Cardiac surgery
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY
PTCA is a technique used for the treatment of CAD. A balloon-tipped
catheter is introduced through a guide wire into a coronary vessel with a
noncalcified atheromatous lesion. The balloon of the catheter is then
inflated, causing disruption of the intima and changes in the atheroma. The
result is an increase in the diameter of the lumen of the coronary vessel (as
judged by angiographic criteria) and improvement of blood flow below the
lesion. Balloon inflation and deflation may be repeated until satisfactory
results are achieved.
Indications

The decision of whether to perform PTCA is based on an assessment
of the potential benefits as compared with the associated risks of the
procedure.
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
Associated risks are based on both technical and clinical factors.
Technical factors are related to the type of atherosclerotic lesion the
patient has, the number of vessels involved, and the patient's ejection
fraction. The clinical risks include age over 65, female gender,
unstable angina (UA), and heart failure.

Patients meeting these criteria are generally acceptable candidates for
PTCA:
o
Stable angina (less than 1 year) or unstable angina (less than 6
months), despite optimal medical therapy.
o
Single-vessel or multivessel disease (balloon dilatation of the
most severe culprit lesion is initially attempted to determine if
successful angioplasty can be achieved); surgery to bypass the
lesion may be recommended if PTCA is unsuccessful.
o
Proximal, accessible noncalcified lesions; midvessel lesions
may also be attempted with success.
o
Suitable candidate for heart surgery and has consented to heart
surgery as an alternative treatment.
o
Evolving MI (may be in combination with thrombolytic
therapy) and obstructed coronary bypass grafts.
Contraindications

Left main coronary artery involvement

Severe left ventricular dysfunction
Complications

Coronary occlusion, coronary dissection, MI, coronary artery spasm,
and prolonged angina may necessitate immediate coronary artery
bypass graft (CABG) surgery. A cardiac surgical team must be on
standby during PTCA procedures.

Restenosis can occur as a result of the combination of elastic recoil
and neointimal hyperplasia as a response to arterial injury during
revascularization. PTCA is associated with a restenosis rate of 30% to
40%. Restenosis rates vary depending on the location of the lesion,
length of the lesion, percentage of stenosis that existed before and
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after angioplasty, and diameter of the artery involved in the PTCA
procedure. Restenosis may occur acutely (within 24 hours) or within 6
months. A second angioplasty may be performed with improved longterm results.
Other Procedures


Laser-assisted balloon angioplasty
o
A laser light is directed by a percutaneously inserted flexible
fiber-optic catheter and can vaporize atheromatous lesions in
the coronary vessels.
o
Balloon angioplasty of the vessel may then be performed.
o
This new technique may minimize damage to the intimal lining,
open diseased vessels more effectively, prevent early and longterm restenosis, and expand the use to calcified, unusual lesions
and total occlusions.
o
The most important complication of laser-assisted balloon
angioplasty involves minor to major coronary dissection of the
treated lesion.
o
Limitations of laser-assisted angioplasty are related to the high
cost of the laser and the rate of greater than 40% restenosis after
the procedure.
Coronary atherectomy
o
Atheromatous plaque deposits are removed by the atherectomy
catheter rather than being compressed or fractured or by
stretching the artery as with PTCA or balloon angioplasty.
o
Atherectomies permit more controlled vascular injury and
decreases the degree of arterial mural stretch that can occur
with PTCA and balloon angioplasty.
o
The removal of plaque by means of atherectomy creates a
smooth surface by changing plaque into microscopic debris,
thereby opening the diseased vessel more effectively, especially
in patients who have coronary lesions not amenable to standard
angioplasty.
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
o
Complications associated with atherectomy.
o
Vascular spasm can occur at the site of plaque removal or distal
to the treated site.
o
Elevations of CK-MB postpercutaneous intervention can be an
indication of myocardial necrosis.
o
Vessel perforation is an infrequent but devastating complication
of atherectomy devices caused by the atherectomy catheter
cutting into a normal vessel wall, extending into the adventitia.
o
Groin complications and groin bleeding are more common with
atherectomy procedures due to the size of the catheters
involved.
Intracoronary stenting
o
Initially, stents (tiny coil or diamond mesh tubular devices)
were invented to provide structural support to an artery, to
prevent vasoconstriction, and to prevent or treat arterial wall
dissections. Stents are becoming easier and safer to place by
means of PTCA. The major complications of coronary stents
are thrombotic occlusion (a potentially life-threatening
complication that can result in death), and stent restenosis.
However, coated stents may prevent occlusion.
Nursing Diagnoses

