1. Cardiac and Cardiovascular Surgery
Nursing 225-226

2. Cardiac
Anatomy:
R. heart…
pulmonary
& venous
L. heart…
systemic
& arterial
NO VALVEs
in Pulmonary
Arteries

4. Myocardial Blood Supply
Right Coronary Artery (RCA):
 R atria, posterior L ventricle
 A-V septum
 SA node – 60%
 A-V node – 90%
 Blockage dysrhythmias

5. Myocardial Blood Supply
Left Coronary Artery (LCA…two major
branches)
LAD:
 Anterior R & L ventricle
Circumflex
 L atria
 Posterior L ventricle
 High blockage angina, ischemia, infarction
 Low blockage dysrhythmias

6. Development of Plaque
Development of

7. Coronary Artery Disease (CAD)
 Grade 1 = < 25 % … fatty streaks, risk factor

Grade 2 = ~ 50% … fibrous plaque

Grade 3 = ~ 75% … calcified plaque

Grade 4 = ~ 100%… complete occlusion

8. Arterial procedures
 Coronary artery bypass surgery
 Either open surgery or closed
 Angioplasty
 PCTA
 Atherectomy (PTRCA… percutaneous
 transluminal rotational coronary
angioplasty)

9. Which procedure to
choose
 Location of the occlusion
 Consistency of the blockage
 Complexity of the blockage
 Pt underlying health
occlusion to previous bypass grafts
Every situation is unique and all factors are
considered

10. Pre-operative
management
 Same as all operative patients
 Physical and psychological assessment
 Informed consent
 Adherence to treatment and protocols
 Helping with coping and understanding
of procedure
 Maintain patient dignify
 Evaluate conditions effecting post op
care

11. Pre operative
management
 History and physical
 Cxr
 Ekg
 Lab tests- blood typing, cross and match,
blood donation
 Identify learning needs, usual functioning,
coping mechanism, support system. How
this effects post op course and rehab.
 Discharge planning

12. Pre operative care
 Planning: reducing fear. Learning
procedure and post op course, avoiding
complications
 Promoting home and community based
care

13. Predictors of Increased
Morbidity with Cardiac Surgery
 Extent of Disease
 Left Main Disease
 Unstable Angina
 Emergent Surgery
 Prior Cardiac Surgery
 LV Dysfunction
 Pre-surgery Cardiogenic Shock

14. Predictors Con’t
 Comorbidities
 Renal Dysfunction
 Diabetes Mellitus
 Cerebrovascular disease
 COPD
 PVD
 Obesity

15. Predictors Con’t
 Social Predictors
 Availability of Support
 Access to Community Resources

16. Post-op Predictors
 Atrial Arrhythmias
 Renal Insufficiency
 Prolonged Ventilation
 CHF
 Peri-operative MI
 Cerebrovascular incidents

17. Coronary Artery Bypass Graft (CABG)
 Performed under general anesthesia
 Surgical procedure
 Surgeon makes a median sternotomy
incision and connects the patient to
cardiopulmonary bypass (CPB) machine
 Use vein or artery from patient
 Attach one end to aorta
 Attach other end of vein to the coronary
artery DISTAL to the blockage
 Candidates:
 =/> 60% blockage of LCA/LAD
 > 70% blockage

19. Harvest the vein:
Mammary
Short/narrow
Atherosclerosis
> 20 yr.
Saphenous
Long and wide
Atherosclerosis
5 – 10 yr.
Other:
cephalic, basilic,
gastro-epiloic

21. Heart Valve Surgery
 True “Open” Heart surgery
 Valves may be either replaced or
repaired
 Can be done through minimally invasive
procedure or TAVI now
 May have valve procedure with CABG

22. Indications for valve surgery
 When the valvular dysfunction causes
symptoms that affect a person’s ability to
function
 When the heart and other systems begin
to fail due to the faulty functioning valve.
Critical stenosis or regurgitation

