Cardiac

Surgery
Jacqueline Redman MSN, RN, ACNP-BC, CCRN-CSC-CMC, FCCS-C
August 18, 2015
Jeanes Hospital
Learning Objective

 Understand the pathophysiology associated with coronary and

valvular heart disease.
 Identify when a person with CAD would need coronary artery
bypass grafting (CABG)
 Recognize when a person with valvular heart disease requires
surgical intervention
 Understand pre-op evaluation and necessary testing
 Develop POC for individuals awaiting cardiac surgery
 Identify possible complications associated with cardiac surgery
 Discuss strategies for prevention and treatment of complications of
cardiac surgery
 In the Beginning…
The first successful open heart procedure on a human utilizing the heart lung machine was performed
by Dr. John Gibbon on May 6, 1953 at TJUH. He repaired an atrial septal defect in an 18-year-old
woman.

Dr Gibbon and Cecelia Bavolek; 10

http://jeffline.jefferson.edu/SML/Archives/Highlights/Gibbon/
years after the procedure.
 In the Beginning…
John Y. Templeton III, MD is often described as the Modern Pioneer of Cardiothoracic Surgery

The first annual 'Rib Crackers' Banquet. Dr. John Y. Templeton III, seated next to Dr. John H. Gibbon Jr.

Dr. Boova trained under Dr. Templeton and when he developed CAD, he also performed his CABG
The Present

Dr. Yoshiya Toyoda Dr. Robert S. Boova Dr. Grayson H. Wheatley III

Dr. T. Sloane Guy Dr. Akira Shiose Dr. Ravishankar Raman

 Heart Disease Prevalence

 Heart disease is the leading cause of death

 610,000 people die of heart disease in the United
States every year
 That’s 1 in every 4 deaths
 CAD is the most common type of heart disease
 Killing over 370,000 people annually
 735,000 Americans have a heart attack annually
 Of these, 525,000 are a first heart attack
 210,000 occur in individuals who have had a previous Mi

http://www.cdc.gov/heartdisease/facts.htm
Coronary Artery Disease
 Build up of plaque (fatty material and inflammatory cells) inside the wall of
arteries.
 As disease progresses these plaques grow, weakening vessel walls
 Calcium can be deposited in large plaques hardening them
 Symptoms are related to lack of blood flow (angina)
 Typical vs Atypical
 Angina
 Stable: Symptoms are provoked by exertion or stress; relieved by rest
 Unstable: Symptoms occur at rest

 Acute Coronary Syndrome

 USA
 NSTEMi
 STEMi
 CAD: Risk Factors

Non-Modifiable Modifiable
 Family History  Smoking
 Age 50  Hypercholestrolemia
 Male Gender  Hyperlipoproteinemia
 Age  High (LDL) and Low (HDL)
 65 And Greater  Diabetes
 High Blood Pressure  Obesity
 High Blood Homocysteine Levels  Physical Inactivity
 Menopause  Cocaine Abuse
Coronary Circulation

Coronary Location of Mi
Artery
RCA Inferior

LAD Septal;
Anterior
LCx Lateral
 Coronary Circulation
 RCA – smaller vessel
 PDA
 PLB
 Right atrium, SA Node, RV, Bottom portion of both ventricles and
posterior septum

 LMain – provides 70% of blood to muscle

 LAD – Branches are called diagonals and septals
 Anterior and distal LV and anterior septum
 CX – Branches are called OMs
 Left atrium, Lateral and posterior LV
 Ramus (present 10-30%)
 LV anterior wall
Coronary Arteries and ECG Correlation
Coronary Arteries and the Electric System

http://eurheartj.oxfordjournals.org/content/32/9/1059
ECG changes of an AMi
What now…
 Cardiac Arrhythmias (80%)  Sudden Death (20%) w/n 1-2 hours
of infarction
 Cardiogenic Shock (15%)
 Ventricular Fibrillation
 Congestive Heart Failure (60%)
 Tamponade
 LV Dysfunction
 Septal Rupture - VSD
 Valve Dysfunction
 Rupture Of Cardiac Muscle (1-5%)
 Papillary Muscle
 VSD
 Recurrent Mi
CAD: Diagnostics
 Cardiac Catheterization
 IVUS
 FFR
 Stress Test
 Exercise
 Pharmalogical
A
 Echo
 2D
3D

C
 Stress Echo
 Excercise
A – Bifurcating LAD lesion
 Dobutamine
B – Osital RCA lesion
 Cardiac MR C – Distal Lmain lesion

B
CAD: Indications for Surgery
 Left main stem stenosis
 Left main equivalent:
 Proximal LAD & Cx lesions
 3 vessel disease
 Severe 2 vessel disease
 LAD stenosis
 Ejection fraction <50%
 Diabetics
 Large area of ischemic muscle (with reversibility)
 Angina despite maximal rx therapy
 Acute failure of PTCA
 CAD when other OHS is indicated
 AVR
 MVR
CAD: Pre-op Management
Stop all blood thinners and Antiplatlets except ASA
Stop 7 days before Surgery Stop 48hrs before Surgery
Apixaban (Eliquis®) Prasugrel (Effient®) Fondaparinux (Arixtra®)
Cilostazol (Pletal®) Rivaroxaban (Xarelto®) Enoxapraxin (Lovenox®)
Clopidogrel (Plavix®) Ticagrelor (Brilinta®)
Dabigatran (Pradaxa®) Warfarin (Coumadin®)