Anxiety related to impending invasive procedure

Decreased Cardiac Output related to dysrhythmias, vessel restenosis,
or spasm

Risk for Injury (bleeding) related to femoral catheter and effect of
anticoagulant and/or thrombolytic therapy

Acute Pain related to invasive procedure or myocardial ischemia
Nursing Interventions
Reducing Anxiety

Reinforce the reasons for the procedure.
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
o
Describe the location of the coronary vessels using a diagram of
the heart.
o
Describe/draw the location of the patient's lesion using heart
diagram.
Explain the events that will occur before, during, and after the
procedure. Preparation minimizes anxiety and increases compliance
with care regimen.
o
Performed in the cardiac catheterization laboratory; similar to
the cardiac catheterization procedure. Review auditory and
tactile stimuli.
o
Mild sedation given; patient remains awake throughout
procedure to report any chest pain (indicates myocardial
ischemia) and to cough when instructed (enhances catheter
placement).
o
Medication (nitroglycerin) will be given prophylactically to
prevent and relieve episodes of chest pain.

Prepare patient for complications of procedure. Provide preoperative
teaching to patient and family regarding heart surgery .

Explain the necessity of the I.V., ECG monitoring, frequent vital sign
and groin checks, and remaining NPO before the procedure.
Maintaining Adequate Cardiac Output

Check vital signs every 15 minutes for 1 hour, then every 30 minutes
for 2 hours, and subsequently every 1 to 2 hours.

Continually evaluate for signs and symptoms of restenosis.
o
Emphasize importance of reporting any chest discomfort or
jaw, back, arm pain and/or nausea, abdominal distress.
o
Take ECG for all complaints suspicious of possible myocardial
ischemia.
o
Administer oxygen and vasodilator therapy for pain as directed.
o
Obtain CK and isoenzymes as directed.
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o



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Keep patient NPO if prolonged chest pain occurs (patient may
return to catheterization laboratory).
Administer medications to maintain vessel patency.
o
Antiplatelet agents may be given after procedure to prevent
reocclusion (eg, abciximab [ReoPro]).
o
Low-dose heparin or low-molecular-weight
(enoxaparin [Lovenox]) may also be used.
o
Many patients are then maintained on ticlopidine (Ticlid) or
clopidogrel (Plavix).
heparin
Evaluate fluid and electrolyte balance.
o
Record intake and output.
o
Encourage fluid intake or maintain I.V. fluids until adequate
oral intake occurs to prevent dehydration. Contrast medium
used during procedure causes diuresis.
o
Observe for dysrhythmias possibly related to potassium
imbalance. Excessive diuresis causes potassium depletion.
o
Administer potassium supplement as prescribed.
Be alert to the risk of vasovagal reaction during removal of groin
catheter.
o
Observe for bradycardia, hypotension, diaphoresis, nausea.
o
Administer I.V. atropine as directed.
o
Place patient in Trendelenburg's position to promote blood
return to the heart and improve hypotension.
o
Give fluid challenge as directed.
Preventing Bleeding

Maintain bed rest with affected extremity immobilized and head of
bed elevated no more than 30 degrees 12 to 24 hours after procedure
to prevent catheter dislodgement, bleeding, and prolonged healing of
vessel lining; less restriction if an intra-arterial suture was used.
Cardiac surgery

Mark peripheral pulses before procedure with indelible ink.

Check peripheral pulse of affected extremity and insertion site after
each vital sign check.

Observe color, temperature, and sensation of affected extremity with
each vital signcheck.
o
Catheter remains in the groin 4 to 6 hours after procedure to
avoid bleeding complications (patient remains on
anticoagulants after procedure).

