cardiac surgery

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Nursing management of patient with surgical conditions of the heart:

Nursing management of patient with surgical conditions of the heart

Open-Heart Surgery :

Open-Heart Surgery Open-heart surgery is any kind of surgery in which a surgeon makes a large incision (cut) in the chest to open the rib cage and operate on the heart. "Open" refers to the chest, not the heart. Depending on the type of surgery, the surgeon also may open the heart. The chest is opened and surgery is done on the heart muscle, valves, arteries, or other parts of the heart

Off-Pump Heart Surgery :

Off-Pump Heart Surgery Surgeons also use off-pump, or beating heart, surgery to do CABG. This approach is like traditional open-heart surgery because the chest bone is opened to access the heart. However, the heart isn't stopped, and a heart-lung bypass machine isn't used.Off -pump heart surgery isn't right for all patients. considering heart problem, age, overall health, and other factors, surgeon decides the type of surgery

Off pump heart surgery:

Off pump heart surgery

Minimally Invasive Heart Surgery :

Minimally Invasive Heart Surgery For minimally invasive heart surgery, a surgeon makes small incisions (cuts) in the side of the chest between the ribs. This type of surgery may or may not use a heart-lung bypass machine. Minimally invasive heart surgery is used to do some bypass and maze surgeries. It's also used to repair or replace heart valves, insert pacemakers or ICDs, or take a vein or artery from the body to use as a bypass graft for CABG. One type of minimally invasive heart surgery that is becoming more common is robotic-assisted surgery.

Closed heart surgeries:

Closed heart surgeries In this chest is not open.Some of them include Closed mitral valvotomy ASD closure PDA closure

Coronary artery bypass surgery :

Coronary artery bypass surgery History The first coronary artery bypass surgery was performed in the United States on May 2, 1960,  by a team led by Dr. Robert Goetz and team

Coronary artery bypass surgery:

Coronary artery bypass surgery   coronary artery bypass graft  ( CABG )  surgery , and colloquially  heart bypass  or  bypass surgery  is a surgical procedure performed to relieve  angina and reduce the risk of death from coronary artery disease.  Arteries or veins from elsewhere in the patient's body are grafted to he   coronary arteries  to bypass atherosclerotic   narrowings  and improve the blood supply to the  coronary circulation supplying the myocardium

Indications :

Indications Class I indications for CABG from the American College of Cardiology (ACC) and the American Heart Association (AHA) are as follows   : Left main coronary artery stenosis >50% Stenosis of proximal LAD and proximal circumflex >70% 3-vessel disease in asymptomatic patients or those with mild or stable angina 3-vessel disease with proximal LAD stenosis in patients with poor left ventricular (LV) function 1- or 2-vessel disease and a large area of viable myocardium in high-risk area in patients with stable angina >70% proximal LAD stenosis with either ejection fraction < 50% or demonstrable ischemia on noninvasive testing Other indications for CABG include the following: Disabling angina (Class I)

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Ongoing ischemia in the setting of a non–ST segment elevation MI that is unresponsive to medical therapy Poor left ventricular function but with viable, nonfunctioning myocardium above the anatomic defect that can be revascularized CABG may be performed as an emergency procedure in the context of an ST-segment elevation MI (STEMI) in cases where it has not been possible to perform percutaneous coronary intervention (PCI) or where PCI has failed and there is persistent pain and ischemia threatening a significant area of myocardium despite medical therapy.

CONDUITS IN CABG:

CONDUITS IN CABG

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Age Urgency Others Anatomy Size Length Pedicle vs free Experience Anti spastic protocol

Conduit options:

Conduit options Arterial conduits Autologous Internal thoracic artery Radial artery Right gastroepiploic artery Inferior epigastric artery Splenic artery Gastroduodenal artery Left gastric artery Intercostal artery 7 Non autologous Bovine internal thoracic artery

Internal mammary artery:

Internal mammary artery

Rt Gastro epiploic artery:

Rt Gastro epiploic artery

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Venous conduits Autologous Greater saphenous vein Short (lesser) saphenous vein Upper extremity veins (cephalic and basilic ) Nonautologous Umbilical vein Greater saphenous vein homografts

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Synthetic conduits ePTFE Dacron Biologic prosthesis Tissue-engineered grafts Synthetic biomaterials and polyurethanes

Types of Coronary Artery Bypass Grafting :

Types of Coronary Artery Bypass Grafting Traditional Coronary Artery Bypass Grafting Traditional CABG is used when at least one major artery needs to be bypassed. During the surgery, the chest bone is opened to access the heart. Medicines are given to stop the heart; a heart-lung bypass machine keeps blood and oxygen moving throughout the body during surgery. This allows the surgeon to operate on a still heart. After surgery, blood flow to the heart is restored. Usually, the heart starts beating again on its own. Sometimes mild electric shocks are used to restart the heart.

Off-Pump Coronary Artery Bypass Grafting :

Off-Pump Coronary Artery Bypass Grafting This type of CABG is similar to traditional CABG because the chest bone is opened to access the heart. However, the heart isn't stopped, and a heart-lung bypass machine isn't used. Off-pump CABG sometimes is called beating heart bypass grafting.

Minimally Invasive Cardiac Surgery,:

Minimally Invasive Cardiac Surgery , also known as  MICS CABG  (Minimally Invasive Cardiac Surgery/Coronary Artery Bypass Grafting) or  The McGinn Technique  is heart surgery performed through several small incisions instead of the traditional open-heart surgery that requires a median sternotomy  approach. MICS CABG is a beating-heart multi-vessel procedure performed under direct vision through an aterolateral mini- thoracotomy

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The McGinn Technique (Proximal Anastomoses ) The McGinn Proximal Technique is performed with blood pressure lowered to 90-100 systolic which reduces stress to the aorta, reducing the risk of damage. A series of tools are used to position and stabilize vessels. The technique uses devices developed by Medtronic® to support the surrounding heart tissues while vital surgery takes place. The devices are managed externally and access the heart through small incisions between the ribs. Pump-assisted beating heart bypass A cannula with a pump and vacuum action is fed up through an artery in the groin to reduce the stress on the heart so that it may still function during the operation. This pump flows at 2-3L per minute to support circulation and eliminates the need for a heart-lung bypass machine.

MID CAB:

MID CAB

MIDCAB in hybrid revascularization :

MIDCAB in hybrid revascularization People with multi-vessel coronary disease, who desire a minimally invasive approach to surgery may be eligible for hybrid bypass. A hybrid approach combines coronary bypass (using the MIDCAB approach) and coronary  stenting .

The procedure:

The procedure MICS CABG is performed through one window incision that stretches 5–7 cm in the 4th intercostal space (ICS). In some cases the thoractomy may be necessary in the 5th ICS instead. A soft tissue refractor is used to allow for greater visibility and access. Two access incisions are also made at the 6th intercostal space and xiphoid process

Procedure - CABG :

Procedure - CABG The patient is brought to the operating room and moved on to the operating table. An anaesthetist places a variety of intravenous lines and injects a analgesic agent (usually  fentanyl ) followed within minutes by an induction agent (usually  propofol ) to render the patient unconscious. An  endotracheal tube is inserted and secured by the anaesthetist and mechanical ventilation is started. General anaesthesia is maintained by a continuous very slow injection of  Propofol . The chest is opened via a median sternotomy  and the heart is examined by the surgeon. The bypass grafts are harvested – frequent conduits are the internal thoracic arteries, radial arteries and  saphenous veins. When harvesting is done, the patient is given heparin to prevent the blood from clotting. In the case of "off-pump" surgery, the surgeon places devices to stabilize the heart. If the case is "on-pump", the surgeon sutures  cannulae  into the heart and instructs the  perfusionist  to start cardiopulmonary bypass (CPB). Once CPB is established, the surgeon places the aortic cross-clamp across the aorta and instructs the perfusionist to deliver  cardioplegia  (a special potassium-mixture, cooled) to stop the heart and slow its metabolism. Usually the patient's machine-circulated blood is cooled to around 84 °F (29 °C )

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One end of each graft is sewn on to the coronary arteries beyond the blockages and the other end is attached to the aorta. The heart is restarted; or in "off-pump" surgery, the stabilizing devices are removed. In cases where the aorta is partially occluded by a C-shaped clamp, the heart is restarted and suturing of the grafts to the aorta is done in this partially occluded section of the aorta while the heart is beating. Protamine  is given to reverse the effects of heparin . Chest tubes are placed in the mediastinal and pleural space to drain blood from around the heart and lungs. The sternum is wired together and the incisions are sutured closed. The patient is moved to the intensive care unit (ICU) to recover. Nurses in the ICU focus on recovering the patient by monitoring blood pressure, urine output and respiratory status as the patient is monitored for bleeding through the chest tubes. If there is chest tube clogging, complications such as cardiac tamponade ,   pneumothorax or death can ensue. Thus nurses closely monitor the chest tubes and under take methods to prevent clogging so bleeding can be monitored and complications can be prevented. After awakening and stabilizing in the ICU (approximately one day), the person is transferred to the cardiac surgery ward until ready to go home (approximately four days).

Totally endoscopic coronary artery bypass surgery:

Totally endoscopic coronary artery bypass surgery Totally Endoscopic Coronary Artery Bypass Surgery (TECAB)  is an entirely endoscopic robotic surgery used to treat coronary heart disease, developed in the very late 1990s. It is an advanced form of Minimally Invasive Coronary Artery Bypass Surgery, which allows bypass surgery to be conducted off-pump without opening the ribcage. The technique involves three or four small holes in the chest cavity through which two robotic arms, and one camera are inserted. TECAB surgery uses the da Vinci tele -robotic Stereoscopic 3-D Imaging system. The system consists of a robotic "slave" system at the bedside. The robot relays its information to an external surgical control unit, where a cardiac surgeon has a three-dimensional view of the chest cavity, and twin-controllers for the robotic arms. The procedure frequently involves grafting of the internal mammary artery to the diseased coronary artery, and therefore does not require external harvesting of blood vessels.

