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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