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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 BENEFITS Fewer complications Less blood loss or need for tranfusion Shorter hospital stay Faster recovery Higher pt satisfaction Less scarring ROBOTIC CABG RISKS RISKS INJURY TO TISSUES/ORGANS BLEEDING Pain from use of air or gas in the procedure INTERNAL SCARRING EQUIPMENT FAILURE Nerve injuryphrenic/diaphragmatic 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 PRESENT TREATMENTS: Medical Management with BB, CB, ACE and ARBS along with diuretics Balloon valvuloplasty Surgical repair/replacement TAVR for severe aortic stenosis MITRAL VALVE REPAIR vs REPLACEMENT Repair is the gold standard Can use minimally invasive – 4-6 inch incision 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 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 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 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 % FDA approved for select pts 15 % risk of mortality EF < 20 % Used in high-risk, inoperable pts with AS. RISKS: May need open procedure emergently 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!!