presentation on open and close heart surgery

cabg

1. CLOSE HEART SURGERY REHAB BY-MD SALMAN AHMED MPT(NEURO )

2. WHAT IS Closed heart surgery ? Closed heart surgery generally means that the patient will not need to be placed on a heart-lung bypass machine and the heart will not need to be opened up.  reduces the possibility of complications compared to open heart surgery In other cases, closed heart surgery may be the first stage of repair for a defect that will require multiple surgeries Some closed heart surgeries are palliative rather than corrective

3. closed heart surgery the cardiac conditions requiring closed heart surgery are. 1.acquired heart surgery a. mitral stenosis b. aortic stenosis c. PTCA d.pulmonary embolectomy e. PACEMAKER 2.congenital heart disease Patent ductus arteriosus Coarctation of aorta

4. closed heart surgery the cardiac conditions requiring closed heart surgery are. Mitral stenosis   Mitral stenosis  is a narrowing of the  mitral  valve opening that blocks (obstructs) blood flow from the left atrium to the left ventricle. Causes Rheumatic heart disease Lutembacherś syndrome Atherosclerosis Endomyocardial fibrosis

5. Clinical features Pulmonary hypertension Right heart failure Atrial fibrillation Vulvular lesion Investigation x ray Enlarged left atrium Right ventrical Enlarge pulmonary conus Calcification of mitral valve Lung changes like pulmonary oedema ,pulmonary congestion ,pulmonary infarction , ECG Later stage P wave will be absent ECHOCARDIOGRAM Most valuable investigation to diagnose and assess severity of muscle. DIAGNOSTIC Loud first heart sound is heard Murmer heart in the mitral area Backward displacement of left ventricle by the enlarged right ventricle. Diastolic heart murmer

6. Treatment Medical and surgery In mild case- bedrest - Salt free diet - Diuretics like furosemide - Anticoagulants - Surgery Valvotomy making one or more incisions at the edges of the  commissure  formed between the two or three valve leaflets, which relieves the constriction of  valvular stenosis

7. Balloon voloplasty It is a procedure that widens the mitral valve so that blood flows more easily through the heart Advantage Avoid major surgery The restenosed of the valve can be repeated AORTIC STENOSIS NARROWING of the opening of of the aortic valve Reduced blood flow through the aortic valve Back pressure in to the chamber behind the valve    

8. CAUSES - Valvular lesion - subvalvular stenosis - supravalvular stenosis SIGNS pallor cerebral anemia chest pain SYMPTOM Angina Syncope Exertional dyspnea Fatigue Pulmonary oedema Sudden death

9. DIAGNOSIS Pulse =rises slowly and fall slowly Bp –low systolic pressure Systolic murmer Second herat sound is soft and absent INVESTIGATION X RAY NORMAL IN MILD CASES Dilated ascending aorta Aortic valve calcified Left ventricular enlargement ECG Arrhythmia occur ECHO Left ventricular hypertrophy Thickened ,calcified and immobile aortic valve cusps  

10. TREATMENT MEDICAL - Avoid sternous activity - Rest and b blocker for angina Surgical - Ballon dilation of aortic valve - Aortic valve replacement 3- pulmonary thrombectomy   A  pulmonary thrombectomy   is an emergency procedure that removes clotted blood from the pulmonary arteries. Thrombectomies can be surgical or percutaneous. TYPES OF EMBOLECTOMY AND THROMBECTOMY - Catheter-based procedures - Open surgery involves making a large incision in the area of the blood clot through the blood vessel to remove it.

11. Percutaneous coronary intervention (PCI) is performed to open blocked coronary arteries and to restore arterial blood flow to the heart tissue . Coronary Angioplasty

12. Clinical Indications # Acute STEMI # Non–ST-elevation acute coronary syndrome (NSTE-ACS) # Stable angina # Anginal equivalent (eg: dyspnea, arrhythmia, or dizziness or syncope)

13. American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines on the management of unstable angina/non-STEMI recommend that an early invasive approach (angiography and revascularization within 24 hours) should be used to treat patients presenting with the following high-risk features: # Recurrent angina at rest or low level of activity # Elevated cardiac biomarkers # PCI in the past 6 months or prior CABG # New ST-segment depression # Elevated cardiac biomarkers # High-risk findings on noninvasive testing # Signs or symptoms of heart failure or new or worsening # mitral regurgitation # Hemodynamic instability # Sustained ventricular tachycardia # LV systolic function < 40% # High risk score ( eg , Thrombolysis in Myocardial Infarction [TIMI] score >2)

14. Stents Stents are expandable metal tubes that come in various types, such as coils or wire mesh. Stents are usually put into the section of the coronary artery that was made wider by the angioplasty procedure. They are expanded and left there to keep this artery wide. Over time, the lining of the artery grows over the stent, so that the metal support becomes part of the artery wall .

