Cardiac Interventions

Question 1

what is electrical cardioversion?

Answer 1

a procedure aimed at restoring normal sinus rhythm

done electrically or pharmacologically

Question 2

PT implications for electrical cardioversion

ie. how long before you can work with them?

Answer 2

withhold care for 24 hours or until the pt can tolerate activity

Question 3

Briefly compare/contrast cardioversion and defibrillation

Answer 3

1. Cardioversion
   
   • elective procedure
   • pt awake & frequently sedated
   • synchronized with QRS
   • 50-200 joules
   • consent required
2. Defibrillation
   
   • emergency procedure
   • V-Fib/V-Tach
   • no CO
   • begin w/200 joules (up to 360)
   • pt unconscious

Question 4

what are coronary artery stents?

Answer 4

small expandable tubes used to open up narrowed arteries including coronary arteries, femoral artery, and carotid

Question 5

what is the procedure of inserting a stent called?

Answer 5

PCI
percutaneous coronary intervention

Question 6

what other procedures are included in the umbrella term PCI? (3)

Answer 6

1. angioplasty
2. atherectomy
3. stenting

Question 7

what are the results of coronary artery stent placement? (3)

Answer 7

1. reduced symptoms (like chest pain)
2. increased blood flow
3. helps keep vessels open and prevent subsequent problems/MIs

Question 8

after the placement of a stent what are patients placed on?

Answer 8

1. aspirin → for life
2. antiplatelet drugs → pt dependent

Question 9

what are stents usually made of?

Answer 9

metal mesh

two types: drug-eluting stent and bare metal stent

Question 10

what is a drug-eluting stent?

Answer 10

a stent that slow releases a drug to block cell proliferation

Question 11

Describe the procedure for stent placement

what might the patient experience briefly?

what is considered sucessful?

Answer 11

1. light sedation (valium, versed, or morphine)
2. peripheral access route thread a catheter to the location of blockage
3. Balloon expanded to fit the stent in place
   
   • pt may experience brief angina
4. considered successful if lumen is open after catheter is withdrawn

Question 12

how long does the procedure take to place a stent? How long are pts in the hospital?

Answer 12

1. lasts 30 minute - 2 hours
2. most pts are D/C home the day after PCI

Question 13

List risks/complications of coronary artery stents (8)

Answer 13

1. Bleeding if arterial wall is perforated
2. CVA → if plaque is dislodged by catheter
3. clot formation
4. restenosis
   
   • scar tissue or plaque can also form in the area of the stent
5. requires anti-coagulation therapy → bleeding risk
6. arrhytmias
7. kidney damage from dye
8. allergy to dye

Question 14

T/F: Stents are safe under MRI

Answer 14

TRUE

most if not all are safe up to 3 Tesla and made of nonferromagnetic materials

Question 15

T/F: stents treat the underlying cause of angina

Answer 15

FALSE

only one area of a narrowed artery and not the underlying condition

arteries can narrow and new blockages can occur

Question 16

Coronary stent prognosis (5)

Answer 16

1. stents tend to damage the artery wall and increase risk of secondary obstruction
2. 60% of all stented coronary stents require restenting
3. PCI was no better at relieving angina symptoms than OMT
4. appear to increase postoperative bleeding, MIs, and CVAs compared to no trx
5. pts recieving stents go back to their bad habit afterwards

Question 17

coronary artery stent implications for PT

Answer 17

1. care with incision site/bleeding
2. cardiac rehab candidate

Question 18

describe a balloon angioplasty

Answer 18

• tiny balloon is deflated and guided through the artery to the blockage
• inflated to widen the opening and increase blood flow to the heart
• stent often placed during procedure

Question 19

what is an atherectomy?

Answer 19

1. catheter with sharp blade attached
2. inserted into artery
3. sharp blade removes plaque from a blood vessel
4. used to treat blockages in arteries that are not easily treated with stents
5. risk for an embolus from dislodged debris

Question 20

Benefits of an atherectomy (6)

Answer 20

1. minimally invasive procedure
2. short recovery time
3. small incision
4. less pain
5. less scaring
6. reduced blood loss

Question 21

list surgical treatments for cardiac diseases

Answer 21

1. CABG
   
   • off pump CABG
   • Minimally invasive CABG
2. Valve replacement/repair
3. Cardiac Ablation
4. Aortic Aneurysm Repair
5. Intra-aortic balloon pump

Question 22

what is a CABG?

Answer 22

Coronary Artery Bypass Graft

• is a surgical procedure used to restore normal blood flow to an obstructed coronary artery

Question 23

List reasons for CABGs (3)

Answer 23

1. to relieve angina unsatisfactorily controlled by max tolerated anti-ischemic meds
2. prevent or relieve left ventricular dysfunction
3. reduce the risk of death

Question 24

list vascular donor sites for CABGs (3)

Answer 24

1. saphenous vein
2. internal mammary arteries
3. radial artery

Question 25

what is an off pump CABG?