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The internal mammary artery (IMA), which runs along the chest wall, is the blood vessel used for the bypass. It is robotically connected to the coronary artery behind the blockage. As many as three additional bypasses can be placed endoscopically . Robotic TECAB can also be combined with coronary artery stenting . This combination is called a hybrid procedure. During the procedure, the surgeon controls the instruments, which are mounted on robotic arms attached to a console. The procedure can be done while the patient is on a heart-lung bypass machine (with the heart stopped) or while the heart is beating

Benefits Include::

Benefits Include: No splitting of the breastbone Dramatic reduction in pain Lower risk of infection Lower risk of bleeding Reduced ICU and hospital stay Improved postoperative pulmonary function Accelerated recovery/return to activity Improved quality of life Greatly improved cosmetic result

Endoscopic vessel harvesting (EVH):

Endoscopic vessel harvesting  (EVH) It is a surgical technique that may be used in conjunction with coronary artery bypass surgery . The most minimally invasive technique is known as endoscopic vessel harvesting (EVH), a procedure that requires a single 2 cm incision plus one or two smaller incisions of 2–3 mm in length. Each method involves carefully cutting and sealing off smaller blood vessels that branch off the main vessel conduit prior to removal from the body. This practice does not harm the remaining blood vessel network, which heals and maintains sufficient blood flow to the extremities, allowing the patient to return to normal function without noticeable effects.

Important Considerations in Successful Vessel Harvesting:

Important Considerations in Successful Vessel Harvesting The harvested blood vessel must be free from damage to ensure proper long-term function and good patient Specifically, damage can be caused during the procedure by: Extent of thermal injury during the branch division, cutting and sealing Overhandling of the vessel – during and after harvest Overdistension of the vessel – when flushing as part of graft preparation Storage conditions between harvest and graft procedure

Complications:

Complications CABG associated Postperfusion syndrome a transient neurocognitive impairment associated with cardiopulmonary bypass.. Nonunion of the sternum ; internal thoracic artery harvesting devascularizes the sternum increasing risk. Myocardial infarction  due to embolism,  hypoperfusion , or graft failure. Late graft  stenosis , particularly of  saphenous vein grafts due to atherosclerosis causing recurrent angina or myocardial infarction. Acute renal failure  due to embolism or hypoperfusion . Strok e, secondary to embolism or hypoperfusion . Vasoplegic syndrome , secondary to cardiopulmonary bypass and hypothermia

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Pneumothorax Hemothorax Pericardial tamponade Pleural effusion Post-operative  atrial fibrillation Infection at incision sites or sepsis. Deep vein thrombosis (DVT) Anaesthetic complications such as malignant hyperthermia. Keloid scarring Chronic pain at incision sites Chronic stress related illnesses Death

Valve surgeries:

Valve surgeries Closed heart surgery for mitral stenosis (closed mitral valvotomy ) : Closed mitral  valvotomy  (CMV) was the closed heart procedure being done to open up a narrowed mitral valve (mitral  stenosis ) in the yester years. Now it is seldom done and most cases of mitral  stenosis  are treated with balloon mitral  valvotomy . In closed mitral  valvotomy  the surgeon opens the left side of the chest and then the left atrium. He feels the mitral valve and then introduce a Tubbs mitral valve dilator through the apex of the left ventricle. Tip of the dilator is positioned across the narrowed mitral valve, guided by the finger in the left atrium. The device is opened using its handle outside the left ventricle to enlarge the opening of the mitral valve. The finger in the left atrium checks for any mitral regurgitation and the efficacy of the dilatation. Serial dilatations are given if the results are not satisfactory.  

Mitral valve repair:

Mitral valve repair Mitral valve repair  is mainly used to treat  stenosis  or  regurgitation  of the  mitral valve . The techniques of mitral valve repair include inserting a cloth-covered ring around the valve to bring the leaflets into contact with each other ( annuloplasty ) , removal of redundant/loose segments of the leaflets (quadrangular resection), re-suspension of the leaflets with artificial (Gore-Tex) cords. Procedures on the mitral valve usually require a median sternotomy , but advances in non-invasive methods .such as keyhole surgery) allow surgery without a sternotomy . Minimally invasive mitral valve surgery is much more technically demanding and may involve higher risk.

Heart valve repair:

Heart valve repair Heart valve repair  is a surgical technique used to fix defects in heart valves in  valvular heart diseases, and provides an alternative to valve replacement. Valvuloplasty  is the widening of a  stenotic valve using a balloon catheter. Types include: Aortic valvuloplasty  in repair of a stenotic aortic valve Mitral valvuloplasty  in the correction of an uncomplicated mitral

Mitral valve annuloplasty:

Mitral valve annuloplasty Mitral valve annuloplasty  is a surgical technique for the repair of leaking mitral valves. Surgical repair typically involves the implantation of a device surrounding the mitral valve, called an annuloplasty device, which pulls the leaflets together to facilitate co aptation and aids to re-establish mitral valve function.

ANNULOPLASTY:

ANNULOPLASTY

LEAF LET REPAIR:

LEAF LET REPAIR

Robotic mitral valve repair:

Robotic mitral valve repair Through a catheter inserted in the groin, the valve leaflets are clipped together. This technique --  percutaneous  mitral valve repair—is available in Europe but still in clinical trial in the United States. It is a highly specialized technique only available at select hospitals. Early trial results suggest that it may be a beneficial approach for patients who are at high risk from conventional surgery.

Aortic valve repair:

Aortic valve repair Aortic valve repair  is a surgical procedure used to correct some aortic valve disorders as an alternative to aortic valve replacement. Aortic valve repair is performed less often and is more technically difficult than mitral valve repair.

Aortic valvuloplasty :

Aortic valvuloplasty Aortic valvuloplasty  is the repair of a  stenotic aortic valve using a balloon catheter inside the valve. The balloon is placed into the aortic valve that has become stiff from calcium buildup . The balloon is then inflated in an effort to increase the opening size of the valve and improving blood flow.

Valvulotomy :

Valvulotomy Commissurotomy  of cardiac valves is called  valvulotomy .   Commissurotomy is an open-heart surgery that making one or more incisions at the edges of the commissure formed between two or three valves, in order to relieve constriction such as occurs in  valvular stenosis , especially mitral valve stenosis . During this surgery, a person is put on a heart-lung bypass machine. The surgeon removes calcium deposits and other scar tissue from the valve leaflets. The surgeon may cut parts of the valve structure. This surgery opens the valve. It is used for people who have severe narrowing of the valve and aren't good candidates for balloon valvotomy .

Tricuspid valve repair :

Tricuspid valve repair Tricuspid valve repair is used to correct tricuspid regurgitation.

Valve replacement surgery:

Valve replacement surgery It  is a cardiac surgical procedure in which a patient’s diseased valve is replaced by either a mechanical or bioprosthetic valve.it is an open heart surgery and needs the use of cardio- pulmonary bypass machine

Artificial heart valve:

Artificial heart valve An artificial heart valve is a device implanted in the heart of a patient with  valvular heart disease.When one of the four heart valves malfunctions, the medical choice may be to replace the natural valve with an artificial valve. This requires open-heart surgery Mechanical -- made of man-made materials, such as metal (stainless steel or titanium) or ceramic. These valves last the longest, but there will need to take blood-thinning medicine, such as warfarin (Coumadin) or aspirin, for the rest of the life.

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Biological -- made of human or animal tissue. These valves last 12 - 15 years. There may not to take the anticoagulants.

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History 1952- The first ever invented artificial heart valve was designed by Charles A. Hufnagel which was the caged-ball design 1960- On September 21, the first human was implanted with the ball and cage design Binet and associates, started using porcine aortic valves for humans 1969- The Bjork-Shiley valves was the first tilting-disc design to come out 1979-the beleaflet design was introduced which was composed of two semicircular leaflets that shifted open and closed

Approaches :

Approaches Laparoscopy or endoscopy Percutaneous surgery (through the skin) Robot-assisted surgery

Valve types:

Valve types Bioprosthetic/Tissue No lifetime warfarin Less durability Mechanical valve Need for warfarin Better durability

Types :

Types Bioprosthetic valves Heterograft ( xenograft ) Bovine porcine Homograft (allograft) Autograft Pericardial Pulmonary (Ross) Mechanical Caged ball valve Tilting disc valve Bileaflet valve

Heterografts(xenografts) :

Heterografts ( xenografts ) Stentless Porcine Toronto SPV valve, medtronic freestyle valve Stented - facilitate implant , maintain 3D relationship,more physiological flow Porcine Hancock , carpenteir edward s, medtronic Bovine Stented bovine p prosthesis The Hancock M.O. II aortic bioprosthesis (porcine) Carpentier -Edwards Duralex mitral bioprosthesis

Tissue heterograft:

Tissue heterograft Advantages - No need of anticoagulation after 1 st 3 m Little hemolysis Disadvantages Limited ,uncertain durability Cuspal tear Perforation degeneration Rapid deterioration esp children Fibrin depostn Ca++ 10-30% need re op in 10 yr 30-60% need re op in 15 yr Small size have poor hemodynamics

Pericardial heart valves:

Pericardial heart valves The  pericardial heart valve  was invented by Marian Ionescu , a British surgeon working at the General Infirmary in Leeds, England. He created this artificial bioprostheticheart valve as a three-cusp structure made of chemically treated bovine pericardium attached to a Dacron cloth-covered titanium frame.