Report if extremities become cool and pale, and pulses become
significantly diminished or absent.

Look for presence of hematoma, and mark hematoma to note change
in size. Report if hematoma continues to enlarge.

Note petechiae, hematuria, and complaints of flank pain (vessel
patency is maintained by not reversing intraprocedure heparinization;
chance of bleeding is increased).

Apply direct pressure over insertion site if bleeding is observed, and
report immediately.

Check bed linen under patient frequently for blood.

Ask patient to report sensation of warmth at groin area.
Relieving Pain

Administer analgesics/anxiolytic medication as directed.

Ensure a restful environment.

o
Provide back rubs for muscle relaxation.
o
Minimize noise and interruptions.
o
Offer sleep medication as indicated.
Progress patient's diet as tolerated (clear liquids/full liquid diet until
catheters removed); assist patient with meals.
Patient Education and Health Maintenance
Instruct patient as follows:
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
Modification of cardiac risk factors as means of controlling
progression of CAD.

Name of medications, action, dosage, and adverse effects.
o
Common medications to prevent clot formation include aspirin,
dipyridamole (Persantine), clopidogrel (Plavix)
o
Medications to increase blood flow to heart such as isosorbide
(Isordil)
o
Medications to slow heart rate and reduce chest pain, such as
metoprolol (Lopressor) or propranolol (Inderal)
o
Medications to increase blood flow and prevent coronary artery
spasm, calcium channel blockers such as diltiazem (Cardizem),
nifedipine (Procardia)

Dates and importance of follow-up tests exercise ECG, thallium 201
perfusion imaging.

Symptoms for which patient should seek medical attention: adverse
effects of medications, chest pain, or weight increases greater than 5
lb (2.3 kg).

Chest pain unrelieved with nitroglycerin and persisting longer than 15
minutes after rest is significant.

Stenosis can recur within 6 months. Second angioplasty is usually
successful for more than 1 year.
Evaluation: Expected Outcomes

Verbalizes understanding of procedure

Vital signs stable; urine output adequate

No bleeding or hematoma at insertion site

Verbalizes relief of pain
HEART SURGERY
Open heart surgery is most commonly performed for CAD, valvular
dysfunction, and congenital heart defects. The procedure requires temporary
cardiopulmonary bypass (blood is diverted from the heart and the lungs and
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mechanically oxygenated and circulated) to provide a dry, bloodless field
during the operation. Newer and less invasive procedures include minimally
invasive direct coronary artery bypass (MIDCAB) and port access
procedures.
Types of Procedures
Coronary Artery Bypass Graft

Traditional CABG surgery involves anastomosis of a graft (leg and
arm veins) anastomosed to the aorta, with the other end of the graft
secured to a distal portion of a coronary vessel. The graft bypasses the
obstructive lesion in the vessel, and adequate blood flow is restored to
the heart muscle supplied by the artery.
o
Multiple grafts can be placed to bypass lesions.
o
Traditional procedure is done through sternotomy.
o
The heart is stopped, and the cardiopulmonary bypass machine
is used.

Primarily done to alleviate anginal symptoms and improve survival.

Indications of CAGB include:

o
Left main coronary artery stenosis of 50% or greater.
o
Proximal vessel disease greater than 50% stenosis of three main
coronary arteries.
o
Multivessel disease and decreased left ventricular function.
o
UA.
o
Chronic stable angina that is lifestyle-limiting and unresponsive
to medical therapies or PTCA and stenting.
Relative contraindications for CABG include:
o
Small coronary arteries distal to the stenosis.
o
Severe aortic stenosis.
o
Severe left ventricular failure with coexisting pulmonary, renal,
carotid, and peripheral vascular disease.
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Valvular Surgery

Prosthetic or biologic valves are placed in the heart as definitive
therapy for incompetent heart valves.

Valve repair or replacement can be done in conjunction with CABG
surgery.

Usually done as open heart procedure through sternotomy incision.