 Continuous Telemetry monitoring

 Daily EKG
 Optimize Medical therapy
 Maintain Heparin and NTG gtts as ordered
 Beta-Blocker, ASA, Statin
 Ambulation
 Smoking Cessation
 Nebs
 Inhalers
 I/S & Pulm toilet
Valvular Heart Disease
 Types of Valve Disease

Congenital Acquired
 Abnormality that develops before birth. Can  Abnormality that develops with valves that
be related to improper valve size, malformed were once normal. Can involve changes in
leaflets, or an irregularity in the way the the structure of your valve or function.
leaflets are attached  Infectious
 Bicuspid Aortic Valve  Rheumatic
 Stenosis  Endocarditis
 Regurgitation  Fibro-calcific Degeneration
 Prolapse  Stretching/Tearing of chordae tendineae or
Papillary Muscles
 Ischemic

 Dilation of the Valve Annulus

 Inherited disorders (Marfans)
Types of Valve Disease
Normal Valve Function
Maintain forward flow and prevent reversal of flow
Valves open and close in response to pressure differences (gradients)
between the cardiac chambers

Insufficiency Stenosis
 Prolapse  Subvalvular – LVOT
 Flail leaflets  Valvular
 Damaged chords  Supravalvular
 Dilation
Valvular Heart Disease
 Aortic Valve Disease
 Stenosis
 Insufficiency
 Mixed AS/AI
 Mitral Valve Disease
 Stenosis
 Insufficiency
 Mixed MR/MS
 Tricuspid Valve Disease
 Insufficiency
Aortic Stenosis

Narrowing of the aortic valve opening that does not allow normal forward
blood flow from the left ventricle
 Aortic Stenosis: Etiology

Congenital AS Acquired AS
 Mono or Unicuspid Aortic Valve  Degenerative Calcific Stenosis
 Bicuspid Aortic Valve
 Aortic Sclerosis
 "Real" bicuspid valves with two symmetric
leaflets  End Stage Renal Failure
 Tricuspid with a fusion of two leaflets
 Paget’s Disease
 Most common valvular anomaly 1,2,3
 Rheumatic Aortic Stenosis
 Occurring in 20/1000 live births 1
 Twice as common in males as in females  Prosthetic Valve Dysfunction
1,2,3
 Endocarditis
 Most patients with a bicuspid aortic valve will
require valve surgery during their lifetime 1,2,3  Mantel Radiation

Typically presents in the 5th and 6th Typically presents in the 6th, 7th and
decades of life 8th decades of life

1. Tzemos N, Therrien J, Yip J, et al. Outcomes in adults with bicuspid aortic valves. JAMA. 2008, Sept 1; 300 (11): 1317–25.
2. Hoffman, J, Kaplan, S. The incidence of congenital heart disease. J Am Coll Cardiol. 2002, Jun;39(12):1890-1900.
3. Lewin, M, Otto, C. The bicuspid aortic valve: adverse outcomes from infancy to old age. Circ. 2005; 111:832-34.
Aortic Stenosis: Risk Factors
Independent risk associated with AS:
 Aortic Sclerosis 100%
90%
 Atherosclerosis
80%
 Diabetes Mellitus 70%
 Hypercholesterolemia 60%
 Bicuspid Aortic Valve 50%
40%
 Increasing Age
30%
 Sex 20%
 Increased prevalence in males 10%
0%
 HTN >65yo Male Diagnosis of
HTN
Current/Former
Smoker
Elevated
Cholesterol
IDDM

 Smoking National Average (STS) Jeanes Average

Data Analyses of the Society of Thoracic Surgeons National Adult Cardiac Surgery Database; 2014 Harvest 1
Aortic Stenosis: Pathophysiology

 Left Ventricular Hypertrophy

 Alterations in Coronary Flow
 Pulmonary Edema
 Pulmonary HTN
 Vasomotor Alterations
 LV Systolic Dysfunction
 Diastolic Dysfunction
 Mitral Regurgitation
 Left Atrial enlargement
 Afib

1. Otto, CM, Prendergast B. Aortic-Valve Stenosis — From Patients at Risk to Severe Valve Obstruction. NEJM. 2014, 21 August; 371(8): 744-56.
Aortic Stenosis: Clinical Findings
Symptoms Associated Clinical Manifestations

 Asymptomatic  Gastrointestinal Bleeding

 Classic  Platelet Dysfunction
 Dyspnea  Embolic Events
 Angina – can occur w/o obstructive  Cerebrovascular Events
CAD; not specific
 Endocarditis
 Heart Failure
 Coronary Artery Disease
 Syncope – carries a high risk of sudden
death  Thoracic Aortic Disease
 Most Common  Sudden Death
 Exercise Intolerance  Mitral Insufficiency
 Exertional Dyspnea
 Easy Fatigability
 Aortic Stenosis: Physical Findings
 Heart Murmur
 Cardiomegaly
 Diminished Pulses
 Heart failure
 Pulmonary Vascular Congestion
 Rales
 Elevated JVP
 Pedal Edema
 End Stage
 Cachexia
 Hypoperfusion

Cary, T, Pearce, J. Aortic Stenosis: Pathophysiology, diagnosis, and medical management of nonsurgical patients. Critical Care Nurse. 2013 Apr 1; 33:2; 58-71.
 Aortic Stenosis: Medical Management
Medical management is not effective for the treatment of symptomatic severe AS.1