Bioprosthetic valve:

Bioprosthetic valve Preferred in Pregnancy Bleeding Diathesis Age> 70 years Poor compliance

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Mechanical Heart Valves All the types of mechanical heart valves are still in use today. Usually made of titanium or carbon which makes them strong and very durable

Mechanical valves :

Mechanical valves Caged ball valve Advantages Oldest durabilty upto 40 yr Disadvantages high profile hemolysis high thrombogenecity Poor hemodynamics in small sizes Unique features Occluder travels completely out of the orifice, reduces thrombus & pannus growing from the sewing ring Continuously changing points of contact of the ball reduces the wear & tear in any one area Thrombogenic risk 4-6% / year

Starr Edwards Valve:

Starr Edwards Valve not suitable - for the mitral position in patients with a small left ventricular cavity - for the aortic position in those with a small aortic annulus - those requiring a valve-aortic arch composite graft

Tilting disc valve- monoleaflet :

Tilting disc valve- monoleaflet - Medtronic Hall valve - Omnicarbon (Medical CV) - Monostrut (Alliance Medical Technologies) - Bjork-Shiley valves Adv Good hemodynamics even in small sizes Excellent durability Permit central laminar flow Medtronic hall valve Titanium housing teflon sewing ring carbon coated disc disadv – Anticoagulation mandatory higher risk of thrombosis than cage ball v sudden catastrophic valve thrombosis

Bileaflet valve :

Bileaflet valve Adv – Low bulk - flat profile Less thrombogenicy Central laminar flow two semicircular discs that pivot between open and closed positions No need for supporting struts Good hemodynamics even in small sizes 2 lat ,1 central minor orifice , no chance of sudden catastro thrombosis Disadv - Anticoagulation mandatory risk of thrombosis St. Jude Medical mechanical heart valve Carbomedics Titanium housing Pyrolytic carbon

TTK chitra :

TTK chitra tilting disc valve - metallic housing (cobalt based wrought alloy) - circular disc high molecular weight polyethylene - A polyester suture ring Hemodynamically comparable to other mechanical valves valve related complications are similar

Desired valves :

Desired valves Mechanical valves - preferred in young patients who have a life expectancy of more than 10 to 15 years who require long-term anticoagulant therapy for other reasons (e.g., atrial fibrillation ) Bioprosthetic valves preferred in patients who are elderly have a life expectancy of less than 10 to 15 years who cannot take long-term anticoagulant therapy A bileaflet -tilting-disk or homograft prosthesis is most suitable for a patient with a small valvular annulus in whom a prosthesis with the largest possible effective orifice area is desired.

algorithm for choice of prosthetic heart valve:

algorithm for choice of prosthetic heart valve

Radiologic Identification :

Radiologic Identification Starr-Edwards caged ball valve Radiopaque base ring Radiopaque cage Three struts for the aortic valve; 4 struts for the mitral or tricuspid valve Silastic ball impregnated with barium that is mildly radiopaque (but not in all models)

Importance of TEE :

Importance of TEE higher-resolution image size of vegetation defined more precisely peri annular complications indicating a locally uncontrolled infection (abscesses, dehiscence, fistulas) detected earlier limitation -inability to detect aortic prosthetic-valve obstruction or regurgitation, especially when a mitral prosthesis is present

Valve dysfunction :

Valve dysfunction complication example Role of echo Primary mechanical failure Ball variance Strut fracture Visualize structure, assess gradient & regurgitation Nonstructural dysfunction Pt- prosthesis mismatch pannus Gradient, visualize tissue in & around the sewing ring Bleeding event Intracranial hge Source of embolus, presence & mobility of masses Endocarditis Vegetation, abcess , dehiscence Visualize area around the sewing ring, echo dense / lucent area, perivalvular regurgitation Thrombosis Thrombus impedes opening &closing of occluder mechanism Localize mass, assess gradient, detect regurgitation Embolism stroke Identify & characterize the source of emboli

FIBRINOLYTIC PROTOCOL heart 2007;93:137-142:

FIBRINOLYTIC PROTOCOL heart 2007;93:137-142 2 types of protocol -rescue fibrinolysis (short protocol for unstable pt) - long protocol for stable pt Short protocol - r tPA 10 mg bolus + 90 mg in 90 min or - SK 15lac in 60 min Long protocol -- SK- 5lac u in 20 min f/b 15lac u for 10 hr -- rtPA -- 10 mgbolus f/b 90mg/hr for 9 hrs Urokinase High dose: 4,500 IU/kg/h for 12 h without heparin Low dose: 2,000 IU/kg/h with heparin for 24 h

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If embolic event occurs while the patient is on adequate antithrombotic therapy If on warfarin with INR of 2.0 to 3.0: increase dose to achieve INR of 2.5 to 3.5 If on warfarin with INR of 2.5 to 3.5: add aspirin 50 to 100 mg/d If on warfarin with INR of 2.5 to 3.5, plus aspirin 80 to 100 mg/d: aspirin dose may also need to be increased to 325 mg/d If on aspirin 325 mg/d: switch to warfarin with goal INR of 2.0 to 3.0

Excessive Anticoagulation:

Excessive Anticoagulation vit K 2.5 mg daily until the INR is acceptable fresh frozen plasma Human recombinant factor VIIa , 15 to 19 g/kg (INR >10.0 with bleeding)

Structural Failure of Bioprosthetic Valves:

Structural Failure of Bioprosthetic Valves About 30 % of heterograft bioprosthetic valves and 10 to 20 % of homograft valves require replacement within 10 to 15 years because of structural failure severe regurgitation due to a tear or rupture of one or more of the valve cusps calcified and rigid valves Rarely severe valvular stenosis

Mitral valve replacement :

Mitral valve replacement Mitral valve replacement  is a cardiac surgical procedure in which a patient’s diseased mitral valve is replaced by either a mechanical or bioprosthetic valve. Mitral valve replacement is performed inmitral valve stenosism for blood to flow into the left ventricle, or mitral valve regurgitation in which case blood can leak back into the left atrium and thereby back into the lung Since a mitral valve replacement is an open heart surgical procedure, it requires placing the patient on cardiopulmonary bypass

Aortic valve replacement :

Aortic valve replacement Aortic valve replacement is a procedure in which a patient's failing aortic valve is replaced with an artificial heart valve. The aortic valve can be affected by a range of diseases; the valve can either become leaky (aortic insufficiency / regurgitation) or partially blocked (aortic stenosis ). Current aortic valve replacement approaches include open heart surgery, minimally invasive cardiac surgery (MICS) and minimally invasive, catheter-based ( percutaneous ) aortic valve replacement.

Surgical procedure:

Surgical procedure Aortic valve replacement is most frequently done through a median sternotomy , meaning the incision is made by cutting through the sternum. Once the pericardium has been opened, the patient is put on a cardiopulmonary bypass machine, also known as the heart-lung machine. This machine takes over the task of breathing for the patient and pumping their blood around while the surgeon replaces the heart valve. Once the patient is on bypass, a cut is made in the aorta and a crossclamp applied. The surgeon then removes the patient's diseased aortic valve and a mechanical or tissue valve is put in its place. Once the valve is in place and the aorta has been closed, the patient is taken off the heart-lung machine.  Transesophageal echocardiogram can be used to verify that the new valve is functioning properly. Pacing wires are usually put in place, so that the heart can be manually paced should any complications arise after surgery. Drainage tubes are also inserted to drain fluids from the chest and pericardium following surgery. These are usually removed within 36 hours while the pacing wires are generally left in place

Minimally invasive cardiac surgery:

Minimally invasive cardiac surgery More recently, some cardiac surgeons have been performing aortic valve replacement procedures using an approach referred to as minimally invasive cardiac surgery (MICS), in which the surgeon replaces the valve through small incisions between two to four inches in length using specialized surgical instruments rather than by cutting a six to ten-inch incision down the center of the sternum. MICS typically involves shorter recovery time and more attractive cosmetic results

Percutaneous aortic valve replacement:

Percutaneous aortic valve replacement Percutaneous aortic valve replacement implants the valve using a catheter, without open heart surgery. It is used in more than 50 countries in patients who are at extreme or high risk to undergo open heart surgery. In high-risk patients with severe aortic stenosis , transcatheter and surgical procedures for aortic-valve replacement had similar rates of survival at 1 year, although there were important differences in risks associated with the procedure

Valve-related complications:

Valve-related complications Thrombosis, embolism and anticoagulation-related haemorrhage Infective endocarditis [ The incidence of endocarditis , in western countries, ranges from 1.5 to 6.2 cases per 100,000 people per annum. The cumulative rate of prosthetic valve endocarditis is 1.5 to 3.0% at one year following valve replacement and 3 to 6% at five years, the risk being the greatest during the first six months after valve replacement. Primary tissue failure The durability of the pericardial valve, like that of all other artificial heart valves, depends on multiple factors, one of the most important being the environment in which the artificial valves function. Primary or intrinsic tissue failure occurred with pericardial valves and it has been reported in several publications. Unfortunately, many reports do not contain some of the essential data and details necessary for building a clear image of this crucial aspect of valve performance  

Valve related complications:

Valve related complications Hemolysis Incidence - 6% Subclinical intravascular hemolysis severe hemolytic anemia uncommon & suggests paravalvular leakage due to partial dehiscence of the valve or infection Patients with a caged-ball valve / multiple prosthetic valves have an increased incidence & severity of hemolysis .