24. Valve Surgeries
 Repair valve
 Balloon angioplasty
 Commisurotomy- separate the fused
leaflets
 Annuloplasty- where the valve adheres to
the heart wall
 Valvuloplasty- repair the valve
 Replace valve

26. Types of Valves
Autograft … use patient’s own pulmonic
valve & replace pulmonic valve with
homograft
Homograft or Allograft … source is
cadaver
Xenograft … source is pig or cow
Mechanical valves

29. Aneurysm:
weakness of
musculature in
wall of blood
vessel …
Causes an
out-pouching
Can rupture if
under pressure

30. Abdominal
Aortic
Aneurysm:
Repaired with
synthetic
grafting
procedure

31. Coronary Artery Bypass Graft: Intraoperative
Procedure Sequence of Events
Intubation } Airway, gas
exchange
General Anesthesia }
Skin preparation/scrub bacteria in
surgical
field
Apply electrodes √ heart rate/rhythm

32. Insert lines
Peripheral I Vs IV meds
Epicardial pacer Pace heart prn
Arterial line √ BP: systolic,
 (radial/femoral) diastolic, MAP
Swan Ganz √ PAP, CVP,
PCWP
Manage fluids
↔

33.  Insert Chest Tube Drain surgical field
Recapture blood for
autotransfusion
 Insert NG tube Decompress stomach
 Insert foley cath Decompress bladder
√ urine output,
fluid status,
renal artery perfusion

34.  Harvest veins … Prepare donor graft
s
 Sternotomy: … Prepare an open
retract sternum, ribs surgical field
and lungs … Lungs minimally inflate
 Cannulate: bypass heart …Removes blood @
VC
(must cross clamp aorta) …Returns blood @
Aorta
D5/LR w/ Heparin …Prevents clotting
Extracorporeal Circulation
Oxygenates, filters, cools 28-320
C ( 82-920
F)
Also … warms the blood post procedure
… allows blood draws q 1-15 minutes (what
labs?)

35. Cardioplegia Solution …Bathe heart in FROZEN
slush… metabolism & O2 consumption
Position/STOP heart … Need a still, stable
surface to attach grafts
Incise pericardium … Arteries on surface of
& perform grafting myocardium
Check blood flow through newly grafted arteries
 Electrically restart heart … reverse the process
i.e., remove cannulas, reverse heparin (protomine),
reinflate lungs, etc.

36. Effects/complications of
Cardiopulmonary Bypass
Increased capillary permeability (interface of
blood & bypass cannulas/tubing) …
fluid shifts to interstitial spaces…
EDEMA & PULMONARY CONGESTION
Caused from:
Inflamation of aterial membranes
Platelet release of vasoactive substances

37. Hemodilution…FLUID VOLUME OVERLOAD
 Solution used to prime bypass machine
 secretion of ADH
 secretion of renin 20
non-pulsatile (MAP)
renal perfusion
Alterations in Coagulation… BLEEDING/CLOTTING
 Heparin and protamine
 Damage to blood cells (interface w/ tubings)
 RBC hemolysis and platelet damage
 Leukocyte damage
 Microemboli (tissue debris, air emboli)


38. Increase systemic vascular resistance (SVR)
…. HYPERTENSION & CARDIAC OUTPUT
 Catecholamine & renin secretion
 Hypothermia
Alteration in glucose metabolism
 Insulin
 Glyconeolysis
 Altered glucose transport across cell
membrane

39. Post op
picture:
Tubes
everywhere

40. Nursing Assessment
Neuro: consider… anesthesia, hypothermia,
possible CVA 20
to cerebral ischemia
hypertension (bleed) or emboli
√ LOC…responsiveness, grasp & movement,
sensation, pupils, pain, tremor/seizure, fever
Respiratory: intubated, mechanical ventilation
√ Airway …ET tube placement? Secure?
√ Rate, rhythm, depth, breath sounds
√ Skin color and temperature, nailbeds
√ O2 sat and/or ABG √ Chest X ray
√ Ventilator settings √ Chest tubes