Answer 25

* a CABG performed on a beating heart * limited to 1-2 lesion bypasses * decreased post op complications and recovery times

Question 26

describe a minimally invasive CABG

Answer 26

1. minithoracotomy or subxiphoid incision into the L chest cavity 2. the internal mammary artery is mobilized from the L chest wall and is sewn to the artery in the front of the heart (LAD)

Question 27

List some CABG complications (9)

Answer 27

1. postperfusion syndrome (pumphead) 2. cardiogenic shock 3. nonunion of the sternum/infection 4. acute renal failure due to embolism or hypoperfusion 5. stroke 6. pneumothorax 7. hemothorax 8. pericardial tamponade 9. arrhythmias

Question 28

what is cardiogenic shock?

Answer 28

heart cannot pump enough blood and oxygen to vital organs (impact MAP) * MAP is too low to adequately perfuse the organs * serious medical emergency → often follows an MI * 50%

Question 29

what is cardiac tamponade?

Answer 29

reduced cardiac function secondary to fluid accumulation in the pericardial cavity restrictive cardiac disease requires Beck's Triad

Question 30

list the components of Beck's Triad

Answer 30

1. hypotension 2. muffled heart sounds 3. bulging neck veins

Question 31

what are some potential sternal wound complications? What is a sternectomy? What are pectoralis flaps?

Answer 31

1. sternal dehiscence 2. sternectomy → partial or torn debridement of sternum to remove infected bone 3. pectoralis flaps → pectoralis muscle used to cover area where sternum removed

Question 32

CABG Post-op complications

Answer 32

1. LE * edema * extravasation → fluid leakage out of harvest site * inflammation and ecchymosis 2. Clotting 3. Mortalitiy → rate ~2%

Question 33

what types of things increase mortality risk in post-op CABG pts? (5)

Answer 33

1. age \> 70 2. female 3. low EF 4. history of stroke, MI, or heart surgery 5. DM or HTN

Question 34

List sternal precautions

Answer 34

1. no pushing or pulling 2. no lifting more than 5 lbs 3. no lifting one arm overhead * can lift both at the same time 4. no reaching behind your back 5. encourage unilateral UE active ROM tolerated to facilitate functional mobility gains 6. avoid full weight bearing through UE 7. no driving and no sitting in passenger seat behind an airbag for 4 weeks

Question 35

Sternal precautions PT implications

Answer 35

1. log rolling for bed mobility 2. avoid activities that may cause excessive Valsalva 3. encourage chest splinting w/pillow when coughing 4. avoid lifting, pushing, and pulling greater than 10 lbs for 3 months

Question 36

what does "keep your move in the tube" mean?

Answer 36

another method of describing sternal precautions

Question 37

CABG harvest site considerations

Answer 37

1. incisions at the harvest site often present as impaired integumentary and contributes to incisional pain, infection, and edema 2. protection incision sites 3. WBAT for pts with LE or UE harvest sites 4. no ROM restrictions given normal healing 5. provide thigh-high compression garments to those with LE harvest site 6. elevate involved extremity while seated and in bed 7. AROM to prevent edema 8. monitor for signs of infection * rubor * purulent discharge * acute pain

Question 38

what is a pericardial window? what are restrictions/precautions?

Answer 38

surgical procedure performed on the sac around the heart used to drain symptomatic pericardial effusions usually small subxiphoid incisions no restriction/precautions

Question 39

list the types of valve surgeries (4)

Answer 39

1. annloplasty 2. valve repair 3. valve replacement * mechanical: metal or synthetic material * tissue: pig or cow tissue 4. transcatheter aortic valve replacement (TAVR)

Question 40

describe an annuloplasty

Answer 40

1. tightens or replaces the rim (annulus) of the mitral or tricuspid valve * can get torn when valve prolapases

Question 41

describe the pros/cons of a mechanical valve replacement

Answer 41

1. high durable, can last a lifetime 2. require lifelong anticoagulation to decrease risk for thromboembolism

Question 42

describe the pros/cons of a tissue valve replacement

Answer 42

1. durability is 10-20 years 2. no lifelong anticoagulation required

Question 43

describe a transcatheter aortic valve replacement where are the 3 access points? who is it used for? what are the restrictions?

Answer 43

1. Access * transfemoral * transapical → anterior thoractomy to get to apex of heart * transaortic → upper hemisternotomy or R anterior thoracotomy to get to aorta 2. minimall invasive 3. useful for pts who are at high risk or who cannot undergo open heart surgery for AVR 4. typically no restrictions, no sternal precautions

Question 44

what are pacemakers?

