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!!