Postoperative care of a patient with either a mitral valve or an aortic
valve is similar to that of a patient who has undergone post-CABG
surgery.
Preoperative Management



Review of patient's condition to determine status of pulmonary, renal,
hepatic, hematologic, and metabolic systems.
o
Cardiac history; history of cardiac dysrhythmias.
o
Pulmonary health: patients with COPD may require prolonged
postoperative respiratory support.
o
Depression: can produce a serious postoperative depressive
state and can affect postoperative morbidity and mortality.
o
Present alcohol intake; smoking history.
Preoperative laboratory studies:
o
CBC; serum electrolytes; lipid profile; and nose, throat, sputum,
and urine cultures.
o
Antibody screen.
o
Preoperative coagulation survey (platelet count, prothrombin
time, partial thromboplastin time): extracorporeal circulation
will affect certain coagulation factors.
o
Renal and hepatic function tests.
Evaluation of medication regimen. These patients are usually taking
multiple drugs.
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

o
Digoxin: may be receiving large doses to improve myocardial
contractility; may be stopped several days before surgery to
avoid digitoxic dysrhythmias from cardiopulmonary bypass.
o
Diuretics: assess for potassium depletion and volume depletion;
give potassium supplement to replenish body stores. May be
omitted several days preoperatively to avoid electrolyte
imbalance and consequent dysrhythmias postoperatively.
o
Beta-adrenergic blockers (propranolol [Inderal]): usually
continued.
o
Psychotropic drugs (diazepam [Valium]; chlordiazepoxide
[Librium]): postoperative withdrawal may cause extreme
agitation.
o
Antihypertensives (reserpine [Serpasil]):omitted as far in
advance of procedure as possible to allow norepinephrine
repletion.
o
Alcohol: sudden withdrawal may produce delirium.
o
Anticoagulant drugs: discontinued several days before
operation to allow coagulation mechanism to return to normal.
o
Corticosteroids: if taken within the year before surgery, may be
given supplemental doses to cover stress of surgery.
o
Prophylactic antibiotics: may be given preoperatively.
o
Drug sensitivities or allergies are noted.
o
If patients are taking herbal supplements, they should be
discontinued as far in advance as possible in order to prevent
interactions with certain types of anesthesia.
Improvement of underlying pulmonary disease and respiratory
function to reduce risk of complications.
o
Encourage patient to stop smoking.
o
Treat infection and pulmonary vascular congestion.
Preparation for events in the postoperative period.
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o
o
o
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Take the patient and family on tour of intensive care unit (ICU).
This lessens anxiety about being in ICU.

Introduce the patient to staff personnel who will be
caring for him.

Give family a schedule of visiting hours and times for
phone contact.
Teach chest physical therapy procedures to optimize pulmonary
function.

Have the patient practice with incentive spirometer.

Show and practice diaphragmatic breathing techniques.

Have the patient practice effective coughing and leg
exercises.
Prepare patient for presence of monitors, chest tubes, I.V. lines,
blood transfusion, ET tube, nasogastric (NG) tube, pacing
wires, arterial line, and indwelling catheter.

Explain to the patient that two chest tubes will be
inserted below incision into chest cavity for drainage and
maintenance of negative pressure.

Explain to the patient that ET tube will prevent speaking,
but communication will be possible through writing until
tube is removed (usually within 24 hours)

Explain to the patient that diet will consist of liquids until
24 hours after surgery.

Explain that monitoring equipment and I.V. lines will
restrict movement, and nursing staff will position the
patient comfortably every 2 hours and as necessary.
o
Discuss with the patient the need to monitor vital signs
frequently and the likelihood of frequent disturbances of the
patient's rest.
o
Discuss pain management with the patient; assure the patient
that analgesics will be administered as necessary to control
pain.
Cardiac surgery
o


