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Jennifer Jones PhD, MSc, PGCertEd, FNIPC, MCSP
HH2602 / HH5607 Cardiovascular Health
Lecture 12
Surgical Interventions in CVD
Brunel University London
Learning Outcomes
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By the end of this lecture and completion of the accompanying workbook you should be able to: Accurately describe common surgical procedures in the management
of: - Acute coronary syndromes - Valve disease - Chronic heart failure - Cardiac arrthymias - Obesity - Peripheral arterial disease
Identify key post-operative considerations from a physiotherapy
perspective
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Let’s get started…….
Part 1: Acute Coronary Syndromes
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58 yo Man, Chest pain after lunch on the way
to car. Bad sushi?
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Angiogram
Indicates site of occlusion
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Investigations
BHF Investigations
Great video clips on investigations for heart conditions
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Balloon inflates and stent
inserted
Percutaneous Coronary Intervention (PCI)
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Coronary Angioplasty
Balloon inflated Coronary stents inserted in > 90% of cases
Drug eluting stents help reduce the risk of in-stent re-stenosis
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Primary Percutaneous Coronary Intervention
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Physiotherapy Considerations – PCI & PPCI
Length of stay is short Progressive physical activity programme Health behaviour change and education Commencement of cardiac rehabilitation within 10
days Management of underlying lifestyle related and
medical risk factors Restenosis is common
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Indications
Left main stem, severe triple vessel disease
Diffuse CAD
Impaired LV function
Procedure
Incision in sternum
Obstructed arteries bypassed using
>Saphenous vein
>Internal mammary artery
>Radial artery
Coronary Artery Bypass Grafting (CABG)
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Internal mammary artery graft
Vein graft
Left internal mammary artery
Graft to left anterior descending artery
Right coronary artery stenosis
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Problems Associated With CPB
• Whole-body inflammatory response (SIRS)
• ARDS
• RBC damage (anaemia)
• Coagulopathies
• Emboli
• Haemorrhage
• Renal failure
• Peri-operative MI
• Peri-operative CVA (1-3%)
• Arrhythmias
• 42% experience neurocognitive impairment
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Coronary Artery Bypass Grafts
(CABG)
Recovery
3-5 days in hospital
Phase I cardiac rehabilitation > Discharge advice
> No heavy lifting
> sternum takes 12 weeks to heal
> Off work 8-12 weeks
Phase III exercise programme
6-8 weeks
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Octopus
MIDCAB
Endoscopic CABG
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Return of symptoms
Majority have complete relief from angina
Some relief from angina, but may reoccur within a few months or years
Some have no relief from angina but still have a better prognosis
Graft patency
>Vein graft 10 years
>Internal mammary artery grafts (IMAG)
> 25+ years (predicted)
>Radial artery similar to IMAG
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Part 2: Valvular Heart Disease
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67 yo Man, Breathlessness
and swollen ankles
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Echocardiogram
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Mechanical valve
For life
Warfarin for life
Tissue valve
10-15 years
Warfarin for limited period but lifelong aspirin or clopidogrel
Frail older patients not well enough for surgery or with co-morbidities
Transcatheter Aortic Valve Implant (TAVI)
Valvular Disease
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Physiotherapy Perspectives
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Many complications
of cardiac surgery relate to the sternal
incision
Complications of Cardiac Surgery
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Cardiac Surgery Complications
• Pain
• Wound infections/healing
> especially diabetes
• Clicking’ or unstable sternum
• Atrial fibrillation
• Nerve problems e.g. brachial nerve plexus
• Emotional and psychological side effect
>Loss of concentration, memory
>Mood swings
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Pulmonary Specific Problems
IMA harvesting enters pleural space Cold cardioplegia can lead to phrenic
nerve damage CPB can lead to increased capillary
permeability and collapse of lungs during CPB reduction in surfactant
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Aims of Early Physiotherapy
Improve efficiency of ventilation
Improve exercise tolerance
Aid sputum clearance
Reduce breathlessness
Reduce post-op pain
Maintain mobility of sh’s, sh. girdle, spine
and chest wall
Education
Positioning
TEE’s
Out of Bed ASAP Mobilise Stairs
Postural advice Cardiac rehab
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Part 3: Chronic Heart Failure
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Spectrum of HF NYHA I-IV
Meet Alan
• Male age 38
• LVEF 45%
• NYHA 1
• No symptoms
• ETT
∙ 92% HRmax
∙ 10 METs
• Goal – return to the gym but lacks confidence since diagnosis
Meet Jean
• Female age 79
• LVEF 25%
• NYHA III
• Symptoms: fatigue, breathlessness
• FCA – 6 min walk
∙ 420 meters / 2 rest stops
∙ 3 METs
∙ CR-10 RPE 4- 5 (legs 7)
• Goal – ADL and walking
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Implantable devices - Pacemakers
• Pacemakers deliver short pulses of electricity to promote the contraction of the heart muscle
– for bradycardia
– for tachycardia
– for heart failure – biventricular (CRT) pacemakers
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CRT and ICD
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Physiotherapy Considerations
Cardiac function Risk Stratification ICD device thresholds and settings Shock history / associated avoidance behaviour Medications Shoulder limitations Perceived limitations of lifestyle Patient goals Sub-maximal Functional capacity assessment Anxiety and depression
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Cardiac Transplant, VAD and Artificial Heart
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Progress…..