15. Stent Types There are two types of stents: bare metal stents (BMS) and drug-eluting stents (DES). BMS DES

16. Contraindications Absolute contraindications include: -Lack of cardiac surgical support -Critical left main coronary stenosis -without collateral flow from a native vessel or previous bypass graft to the left anterior descending artery Relative contraindications include: -Coagulopathy -Hypercoagulable states -Diffusely diseased vessels without focal stenoses -A single diseased vessel providing all perfusion to the myocardium -Total occlusion of a coronary artery -Stenosis < 50%

17. Complications The main complications of balloon angioplasty and stent placement are: -Thrombosis -Restenosis -Arterial dissection

18. Arterial Dissection

19. Goals

20. Resistance Training PCI patients can begin light resistance training with elastic bands and small hand weights almost immediately for the upper body muscles. Training for lower limb will start when the catheter access site has healed properly. More aggressive resistance training for the PCI patient can be safely initiated 3 weeks (including 2 weeks of endurance activity) post intervention.

21. Resistance training with thera bands.

22. Evidence based Balady and colleagues demonstrated that in patients who had undergone uncomplicated balloon angioplasty, treadmill exercise testing( Bruce protocol) could be performed safely as early as 1-3 days post procedure. The study, performed during the relatively early days of coronary angioplasty demonstrated that such exercise testing could allow physician to recommend patients return to various activities early.

23. Benefits of Physiotherapy Post Coronary Angioplasty Participation in cardiac rehabilitation for post-PCI patients can: #improve functional capacity #improve lipid profile #improve exercise tolerance #decrease morbidity rate #decrease hospital readmission rate #improve sympathovagal balance #improve quality of life #decrease inflammatory biomarkers ( e.g., C-reactive protein )

24. #increase endurance exercise training # reduce risk of restenosis #improve psychosocial outcomes PRECAUTION Gross obesity Chronic chest conditions Transient ischemic attacks Intermittent claudication Poor ejection fraction Heart failure

25. 2.congenital heart disease Patent ductus arteriosus Coarctation of aorta Patent ductus arteriosus -- is a hole that allows the blood to skip the circulation to the lungs. However, when the baby is born, the blood must receive oxygen in the lungs and this hole is supposed to close. If the ductus arteriosus is still open (or patent) the blood may skip this necessary step of circulation. The open hole is called the patent ductus arteriosus . SYMPTOM ASYMPTOMATIC OR EXERTIONAL DYSPNOEA There is a risk of bacterial endocarditis PULMONARY HYPERTENSION INCISION a left postero -lateral thoracotomy ,4 th ics

26. Coarctation of aorta Coarctation of the aorta is a congenital (present at birth) heart defect involving a narrowing of the aorta. he narrowed segment called coarctation can occur anywhere in the aorta, but is most likely to happen in the segment just after the aortic arch The condition can range from mild to severe, and might not be detected until adulthood, depending on how much the aorta is narrowed. Symptoms Irritability Pale skin Sweating Heavy and/or rapid breathing Poor feeding Poor weight gain Cold feet and/or legs Diminished or absent pulses in the feet Blood pressure in the arms significantly greater than the blood pressure in the legs

27. Babies with severe coarctation of the aorta may begin having signs and symptoms shortly after birth. These include: Pale skin Irritability Heavy sweating Difficulty breathing Difficulty feeding

28. Pre-operative period PT may be involved in the overall assessment of the Patient ,particularly exercise tolerance testing from which decision can be made as to whether surgery is possible. OBJECTIVES- 1 FULL ROM AND ADEQUATE CIRCULATION 2 CORRECT POSTURE 3 ADEQUATE VENTILATION 4 GENERAL MOBILITY 5 COUGH EFFECTIVELY 6 DBE

29. Post Thoracotomy Rehab Protocol Physical Therapy and/or Respiratory Therapy following thoracic surgery, providing individualized comprehensive personal care for these patients. The goals of this program are: - To strengthen the shoulder girdle and prevent any negative effects of disuse, i.e. frozen shoulder. - General reconditioning to increase endurance and overall health. - To allow patients to come off their oxygen sooner. - To provide education to effectively manage their condition and maximize their physical and emotional independence. - To minimize loss of function and morbidity associated with thoracic surgery. - To maximize pulmonary function and clearance of secretions. - To wean patients off pain medication more rapidly as their function is restored.

30. POST-OPERATIVE PERIOD following surgery and before each treatment the PT should check the following: POST-OPERATIVE PROBLEM LIST 1 pain 2 poor posture 3 icd in situ 4 decrease air entry 5 retained secretion 6 decrease movement 7 decrease mobility

31. POST-OPERATIVE TREATMENT PLAN DAY 1 1 DBE 2 ACBT 3 TRUNK SHOULDER GIRDLE EXERCISE 4 ACTIVE ANKLE TOE MOVEMENT – SHOULDER ROM DAY 2- MOBILTY Chest treatment given 2-3 time. DAY-3 Postural exercise and general activities should be progressed.