Tell the patient that both hands may be loosely restrained for a
few hours after surgery to eliminate possibility of pulling out
tubes and I.V. lines inadvertently.
Evaluation of emotional state to reduce anxieties.
o
Patients undergoing heart surgery are more anxious and fearful
than other surgical patients. (Moderate anxiety assists patient to
cope with stresses of surgery. Low anxiety level may indicate
that the patient is in denial. High anxiety may impair the
patient's ability to learn and listen.)
o
Offer support and help patient and family mobilize positive
coping mechanisms.
o
Answer questions and allay fears and misconceptions.
Surgical preparation:
o
Shave anterior and lateral surfaces of trunk and neck; shave
entire body down to ankles (for coronary bypass).
o
Shower or bathe per policies.
o
Give sedative before going to the operating room if ordered.
GERONTOLOGIC ALERT
Elderly and debilitated patients are at greater risk for postoperative
respiratory complications.
Complications
Complications following cardiac surgery can be divided into early
complications
(cardiovascular,
pulmonary,
renal,
GI,
and
neuropsychological) and late postoperative complications.
Early Complications

Cardiovascular dysfunction or low output syndrome can occur as a
result of decreased preload, increased afterload, arrhythmias, cardiac
tamponade, or myocardial depression with or without myocardial
necrosis.
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
Postoperative bleeding can occur secondary to coagulopathy,
uncontrolled hypertension, or inadequate hemostasis.

Cardiac tamponade results from bleeding into the pericardial sac or
accumulation of fluids in the sac, which compresses the heart and
prevents adequate filling of the ventricles. Cardiac tamponade should
be suspected when there is low CO postoperatively.

Myocardial depression (impaired myocardial contractility), which can
be reversible, occurs secondary as a result of myocardial necrosis in
15% of all CABG surgeries.

Perioperative MI continues to be a serious problem that can occur in
5% of patients with stable angina and up to 10% of patients with UA
postoperatively as a result of the surgical procedure.

Cardiac dysrhythmias commonly occur after heart surgery. Ischemia,
hypoxia, electrolyte imbalances, alterations in autonomic nervous
system, hypertension, increased catecholamine levels, among others,
may attribute to dysrhythmia development.
o
Atrial arrhythmias may occur after CABG or after valvular
surgery; can occur anytime during the first 2 to 3 weeks
postoperatively, but peak incidence is 3 to 5 days.
o
PVCs occur in 8.9% to 24% of patients, most frequently after
aortic valve replacement and CABG.

Hypotension may be caused by inadequate cardiac contractility and
reduction in blood volume or by mechanical ventilation (when the
patient fights the ventilator, or positive end-expiratory pressure is
used), all of which can produce a reduction in CO.

Pulmonary complications occur as a result of intubation and coronary
pulmonary bypass.
o
Continuous pulse oximetry, arterial blood gas (ABG) studies,
and chest X-ray are done frequently in order to monitor
pulmonary function of a patient after heart surgery.
o
Noncardiac pulmonary edema can occur immediately after
surgery and can occur the first several days after surgery as a
result of increased pulmonary capillary permeability.
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o
Pneumothorax can occur anytime postoperatively, especially
when chest tubes are removed.
o
Phrenic nerve damage can occur, resulting in diaphragmatic
paralysis.
o
Pulmonary emboli, although uncommon, can result from atrial
fibrillation, heart failure, obesity, hypercoagulability, and
immobilization.
o
Elderly patients are at increased risk of developing pneumonia,
atelectasis, and pulmonary effusions.

Renal insufficiency or failure can occur as a result of deficient
perfusion, hemolysis, low CO before and after open heart surgery, and
by use of vasopressor agents to increase blood pressure.

GI postoperative complications can include abdominal distention,
ileus, gastroduodenal bleeding, cholecystitis, hepatic dysfunction
shock liver syndrome, pancreatitis, mesenteric ischemia, diarrhea, or
constipation.

Neuropsychological
complications
postoperatively
include
neuropsychological dysfunction, postcardiotomy delirium, and
peripheral neurologic deficits.
Late Complications of Cardiac Surgery

Late complications of cardiac surgery usually occur after the fourth
day of surgery and include postpericardiotomy syndrome, cardiac
tamponade, and incisional wound infections.

Postpericardiotomy syndrome is a group of symptoms occurring
several weeks to months after cardiac and pericardial trauma and MI.
o
The cause of postpericardiotomy syndrome is not certain, but it
may result from anticardiac antibodies, viral etiology, or other
cause.
o
Postpericardiotomy syndrome occurs as the result of tissue
trauma, which triggers an autoimmune response and
inflammation of the pericardial cavity resulting in pericardial
and severe pleural pain.
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o
Manifestations:fever, malaise, arthralgias, dyspnea, pericardial
effusion, and pleural effusion and friction rub.