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Para valvular leak improper implantation of a valve A heavily calcified annulus is a risk factor for paravalvular leaks -- incomplete debridement of calcium compromises both suture placement and valve seating Active endocarditis is also a risk factor Late paravalvular leaks are suggestive of prosthetic valve endocarditis generally result in hemolysis In the absence of a paravalvular leak, a normally functioning modern valve should not result in hemolysis

PVE (2-6%) salient features :

PVE (2-6%) salient features Endovascular, microbial infection occurring on parts of a valve prosthesis or on reconstructed native heart valves , with or without implantation of an annular ring early PVE is 5% higher in surgery during active IE Diagnostic approach, surgical indications same

:

Thrombus mobile, somewhat less echo-dense, associated with spontaneous contrast Pannus Pannus formation -more common in aortic position fibrous tissue ingrowth highly echogenic usually firmly fixed to the valve apparatus Pre valve jet suggests pannus

Need for anticoagulation:

Need for anticoagulation Systemic embolization (predominantly cerebrovascular events) occurs at a frequency of approximately 0.7 to 1.0 percent per patient per year in patients with mechanical valves who are treated with warfarin . In comparison, the risk is 2.2 percent per patient per year with aspirin  and 4.0 percent with no anticoagulation. Patients with mitral valve prostheses are at approximately TWICE the risk as those with aortic valve prostheses

Ross procedure:

Ross procedure The  Ross procedure  (or  pulmonary autograft ) is a cardiac surgery operation where a diseased aortic valve is replaced with the person's own pulmonary valve. A pulmonary allograft (valve taken from a cadaver) is then used to replace the patient's own pulmonary valve Advantages:Freedom from  thromboembolism  without the need for anticoagulation

Pulmonary valve replacement:

Pulmonary valve replacement Homografts (aortic or pulmonary) should be the replacement of choice; no other valve performed as well in the pulmonary position. The results of the pulmonary autograft procedure are likely to be superior with the use of fresh homograft valves.Today , cryopreservation is the method of choice for homograft preservation

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Future of heart valve replacement Polymeric Heart Valves - Scientists are looking more into polymer materials for heart valves because it’s easy to fabricate, has a large range of polymer properties, and durability. Tissue engineered heart valves- Obtaining the number of types of cells for tissue valves, lack of scaffold material

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Advantages Mechanical heart valves: The biggest advantage is the durability. While the tissue heart valves are estimated to last about 10-15 years, a mechanical heart valve can last 30 year Tissue heart valves: There is minimal blood regurgitation, minimal transvalvular pressure gradient, self repairing. Does not require and anti- coagulant drug.

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Disadvantages Mechanical heart valves – In order to decrease the risk of blood clotting, the patient must take blood thinners. Some patients can hear their mechanical heart valve open and close. Tissue heart valves – Wear, there is a small possibility that the body will reject the valve, inability to implant them into infants and children.

Patient teaching:

Patient teaching Do not stand or sit in the same spot for too long. Move around a little bit. Walking is a good exercise for the lungs and heart. Take it slowly at first. Climb stairs carefully because balance may be a problem. Hold onto the railing. Rest part way up the stairs if you need to. Begin with someone walking with you. It is okay to do light household chores, such as setting the table or folding clothes. Stop your activity if you feel short of breath, dizzy, or have any pain in your chest. Do not do any activity or exercise that causes pulling or pain across your chest, (such as using a rowing machine, twisting, or lifting weights.) Do not drive for at least 4 - 6 weeks after your surgery. The twisting movements needed to turn the steering wheel may pull on your incision. Expect to take 6 - 8 weeks off work. Ask your doctor when you may return to work. Do not travel for at least 2 - 4 weeks. Ask your doctor when you can travel again

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Foods to be avoided Mayonnaise    Oils (canola, salad, soybean)  Broccoli  Brussel Sprouts Green Cabbage (raw) Collard Greens   Cucumber Peel (raw) Endive (raw) Kale (raw) Lettuce Mustard Greens (raw) Parsley Spinach (raw) Turnip Greens (raw) Watercress (raw) Green Scallion (raw)

Bentall procedure:

Bentall procedure A  Bentall procedure  is a cardiac surgery operation involving composite graft replacement of the aortic valve, aortic root and ascending aorta, with re-implantation of the coronary arteries into the graft. This operation is used to treat combined aortic valve and ascending aorta disease, including lesions associated with  Marfan syndrome. Indications Aortic aneurysm Aortic regurgitation Aortic dissection

Apicoaortic Conduit:

Apicoaortic Conduit Apicoaortic Conduit (AAC) , also known as  Aortic Valve Bypass (AVB) , is a cardiothoracic surgical procedure that alleviates symptoms caused by blood flow obstruction from the left ventricle of the heart. Left ventricular outflow tract obstruction (LVOTO) is caused by aortic stenosis and other valve disorders. AAC, or AVB, relieves the obstruction to blood flow by adding a bioprosthetic valve to the circulatory system to decrease the load on the aortic valve. When an apicoaortic conduit is implanted, blood continues to flow from the heart through the aortic valve. In addition, blood flow bypasses the native valve and exits the heart through the implanted valved conduit. The procedure is effective at relieving excessive pressure gradient across the natural valve. High pressure gradient across the aortic valve can be congenital or acquired. A reduction in pressure gradient results in relief of symptoms.

APICO AORTIC CONDUIT:

APICO AORTIC CONDUIT

Heart transplantation :

Heart transplantation A  heart transplant , or a  cardiac transplant , is a surgical transplant procedure performed on patients with end-stage heart failure or severe coronary artery disease. The patient's own heart is either removed ( orthotopic procedure) or, less commonly, left in place to support the donor heart ( heterotopic procedure) Norman Shumway  is widely regarded as the father of heart transplantation

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world's first adult human heart transplant was performed by a South African cardiac surgeon, Christian Barnard on December 3, 1967 at the Groote Hospital in Cape Town South Africa Worldwide, about 3,500 heart transplants were performed annually. The vast majority of these are performed in the United States (2,000-2,300 annually). California currently is the largest heart transplant center in the world.

Indications:

Indications Dilated cardiomyopathy Ischemic cardiomyopathy Congenital heart disease for which no conventional therapy exists or for which conventional therapy has failed Ejection fraction of less than 20% Intractable angina or malignant cardiac arrhythmias for which conventional therapy has been exhausted Pulmonary vascular resistance of less than 2 Wood units Age younger than 65 years Ability to comply with medical follow-up care

Contraindications :

Contraindications Some patients are less suitable for a heart transplant, especially if they suffer from other circulatory conditions related to the heart. The following conditions in a patient increase the chances ofcomplications : Kidney, lung, or liver disease Insulin-dependent diabetes with other organ dysfunction Life-threatening diseases unrelated to heart failure Vascular disease of the neck and leg arteries. High pulmonary vascular resistance Recent  thromboembolism Age over 60 years Substance abuse

Procedures :

Procedures Pre-operative A typical heart transplantation begins when a suitable donor heart is identified. The heart comes from a recently deceased or brain dead donor, also called a beating heart cadaver. The patient is contacted by a nurse coordinator and instructed to come to the hospital for evaluation and pre-surgical medication. At the same time, the heart is removed from the donor and inspected by a team of surgeons to see if it is in suitable condition. The patient must also undergo emotional, psychological, and physical tests to verify mental health and ability to make good use of a new heart. The patient is also given  immunosuppressantmedication so that the patient's immune system does not reject the new heart.

Operative:

Operative Once the donor heart passes inspection, the patient is taken into the operating room and given a general anaesthetic. Either an orthotopic  or a  heterotopic  procedure follows, depending on the conditions of the patient and the donor heart.

Orthotopic procedure:

Orthotopic procedure The  orthotopic procedure  begins with a median sternotomy , opening the chest and exposing the  mediastinum . The pericardium is opened, the great vessels are dissected and the patient is attached to cardiopulmonary bypass. The donor's heart is injected withpotassium chloride ( KCl ). Potassium chloride stops the heart beating before the heart is removed from the donor's body and packed in ice. Ice can usually keep the heart usable four to six hours depending on preservation and starting condition. The failing heart is removed by transecting the great vessels and a portion of the left atrium. The patient's pulmonary veins are not transected ; rather a circular portion of the left atrium containing the pulmonary veins is left in place. The donor heart is trimmed to fit onto the patient's remaining left atrium and the great vessels are sutured in place. The new heart is restarted, the patient is weaned from cardiopulmonary bypass and the chest cavity is closed.

ORTHOTOPIC HEART TRANSPLANTATION:

ORTHOTOPIC HEART TRANSPLANTATION

Heterotopic procedure :

Heterotopic procedure In the  heterotopic procedure , the patient's own heart is not removed. The new heart is positioned so that the chambers and blood vessels of both hearts can be connected to form what is effectively a 'double heart'. The procedure can give the patient's original heart a chance to recover, and if the donor's heart fails (e.g., through rejection), it can later be removed, leaving the patient's original heart. Heterotopic procedures are used only in cases where the donor heart is not strong enough to function by itself (because either the patient's body is considerably larger than the donor's, the donor's heart is itself weak, or the patient suffers from pulmonary hypertension

HETROPIC HEART TRANSPLANTATION:

HETROPIC HEART TRANSPLANTATION

'Living organ' transplant :

'Living organ' transplant In February 2006, at the Bad Oeynhausen  Clinic for Thorax and Cardiovascular Surgery, German, surgeons successfully transplanted a 'beating heart' into a patient. Rather than cooling the heart, the living organ procedure keeps it at body temperature and connects it to a special machine called an Organ Care System that allows it to continue pumping warm, oxygenated blood. This technique can maintain the heart in a suitable condition for much longer than the traditional method.

