA of stenotic vessel 60% patency at
6 months
4. PTCA + stent of stenotic vessel 80% patency at
6 months

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LIMA is the most commonly used
Arterial graft, most commonly
grafted
W/ LAD, 90-95% 10 yr patency
10 yr patency for vein grafts
is 50%

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CABG

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Cardiopulmonary Bypass
•Moves oxygenated blood around the body
during open heart surgery
•Core body temp is lowered to 28° C to 32°

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Cardiopulmonary Bypass

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Cardiopulmonary Bypass
Complications
•Arrhythmias
•Fluid resuscitation
•Decreased cardiac contractility
•Control of blood pressure
•Respiratory problems
•Postoperative bleeding

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Overview of CABG procedure
Skin
incision
Expose
breast
bone
Divide
breast
bone
Retractor
placed

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Overview of CABG procedure
pericardiotomy Heart visualized
Aortic cannula brings blood
from CPB to aorta
Venous cannula drains blood
From heart to CPB

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Overview of CABG procedure
Cardioplegia tube inserted
In aorta
Cardioplegia tube
In coronary sinus

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Overview of CABG procedure
Heart stopped, aortic clamp
Placed, no flow in heart Bypass vessel grafted
Clamp removed,
Cardioplegia reversed
Heart beating normally,
CPB stopped

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Overview of CABG procedure
Chest tubes
placed
Sternum closed w/
Metal wire
Skin closed
Sterile bandage applied

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Overview of CABG procedure

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NURSING DIAGNOSIS
INTRAOPERATIVELY FOR CABG
•High risk for injury r/t surgical position
•High risk for infection r/t surgical disruption of
tissues
•Knowledge deficit r/t perioperative events
•High risk for impaired tissue integrity related to
bypass pump and hypothermia
•Decreased cardiac output r/t to mechanical
factors (altered preload, afterload, contractility,
and HR)
•

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POST-OP NURSING CARE FOR CABG
INITIAL PRIORITIES
•Patient is Admitted to the ICU first 24-72 hours.
•Monitor 12-lead ECG
•Maintain oxygenation, pulse Ox.
•Monitor hemodynamic pressures/stability
•Obtain Co, CI
•Monitor chest tubes drainage (amount color, flow, air leak)
•Chest radiology (x-ray to monitor chest tubes placement
and pulmonary congestion if any).

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POST-OP NURSING CARE FOR CABG
INITIAL PRIORITIES
•Use of clinical pathways
•NOC, ND--NIC
•Complications-Prevention & Early
Recognition
•Family information needs
•Pain control esp the elderly

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Clinical Pathways
•LOS for uncomplicated CABG is 9.8
days- try to have patient home in 4 days
•Areas of progression
–Activity
–Nutrition
–Elimination
–Meds
–Nursing interventions

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Initial Priorities cont.
•Clarify drug drips, & obtain hemodynamic
pressures
•record chest tube drainage, connect to
suction, if ordered
•measure urine output hourly
•connect bladder probe
•clarify MD orders

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Collaborative Management
•Resp. therapy for vents, IPPB,
•PT, PRN
•Pharmacy on drips
•Cardiac Rehab for discharge
•Social Service for placement

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Initial Priorities cont.
•Rewarm the patient
•obtain CXR, ABG’s, electrolytes, & coag studies
•CXR
–gives baseline on heart size, ET tube, pneumo, NG
tube, PA catheter, & pulmonary vasculartity

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Priorities of Care
•PT. recovered in
ICU
•Connect EKG
leads, obtain BP,
•connect ventilator
80% -100% FIO2
•connect pulse
oximeter
•connect transducer
lines-PA, art, RA

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COMPLICATIONS OF CABG : Early PO Period
•Low CO syndrome, 2L/m/m2-- caused by hypovolemia,
acidosis, AMI, CHF, drugs, such as Inderal, mediastinal
tamponade, incr. SVR
•Systemic HTN, & Cardiac arrhythmias
•Microemboli to lungs, heart, brain , & kidneys
•It is now the routine to do a carotid duplex before elective
CABG to see if carotids have plaque or narrowing, & many
CABG’s now include carotid endarterectomy to prevent CVA
•Fever
•Electrolyte imbalances
•Depression or confusion, agitation & disorientation
•DIC, ARDS.