 Treatment is aimed at symptom relief and management of co-morbidities

 Beta blockers, diuretics, digoxin, ACE inhibitors, angiotensin receptor blockers1,2
 Avoid excessive decrease in preload or hypotension1,2
 In the absence of serious co-morbid conditions, SAVR is indicated in virtually all
symptomatic patients with severe aortic stenosis 1,2

Age by itself is NOT a contraindication to surgery1

Surgical aortic valve replacement (sAVR) is the current gold standard, but it has
been estimated that between 30% and 60% of patients do not undergo AVR 2,3
1. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines. J Am Coll Cardiol. 2014;63(22):e57-e185.
2. Otto, CM, Prendergast B. Aortic-Valve Stenosis — From Patients at Risk to Severe Valve Obstruction. NEJM 371:8.
3. Wenaweser, P, Pilgrim, T, Kadner, A, et al. Clinical outcomes of patients with severe aortic stenosis at increased surgical risk according to treatment modality. J Am Coll Cardiol 2011;58:2151–62
Aortic Stenosis: Indications for Surgery
 Symptomatic - Severe
 Asymptomatic - Severe
 Asymptomatic and LVEF <50%
 Low surgical risk
 Decreased exercise tolerance or fall in SBP with exercise
 Undergoing other cardiac surgery
 Moderate or severe disease
Aortic Stenosis: Pre-Op Management
 Maintain SR (50-70 BPM)
 Coronary Perfusion
 Reduce Time for Systolic Ejection
 Be Cautious With Vasodilators
 Avoid In Severe AS
 Avoid B-Blocker
 ↓ LVEDV and CO
 Alpha-Adrenergic
 ↑ Systemic Vascular Resistance

Avoid excessive decrease in preload or systemic arterial blood

Aortic Stenosis: Conconiment Disease

Individuals with critical Aortic Stenosis and Coronary

Artery Disease are at high risk for sudden death.

Typically remain in the hospital for intervention

BP monitoring is very important

Aortic Insufficiency

The aortic valve does not close tightly, causing backflow of blood into
the left ventricle
Aortic Insufficiency: Etiology
Congenital AI Acquired AI
 Bicuspid Aortic Valve  Rheumatic Aortic Valve
 Endocarditis
 "Real" bicuspid valves with two symmetric leaflets
 Aortic Root Dilation
 Tricuspid with a fusion of two leaflets
 Idiopathic (80% Of Cases)
 Aortic Root Dilation  Aging
 Idiopathic (80% Of Cases)  Syphilitic Aortitis
 Osteogenesis Imperfecta  Systemic Hypertension
 Behçet's Disease  Connective tissue disorder
 Reactive Arthritis  Ankylosing spondylitis

 Thoracic Aortic Aneurysms/Dilatation  Rheumatoid arthritis

 Reiter’s syndrome
 Connective Tissue Disease
 Giant-cell arteritis
 Marfans Syndrome
 Acute AI
 Trauma
 Aortic Dissection
 Endocarditis
 Aortic Insufficiency: Pathophysiology
 Chronic
 Left Ventricular Dilation
 Pulmonary HTN
 RV dysfunction
 LA Dilation
 Arrhythmias
 RV & LV Failure
 Acute
 No time for compensation
 Sudden volume overload leads to HF
and pulmonary edema
1. Otto, CM, Prendergast B. Aortic-Valve Stenosis — From Patients at Risk to Severe Valve Obstruction. NEJM. 2014, 21 August; 371(8): 744-56.
Aortic Insufficiency : Pathophysiology
Incomplete closure of the AV

Blood backs into LV Increased LAPs

LVH & Dilation LA Hypertrophy

Left Sided HF Increased PAPs

Decreased CO Increased RVPs

Right Sided HF
Aortic Insufficiency: Clinical Findings
Symptoms Associated Clinical Manifestations

 Asymptomatic  Heart Failure

 Palpations  Endocarditis
 Heightened sense of heart beat (esp. in  Atrial Fibrillation
left lateral position)
 Ventricular Arrhythmias
 Tachycardia
 Thoracic Aortic Disease
 Ectopic beats
 Bounding Pulse  Sudden Death

 Decompensation
 DOE
 CP/Angina
 LHF
 RHF
 Aortic Insufficiency: Physical Findings
 Heart Murmur
 Cardiomegaly
 Diminished Pulses
 Heart failure
 Pulmonary Vascular Congestion
 Rales
 Elevated JVP
 Pedal Edema
 End Stage
 Cachexia
 Hypoperfusion

Cary, T, Pearce, J. Aortic Stenosis: Pathophysiology, diagnosis, and medical management of nonsurgical patients. Critical Care Nurse. 2013 Apr 1; 33:2; 58-71.
Acute Aortic Insufficiency
Severe acute aortic insufficiency is a medical emergency.
It is associated with a high mortality rate if not immediately corrected.

Acute AI presents as florid congestive heart failure, and will not have any of
the signs associated with chronic AI since the left ventricle has not developed
hypertrophy and dilatation.