Answer 44

a tool that creates artificail action potentials to maintain appropriate cardiac conduction/rhythm

Question 45

where are pacemakers typically placed? how many weeks for incision healing and firm adhesion?

Answer 45

1. Usually inserted under the skin in the L infraclavicular pocket, with leads inserted into the R side of the heart via the L subclavian vein to the superior vena cava 2. device leads are attached via passive (tined) or active (screw) fixation into the myocadium 3. 4-6 weeks needed to allow incision healing and firm adhesion of pacemaker leads

Question 46

general indications for pacemakers (3)

Answer 46

1. SA node disorder 2. AV node disorders 3. Supraventriclar tachycardia

Question 47

Pacemaker implications for PT

Answer 47

1. keep the involved UE in a standing sling for 24 hours 2. no theraeutic exercise to involved shoulders for 4-6 weeks 3. involved UE may be used functionally but limit shoulder flexion and abduction to 90 for 4-6 weeks, then may use functionally as tolerated 4. no lifting greater than 5 lbs with involved UE for 4-6 weeks 5. no driving until after follow up visit with electrocardiologist

Question 48

what is an ICD?

Answer 48

Implantable Cardioverter Defribillator * small battery-powered electrical impulse generator capable of cardioversion, defibrillation and pacing of the heart * is programmed to detect cardiac arrhytmia and correct it by delivering a jolt of electricity * ICDs constantly monitor the rate and rhythm of the heart * often permanent safeguards against sudden abnormalities

Question 49

ICD implications for PT

Answer 49

1. know that the patient has one 2. almost all forms of physical activity can be performed by patients with an ICD 3. no sports which might damage the device 4. no excessive strain on the shoulder, arm or torso where the ICD is implanted

Question 50

Exercises to avoid in ICD pts

Answer 50

ones that cause the clavicle to be pulled down towards the ribs such as lifting weights with the arms, on the ICD site, while standing

Question 51

what is cardiac ablation

Answer 51

used to treat conduction defects/heart rhythm problems

Question 52

briefly describe the procedure for cardiac ablation

Answer 52

1. catheter is inserted into a cardiac chamber 2. electrodes at the tip of the catheter gather data, allowing the mapping of the heart 3. data pinpoints the location of the faulty electrical site 4. that site or those sites are then destroyed (cold/heat)

Question 53

why is a rupture aneuysm bad?

Answer 53

it can lead to bleeding and subsequent hypovolemic shock, leading to death it can also be a site for clot formation

Question 54

describe abdominal aortic aneurysm repair

Answer 54

1. open repair * large abdominal incision in the abdomen to expose aorta 2. endovascular aneurysm repair * minmally invasive * small groin incisions

Question 55

what is an IABP?

Answer 55

Intra-Aortic Ballon Pump * a mechanical device that increases coronary perfusion * increased O2 availability to the heart

Question 56

Indications for IABP

Answer 56

1. failure to wean from cardiopulmonary bypass 2. HF 3. support during high-risk percutaneous transluminal coronary (balloon) angioplasty, rotoblator procedure, and coronary stent placement 4. cardiogenic shock 5. acute heart attack 6. cardiogenic shock 7. ventricular arrhythmias 8. post cardiac surgery

Question 57

describe the mechanism of action of an IABP

Answer 57

1. the balloon deflates during ventricular systole 2. the balloon inflates during ventricular diastole * increases coronary artery perfusion pressure * increases diastolic BP by 15-30% and increases SBP

Question 58

IABP Implications for PT

Answer 58

1. patients are typically hemodynamically unstable and inapproriate for therapeutic exercise programs 2. protection of the catheters integrity most important * movement and activity should be limited to avoid disruption of the catheter, balloon rupture, or incision site infection 3. therapeutic exercise to the uninvolved extremitites 4. avoid hip flexion \>70 degrees on affected 5. minimize extreme joint range of motion

Question 59

what is a LVAD?

Answer 59

Left Ventricular Assist Device 1. pump that we use for pts who have reached end-stage HF * LVAD is battery-operated, mechanical pump * helps the LV pump blood to the rest of the body * may remain implanted for years

Question 60

Indications for LVAD

Answer 60

1. Bridge to transplantation 2. Bridge to candidacy 3. Destination therapy 4. Bridge to recovery

Question 61

LVAD: PT considerations

Answer 61

1. often have multi-organ involvement 2. devices prevent pts from increasing CO 3. often also have RV dysfunction 4. may have chronotropic incompetence 5. may have impaired pulmonary function 6. may have skeletal myopathy, endothelial dysfunction and anemia 7. at rest the device provides most of the CO, whereas during exercise the contribution is variable 8. these are complex pts with limited ability to respond to CV demands of exercise