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Complications: Hypothermia
•Hypothermia
–Common complication
–Assess T
0
by pulmonary artery or tympanic membrane
T
0
in ICU
–Rectal T
0
does NOT correlate to core T
0
until 8 hours
after surgery
–Prevent Shivering.
–Monitor for T
0
overshoot

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Complications: Bleeding
•PO blood loss not to exceed 300cc/hr (200) in first
several hours. After several hours should slow to
150-200 cc/hr.The average total loss is 1 liter. Use the
auto transfuser on chest tube drainage to re infuse
•Possible bleed sites
–leg & chest wounds
–cardiac tamponade- heart is compressed by blood in the
mediastinal. The heart is unable to fill adequately causing low
CO and Hypotension

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Complications
•Systemic Inflammatory Response Syndrome
(SIRS)
–Fever, tachycardia, tachypnea, increased WBCs
•Steroids before surgery
•Pain at surgery site, leg, neck and back
–Sever first 3-4 days post surgery
–Differentiate angina from incisional pain
–Morphine, Fentanyl, Hydromorphone (Dilaudid),
NSAID (Toradol)
–PCA pumps
–Alternative therapies

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Complications of CABG:
Late Postoperative Period
•Wound Infection
•Hepatitis
•Pancreatitis [early or late]
•Post-pericardiotomy syndrome
•Systemic arterial emboli & infective
endocarditis, with valvular surgeries
•Occlusion of graft

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Complications of CABG
Complications include 2-5% reoperation for
bleeding, up to 75% transient impairment of
intellectual function, 1-5% stroke rate, 40%
early (2-3d) atrial fibrillation and 1%
bradyarrhythmia requiring permanent
pacemaker. The incidence of sternal wound
infections is increased when both internal
mammary arteries are used. There is an
8-12% early saphenous vein graft occlusion
rate.

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Prevention of CABG Complications
•Preventing Cardiovascular Complications
–Volume resuscitation:
•Fluids (NS, hyperosmolar fluid (3% NS), Blood)
•Maintain hemodynamic parameters (CVP, PAWP,
CI)
•Assess extremities and peripheral pulses
–Monitor for Dysrhythmias
•Antiarhythmic drugs
•Monitor K, Mg

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Prevention of CABG Complications
•Preventing Cardiovascular Complications (Continued)
–Improving cardiac contractility
•Volume resuscitation
•Drugs; sympathomemetic (epinephrine, doputamine,
milrinone)
•IABP
–Controlling BP:
•Maintain MAP > 70 mm Hg or SBP > 120 mm Hg
•Reduce afterload by medications (nitroprusside,
ACE inhibitors, nitroglycerine, hydrralazine)

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Prevention of CABG Complications
•Preventing Pulmonary Complications
–Monitor O
2
Sat., ABG, O
2
delivery (starting 40%-50%),
PEEP (5-10 mmHg), Mode (Assisted, SIMV, CPAP),
tidal volume, end -tidal Co
2
.
–Intensive use of IS, ambulation, monitor breath sounds
•Preventing Neurological Complications:
–Patient is allowed to wake up as soon as possible
–If unable to clear narcotics, Naloxone is used to reverse
narcotics.
–Assess LOC (motor & sensory)
–CT & MRI

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Prevention of CABG Complications
•Preventing Renal complications
•Preventing GI complications
•Preventing Endocrine complications
•Preventing Infection

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Nursing Diagnosis
•Impaired gas exchange r/t
ventilation/perfusion mismatching or
intrapulmonary shunting, cardiopulmonary
bypass, anesthesia, poor chest expansion,
atelectasis, retained secretions
• Ineffective airway clearance r/t excessive
secretions of abnormal viscosity of mucus
•Fluid volume deficit r/t loss in OR