On auscultation, there may be a short diastolic murmur and a soft S1. S1 is soft
because the elevated filling pressures close the mitral valve in diastole (rather
than the mitral valve being closed at the beginning of systole).
 Aortic Insufficiency: Indications for Surgery
 Symptomatic - Severe
 Asymptomatic – Severe
 LVEF <50%
 LVEF >50%, with ESD >50mm
 LVEF >50% with LV dilatation (EDD >65mm)
 Undergoing other cardiac surgery
 Moderate or severe disease
 Acute Insufficiency
 Aortic Dissection
 Endocarditis
 Traumatic Leaflet Rupture
 Iatrogenic injury during BAV or TAVR
1. Stout KK, Verrier ED. Acute valvular regurgitation. Circulation 2009; 119:3232.
2. Mokadam NA, Stout KK, Verrier ED. Management of acute regurgitation in left-sided cardiac
valves. Tex Heart Inst J 2011; 38:9.
Aortic Insufficiency: Pre-op Management
 Acute AI = Surgical Emergency
 Stabilization with:
 Vasodilator

 Dobutamine

 Chronic AI = Medical Management…sAVR

 After load-reducing agents
 Angiotensin-converting enzyme inhibitor
 Have been shown to decrease the progression of cardiac enlargement
and even postpone the timing of valve replacement
Mitral Valve
 Two leaflets of endocardial tissue with inner framework of connective
tissue
 Leaflets anchored to papillary muscles by chordae tendineae
 Located between left atria & ventricle
 Valve opens as blood flows from pulmonary vein into the left atrium
then left ventricle
 Valve closes when left ventricle contracts
Mitral Stenosis

Narrowing of the mitral valve that does not allow it to fully open causing
decreased volume into the LV and increased volume in the LA.
 Mitral Stenosis: Etiology

Congenital MS Acquired MS

A Rare Entity 1  Rheumatic Fever

 Hypoplasia of The Mitral Valve Annulus  Group A Strep

 Mitral Valve Commissural Fusion  Calcium Deposits

 Double Orifice Mitral Valve  Malignant Carcinoid Disease

 Mantle Radiation
 Shortened or Thickened Chordae
Tendinae  Immune Disease
 Parachute Mitral Valve (All Chordae  Systemic Lupus Erythematosus
Attach To A Single Papillary Muscle)
 Rheumatoid Arthritis

 Pseudo Ms
 Severe Nonrheumatic Mitral Annular
Calcification

1. Foster, E.. Mitral Valve Disease. NEJM. 2010; 363:156-165.

 Infective Endocarditis with Large Vegetation
2. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With
Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association  Left Atrial Myxoma
Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(22):e57-e185
Mitral Stenosis: Pathophysiology

 Increased LA Pressure
 Pulmonary HTN
 RV Dilation
 RVH
 Tricuspid Regurgitation
 Heart Failure
 Pulmonary Edema
 Left Atrial Enlargement
 Afib

1. Foster, E.. Mitral Valve Disease. NEJM. 2010; 363:156-165.

Mitral Stenosis: Clinical Findings
Symptoms Associated Clinical Manifestations

 Asymptomatic  Afib
 Classic  Embolic Events
 Dyspnea  Cerebrovascular Events
 Heart Failure  Endocarditis
 Most Common  Right sided HF
 Exercise Intolerance  Tricuspid Regurgitation
 Exertional Dyspnea
 Pulm HTN
 Easy Fatigability
 Mitral Stenosis: Indications for Surgery
 Symptomatic
 Severe (MVA <1.5)
 Low Risk

 Asymptomatic
 Very Severe (MVA <1.0)
 Other Cardiac Surgery
 Moderate to Severe MS
 Recurrent embolic events with therapeutic AC

1. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(22):e57-e185
Mitral Stenosis: Pre-Op Management
 Maintain SR (50-70 BPM)
 If Afib – Tx with AC and rate control
 B-Blocker
 ↓ HR
↓ transmitral gradient
↓ PCWP & mean PAPs
 Diuretics
Mitral Insufficiency

The mitral valve does not close tightly, allowing blood to flow into the
left atrium
Mitral Insufficiency: Etiology
Congenital AI
 Marfan Syndrome
 Ehlers-Danlos syndrome
 Down syndrome
 Osteogenesis imperfecta
 Systemic lupus erythematosus
Acute MR
 Mi
 Can be sudden and severe
 Ruptured chordae tendineae
 Ruptured Papillary muscle
 Flail leaflets (ischemia)
 Trauma
 Ruptured chordae tendineae
 Ruptured Papillary muscle
Acquired AI
 Mitral Valve Prolapse
 Most Common Cause
 Rheumatic Fever
 Mitral Annular Calcification
 Endocarditis
 Cardiomyopathy
 Dilatation of the LV & MV Annulas
 Mantle Radiation
Functional MR
 Ischemic heart disease
 Left ventricular systolic dysfunction
 Hypertrophic cardiomyopathy
 Aortic Stenosis
Mitral Insufficiency: Pathophysiology

 Chronic
 Gradual enlargement of the left atrium
 LV enlargement and hypertrophy
 Initially

 Compensates for regurgitant flow (= SV)

 Eventually

 Decompensates = Decrease SV + CO

Foster, E.. Mitral Valve Disease. NEJM. 2010; 363:156-165

 Mitral Insufficiency: Pathophysiology
Acute
Sudden rupture of chordae, papillary muscle dysfunction,
flail leaflet, severe ischemia or trauma
Significant hemodynamic abnormalities