CANDIDATE EVALUATION TESTING :

CANDIDATE EVALUATION TESTING I. Clinical Laboratory Studies: A. Blood type and antibody screen B. Random chemistry profile with T4 C. Complete blood count with differential D. Percent reactive antibody (send 1 cc in a red top tube to Histocompatibility ) E. Urinalysis F. HLA typing and crossmatching (completed when donor is identified) G. Prostatic Specific Antigen (as indicated) H. Stool for occult blood (as indicated) II. Other Tests: A. Echocardiogram B. Right heart catheterization C. Chest radiograph D. Coronary angiography (if indicated) E. Pulmonary function test (if indicated)

DONOR PRE-OPERATIVE PROTOCOL :

DONOR PRE-OPERATIVE PROTOCOL 1 . If the individual is found to be a satisfactory donor following the donor evaluation, supportive care is Contin ued until the time of surgery. 2. Heart (multi-organ) procurement is accomplished. 3. Pre-operative donor medications administered in the operating room by anesthesia include: Methylprednisolone 1000 mg IV Kefzol 1000 mg IV 50% Dextrose 50 cc IV 4. Roe’s Solution for cardioplegia : NaCl 27 mEq /1 KC1 20 mEq /1 Methylprednisolone 250 mg/liter MgSO4 3mEq/liter D5W 1000 ml (kept in refrigerator) pH adjusted to 7.40 with NaHCO3 (2.25 mEq ) Store in refrigerator. Do not prepare in advance. 5. Graft stored in 4_ C normal saline (500 cc of normal saline to which 10 cc of 50% dextrose has been added).

RECIPIENT INCLUSION CRITERIA :

RECIPIENT INCLUSION CRITERIA 1. Significant functional limitation despite maximum medical therapy. New York Heart Association Class III toIV . 2. Heart disease not amenable to surgical correction or left ventricular volume reduction surgery ( BatistaProcedure ). 3. Refractory angina or refractory life-threatening arrhythmia despite maximal medical therapy and or surgicalmodatities . 4. Age _ 65 years, older ages in selected patients with isolated heart disease. 5. Medically compliant and capable of following a complex medical regimen with support of family 6. Supportive family structure residing with or near the candidate

RECIPIENT EXCLUSION CRITERIA :

RECIPIENT EXCLUSION CRITERIA 1. Severe cardiac cachexia 2. Insulin dependent diabetes 3. Severe atherosclerotic vascular disease and/or cerebrovascular disease 4. Peptic ulcer disease* 5. Malignancy or other disorder that might decrease life expectancy 6. Pneumonia, recent or unresolved pulmonary infarction. Any infiltrate on chest X-ray is a relativecontraindication 7. Pulmonary vascular resistance > 5-6 Wood units, unresponsive to vasodilators 8. Serum creatinine _ 2.0 mg/dl except for acute increase due to severe heart failure 9. Severe obesity: > 140% of ideal body weight 10. Moderate obesity (120 - 140% of ideal body weight)* 11. Severe primary pulmonary disease 12. History of central nervous system disorder* 13. Recent major psychiatric illness that would significantly impair the patient’s ability to consistently and reliably comply with the complex post-transplant medical regimen. 14. History of substance abuse (alcohol, tobacco, drugs) or mental illness* 15. HIV positivity, Hepatitis B surface antigenemia , Hepatitis C* (liver biopsy to exclude cirrhosis) 16. Untreated bacteremia 17. Untreated intravenous line sepsis

III. Consults: :

III. Consults: A. Social Services B. Dentistry C. Infectious Diseases D. Psychiatry (as indicated) E. Neurology (as indicated) F. Nephrology (as indicated) G. Gastroenterology (as indicated) IV. Pre transplantation Infectious Diseases Screening: A. Coccidioidomycosis titer B. Hepatitis B surface antigen C. Hepatitis C antibody D. HIV screen E. RPR or VDRL F. PPD skin test

DONOR INCLUSION CRITERIA :

DONOR INCLUSION CRITERIA Once a diagnosis of brain death has been made, other considerations in the evaluation of a potential organ donor nclude the following: 1. Hemodynamically stable with appropriate volume loading and inotropic support 2.Preferably under age 60 3.No occlusive coronary artery disease as identified by coronary angiography*, coronary angiogram for women >50 years old and men > 45 years old) 4. No history of heart disease 5. No sepsis 6. No known malignancy (exception: primary brain tumor) 7. Electrocardiogram, echocardiogram 8. Appropriately signed consent for organ donation 9. ABO blood group compatibility with recipient 10. Appropriate weight compatibility with recipient 11. Donor allocation according to Classification System specified by procurement agency *relative criteria

DONOR EXCLUSION CRITERIA :

DONOR EXCLUSION CRITERIA 1. Does not meet brain death criteria as outlined under Donor Inclusion Criteria 2. Significant cardiac malformations 3. Significant ventricular arrhythmia 4. Significant coronary disease by arteriography or documented previous myocardial infarction 5. Evidence of severe myocardial ischemic injury: e.g., poor ventricular function on echocardiography without improvement after volume replacement and appropriate inotropic support and/or: a. Ejection fraction < 45% b. Shortening fraction < 25% c. Significant valvular abnormality 6. Evidence of significant infection a. Uncontrolled bacterial sepsis b. HIV positivity c. Hepatitis B surface antigenemia d. Hepatitis C positivity* 7. Any acute malignancy, except primary brain tumor 8. Death from carbon monoxide poisoning, with carboxy hemoglobin level > 20% 9. History of intravenous drug use 10. ABO incompatibility with potential recipient 11. Inappropriate size match for potential recipient

Initial post operative recipient immunosuppression treatment guidelines :

Initial post operative recipient immunosuppression treatment guidelines A combination of the following immunosuppressants may be used based upon the recipient’s needs and physician’s preference. 1. Cyclosporine 2.0 - 3.0 mg/kg PO every 12 hours* If unable to tolerate PO, administer cyclosporine IV (1 mg/ml) by a continuous intravenous infusion at 1/3 the oral dose. 2. Azathioprine 1.0 - 3.0 mg/kg P.O./IV daily** 3. Methylprednisolone taper - 500 mg IV every 12 hours x 6 doses 4. Tacrolimus (FK-506) .05 - .15 mg/kg PO BID to obtain a trough level of 10-15 ng /ml for the first 3 weeks and then a target trough drug level of 8-10 ng /ml using the Abbott IMX Microparticle EIA – whole blood. 5. Mycophenolate Mofetil - 500 mg to 1500 mg/day in divided doses - BID.** 6. Prednisone to start after course of Methylprednisolone is completed.

Atrial myxoma :

Atrial myxoma An atrial myxoma is a noncancerous tumor in the upper left or right side of the heart. It grows on the wall that separates the two sides of the heart. Causes A myxoma is a primary heart (cardiac) tumor . Primary cardiac tumors are rare. Myxomas are the most common type of these rare tumors . About 75% of myxomas occur in the left atrium of the heart, usually beginning in the wall that divides the two upper chambers of the heart. The rest are in the right atrium. Right atrial myxomas are sometimes associated with tricuspid stenosis and  atrial fibrillation . Myxomas are more common in women. About 1 in 10 myxomas are passed down through families (inherited). Such tumors are called familial myxomas .

Intra cardiac tumor resection:

Intra cardiac tumor resection

Preoperative preparation:

Preoperative preparation Physical examination and patient history Dyspnoea Palpitations History of angina Syncope Cyanosis Embolism Edema

Facial and general appearance :

Facial and general appearance Down’s syndrome: an atrioventricular canal defect, which is a complicated and serious malformation; it occurs within 7 weeks of foetal life and is basically a malformation of the septum giving rise to a large VSD or ASD • Elf-like faces: supravalvular aortic stenosis • Turner’s syndrome: coarctation , aortic stenosis • Moon-like plump faces: pulmonary stenosis • Noonan’s syndrome: pulmonary stenosis , peripheral pulmonary artery stenosis • Mitral facies with pulmonary hypertension • Central cyanosis • Differential cyanosis in patent ductus arteriosus (PDA) with pulmonary hypertension or interrupted aortic arch

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Xanthelesma Pulse Bp Percussion Auscultation ECG

Patient preparation:

Patient preparation American Society of Anesthesiologists’ (ASA) physical status classification I Normal, healthy patient II Patient with mild systemic disease III Patient with systemic disease that limits activity but is not incapacitating IV Patient with an incapacitating systemic disease that is a threat to life V Moribund patient not expected to survive 24 hours even with an operation

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Cardiac surgery continues to be a difficult area for outcome prediction but much effort has gone into predicting operative risk based on general preoperative condition and perioperative risk. Two widely used, simple and fairly reliable systems are the Parsonnet Score and the EuroScore (European System for CardiacOperative Risk ).

Parsonnet scoring system:

Parsonnet scoring system

Euro scoring system:

Euro scoring system

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EuroScore – European System for Cardiac Operative Risk Evaluation. Score weights add up to an approximate percentage predicted mortality.

Assessment of risks:

Assessment of risks Assessment of respiratory Renal Diabetes Neurological Peripheral vascular disease bleeding

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Pre operative blood tests Skin preparation and shaving Discontinuation of medication Consent Fasting

Intraoperative:

Intraoperative Prior to initiation of anesthesia, most cardiac surgery patients undergo the insertion of a large-bore peripheral intravenous catheter, an arterial line, and a pulmonary artery catheter. These are needed so intravenous fluids can be administered and hemodynamics monitored during the operation and in the postoperative period.

