objectives 1. review normal physiology of cardiac vessels and valves 2. contrast when cpi vs cabg is...
TRANSCRIPT
OBJECTIVES
1. REVIEW NORMAL PHYSIOLOGY OF CARDIAC VESSELS AND VALVES
2. Contrast when CPI vs CABG is needed
3. DISCUSS TYPES OF CPI/CORONARY ARTERY BYPASS TECHNIQUES AVAILABLE
4. REVIEW PRE AND POST OP CARE
5. DISCUSS POSSIBLE COMPLICATIONS AFTER CABG/VALVE SURGERY
6.IDENTIFY THE NEED FOR PRE/POST OP TEACHING ESPECIALLY PATIENTS SENT HOME ON COUMADIN OR INSULIN/ORAL AGENTS
7.FOLLOW UP CALLS TO PATIENTS- DOES IT REALLY MAKE A DIFFERENCE
No disclosure or conflicts
THE LATEST ON OPEN HEART CABG AND VALVE SURGERY
WHATS OLD AND WHATS NEW OUT THERE?
By Arlene Meyer RN APN-BC FNP-BC CCRN-BC
Coronary Artery Disease
Heart disease is the #1 killer in the US
We are diagnosing heart disease more frequently due to better testing, improved sensitivity and increased awareness
As a nation, we have too much obesity and lack of physical activity, risk factors for the development of coronary artery disease
+Angina relief+Reduced
re-intervention+Complete
revascularization
High costs Invasive
+Cost effective +Fast recovery+Reduced acute
complications
- Increased restenosis
- Repeat revascularization
P C I C A B G
The pros and cons of CABG historically outweighed those of PCI
CABG & PCI: Historical Pro & Cons
Evolution of Revascularization
+Off pump technique
+Less invasive approach
+Increased arterialrevascularization
+Optimal perioperative monitoring
+Improved technique
+Improved stent design
+DES P C IC A B G
High costs Invasive Recovery
time
- Increased restenosis
- Repeat revascularization
?
Over the last decade, the standard of care for both CABG and PCI has continuously improved, leveling the playing field.
Drug Eluding Stent vs Bare Metal Stent
DES BMS
TRADITIONAL CABG SURGERYON PUMP/OFF PUMP/BEATING HEART: WHATS THE DIFFERENCE
MINIMALLY INVASIVE OR MIDCAB (minimally invasive direct coronary artery bypass) -ON PUMP VS OFF PUMP
How do surgeons perform surgery on a beating heart?a stabilization system is used to steady only the portion of the heart where the surgeon is operating. A stabilization system avoids use of the heart-lung machine by making it possible for the surgeon to carefully work on the patient's heart while it continues to beat.
Potential Patient Benefits of Minimally Invasive Bypass Surgery
• Restoring adequate blood flow and normal delivery of oxygen and nutrients to the heart.
• Smaller incisions• Shorter length of stay. Patients may experience
less pain and may have a better ability to cough and breathe deeply after the operation so they are often discharged from the hospital in 2 to 3 days, compared to the typical 5 to 10 days for conventional CABG surgery.
• Faster recovery: Avoidance of the heart-lung machine and the use of smaller incisions may reduce the risks of complications such as stroke and renal failure so that patients can return to their normal activities in 2 weeks rather than the typical 6 to 8 weeks with conventional surgery.
• POTENTIAL BENEFITS FROM MINIMALLY INVASIVE CABG
• Less bleeding and blood trauma: Any time blood is removed from the body and put into the heart-lung machine, the patient must be put on anticlotting medications or given "blood products". Artificial circuits such as the CPB can also damage blood cells.
• Lower infection rate: A smaller incision means less exposure and handling of tissue, which may reduce the chances of infection.
• Less cost: The cost of minimally invasive cardiac surgery may be approximately 25% less than the cost of conventional surgery.
Who is a candidate for MIDCAB,or Minimally Invasive CABG?