Sudden Increase LA & LV volume

Increase LA pressure
Pulmonary Congestion
Increase LV wall stress
Decrease CO

Compensatory tachycardia & Increased vascular resistance

Compensatory mechanism worsen MR

Foster, E.. Mitral Valve Disease. NEJM. 2010; 363:156-165
CO falls & shock occurs
Mitral Insufficiency: Clinical Findings
Symptoms Associated Clinical Manifestations

 SOB / DOE  Chronic:

 Palpations  Heart Failure

 Fatigue  Atrial Fibrillation

 Lightheadedness  LVH

 Cough / Orthopnea / PND  Acute:

 Endocarditis
 Anorexia
 Mi
 Edema
 Mitral Insufficiency: Indications for Surgery
 Acute
 Surgical Emergency
 Chronic Primary
 Severe
 Onset of symptoms
 LV Dysfunction
 LV end-systolic diameter > 40 mm
 High likely hood of successful repair
 New onset AF
 Resting PAS >50mmHg
 Chronic secondary
 No real place for intervention

When the LVF drops to <30% the surgical risk is extremely high
Foster, E.. Mitral Valve Disease. NEJM. 2010; 363:156-165
Mitral Insufficiency: Pre-op Management
 Acute MR/MI = Surgical Emergency
 Stabilization with:
 Vasodilator
 IABP for shock

 Chronic MR/MI = Medical Management…sMVR

 Preserved LVF
 If present treat HTN
 Decreased LVF
 Vasodilators
 Diuretics if HF
 AC if AFib
A CVS Consult is Called…

Jacqueline, we can fix that…

-Famous last words from RSB
Risk vs. Benefit

Each case is weighed risk vs. benefit and a

decision is made to operate or not

 STS Risk calculator

 Katz Frailty Score
 Walk Test
 Extensive pre-op testing
  Urine Analysis

Diagnostics  Blood
 CBC

 Cardiac Catheterization  CMP

 Coags
 Stress Test
 BNP (LV dysfunction & Valvular heart disease)
 Exercise
 HgbA1c (Undiagnosed DM)
 Pharmalogical
 Albumin
 Echo
 Thyroid Function Studies
 Stress Echo
 Type & Screen (4RBCs, 4 Plts, 4 FFP on hold)
 Dobutamine Stress Echo
 Bleeding time (Plt function)
 Cardiac MR
 Pulmonary function testing
 CTA Chest, Abd & Pelvis
 Room Air ABG
 Ambulatory POX
 Nocturnal POX
 Carotid US
 ABIs
 PA Lateral CXR
 ECG
Risk Assessment – STS Risk Calculator
 Age  Prior OHS
 Gender  Prior Stent
 BMI  Endocarditis
 Co-morbidities- DM etc  IABP
 Immunosuppression  Pre- Op MI
 End Organ Failure – CRF  Concomitant Disease
 COPD
 CHF  Not Included
 CVA  Pulmonary HTN
 LV Dysfunction  RV Failure

 Urgency- elective/emerg  Frailty

 Coronary Run off
 Nutritional Status
 Mental Status
Risk Assessment – STS Risk Calculator
 Risk of Mortality
 Risk of Major morbidity/ mortality
 Risk of Bleeding
 Risk of Re-operation
 Risk of Permanent Stroke
 Risk of Renal failure req. Dialysis
 Risk of Prolonged Ventilation
 Risk of Sternal Wound Infection
 Prolonged LOS
 Risk of Re-admission
 Low Risk < 5%
 Intermediate Risk 5-10%
 Advanced Risk >10%
Risk Model and Variables - STS Adult Cardiac Surgery
Database Version 2.81
RISK SCORES
Procedure: MV Repair + CAB
Risk of Mortality: 6.365%
Morbidity or Mortality: 29.522%
Long Length of Stay: 13.391%
Short Length of Stay: 12.584%
Permanent Stroke: 2.88%
Prolonged Ventilation: 18.933%
DSW Infection: 0.541%
Renal Failure: 9.474%
Reoperation: 11.572%
 Intra Aortic Balloon Pump Therapy
Most commonly used mechanical circulatory
support device
Works by diastolic augmentation and
afterload reduction
 Balloon inflates during diastole to increase
blood in the proximal aorta which
increases coronary artery perfusion.
 The balloon deflates just before the onset
of systole removing the volume of blood
from the aorta(like a vaccum); decreasing
afterload and increasing LV ejection
IABP Therapy: To Use Or Not To Use…
Indications Contraindications
 Cardiogenic Shock  Absolute
 Possibility of extending Mi
 Severe AI
 Unstable Angina
 Aortic Dissection
 Intractable Ventricular Arrhythmias

