Transcript THE LATEST ON OPEN HEART CABG AND VALVE SURGERY

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 PATIENTSDOES 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
CABG & PCI: Historical Pro & Cons
+ Cost effective
+ Fast recovery
+ Reduced acute
complications
- Increased
restenosis
- Repeat
revascularization
P C I
C A B G
+ Angina relief
+ Reduced
re-intervention
+ Complete
revascularization
- High costs
- Invasive
The pros and cons of CABG historically outweighed those of PCI
Evolution of Revascularization
+ Improved
technique
+ Improved stent
design
+ DES
- Increased restenosis
- Repeat
revascularization
?
+ Off pump
technique
+ Less invasive
approach
+ Increased arterial
revascularization
+ Optimal
perioperative
monitoring
- High costs
- Invasive
- Recovery time
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 SURGERY
ON 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
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BENEFITS

Fewer complications
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Less blood loss or need for
tranfusion
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Shorter hospital stay
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Faster recovery
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Higher pt satisfaction
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Less scarring
ROBOTIC CABG
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RISKS

RISKS

INJURY TO TISSUES/ORGANS


BLEEDING
Pain from use of air or gas in the
procedure
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INTERNAL SCARRING
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
EQUIPMENT FAILURE
Nerve injuryphrenic/diaphragmatic
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
HUMAN ERROR
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?
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

PREVALENCE:

Valve disease is present in 2.5 % of the
population and more common in the
elderly >75 yrs of age
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PRESENT TREATMENTS:

Medical Management with BB, CB, ACE
and ARBS along with diuretics
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Balloon valvuloplasty
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Surgical repair/replacement
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TAVR for severe aortic stenosis
MITRAL VALVE REPAIR vs
REPLACEMENT
Repair is the gold standard
Can use minimally invasive – 4-6 inch incision
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Preoperatively
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ECHO/stress or 2D
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Cardiac angiogram

CT of chest or cardiac MRI for
morphology and function
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Carotid US

Dental Clearance
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Labs/xrays

PFT’s
MITRAL VALVE REPLACEMENT
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PREOP TESTS/Same as with repair
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As with repair to discuss with surgeon
possibility of MAZE procedure and LAA
clip to prevent CVA incidence;
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Postoperatively
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See postop in 7-10 days for suture
removal
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Post op instructions
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Medication including
amiodarone/Coumadin
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INR 2-3
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3 month 5 day holter monitor
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If no afib stop the amiodarone
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6-12 wk later holter for 5 days
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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
Generally repair done only in the “bigger CV
institutions such as CCF, Northwestern,
Loyola etc
Most AVR’s done in CV hospitals

Preop op requirements same as with
the Mitral Valves

D/W surgeon the type of valve

Mechanical-metal

Bioprosthetic- pig or cow valve
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Homograft-cadaver valve frozen

Ross valve- pulmonic valve to aortic
and then place a homograft in the
pulmonic valve
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
Operative risk score > 8 %
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FDA approved for select pts
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15 % risk of mortality


EF < 20 %
Used in high-risk, inoperable pts with
AS.
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RISKS: May need open procedure
emergently
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Usually elderly with many co
morbidities

Death from damage to heart during the
procedure


Stroke, bleeding or ruptured Aorta
COST: the Edward Sapien Valve costs
around $30,000 ( balloon expansion).

Medtronic now has a CORE Valve(selfexpanding)
TAVR
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)

Where presently done?

Northwestern

Edward

Christ

Loyola
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
SURGERY
DENTAL 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
SURGERIES
EARLY EXTUBATION
EARLY GLUCOSE CONTROL
EARLY AMBULATION
EARLY EXTUBATION
NATIONAL GOAL PER STS
CDH GOAL
EARLY GLUCOSE CONTROL
WHY 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 AMBULATION
DOES 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!!