Cardiac/Vascular Nurse Exam Secrets Study Guide (27 page)

Coronary artery bypass graft is indicated for angina refractory to drugs and other surgical interventions, significant left cardiac main disease, triple vessel coronary artery disease, acute myocardial infarction, and left ventricular failure due to cardiogenic shock or congestive heart failure.

Contraindications associated with coronary artery bypass graft include lack of adequate graft, small coronary arteries, severe aortic stenosis and severe left ventricular failure and coexisting peripheral vascular, renal, and pulmonary disease.

Complications associated with coronary artery bypass graft procedures include postoperative bleeding such as heparin induced thrombocytopenia, disseminated intravascular coagulopathy and diluted anemia, myocardial depression, cardiac tamponade, perioperative myocardial infarction, dysrhythmia including atrial tachycardia or atrial fibrillation, pulmonary edema, pulmonary atelectasis, pneumothorax, renal impairment, abdominal distention, cerebral ischemia, postcardiotomy delirium, peripheral neurological deficits, postpericardiotomy syndrome, wound infection and sudden death.

Prior to coronary artery bypass graft procedure, practicing clinicians should take patient’s medical history, perform a physical examination, and evaluate the patient’s overall health. Patients should be screened for drug-drug interactions, allergies, vital signs such as heart rate and blood pressure and cardiovascular blood indicators such as potassium levels, prothrombin time, hematocrit, and creatinine levels. Patients should also undergo electrocardiogram and echocardiogram prior to procedure. Additionally, they should take prophylactic antibiotic therapy and undergo chest x-ray. Overall, a full cardiovascular work-up should be conducted prior to the procedure.

During the procedure, patients should only receive medications via intravenous route, except for aspirin, which is given orally prior to procedure.

Post coronary artery bypass graft, practicing clinicians should perform an electrocardiogram, echocardiogram, perform a physical assessment, monitor peripheral blood flow and look for swelling and evaluate cardiac pain. Hospital protocols for aftercare should be followed. Prior to patient release, practicing clinicians should perform additional physical assessments such as assess patient’s heart sounds and laboratory tests such as hematocrit, potassium levels, creatinine levels and cardiac enzymes. Overall, a full cardiovascular work-up should be conducted prior to releasing the patient.

Valvular replacement

Valvular replacement is a procedure that is used when repair will not be effective for fixing a dysfunctional valve. Two types of valvular replacements are currently available including mechanical valve replacements such as bileaflet, tilting-disk and caged ball valves and biologic valve replacements such as xenografts, homografts or allografts.

The procedure can be performed as standard cardiovascular procedure with sternum access, minimally invasive approaches or through port access. However, cardiac arrest is required to perform the procedure; therefore, patients need to undergo general anesthesia and cardiopulmonary bypass. Valvular replacement may be performed for aortic stenosis and aortic insufficiency.

Two types of valvular replacements are currently available including mechanical valve replacements such as bileaflet, tilting-disk, and caged ball valves and biologic valve replacements such as xenografts, homografts, or allografts. Mechanical valve replacements require life-long anticoagulation therapy due to risk of thrombosis.

Mechanical valves last longer and are typically used for patients under 65 or patients over 65 that have a long life expectancy. Biologic valves deteriorate at a rate inversely proportional to the patient’s age (wear out faster in younger patients). Thus, biological valves are typically great for elderly patients in whom the expected lifespan is less than the life of the valve (15-20 years). Women that would like to become pregnant should also have biologic valves placed to avoid long-term teratogenic anticoagulants.

Valvular repair

Valvular repair is a procedure that involves repair of calcified or nonfunctioning cardiac valve. Several types of valve repair procedures may be performed including commissurotomy, annuloplasty, and chordoplasty. Commissurotomy is a procedure that separates fused leaflets of a cardiac valve. Annuloplasty is a procedure that repairs the junction between the cardiac valve leaflet and cardiac muscle. Two different approaches can be used to perform annuloplasty including the use of ring prosthesis and/or sutures. Chordoplasty is a procedure that involves the repair of an elongated or ruptured chordae tendinea.