 Mechanical defects  Severe aortoilliac occlusive disease

 Acute MR

 VSD
 Relative
 Anatomy
 LMain
 Moderate AI
 TVD  Abdominal aortic aneurysm
 High risk PCI  Uncontrolled bleeding diathesis
 Prophylactic Support Pre-Op CVS
 Contraindication to IV AC
 LV Dysfunction (EF <35%)
 Severe peripheral vascular disease
 Post-op CTS
 Failure to wean from CPB  Aortic or iliofemoral bypass grafts
 IABP Therapy: Now That Its In
Assessment Complications Weaning
Should be in 1:1 mode unless weaning Vascular Balloon Weaning is a decision made by CV Surgery
Side port of sheath needs to be tranducded Dissection Perforation Typically requires pts be on:
in addition to other arterial lines
Paraplegia Tear
ECG trigger 1 Mod dose Inotrope
Perforation Rupture
Pressure for codes only 2 low dose Inotropes
Infusions titrated to IABP MAP Thrombosis Incorrect Positioning
Heparin should be stopped at least 2 hrs before
Neuro check and Cap refill q1hr Embolization Gas Embolization removal
(peripheral)
 L radial Pulse Entrapment Cont frequent Neuro checks (Inc risk of emboli off AC)
Limb Ischemia
Pedal pulses
Wean should happen over a set amount of hours
On CXR the tip should be 1-2cm below the Visceral Ischemia
Hemologic While weaning CO/CI should be performed
aortic knob
CVA
PreOp Heparin Gtt required Sepsis •30mins after frequency of balloon inflation is changed
PostOp Heparin Gtt not req for 24hrs Bleeding •15 mins after infusion change
Continuous monitoring of: Thrombocytopenia
BP & MAP (All lines)

Augmented Pressure

Augmentation

Rhythm
IABP Therapy: CXR Confirmation
Cardiopulmonary Bypass
CPB takes over the function of the heart and lungs during surgery, maintaining circulation
and oxygen/CO2 exchange
 Managed by perfusion
 Circuit is primed with 2000mL of fluid
 Must be anticoagulated before going on pump
 Heparin administered to achieve and ACT >480seconds
 Protamine reversal at the end to achieve ACT at baseline

 Cannulas:
 One cannula
 Right atrial appendage
 Two cannulas
 Inferior vena cava
 Superior vena cava
Cardiopulmonary Bypass
 Passage through the membrane oxygenator
 Oxygenated blood returned
 Cannula in ascending aorta
 Series of rollers (older) or centrifugal pump
(newer)
 Cooled to 28-32*c
 Ao Cross clamped
 Cardioplegia is delivered through the
coronary arteries via AoR
 Induce Asystole - motionless
 Induce hypothermia – to protect the muscle
Cardiopulmonary Bypass
Weaning from CPB is a gradual, complex and
multistep process

 Blood is rewarmed to 37* c

 Cross clamp is removed
 Blood perfuses coronary arteries
 Myocardium is warmed
 Maintain Rhythm
 Pacing
 Cardiopulmonary bypass reduced to partial
 Heart assumes total responsibility
 Protamine is administered
 A small test dose followed by full dose
 Cannulas removed
 Chest is closed
Complications of Cardiopulmonary Bypass
 Systemic Inflammatory Response
 Blood loss & Coagulopathy
 Hypothermia
 Neurological Complications
 Embolization, Inflammation,
Hypoperfusion and Hyperthermia
 Higher incidence of CVA (1% opCAB vs 9% on-
pump)

 Respiratory Dysfunction
 Renal Function
 GI Complications
 Non-Pulsatile Pressure
 Electrolyte Abnormalities
 Ca, MG, Phos, K+, Zinc
Cardiopulmonary Bypass: Can It Be Avoided
If CPB can be avoided it should be
 CAD
 On Pump CABG
 Off Pump CABG

 Valvular Disease
 All surgical valve repairs or replacements require CPB
 AV Replacement
 MV Repair
 MV Replacement
 TV Repair
 TV Replacement
 Thoracic Aorta Disease
 Requires CPB
 Arrhythmia Correction Surgery
 Partial Maze can be done off Pump
 Full Maze requires CPB
Coronary Artery Bypass Grafting : Use of CPB

On Pump – Cold Ischemic Off Pump – Warm beating

 Surgical Technique: On Pump CABG
 The patient is placed on the heart-
lung machine. The heart is stopped.
 The blockages are identified and
the vessel is opened below the level
of stenosis. Distal anastamoses are
created using fine non-absorbable
suture.
 Once all distal anastamoses
(sequential or straight) are
completed proximal anastamoses
are made (typically to the aorta).
Bypass is weaned off and the heart
and lungs take over their functions
 Performed with concomitant surgery
requiring CPB
 Advantages
 Bloodless field
 Motionless
Surgical Technique: On Pump CABG
Most common issues complicating weaning from CPB

LV Dysfunction Arrhythmias
Preexisting LVDysfx Ventricular arrhythmias
Exacerbated by ischemia-reperfusion injury Reperfusion VF
Myocardial stunning Electrolyte Imbalances
Requires inotrope support Refractory VF indictive of myocardial ischemia
RV Dysfunction Bradycardia
Preexisting CHB
Exacerbated by PHTN Vasodilatory Shock (Vasoplegia) Defined as severe
hypotension despite normal CO Risk factors are
RV ischemia
ACE I, ARBs, Pre-op use of Heparin, Statins
Infarct
Requires inotrope support
Continous inhalation agents (NO, Flolan)
 Surgical Technique: Off Pump CABG

Coronary artery bypass is performed

without the use of CPB
 The heart isn’t stopped or cooled
 A stabilizer is used to hold an area
still while grafting
 Allows the heart to keep pumping
and circulating blood to the body