High risk patients – including those with vascular disease, S/P CVA, calcified aorta’s, carotid artery disease, kidney disease, or over age 70
ROBOTIC CABG USING DI VINCI ROBOT
With the Di Vinci system surgeons operate through a few small incisions between the ribs.
CPB is not needed
Uses 3D HD vision and special wristed instruments that bend and rotate
BENEFITS
Fewer complications
Less blood loss or need for tranfusion
Shorter hospital stay
Faster recovery
Higher pt satisfaction
Less scarring
ROBOTIC CABG
RISKS
INJURY TO TISSUES/ORGANS
BLEEDING
INTERNAL SCARRING
EQUIPMENT FAILURE
HUMAN ERROR
RISKS
Pain from use of air or gas in the procedure
Nerve injury-phrenic/diaphragmatic
Longer time for surgery
May still need to convert to open procedure
Prolonged anesthesia time
So now that I know all about CABG surgery but what if I
SO NOW THAT I KNOW ALL ABOUT CABG SURGERY WHAT IF I HAVE A LEAKY OR STENOTIC VALVE
WHAT IS VALVE DISEASE?
PREVALENCE:
Valve disease is present in 2.5 % of the population and more common in the elderly >75 yrs of age
PRESENT TREATMENTS:
Medical Management with BB, CB, ACE and ARBS along with diuretics
Balloon valvuloplasty
Surgical repair/replacement
TAVR for severe aortic stenosis
Stenotic valve. Ristricted opening or narrowing of the valve
Regurgitation: Valve doen not close properly cause the blood to flow backward.
Most often this problem is with the mitral and aortic valves
CAUSE: May be congenital or caused by endocarditis, CAD, CM, HTN or aneurysms
MITRAL VALVE REPAIR vs REPLACEMENT Preoperatively
ECHO/stress or 2D
Cardiac angiogram
CT of chest or cardiac MRI for morphology and function
Carotid US
Dental Clearance
Labs/xrays
PFT’s
Repair is the gold standard
Can use minimally invasive – 4-6 inch incision
MITRAL VALVE REPLACEMENT
PREOP TESTS/Same as with repair
As with repair to discuss with surgeon possibility of MAZE procedure and LAA clip to prevent CVA incidence;
Postoperatively
See postop in 7-10 days for suture removal
Post op instructions
Medication including amiodarone/Coumadin
INR 2-3
3 month 5 day holter monitor
If no afib stop the amiodarone
6-12 wk later holter for 5 days
If no afib stop the coumadin
Determine type of valve for replacement
Mechanical- positive and negative
Bioprosthetic –positive and negative
Homograft
+/- afib; may include MAZE procedure and LAA clip to reduce risk of blood clots/CVA
AORTIC VALVE REPAIR/ REPLACEMENT
Preop op requirements same as with the Mitral Valves
D/W surgeon the type of valve
Mechanical-metal
Bioprosthetic- pig or cow valve
Homograft-cadaver valve frozen
Ross valve- pulmonic valve to aortic and then place a homograft in the pulmonic valve
Generally repair done only in the “bigger CV institutions such as CCF, Northwestern, Loyola etc
Most AVR’s done in CV hospitals
Types of valves Bioprosthetic/homograft/mechanical
TAVI AORTIC VALVE REPLACEMENT Enables a placement of a balloon
expandable Aortic heart valve into the body via a catheter-based transfemoral or transapical delivery system.
Offered to pts in whom the traditional open heart surgery is too risky
FDA approved for select pts
Used in high-risk, inoperable pts with AS.
Usually elderly with many co morbidities
COST: the Edward Sapien Valve costs around $30,000 ( balloon expansion).
Medtronic now has a CORE Valve(self-expanding)
Operative risk score > 8 %
15 % risk of mortality
EF < 20 %
RISKS: May need open procedure emergently
Death from damage to heart during the procedure
Stroke, bleeding or ruptured Aorta
TAVR Where presently done?