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Survival Rates (%)
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Altered Physiology
surgical denervation Schimdt 2002
altered ventricular function Al-Rawas 2000
altered vascular endothelium Schwaiblmair 1999
pulmonary diffusion changes Braith 1996
accelerated graft vascular disease Tegtbur 2005
reduced bone mineral density Zoll 2008
changes in skeletal muscle morphology McKenzie 2004, Banner 1998
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Bi-Caval technique
Surgical denervation means high resting HR usually around 100–120bpm
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Organ Rejection
Few physical symptoms which are non-specific and include:
Malaise
Fatigue
Lethargy
Low-grade pyrexia
Patients should monitor and report sudden weight changes
& record their temperature daily to check for early signs of an infection
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Grading system for acute cellular rejection
Grade Formula Description
0 R No rejection No change from the 1990 grades
1 R Mild rejection Continue exs,
progress slowly
1990 grades 1A, 1B and 2
Interstitial and/or perivascular infiltrate with up to 1 focus of myocyte damage.
2 R Moderate rejection Continue exs, no
progression
1990 grade 3A
Two or more foci of infiltrate with associated myocyte damage.
3 R Severe rejection Discontinue
exercise
1990 grade 3B and 4
Diffuse infiltrate with multifocal myocyte damage ± oedema ± haemorrhage ± vasculitis.
ISHLT consensus report 2005 (Stewart et. al 2005)
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Life and beyond……
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Mechanical Circulatory Support
MCS
Cardiogenicshock post-MI
Congenital disorders
(Fallot’s tetralogy, Coarctation of the
aorta, Ebstein’s anomaly)
Myocarditis
Post- cardiotomy
Cardiomyopathies
(dilated, viral, familial, post-partum, congenital)
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Indications for VAD use
•Immediately post cardiotomy or other cardiac surgery (short-term device)
•Bridge-to-transplantation
•Bridge-to-recovery
•Destination therapy
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Ventricular Assist Devices
Thoratec VAD and IVAD systems:
> Right, left or bi-ventricular support
> Provides pneumatic drive power via the portable system
> Implantable system designed for longer-term usage
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Thoratec BiVAD
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Heartmate® XVE & II LVAS
Pulsatile Apulsatile
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Temporary Total Artificial Heart
2012 Alice Hipkiss in USA
228 days with artificial
heart awaiting a transplant
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Physiotherapy considerations
Underlying condition
Level of support provided from the VAD (fixed pump speeds) and current circulating volume
Other devices; CRT +/or ICD
May have sternotomy scar
Limited ability to monitor changing cardiovascular function
Rely more on subjective markers, observation and RPE (but little evidence for use of Borg with VADs)
Drive line insertion will limit trunk ROM
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Part 4: Surgical Interventions in Obesity
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Sleeve gastrectomy
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Part 5: Surgical Interventions in PAD
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Look familiar…..?
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Part 6: Exercise Training!!!!
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Exercise Training
Anti-
atherosclerotic
Psychological Anti-thrombotic Anti-Ischaemic Anti-arrhythmic
Improved lipids Depression Platelet adhesiveness
Myocardial O2 demand
Vagal tone
Blood pressure Stress Fibrinolysis Coronary blood flow
Heart rate variability
Adiposity Social support
Fibrinogen Endothelial dysfunction
Adrenergic activity
Insulin sensitivity
Blood viscosity Endothelial progenitor cells
(EPC’s)
Inflammation Circulating angiogenic cells
Nitric oxide
Franklin and Gordon, 2009 ISBN: 978-1-935103-19-6
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Exercise Training
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ACS Post PCI/PPCI/CABG/OPCAB/MIDCAB
Valve Disease Valve repair replacement / TAVI
Devices for Rhythm Disturbances CRT / ICD / Pacemaker
Devices CRT / ICD / Pacemaker
Chronic Heart Failure Cardiac Transplant / LVAD / TAH
PAD Bypass, Stenting etc
Gastric Surgery Gastric banding / Roux-en-Y / Sleeve gastrectomy Duodenal switch surgery
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Exercise is one of the most powerful medicines available!
BUT….. for many a bitter pill to swallow!
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Thank you for listening