The procedure can be performed open or through minimally invasive approaches or through port access. However, cardiac arrest is required to perform the procedure; therefore, patients need to undergo general anesthesia and cardiopulmonary bypass. Valvular repair may be performed for mitral valve stenosis and mitral insufficiency.

Indications, contraindications, and complications of valvular repair and valvular replacement

Valvular repair or valvular replacements are indicated for aortic or mitral valve disease. Contraindications for valve repair and/or replacement include presence of other cardiovascular comorbidities or poor health status as well as those patients at high surgical risk.

Complications of valvular repair and/or valvular replacements include postoperative bleeding such as heparin induced thrombocytopenia, disseminated intravascular coagulopathy and diluted anemia, myocardial depression, cardiac tamponade, perioperative myocardial infarction, dysrhythmia including atrial tachycardia or atrial fibrillation, pulmonary edema, pulmonary atelectasis, pneumothorax, renal impairment, abdominal distention, cerebral ischemia, postcardiotomy delirium, peripheral neurological deficits, postpericardiotomy syndrome, wound infection, and sudden death.

Role of practicing clinician pre, during, and post valvular repair or valvular replacement

Prior to valvular repair or replacement, practicing clinicians should take a patient’s medical history, perform a physical examination, and evaluate a patient’s overall health. Patients should be screened for drug-drug interactions, allergies, vital signs such as heart rate and blood pressure and cardiovascular blood indicators such as potassium levels, prothrombin time, and hematocrit and creatinine levels. Patients should also undergo an electrocardiogram and echocardiogram prior to procedure. Additionally, they should take prophylactic antibiotic therapy and undergo a chest x-ray. Overall, a full cardiovascular work-up should be conducted prior to the procedure.

During the procedure, patients should only receive medications via an intravenous route, except for aspirin, which is given orally prior to procedure.

Post-valvular repair or replacement, practicing clinicians should perform an electrocardiogram, echocardiogram, perform a physical assessment, monitor peripheral blood flow, look for swelling, and evaluate cardiac pain. Hospital protocols for aftercare should be followed. Prior to patient release, practicing clinicians should perform additional physical assessments such as assess the patient’s heart sounds and laboratory tests such as hematocrit, potassium levels, creatinine levels, and cardiac enzymes. Overall, a full cardiovascular work-up should be conducted prior to releasing the patient.

Arterial bypass surgery

In cases of severe ischemia or occlusion of cardiac blood vessels, bypass grafts may be used to reroute blood flow and improve cardiac function. Bypass vessels that can be used to reroute cardiac blood flow include femoral artery bypass grafting or axillofemoral reconstruction. Bypass grafts can be made from the patient’s own tissue or of synthetic nature. Synthetic graft materials include expanded polytetrafluoroethylene and woven or knitted Dacron.

Various approaches may be used to perform arterial bypass surgery including aortobifemoral bypass, aortoiliac endarterectomy, or femoral to popliteal graft. Other approaches may be used dependent on the extent and degree of the patient’s disease and/or presence of other comorbid conditions.

Arterial bypass surgery is indicated for severe unilateral or bilateral aortoiliac disease, distal aortic occlusion, and critical limb ischemia with diffuse disease and severe occlusion.

Contraindications for arterial bypass surgery include patients who are medically unstable and have poor distal runoff. Complications of arterial bypass surgery include thrombosis, embolization, bleeding, arterial dissection, infection, restenosis, compartment syndrome, mesenteric ischemic, mesenteric infarction, and/or sudden death. Other complications may arise due to the presence of other comorbid conditions such as diabetes and various cardiovascular conditions as well as due to patient’s overall health.

Prior to arterial bypass surgery, practicing clinicians should take the patient’s medical history, perform a physical examination, and evaluate the patient’s overall health. Patients should be screened for drug-drug interactions, allergies, vital signs such as heart rate and blood pressure and cardiovascular blood indicators such as potassium levels, prothrombin time, and hematocrit and creatinine levels. Patients should also undergo an electrocardiogram and echocardiogram prior to the procedure. Additionally, they should take prophylactic antibiotic therapy and undergo a chest x-ray. Overall, a full cardiovascular work-up should be conducted prior to the procedure.