 Anesthesia is KEY!
Having to Convert… off to on

 Small, calcified vessels

 Deep intramyocardial vessels
 Hemodynamic instability
 Reduced LVF
 RV Failure
 Cardiomegaly
 Cardiac dilatation
 Mitral regurgitation (MR)
 CABG: Bypass Conduit
 Conduits are choose with this in mind:
 Doesn’t impair circulation
 Long enough to reach from the aorta to the coronary
artery
 Large enough in diameter to attach
 Arteries last longer without reocclusion
 SVs are first choice for venous conduits
 Radial arteries are prone to spasm
 Tx with CaCB
CABG: Bypass Conduit
 CABG: Outcome of Surgery
We perform bypass grafting for 2 reasons
 Survival Benefit
 Operative mortality of 1-4%
 95% survival rate at 1-year
 At 5 years1:
 Mortality : 13% CABG vs 16.6% PCTA
 Mi: 4.3% CABG vs 14.9% PCTA
 TVR: 7.9% CABG vs 27.9% PCTA

 Symptom Relief
 Relief of Angina (90%)
 SOB/DOE complex symptoms (not always related to CAD)
1. Circulation. Five-year outcomes in patients with left main disease treated with either percutaneous coronary intervention or coronary artery bypass grafting in the synergy
between percutaneous coronary intervention with taxus and cardiac surgery trial. 2014 Jun 10;129(23):2388-94.
CAD: Take Home Points
 CABG will improve blood flow
 Stents are not benign
 Neither prevent the eventual recurrence of coronary blockage
 Borrowed Time
 Lifestyle changes are necessary
 Smoking
 Improved diet
 Regular exercise
 Treating high blood pressure
 High cholesterol
Valvular HD: Considerations
 These patients typically have more comorbidities
than patients undergoing CABG
 Surgeries are typically longer and more complex
 Atrial tissue is disturbed
 Higher risk of Afib
 Myocardial edema
 Conduction delays
 Valvular HD: Prosthetic Valve Selection1
 Should be a shared decision-making
 Takes into account the patient’s values and preferences
 Full disclosure of the indications for and risks of anticoagulant therapy and the
potential need for and risk of reoperation

Considerations:
 Valve durability & longevity
 Expected hemodynamics for a specific valve type & size
 Surgical or interventional risk
 Compliance & the potential need for life long anticoagulation
 Technical Implant Issues / Patient anatomy
 Patient Prosthesis Mismatch
 Reoperation

Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll
Cardiol. 2014;63(22):e57-e185.
 Valvular HD: Prosthetic Valve Selection

Mechanical Prosthesis - AV
 Bileaflet (St Jude)  Pro Mitral
 Monoleaflet (Medtronic)  Longevity

 Caged ball(Starr-Edwards)  Excellent Hemodynamics

 Better efficiency in small sizes
 Low risk for reoperation
 Rec in patients <60 y of age who
do not have a contraindication to  Smaller sewing ring
Aortic
anticoagulation (IIa; B)1
 Reasonable in patients between  Con
60 and 70 y of age (IIa; B) 1
 Life long anticoagulation - Risk of
bleeding

1. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(22):e57-e185.
 Valvular HD: Prosthetic Valve Selection
Biologic Prosthesis – Aortic Valve
 Xenograft  Pro
 Stented v Stentless  Valve does not require life-long
 Homograft anti-coagulation
 Ross Procedure
Mitral
 Con
 Recommended in patients of any age  Decreased longevity
for whom anticoagulant therapy is
contraindicated, cannot be managed  Potential need for reoperation
appropriately, or is not desired (I,C) 1
Aortic
 Reasonable in pts >70 y of age (IIa, B) 1
 Reasonable in patients between 60
and 70 y of age (IIa; B) 1

1. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(22):e57-
e185.
 Valvular HD: Pt Prosthesis Mismatch
 If the size of the prosthetic valve that is implanted results in inadequate blood flow
to meet the metabolic demands of the patient, even when the prosthetic valve
itself is functioning normally.

 Prosthetic valve-patient mismatch is considered to be present when the EOA is

less than that of a normal human valve.

 The main clinical concern is the presence of a high transvalvular gradient

Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll
Cardiol. 2014;63(22):e57-e185.
Valvular HD: Surgical Approaches
Median Sternotomy Minimally Invasive
 Conventional  Conventional procedure w/o full sternotomy
 Less Invasive
 Full Access
 Less Traumatic
 Concomitant Procedure
 Less Pain
 Reduced Blood Loss
 Shorter Length of Stay
 Reduced Cost
 Expedite Recovery
 Improved Cosmetics
 Increased Patient Satisfaction
Valvular HD: Aortic Valve Replacement
 Treatment for AS and AI
 Requires CPB
 Incision is made in the aorta
 AV leaflets are excised
 The annalus is sized and a prosthesis is implanted
 More complicated because the coronary arteries
originate from the aorta
 Great care to not disturb ostia or
 Ostia must be moved to a better location
 Surgical Technique: MVD
Repair vs. Replacement
 Indications
 Ruptured chordae to the posterior leaflet
 Ischemia
 Ischemic cardiomyopathy resulting in
dilation of the mitral valve
 Benefits
 Pt retains the native tissue
 Avoidance of long term anticoagulation
 Annular-papillary muscle continuity
 EF stable or improved
 MV repair is very durable
 Procedures:
 Commissurotomy
 narrowed valves
 leaflets are thickened
 cutting the points where the leaflets meet
 Valvuloplasty
 strengthens the leaflets
 support and valve close tightly.
 ring-like device attach around the outside of
valve opening.
 Repair of structural support
 shortens the cords that give the valves
support.
 Replaces dysfunctional chords
 Patching; covers holes or tears in the leaflets
with a tissue patch.
Valvular HD: Mitral Valve Replacement