41. Nursing Assessment: cardiac/cardiovascular
Heart Rate & Rhythm
 cardiac monitor AND auscultate
Blood Pressure
 Arterial line: sys/diastolic (if ?… manual √ )
 MAP (mean arterial pressure)…
Organ perfusion is dependent on MAP
 Needs to be > 80 --
Cardiac output x systemic resistance
Systolic BP + 2 (diastolic BP) / 3
BP = 125/75; MAP = 125 + 150/3 = 92

42. Nursing Assessment: cardiac/cardiovascular
Cardiac Index - value computed ..
 Cardiac output/meter2
body surface area
Cardiac Output – Volume of blood going into
systemic circulation each minute
SV (cc ejected w/ ea. contraction) X BPM
SV= 60 cc x heart rate= 60 BPM =3,600cc/min.
3.6 liters/min.
Normal cardiac output is 3 – 4 liters/minute

43. Nursing Assessment: cardiac/cardiovascular
Pulse Pressure – narrowing or widening
interval between systolic & diastolic BPs:
Reflects cardiac output, i.e., stroke volume,
rate, systemic resistance
Normal is 30-40 mm Hg (ie. 140/80)
Significance: 140/80  140/40, PP = 80
(anxiety-exercise-bradycardia-fever-atherosclerosis)
140/80  140/120, PP = 20
(shock, heart failure, hypovolemia, aortic stenosis)
Other: Peripheral Pulses, CSM, Capillary Refill, skin
color and temperature, cyanosis;
Labs: H&H (CBC), Platelets, Clotting- APTT, PT, INR

44. Nursing Assessment: cardiac/cardiovascular
Pulse deficit – difference between apical
rate and radial rate
Significance:
 NON-conducted beats
 Electrical stimuli/conduction intact but
may have volume/mechanical failure
 L Ventricle failure?
 low blood volume?
 High systemic resistance?
 Compare EKG and physical assessment.

45. Nursing Assessment: cardiac/cardiovascular
Hemodynamic Monitoring
Central Venous Pressure (CVP)
 Sensor in SVC or R Atrium
 Measures pressure in the RIGHT atrium
 Reflects VENOUS pressure/volume fluid
coming back to the heart …preload
 Significance: used to determine and help regulate
fluid balance…
 Fluid volume deficit or overload?
 Normal is 0-8mm Hg

46. Swan-Ganz cath…√ CVP
√ PAP- pulmonary
artery pressure
√ PACWP-PAWP
“wedge pressure”
*Sensor wedged in
pulmonary capillary
*Reflects LEFT atrial &
ventricular pressure
(preload)
(*Assesses hydration,
regulate fluid status)
*Normal–4-12 mm Hg
*Complication: pulmonary
infarct

47. Nursing Assessment
 Renal:
 Hourly output, specific gravity, √ pink or bloody
urine; √ BUN/Creatinine
Electrolytes:
 √ Electrolytes: K+
Ca ++
, Mg + +
 √ EKG- K +
= tall, peaked “T” waves
K +
= flat “T” waves
Musculo-Skeletal - tremor, seizure, etc.
Endocrine: Blood glucose,
S & s of hypo/hyperglycemia
Hyper/hypoglycemia protocols

48. Nursing Care/Nursing Diagnoses
Risk for Decreased Cardiac Output re:
 Hemorrhage, hypovolemia
 Swan- PAWP, CVP, HR, BP, Periph.Circ.
 CT drainage:< 200cc/hr (1st few hrs post-op)
 Hourly intake: I Vs, blood, plasma, etc.
output: DT, Foley, NG, incisions, etc.
 Dysrhythmia – cardiac monitor, heart sounds
 Cardiac Tamponade – Blood collection
between pericardial layers…constricts/restricts
ventricular
filling & decreases cardiac output
(pulsus paradoxus –
fluctuation with
respiration)