During the procedure, patients should only receive medications via an intravenous route, except for aspirin, which is given orally prior to the procedure. Post arterial bypass surgery, practicing clinicians should perform an electrocardiogram, echocardiogram, perform a physical assessment, monitor peripheral blood flow and look for swelling and evaluate cardiac pain. Extremity swelling of legs and feet is typical after arterial bypass surgery and should be monitored and treated if it becomes severe. Additionally, patients should be evaluated for compartment syndrome and/or infection.

Pharmacologic management postsurgery may include anticoagulants, antiplatelet agents, aspirin, and/or board spectrum antibiotics.

Hospital protocols for aftercare should be followed. Hemodynamic blood flow should be monitored and patients should be assessed for hemorrhagic shock. Doppler evaluation of vessels may also be completed. Prior to patient release, practicing clinicians should perform additional physical assessments such as assess patient’s heart sounds and laboratory tests such as hematocrit, potassium levels, creatinine levels, and cardiac enzymes. Overall, a full cardiovascular work-up should be conducted prior to releasing the patient.

Aneurysm repair

Aneurysm repair involves aneurysm resection and bypass grafting. Aneurysms can be categorized as abdominal, thoracic, aortic, subclavian, femoral, or popliteal. Aneurysm repair procedures may be done on an emergency basis or as a routine procedure to prevent other cardiovascular complications such as stroke, myocardial infarction, or congestive heart failure.

The procedure requires removal of the aneurysm by accessing the location of the aneurysm, clamping above and below the site as well as opening the aneurysm and inserting a graft. Types of aneurysm repair procedures include endovascular grafting, abdominal aortic aneurysm grafting and ascending thoracic aneurysm grafting.

Aneurysm repair is indicated for abdominal aortic aneurysms and thoracic aneurysms. Contraindications for aneurysm repair include patients who are medically unstable. However, in the case of dissection, emergency surgery may be performed.

Complications associated with aneurysm repair procedures include postoperative bleeding, cardiac tamponade, myocardial infarction, pulmonary complications such as pulmonary edema or embolism, renal impairment, gastrointestinal upset such as abdominal distension, ileus, hepatic dysfunction or mesenteric ischemia, hematoma, infection, endocarditis, ischemia, embolism, spinal cord ischemia and/or sudden death. Other complications may arise due to the presence of other comorbid conditions such as diabetes and various cardiovascular conditions as well as due to the patient’s overall health.

Prior to aneurysm repair, practicing clinicians should take the patient’s medical history, perform a physical examination, and evaluate the patient’s overall health. Patients should be screened for drug-drug interactions, allergy, vital signs such as heart rate and blood pressure and cardiovascular blood indicators such as potassium levels, prothrombin time, hematocrit and creatinine levels. Patients should also undergo an electrocardiogram and echocardiogram prior to the procedure. Additionally, they should take prophylactic antibiotic therapy and undergo a chest x-ray. Overall, a full cardiovascular work-up should be conducted prior to the procedure.

Practicing clinicians should also assess the patient for signs of impending aneurysm rupture. Symptoms associated with abdominal aneurysm that can lead to rupture include back or abdominal pain. Symptoms associated with thoracic aneurysm include severe chest, back, shoulder, or abdominal pain. Other associated symptoms include hypotension, congestive heart failure, and/or falling hematocrit.

During the procedure, patients should only receive medications via an intravenous route, except for aspirin, which is given orally prior to procedure. Post-aneurysm repair, practicing clinicians should perform an electrocardiogram, echocardiogram, perform a physical assessment, monitor peripheral blood flow, look for swelling, and evaluate cardiac pain.

Hospital protocols for aftercare should be followed. Hemodynamic blood flow should be monitored and patients should be assessed for hemorrhagic shock. Doppler evaluation of vessels may also be completed. Prior to patient release, practicing clinicians should perform additional physical assessment such as assessing a patient’s heart sounds and laboratory tests such as hematocrit, potassium levels, creatinine levels, and cardiac enzymes. Overall, a full cardiovascular work-up should be conducted postsurgery and prior to releasing the patient, including cardiac status, respiratory status, neurological status, peripheral vascular status, gastrointestinal status, pain status, psychosocial status, and potential high-risk complications associated with aneurysm repair.