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Induction of anaesthesia Draping Incision Establishment of extacorporeal oxygenation Choice of donor site in coronary artery bypass grafts Sternal wires Pericardial window Placing pacing wires

Incision :

Incision Most cardiac procedures are performed by a median sternotomy . This incision provides the best overall access to the heart chambers, results in the least respiratory impairment and the least discomfort for the patient, and an optimum exposure for the institution of cardiopulmonary bypass (CPB)The skin incision is made in the midline, from below the sternal notch to the linea alba below the xiphoid process. The sternum is split using an air-driven saw. A new technique for CABGs, a single left internal mammary artery to the left anterior descending artery, using a left anterior small thoracotomy (LAST).

Cardiopulmonary bypass :

Cardiopulmonary bypass The first successful use of mechanically supported circulation and respiration during open heart surgery was performed by Gibbon in 1953.

FUNCTIONS OF CPB:

FUNCTIONS OF CPB Diversion of blood from heart Oxygenation, elimination of CO2 Systemic cooling and rewarming Circulation of blood. Non physiological hypothermic hemodiluted non pulsatile circulation.

Process :

Process Venous blood is drained from the right side of the heart via the superior vena cava and the inferior vena cava, arterialised in the oxygenator and pumped back into the aorta. To prevent thrombosis within the bypass circuit from exposure of the blood to a foreign surface patient’s system is anticoagulated with heparin. Heparin prolongs whole blood clotting time, thrombin time, partial thromboplastin time and prothrombin time, and usually has a platelet-inhibiting effect. It is given before cannulation for CPB or before clamping of the blood vessels. Heparin may be given by the surgeon directly into the right atrium or by the anaesthetist through the central line. To determine whether adequate heparinisation has been achieved, the activated clotting time (ACT) is measured about 3 min after the heparin is given. During the bypass, periodic ACTs are measured, and additional heparin is administered to maintain the ACT well above 400 seconds (three times above normal

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Protamine sulphate, despite its own anticoagulating properties, is given to reverse the effects of heparin. A calculated dosage of 1–1.3 times the total heparin dose is normally administered, and the ACT results can guide additional protamine infusions.The infusion is commenced before removal of the arterial cannula so that volume may be given to maintain an adequate blood pressure . The patient’s height and weight are used to calculate body surface area. Standard bypass usually maintains flows between 1.8 l/min per m2 (low flow) and 2.4 l/min per m2 (high flow), moderate systemic temperature of 26°C and 30°C, and moderate haemodilution with the haematocrit between 20% and 30%. The flow can be pulsatile . High flow is usually maintained at normothermia and during cooling, and re-warming. Low flow is satisfactory during hypothermia because body oxygen consumption at 30°C is half that at 37°C. Low flow decreases bronchial flow and non-coronary collateral flow, and can facilitate an operation.

Heart Lung Machine:

Heart Lung Machine

Adverse effects of CPB :

Adverse effects of CPB prolonged pulmonary insufficiency elevated temperature vasoconstriction, coagulopathy degrees of renal or other organ dysfunction.

Intra operative period:

Intra operative period The cardiopulmonary bypass (CPB) machine can be used during the operation to maintain cardiopulmonary function and tissue perfusion. Sites of cannulation for CPB are usually the aorta and the right atrium. After the aorta is cross-clamped, cardioplegia is administered to stop the heart. Cardioplegia can be a cold solution that is high in potassium. In certain patient populations, warm blood cardioplegia may be indicated. The surgeon performs the anastomoses while the heart is stopped During extracorporeal circulation, anesthesia may be maintained with propofol , an intravenous medication that provides anesthesia as well as amnesia. Propofol can cause myocardial depression and hypotension so the hemodynamic status of the patient should be closely monitored.

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Rewarming the body must occur prior to the completion of the operation to begin to offset the surgically induced hypothermia. Rewarming is initiated with the heat exchanger on the bypass machine while the surgeon finishes the anastomoses . The cross clamp is then removed from the aorta. The intrinsic cardiac rhythm is often spontaneously reestablished as blood begins to flow through the heart. Sometimes defibrillation is necessary if the heart does not automatically resume sinus rhythm. After the adequacy of the heart rate and blood pressure is certain, the patient is separated from the CPB machine and protamine sulfate is administered to reverse the effects of the heparin. Inotropic agents may be required to wean the patient from the bypass machine if cardiac index is diminished. Epicardial atrial and ventricular pacemaker wires may be inserted at this time. Mediastinal and/or pleural chest tubes will be inserted. The sternum is wired, the tissues are sutured, surgical dressings are placed, and the patient is transported to the recovery room

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Some surgeons elect off-pump coronary artery bypass (OPCAB). The potential complications of extracorporeal circulation are minimized with this surgical option. With the OPCAB procedure, a [beta]-adrenergic blocking medication such as esmolol may be used to slow the heart for the anastomoses to be completed. Surgical stabilizers may be used to decrease the motion of the heart so that the surgeon can complete the anastomoses.Heparin is administered with the OPCAB to prevent potential clotting. The patient may receive protamine to reverse the heparin at the end of the operation. A smaller dose of heparin may be used with the OPCAB than if extracorporeal circulation is used. Fluid shifts and hematuria related to long pump times would be minimized and hemodilution from priming the CPB machine is not an issue with the OPCAB.

Intra operative Phase:

Intra operative Phase Patient will receive general anesthesia , be intubated , and placed on mechanical ventilator , the preoperative nurse are responsible for the patient safety and comfort. Some of the areas of intervention include positioning, the skin preparation wound care, and emotional support to the patient and family. Before chest incision is closed, chest tubes are positioned to evacuate air and drainage from the media sternum and the thoracic cavity .

Intra operative complication:

Intra operative complication Possible Intraoperative complication includes Dysrthmyais,Hemorrhage , Emobilization , Organ failure from shock , or adverse drug reaction.

Post operative period :

Post operative period The respiratory needs of the cardiac surgical patient The principal goal in the care of patients recovering from general anaesthesia is to protect the airway and ensure adequate oxygenation. immediately after surgery, and were routinely ventilated for periods greater than 8 hours. The purpose of this ventilated period was to ensure complete recovery from anaesthesia, to maintain haemodynamic stability and to allow the patient to rest, which ultimately reduced myocardial oxygen demand The nurse, who is constantly present, needs good knowledge and skill in the assessment of respiratory status, and should have an ability to analyse results of respiratory observations.   complications associated with extubation Potential hazards during extubation Laryngeal spasm Regurgitation/inhalation Vagal stimulation, dysrhythmias, cardiac arrest Trauma Potential complications following extubation Hoarseness Vocal cord paralysis Dysphagia Respiratory complications after cardiac surgery Respiratory problems will result in a prolonged hospital admission. Vargas et al. (1993) suggest that 30% of patients will experience some respiratory complications by day 6 postoperatively. Prolonged mechanical ventilation Ventilatory complications are more likely to occur with a prolonged spell of mechanical ventilation or if there is a history of chest disease. This can occur as a direct result of a patient’s respiratory function or as a result of cardiovascular instability, which requires an enforced period of ventilation. Patients who require long-term ventilation have a mortality rate of 30–40% .Adequate nutrition and supplementary minerals are vital to provide energy for weaning. Factors identified as affecting the ability of a patient to be weaned include the following: • the respiratory load and the capacity of the neurological system to cope with this load • oxygenation • cardiovascular performance • psychological factors. Respiratory failure Impairment of pulmonary function is one of the most significant complications after bypass surgery. Many factors may increase the likelihood of respiratory failure, including respiratory depressant drugs, high left atrial pressure, atelectasis , pulmonary microembolism , increase in extravascular lung water, and the use of single or bilateral internal mammary artery grafts Respiratory infection The incidence of infection is increased if prolonged ventilation occurs. Pneumonia Bronchospasm Bronchospasm can occur at the termination of surgery, and may hinder sternal closure or mechanical ventilation. Patients with known asthma should have salbutamol inhalers recommenced after surgery. Bronchospasm can also occur after extubation . It should be treated with the appropriate agonists, theophylline derivatives or steroids. Pulmonary oedema This can be divided into cardiogenic ( haemodynamic ) and non- cardiogenic (permeability). The latter is most commonly the result of ARDS. Factors such as upper lobe venous enlargement, perihilar and basal distribution, enlargement of the vascular pedicle, and cardiomegaly , have been proposed as indicative of a cardiogenic cause. Atelectasis Causes of lobar collapse include malposition of the ET tube and mucus plugging. More frequently, peripheral airway plugging with secretions results in peripheral subsegmental atelectasis , seen as thin band shadows usually present in the mid and lower zones of the lung. Minor degrees of atelectasis are extremely common following surgery, occurring in up to 85% of patients after thoracic surgery and 20% after extrathoracic procedures. Any ventilated patient is prone to atelectasis . This can be prevented by turning/repositioning a patient at regular intervals and physiotherapy. Once it occurs, the effects can be improved by the use of PEEP/CPAP and turning the patient. usually responds to physiotherapy   Pneumothorax This is an identified complication of mechanical ventilation, but can also occur during the insertion of central lines. Depression of one hemidiaphragm and mediastinal shift away from the affected side suggest a tension pneumothorax Anxiety Patients who require mechanical ventilation often have anxieties related to their dependence on the machine, as well as the tubing, alarms and communication barriers. Unaddressed, these concerns may delay the patient’s weaning from a ventilator. Mechanical ventilation can affect the patient’s sensory input and this can be aggravated by the use of sedation

The patient requiring mechanical ventilation:

The patient requiring mechanical ventilation Most patients undergo a period of positive pressure ventilation, the length of which is determined by the condition of the patient, although 80% of patients should require only a short period of this support, i.e. up to 4 hours. A small percentage of patients may not require any positive pressure ventilation. Arterial blood gases give a general overview of any acidosis/alkalosis and how well the patient is tolerating the ventilator and the prescribed mode. Although these results need to be acknowledged, it is common for patients to demonstrate a metabolic acidosis (defined as a pH < 7.36, base excess (BE) < 2 mmol /l and sodium bicarbonate > 22 mmol /l), during the hypothermic phase of their recovery.