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Nursing Diagnosis
•Decreased Cardiac Output related to
–Changes in LV preload, afterload, and
contractility
–Cardiac dysrhythmias
•Decreased Tissue Perfusion related to
–Cardiopulmonary bypass, decreased CO,
hypotension

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Nursing Diagnosis
•Risk for infection r/t invasive catheter, surg.
Wds.
•Acute pain r/t transmission and perception of
cutaneous visceral, muscular, or ischemic
pain [Gerontological Consider.]
•Knowledge deficit r/t risk factor
modification, discharge regime

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Nursing Diagnosis
•Risk for Fluid Volume Deficit related to
abnormal bleeding
•Impaired Comfort related to endotracheal
tube, surgical incision, chest tubes, rib
spreading
•Anxiety related to fear of death, ICU
environment

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HEART TRANSPLANTATION
INDICATIONS
•End Stage Coronary Artery Disease; Valvular Disease
•Congenital Heart Abnormalities; Cardiomyopathy
GENERAL CRITERIA:
•A life expectancy of only 6-12 months because of end-stage cardiac
disease. Ages neonatal-65yr old
•Absence of chemical dependence
•Familial or social support
•Commitment of lifelong medical regimen & follow-up
•Many centers grade the severity of heart failure by NY Heart
Association Functional classification of HD.

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IABP
•increase myocardial oxygen supply (coronary
blood flow) & decrease myocardial oxygen
demand by decreasing afterload
•Secondary: improvement of cardiac output (CO),
ejection fraction (EF), increase of coronary
perfusion pressure and systemic perfusion,
pulmonary capillary wedge pressure and systemic
vascular resistance
•supplementing cardiac output by 20 - 30 %

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IABP
Indications
•Cardiac failure after a cardiac surgical procedure
•Refractory angina despite maximal medical
management
•Perioperative treatment of complications due to
myocardial infarction
•Failed PTCA
•As a bridge to cardiac transplantation

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IABP
Indications
•Prophylactic use prior to cardiac surgery in
patients with:
–Left main disease
–Unstable angina
–Poor left ventricular function
–Severe aortic stenosis

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IABP

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IABP
Positioning
The end of the balloon should be just
distal to the takeoff of the left subclavian
artery
Position should be confirmed by
fluoroscopy or chest x-ray

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IAPB

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IABP
•Inflation at
the onset of
diastole
•Deflation
occurs just
prior to the
onset of
systole

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IABP
•Trigger:
●
patient’s ECG signal, patient’s arterial waveform or intrinsic
pump rate
•The most common method:
●
triggering  R wave of the patient’s ECG signal
●
balloon inflation  start in the middle of the T wave
●
balloon deflate  prior to the ending QRS complex
•Balloon synchronization:
●
starts usually at a beat ratio of 1:2

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IABP
•inflation is too early or deflation too late:
–results in an increase in afterload
–ventricular emptying is incomplete
•inflation is too late or deflation is too early:
–diastolic augmentation is suboptimal

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Weaning of IABP/
Decreasing inotropic support
Decreasing pump ratio
• weaning from the IABP: gradually decreasing the balloon
augmentation ratio under control of hemodynamic stability
●
Decrease assist ratio from 1:1 to 1:2 and so on until
minimum assist ratio is achieved
●
The first decrease in assist should be maintained for up
to 4-6 hours (minimum 30 minutes)
• After appropriate observation at 1:8 counterpulsation, the
balloon pump is removed.

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IABP/complications
•Limb ischemia
–Thrombosis
–Emboli
•Bleeding and insertion site
–Groin hematomas
•Aortic perforation and/or dissection
•Renal failure and bowel ischemia
•Neurological complications including paraplegia
•Heparin induced thrombocytopenia
•Infection

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IABP/Complications

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IABP Removal
•Discontinue heparin six hours prior
•Check platelets and coagulation factors
•Deflate the balloon
•Apply manual pressure above and below IABP
insertion site
•Remove and alternate pressure to expel any clots
•Apply constant pressure to the insertion site for a
minimum of 30 minutes
•Check distal pulses frequently