Northwestern
Edward
Christ
Loyola
Small incision on leg or between the pts ribs. Catheter then inserted in the artery and led through the body to the heart.
When reaches the aortic valve the catheter is inflated ( done on beating heart)
What about the pulmonic or tricuspid valves?
Tricuspid valves are not usually an issue. The right side of the heart is a low pressure system, whereas the left side tends to be more high pressure. The pulmonic valve can be used in a Ross procedure to be placed in the aortic position and a homograft then placed in the pulmonic position ( aortic and mitral valves are part of the left heart)
REQUIREMENT PRIOR TO VALVE SURGERYDENTAL CLEARANCE CARDIAC ANGIOGRAM
CT CHEST WITHOUT CONTRAST DISCUSS TYPE OF VALVE NEEDED
TEE/TTE MRSA TEST
+ or – STRESS ECHO OTHER LABS/DIAGNOSTICS
POST OP COMPLICATIONS+STROKE +INFECTION
+MI +ATRIAL FIBRILLATION/SVT
+DVT +HYPERGLYCEMIA/HYPOGLYCEMIA
+BLEEDING +OTHERS
THANK YOU!
INITIAL DRUGS TO USE FOR AFIB/RVR
LONGER TERM MEDICATIONS- AMIODARONE/COUMADIN
INR EXPECTATIONS
LATER FOLLOW UP’S
POST OP CARE
• DRIPS – INOTROPES/PRESSORS
• INSULIN? Even if not diabetic?
• BETA BLOCKERS/CCB
• ACEi
GOALS FOR CABG AND VALVE SURGERIESEARLY EXTUBATION
EARLY GLUCOSE CONTROL
EARLY AMBULATION
EARLY EXTUBATIONNATIONAL GOAL PER STS
CDH GOAL
EARLY GLUCOSE CONTROLWHY CHECK THE A1C?
CORTISOL AND ITS RELATIONSHIP TO CREATE HYPERGLYCEMIA
WHY INSULIN GTT AND THEN SQ INSULIN?
WHY INSULIN OR ORAL AGENTS UPON D/C WHEN NOT A DIABETIC PREOP
EARLY AMBULATIONDOES IT REALLY MATTER IF I’M UP AND MOVING AROUND WHEN I’D RATHER JUST STAY IN BED? I’D RATHER JUST STAY IN BED BECAUSE I ‘HURT’
PAIN CONTROL
OK, MY PAIN IS UNDER CONTROL BUT NOW I’M CONSTIPATED. HELP!!
• STOOL SOFENERS- COLACE/SENAKOT/METAMUCIL AND OTHERS
• ACTIVITY
• GOOD OLE PRUNE JUICE
• FLUIDS?
I’M READY TO GO HOME. NOW WHAT?SNF/SHORT TERM NURSING FACILITY/REHAB HOSPITAL OR HOME? WHICH IS BEST FOR ME?
WHEN DO I SEE THE DR/APN POST OP?
WHEN DO I SEE MY CARDIOLOGIST/PCP?
WHO ORDERS REFILLS OF MEDICATION
WHO MONITORS MY COUMADIN DOSING
TEACHING NEEDS
DIET? COUMADIN/INR?
DAILY WEIGHTS? HOLTER MONITORING?
DIURETICS? K+? SEX?
DRIVING? INCISION CARE/WHEN IS MY STERNUM STABLE?
FOLLOW UP CALLS TO PATIENTS
CNS VISITS
APN OR NURSE NAVIGATOR CALLS PATIENTS- WHAT KIND OF THINGS CAN ONE “CATCH” BEFORE A PROBLEM ENSUES
WT GAIN/ELEVATED GLUCOSES/PAIN CONTROL/CONSTIPATION/CHF/PLEURAL EFFUSIONS? DECREASED OXYGENATION DUE TO EFFUSION OR PE?
QUESTIONS?
THANK YOU!!