Ventilation control :

Ventilation control Blood gases with a low PaCO2 and a high pH generally indicate hyperventilation. To increase the PaCO2, the minute volume needs to be decreased by decreasing either the respiratory rate or the tidal volume. The patient’s condition will often indicate whether the respiratory rate or the tidal volume needs to be decreased. Blood gases with a high PaCO2 and a low pH generally indicate hypoventilation. To remove the excess PaCO2, the minute volume needs to be increased, by increasing the respiratory rate or tidal volumes. ET tube suction should generally be performed only when: • there are audible secreations • chest sounds indicate secretions • there are deteriorating arterial blood gases with increased airway pressures • extubating During a suctioning procedure, no more than –300 kPa of negative pressure should be used, and ideally only up to −200 kPa to minimise tracheal tissue damage. The size of the suction catheter should be the smallest possible size and should not exceed half the diameter of the ET tube

criteria used in weaning off ventilation:

criteria used in weaning off ventilation • The patient is cardiovascularly stable. On occasions, it may be appropriate to initiate weaning on low doses of inotropes or vasodilators but the patient should be warmed centrally to 35°C and peripherally showing signs of warming • Arterial blood gases are not showing a deteriorating trend, and electrolytes are within normal limits • There is no significant respiratory depression from sedatives or opioids • There is no evidence of respiratory distress • Tidal volumes are > 300 ml • If the patient’s spontaneous rate is > 35, re-ventilation should be considered because chances of successful weaning are reduced, and therefore a further short period of ventilation should be considered • The PaO2 level is > 10 kPa on 40% oxygen • Oxygen saturation should be > 95% • Positive end-expiratory pressure or continuous positive airway pressure is down to 8 cmH2O and/or PPS 12 cmH2O (as measured at the endotracheal tube)

Respiratory complications after cardiac surgery :

Respiratory complications after cardiac surgery Respiratory failure Many factors may increase the likelihood of respiratory failure, including respiratory depressant drugs, high left atrial pressure, atelectasis , pulmonary microembolism , increase in extravascular lung water, and the use of single or bilateral internal mammary artery grafts Respiratory infection The incidence of infection is increased if prolonged ventilation occurs. Pneumonia Bronchospasm Bronchospasm can occur at the termination of surgery, and may hinder sternal closure or mechanical ventilation. Patients with known asthma should have salbutamol inhalers recommenced after surgery. Bronchospasm can also occur after extubation . It should be treated with the appropriate agonists, theophylline derivatives or steroids.

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Pulmonary oedema This can be divided into cardiogenic ( haemodynamic ) and non- cardiogenic (permeability). The latter is most commonly the result of ARDS Atelectasis Causes of lobar collapse include malposition of the ET tube and mucus plugging. Minor degrees of atelectasis are extremely common following surgery, occurring in up to 85% of patients after thoracic surgery and 20% after extrathoracic procedures. Any ventilated patient is prone to atelectasis . This can be prevented by turning/repositioning a patient at regular intervals and physiotherapy. Once it occurs, the effects can be improved by the use of PEEP/CPAP and turning the patient. usually responds to physiotherapy   Pneumothorax This is an identified complication of mechanical ventilation, but can also occur during the insertion of central lines. Depression of one hemidiaphragm and mediastinal shift away from the affected side suggest a tension pneumothorax

Maintaining a patient’s haemodynamic stability :

Maintaining a patient’s haemodynamic stability The patient’s cardiovascular function requires careful monitoring during the initial period of the recovery, and definitely during the intensive care phase of the recovery. Central venous pressure Blood pressure Haemodynamic pressure monitoring Cardiac output studies Low cardiac output High cardiac output

Haemodynamic pressure monitoring :

Haemodynamic pressure monitoring Flow directed pulmonary artery catheters were initially introduced by Dr Swan and Dr Ganz and are still referred to as Swan– Ganz catheters. They allow for the measurement of pulmonary artery wedge (PAW) pressure which is an index of left ventricular function. The tip of the catheter has a balloon,which when inflated causes the tip of the catheter to become buoyant. When dvanced , the catheter will float in the direction of the blood flow. It can then be passed into the right atrium, through the tricuspid valve into the right ventricle, through the pulmonary valve and into the pulmonary artery, and the tip should lie less than 2 cm from the hilum of the pulmonary artery If advanced further, the catheter will obstruct forward blood flow, which allows left heart pressures to be reflected though the catheter tip. It is indicated when accurate measurements of fluid status, cardiovascular function, and oxygen delivery and consumption are required

PowerPoint Presentation:

The pressure generated by myocardial contraction and relaxation are reflected through the lumen of the catheter to the transducer, where the pressure is converted to an electrical waveform. For accurate pressure measurement, the transducer must be zeroed and placed at a standard level in relation to the patient position .

Swan ganz catheter:

Swan ganz catheter

Management of low cardiac output:

Management of low cardiac output Inotropes and vasopressors The following is a very simplified approach to the choice of inotropes and vasopressors . Inotropes Adrenergic (catecholamine) Dobutamine - beta-agonist (ß1 >ß2). Increases contractility and HR. ß2 effect can sometimes decrease SVR and BP. ß1 effect can cause dysrhythmias. Start at 2.5 mcg/kg/min. Titrate upward by 2.5 mcg/kg/min until adequate cardiac index. Maximum 15 to 20 mcg/kg/min. Notify ICU Fellow or Attending if at 10 mcg/kg/min or higher. Epinephrine -alpha and beta agonist (ß > alpha). Increases HR, CO, and SVR. Generally a second-line inotrope . A subset of patients who do not respond to dobutamine will respond to epinephrine. Potential detrimental effects include significant increases in myocardial oxygen consumption, increased lactic acidosis, arrhythmias. Start at 0.5 to 1.0 mcg/min and increase by these amounts until adequate cardiac index. Notify ICU Fellow or Attending if > 5 mcg/min and each increase of 5 mcg/min above that. Dopamine - stimulates dopaminergic , beta, and alpha receptors in dose-dependent fashion. Inotropic effect (beta-effect) predominates in the 5 to 10 mcg/kg/min range. Notify ICU Fellow or Attending if at 10 mcg/kg/min or higher. There appears to be little benefit over Dobutamine as an inotrope . In low doses ( 2 - 4 mcg/kg/min) it has been purported to have beneficial renal protective effects ("renal-dose dopamine"). While it can increase urine output by several mechanisms, there is little evidence that it improves creatinine clearance or decreases the incidence of acute renal failure.

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Phosphodiesterase inhibitors Milrinone - phosphodiesterase inhibitors decrease the metabolism (breakdown) of cAMP . cAMP is the "second messenger" that leads to increased calcium availability at the actin -myosin complexes and thus increased contractility.. Milrinone increases cardiac output. It also decreases Pulmonary Vascular Resistance (PVR) and thus can be useful if pulmonary hypertension or significant right ventricular dysfunction is a problem. The bolus dose is 50 mcg/kg followed by an infusion between 0.375 and 0.75 mcg/kg/min. The half life of milrinone is several hours, unlike the catecholamines that have half-lives of a few minutes. When weaning milrinone , the rate of decreases should be slower and more gradual than with dobutamine or epinephrine. Reassess the patient 4 to 6 hours later to verify that patient has tolerated the decrease. Vasopressors Adrenergic (catecholamine) Norepinephrine ( Levophed ) -Strong alpha agonist with beta activity as well. Causes vasoconstriction and thus increases SVR and BP. Theoretically, since it has inotropic activity as well, it is less likely to cause a decrease in cardiac output due to increased afterload compared to a pure alpha agonist such as phenylephrine . Negative effects include myocardial and mesenteric ischemia, LIMA spasm, dysrhythmias, and decreased cardiac output due to afterload increases. Starting dose is usually 2 to 5 mcg/min. Notify the ICU Attending or Fellow if the dose is increased to 10 mcg/min and each additional increase of 5 to 10 mcg/minute beyond that.

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Phenylephrine ( Neosynephrine ) - Pure alpha agonist. Can be used as a continuous infusion but more commonly used as bolus infusions of 100 to 200 mcg for sudden severe hypotension not responding to volume infusion. Peptides Vasopressin - used for hypotension with a normal or high cardiac output and low SVR state that is refractory to norepinephrine . Has a significant side effect profile including myocardial and mesenteric ischemia.

Intra-aortic balloon counterpulsation :

Intra-aortic balloon counterpulsation The intra-aortic balloon pump (IABP) is a cardiac assist device designed to increase coronary perfusion and decrease myocardial oxygen consumption .The balloon catheter is usually inserted percutaneously through the femoral artery. It is positioned in the descending thoracic aorta, distal to the left subclavian artery; . It is connected to a console, which shuttles helium in and out of the balloon to inflate and deflate it in cycle with the mechanical cardiac cycle. It increases aortic pressure during diastole to augment coronary perfusion and decreases aortic pressure during systole to lessen the workload on the left ventricle. The balloon is inflated during diastole and deflated during systole .