Cardiac tamponade that occurs as a late complication of cardiac
surgery, 1.3% of patients and is commonly associated with
administration of anticoagulants or antiplatelet therapy, usually
occurring within 2 weeks of surgery.

Wound infections, including sternal wound infections and
mediastinitis, occur in 0.4% to 5% of all patients having cardiac
surgery.
o
Wounds infections usually appear 4 to 14 days postoperatively
with symptoms of fever, leukocytosis, inflammation, and
purulent drainage.
o
Staphylococci organisms are the most common causative
organism.
Other Complications

Postperfusion syndrome: diffuse syndrome characterized by fever,
splenomegaly, and lymphocytosis.

Febrile complications: probably from body's reaction to tissue trauma
or accumulation of blood and serum in pleural and pericardial spaces.

In elderly patients, decreased kidney function can increase the risk of
developing drug toxicities, adverse reactions, and oliguria and renal
failure.
Nursing Responsibilities in Caring for the Cardiac Surgery
Patient in the Immediate Postoperative Period
Priority Interventions Performed by the Critical Care Team on Arrival
■ Attach patient to bedside cardiac monitor and note rhythm.
■ Attach pressure lines to bedside monitor (arterial and pulmonary artery);
level and zero transducers and note pressure values and waveforms.
■ Obtain cardiac output/index and note existing inotropic or vasoactive
drips.
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■ Connect ventilator and auscultate breath sounds bilaterally.
■ Apply end-tidal carbon dioxide (ETCO2) device to ventilator circuit and
note waveform and value (best indicator of endotracheal tube placement).
■ Apply pulse oximetry device to patient and note SpO2 value and
waveform.
■ Check peripheral pulses and perfusion signs.
■ Monitor chest tubes and character of drainage: amount, color, flow. Check
for air leaks.
■ Measure body temperature and initiate rewarming if temperature <96.8°F
(36°C).
Once the Patient Is Determined to Be Hemodynamically Stable
■ Measure urine output and note characteristics.
■ Obtain clinical data (within 30 minutes of arrival).
■ Obtain chest radiograph.
■ Obtain 12-lead electrocardiogram (ECG).
■ Obtain routine blood work within 15 minutes of arrival; tests may include
ABGs, potassium, glucose, PTT, hemoglobin (varies with institution).
■ Assess neurological status.
■ Test pacemaker function by assessing capture and sensing.
Recovering From Cardiac Surgery
General Instructions
■ Avoid lifting heavy objects (10–15 lbs or more) for first 3 months.
■ Avoid strenuous arm movement such as golf or tennis.
When getting in and out of chair or bed, use legs. Arms should not bear
weight and should be used only for balance.
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■ Do not drive for 6 weeks after surgery. (May ride in automobile.)
■ Follow physician’s instructions for activity progression.
■ Resume sexual activity when you can climb two flights of stairs without
stopping (with physician’s recommendations).
■ Use alternative positions for 3 to 4 months to decrease stress on sternum;
avoid side-lying and prone positions.
■ Inspect and cleanse surgical incisions daily with soap and water.
■ Understand medications, including reason for taking, dosage, frequency,
and side effects.
■ Follow dietary restrictions.
■ Understand how much pain to expect and how to manage it.
Risk Factors
■ Follow instructions on individual risk factors, their impact on health after
cardiac surgery, and how to modify them.
■ Seek referrals as appropriate (e.g., for a weight loss program or a smoking
cessation program).
Follow-up With Physician
■ Know how and when to schedule follow-up appointments.
■ Be alert for signs and symptoms of infection, such as fever, increased
redness, tenderness, drainage, or swelling of incisions.
■ Report palpitations, tachycardia, or an irregular pulse (if normally regular)
to the physician immediately.
■ Seek follow-up care if you experience dizziness or increased fatigue,
sudden weight gain or peripheral edema, shortness of breath, or chest pain.
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