49. Cardiac Tamponade/
Pericardial Effusion:
CO, BP  syncope,
Narrow pulse pressure
Venous pressure JVD
Muffled heart sounds,
Dyspnea, pain, anxiety
Pulsus paradoxus:
Systolic pressure heard
during expiration but
NOT w/ inspiration
Difference systolic BP
expiration inspiration
> 10mm Hg is abnormal

50. Nursing Care/Nursing Diagnoses
Risk for decreased tissue perfusion (arterial flow, specify)
 Coronary  MI
 Cerebral  Stroke
 Renal  Renal failure
 GI  Ischemic bowel
 Extremities  Arterial occlusion
Re:
 Hemorrhage/bleeding, emboli or clot formation

51. Nursing Care/Nursing Diagnoses
Risk for Impaired Gas Exchange
Risk for Ineffective Airway Clearance
Risk for … Fluid Volume Deficit
… Fluid Volume Overload
Risk for Electrolyte Imbalance (specify)
Risk for Sensory Perceptual Alterations
Risk for … Decreased LOC
… Altered Thought processes
Impaired Skin Integrity, Risk for Infection
Knowledge Deficit
Impaired Home Maintenance Management

52. Cardiac/Cardiovascular Surgery : What’s
NEW?
Beating Heart Surgery
 Coronary artery revascularization
 No need for cardiac bypass machine
(avoid all the asssociated complications)
 No aortic manipulation or cross clamping

53. Advantages of Off pump CABG
 Benefits high risk and elderly
 Thoracotomy vs Sternal incision
 NO cardioplegia arrest
 Decrease use of blood products
 Less damage to blood cells/coagulation
 Less myocardial invasion
Myocardial damage/dysrhythmia?)
 Reduced neuro/cognitive impairment
 Decreased LOS, cost, mortality

54. Disadvantages
Only 10% patients are eligible
 Lesions HIGH LAD or RCA
 Patent internal mammary artery
 Conversion to traditional CABG…
5% to 10%

55.  What else is “cutting edge?”
 Robotic Cardiac Surgery
da Vinci Surgical system
Endoscopoic
3-D optics and wristed
instruments
 Antiarrhythmic surgery

57. Carotid Artery Repair
 Stent
 Angioplasty
 Surgery
 Remember baroreceptors especially with
Carotid Artery manipulation

58. Procedures for Coronary Artery Blockage…
first line in invasive procedures
(less risk/expense than CABG)
Coronary angioplasty (PTCA…
percutaneous transluminal coronary
angioplasty)
 Introduce catheter into artery
 Inflate a balloon to compress plaque
 Used with single, large, proximal occlusions
Complications
 Bleeding at sheath/catheter insertion site
 Bleeding… retroperitoneal
 Thrombus and fistula formation

59. Procedures for Coronary Artery Blockage
Atherectomy (PTRCA… percutaneous
transluminal rotational coronary angioplasty)
 Introduce catheter into artery
 Inflate a balloon to press a bladed surface against
plaque… blade rotates & shaves off the plaque.
 Uses with single, large, proximal occlusions
Complications
 Dysrhythmias, myocardial ischemia with
possible myocardial infarction

60. Procedures for Coronary Artery
Blockage
 Coronary Artery Stenting
 Introduce catheter into artery
 Can be used with multiple occlussions
 Several stents can be deployed into the same
artery
 Difficult to place at bifurcations
 Complications same as PTCA and PTACA

61. Stents

62. PTCA, PTCRA and Stent: advantages/disadvantages
Advantages:
 Minimally invasive
 Local anesthetic
 No need for bypass
 90% success rate… initially
Disadvantages:
 3 - 8 % close within the first 24 hours
 33% close within first 6 months
(damage to intima of artery causes rapid
progression of recurring atherosclerosis)
Need for anticoagulation with stent(s)

63. Nursing Care Post-Intervention
 VS, Groin and Pulse Checks – every 15 minutes x 4,
every 30 minutes x 2, then hourly
 Monitor urinary output
 Assess for pain in groin, abdomen, and back
 Assess for chest pain and difficulty breathing

64. Medical/Nursing
Interventions

65. Medical/Nursing
Interventions