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" Augmentation." By inflating at the beginning of diastole (just after the closure of the aortic valve), the aortic diastolic pressure is increased or "augmented", thus improving coronary perfusion. Remember, left ventricular coronary flow occurs during diastole with the gradient to flow being the difference between the aortic diastolic pressure (ADP) and the right atrial pressure (RAP). That is CPP = ADP - RAP. " Diastolic decrement" .The balloon deflates just before cardiac systole (just before opening of the aortic valve). This leads to a sudden decrease in the aortic pressure and thus LV afterload . The IABP can be adjusted so that the balloon inflates and deflates with every cardiac cycle (1:1), every second cardiac cycle (1:2), or every third cardiac cycle (1:3). It is also possible to decrease the volume the balloon inflates to by decreasing the amount of gas injected into it. " Timing". Two methods are commonly used to time or "trigger" the IABP. It can be triggered from the arterial waveform recorded from the catheter tip, or it can be timed to the QRS complex of the cardiac monitor. The arterial waveform usually works better if the patient is having arrhythmias. The IABP should inflate just after closure of the aortic valve. This corresponds to the dicrotic notch on the arterial waveform. If it inflates too late, its ability to "augment" and effectiveness will be limited. It should deflate just before left ventricular ejection. If it remains inflated during early systole it will impair LV ejection. If it deflates too early in diastole its ability to afterload reduce will be limited. The IABP console allows for manual adjustment of the balloon inflation and deflation. A cardiac perfusionist is always on call to help with adjustment of balloon timing or any "trouble-shooting" that may be required.

Indications :

Indications Refractory ventricular failure Cardiogenic shock Unstable refractory angina Impending infarction Mechanical complications of myocardial infarction Ischaemia related to intractable ventricular dysrhythmias Cardiac support for high-risk surgical patients Septic shock Weaning from cardiopulmonary bypass Intraoperative pulsatile flow generation Support for failed angioplasty and valvuloplasty  

Other Indications for IABP:

Other Indications for IABP Prophylactic use prior to cardiac surgery in patients with: Left main disease Unstable angina Poor left ventricular function

Contraindications :

Contraindications Severe aortic insufficiency Abdominal or aortic aneurysm Severe calcific aortic iliac disease or peripheral vascular disease Adverse effects Balloon membrane perforation Limb ischaemia Bleeding at the insertion site Infection Thrombocytopenia Aortic dissection Thrombosis

Positioning:

Positioning The end of the balloon should be just distal to the takeoff of the left subclavian artery Position should be confirmed by fluoroscopy or chest x-ray

Weaning of IABP:

Weaning of IABP Decreasing inotropic support Decreasing pump ratio

IABP Removal:

IABP Removal Discontinue heparin six hours prior Check platelets and coagulation factors Deflate the balloon Apply manual pressure above and below IABP insertion site Remove and alternate pressure to expel any clots Apply constant pressure to the insertion site for a minimum of 30 minutes Check distal pulses frequently

Cardiac tamponade :

Cardiac tamponade Cardiac tamponade is the pathological accumulation of fluid within the pericardial sac that compresses venous return and reduces cardiac output by preventing adequate cardiac filling. The fluid exerts pressure that is transmitted across the myocardium, increasing ventricular end-diastolic pressure and impairing ventricular filling during diastole. Signs and symptoms • Decreased tissue perfusion/cold peripheries related to low cardiac output • Confusion • Hypotension • Tachycardia • Distension of neck veins/raised jugular venous pressure • Reduced urine output.

Management :

Management The only treatment for cardiac tamponade is return to the OR, re- sternotomy , and evacuation of the clot with hemostasis of any ongoing bleeding. The  cardiac surgery surgeon should be notified early if potential tamponade is suspected. Volume resuscitation, inotropes , and vasopressors are temporizing measures only in this situation. If a patient with suspected tamponade suddenly deteriorates and develops PEA ( pulseless electrical activity) an urgent sternotomy should be done in the ICU.  This should only be done by the Cardiac Surgeon or Cardiac Surgery Fellow. Page them STAT and move the thoracotomy tray to the bedside while following standard ACLS algorithms.

Dysrhythmias :

Dysrhythmias Heart rate Atrial fibrillation Heart block Epicardial pacing Ventricular ectopics Ventricular tachycardia Ventricular fibrillation

Temperature :

Temperature Shivering Impaired immunity Impaired liver and pancreas Acidosis Impaired kidney function Patient re-warming

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neurological welfare- Neurological impairment Analgesics- for pain relief Sedation Non- opioid analgesia Caring for a patient’s nutritional needs Oral care

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Hydration Intravenous fluids Postoperative nausea and vomiting Control of gastrointestinal bleeding Intravenous fluids Management of the patient with diabetes Chest drainage

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Renal failure Diet Fluid management Bowel function Hygiene and the prevention of infection Wound infections

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Pressure sore development Eye care Deep venous thrombosis Ambulation Psychological care Discharge and rehabilitation

Nursing management:

Nursing management Pre- operative nursing diagnosis Fear/Anxiety related to: unfamiliar environment and separation from significant others; lack of understanding of diagnostic tests, preoperative Procedures preparation, planned surgery, and postoperative course Decreased cardiac output related to: pre-existing compromise in cardiac function;

Post operative diagnoses :

Post operative diagnoses Ineffective breathing pattern related to: increased rate and decreased depth of respirations associated with fear and anxiety decreased rate and depth of respirations associated with the depressant effect of anesthesia and some medications (e.g. narcotic [ opioid ] analgesics) diminished lung/chest wall expansion associated with weakness, fatigue ineffective airway clearance related to: stasis of secretions associated with decreased activity, depressed ciliary function resulting from the effect of anesthesia , and a weak cough effort increased secretions associated with irritation of the respiratory tract (can result from inhalation anesthetics and endotracheal intubation);

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Impaired gas exchange related to ventilation/perfusion imbalances associated with: atelectasis (can occur as a result of deflation of the alveoli and decreased surfactant production while on the cardiopulmonary bypass machine and/or postoperative hypoventilation or ineffective clearance of secretions) accumulation of fluid in the pulmonary interstitium and alveoli (can occur as a result of fluid volume excess)

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Assess for and report signs and symptoms of impaired respiratory function: rapid, shallow, or slow respirations dyspnea , orthopnea use of accessory muscles when breathing adventitious breath sounds (e.g. crackles [ rales ], rhonchi ) diminished or absent breath sounds asymmetrical chest excursion cough restlessness, irritability confusion, somnolence central cyanosis (a late sign) abnormal blood gases significant decrease in oximetry results abnormal chest x-ray results.

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Implement measures  to maintain adequate respiratory function: monitor mechanical ventilation carefully  to ensure that ventilatory rate and pressures are correct perform actions to decrease pain (see Standardized Postoperative Care Plan, Diagnosis 6, action d) and increase strength and activity tolerance (see Postoperative Diagnosis 4)  in order to increase client's willingness and ability to move, cough, deep breathe, and use incentive spirometer perform actions  to decrease fear and anxiety  (e.g. explain procedures, interact with client in a confident manner, initiate pain relief measures)  in order to prevent the shallow and/or rapid breathing that can occur with fear and anxiety

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perform actions to maintain an adequate cardiac output perform actions to prevent or treat fluid volume excess and water intoxication   in order to reduce the risk for fluid accumulation in the lungs place client in a semi- to high Fowler's position unless contraindicated if client must remain flat in bed, assist with position change at least every 2 hours assist with positive airway pressure techniques (e.g. positive end-expiratory pressure [PEEP], continuous positive airway pressure [CPAP]) if ordered instruct and assist client to cough and deep breathe or use incentive spirometer every 1-2 hours; assure client that chest tube is sutured in place and that these activities should not dislodge the tube

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maintain an adequate fluid intake and humidify inspired air if ordered  to thin tenacious secretions and reduce dryness of the respiratory mucous membrane maintain oxygen therapy as ordered instruct client to avoid intake of gas-forming foods (e.g. beans, cauliflower, cabbage, onions), carbonated beverages, and large meals  in order to prevent gastric distention and subsequent pressure on the diaphragm discourage smoking ( the irritants in smoke increase mucus production, impair ciliary function, and can cause damage to the bronchial and alveolar walls; the carbon monoxide decreases oxygen availability) maintain activity restrictions as ordered; increase activity gradually as allowed and tolerated

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Acute pain related to heart surgery AS EVIDENCED BY: Patient reports or demonstrates discomfort. (Pain Score) Autonomic response to acute pain: (e.g., diaphoresis, change in BP, P, R, pupillary dilatation, pallor, nausea) Interventions Eliminate additional stressors or sources of discomfort whenever possible. Provide rest periods to facilitate comfort, sleep, and relaxation. A quiet environment and a darkened room are measures that help facilitate rest. Offer analgesics every __ hours or prn (according to physician’s order). Evaluate effectiveness and observe for any signs and symptoms of untoward effects.

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Explore non-pharmacological methods for reducing pain/promoting comfort: Back rubs Slow rhythmic breathing Repositioning Diversional activities such as music, TV, etc. Warm or cold compress

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: Altered fluid and electrolyte balance fluid volume excess or water intoxication related to: vigorous fluid therapy during and immediately following increased production of antidiuretic hormone (output of ADH is stimulated by trauma, pain, and anesthetic agents)

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Risk for infections Potential complications

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Thank you………..

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