 Treatment for MR and MS

 Repair is always preferable
 Requires CPB
 Incision is made in the left
atrium
 MV leaflets are excised
 The annalus is sized and a
prosthesis is implanted
Post Operative Management
 Understand the patient’s preoperative status
 Review intraoperative events
 Appropriate and accurate hemodynamic monitoring
 Rapid determination and correction of underlying cause
of hemodynamic or respiratory compromise

The first few hours of recovery are critical and require skilled
nursing care and attention
 The First Few Hours: Initial Recovery
 Receive report from Anesthesia including:  First Set of hemodynamics
 Procedure  Labs drawn
 Abnormal findings  CXR
 Surgeon difficulties
 EKG (Off pacing if underlying rhythm)
 Intraop Events
 Check thresholds on epicardial wires
 Difficult Airway
 CTs should be placed to -20cm wall
 Hemodynamic compromise
suction
 Difficulty coming off pump or closing
 Ensure patency through milking
 Best Hemodynamics in OR
 Physical Exam
 EBL, Transfusions
 Neurological
 Medications
 Respiratory
 Infusions & Pushes
 Sedation, Paralytics, Reversal
 Cardiac

 Anticoagulation & Reversal

 The First Few Hours: Initial Recovery
 Bleeding
 Hemodynamic Stability
 Adequate CO/CI  Surgical vs non-surgical

 Preload  Surgical – bleeding is caused by poor

intraoperative hemostasis
 Afterload
 Non-surgical
 Contractility
 Inadequate reversal of AC
 HR & Rhythm
 Platelet dysfunction
 BP
 Platelet consumption
 MAP 65-80mmHg
 Hypertension
 Higher for CVD, CKD & elderly
 Fluid & Electrolyte Status  Hypothermia & Shivering

 I & O from OR should be included  Arrhythmias - Pacing

 Frequent electrolyte checks – replete PRN  Brady; Tachy

 Third spacing  Atrial; Ventricular

 Limit use of crystalloid for volume  Ischemia

 Albumin & PRBCs  Electrolyte Imbalance
 Bulk of FR occurs in the first 6-8hrs  Low CO state
 Pts receive 1-3Ls  Hypoxia
 The First Few Hours: Initial Recovery
 Hypothermia
 Complications:
 Low CO State (CI <2.2)
 >96.8F ( 36C)
 Volume Status
 Warming blanket  Preload, Afterload
 Warm fluids & blood  Myocardial Depression
 Respiratory Status  Contractility
 Acidosis
 ABG on arrival and frequently there after
 Hypoxemia
 Monitor CO2
 Underlying Pre-op Conditions
 Hypercapnia  Inflammatory response to surgery & CPB
 NIPV (Bipap)  Decreased ventricular compliance
 Increase TV or RR on Vent  LVH
 Outflow obstruction
 Acid base balance
 LV Dilatation
 Metabolic or Resp  Myocardial stunning
 Treat clinically  Poor protection in OR
 LV Dysfunction worsened by CPB
 Treat base excess
 If extubated limit narcotics as to not depress RR
Find reason and treat
 Cardiac Output States
MAP CVP CO PCWP SVR Strategy
Normotensive High Low High Normal/High Vasodilator/
Diuretic/
Inotrope

Hypertensive High Normal High High Vasodilator

Hypotensive Low Low Low Normal Volume

Hypotensive High Low High High Inotrope/IABP/

Vasodilator
Hypotensive Normal/ Normal/ Normal/ Low Alpha Agent
Low High Low
 The First Few Hours: Complications
 Cardiac Tamponade:  Pulmonary Compliactions
 Flash Pulm Edema
 The sac is usually not closed
 Lv Dysfunction
 Blood in the medistinum can lead to tamponade
 Volume Overload
 Pressure on atria
 Tx: Diuretics, Vasodilators, Inotropes
 Decreases Preload
 Hypoxia
 S/S:  Atelectasis – Occurs in the OR
 Low CO  Narrow PP  Volume Overload
 Hypoperfusion  Change in MS  SIRS
 Tachycardia  Diaphoresis  Effusions
 Hypotension  Dyspnea  Splinting
 Elevated filling  Anxiety  Tx: Aggressive Pulm toilet
pressures
 I/S as soon as extubated
 Prevention is Key
 Pneumothorax
 Maintain CT patency  Injury in OR
 DX:  Barotrauma (vent)
 EKG, CXR, Echo  CVC Insertion

 Graft Dysfunction / Coronary Vasospasm  Dx: SQ Air, CXR, hypoxia, hypotension (tension)
 TX: Depending on size and vent status
 IV Nitro or CaCB
 Monitor
 Switch to oral on POD 1
 Place CT tube
 Continue for 1 year

 Dx: ST changes by EKG

Postop Considerations: AVR for AS
 Hypertrophied LV
 Poor compliance
 LV Filling depends on preload & atrial kick
 LV used to higher pressures
 LVH (Outflow Obstruction)
 Volume, BB, Afterload
 Increased Afterload then sudden decrease
 Afterload Reduction
 Blood Pressure – Avoid HTN
 Fresh suture lines
 Preload
 Will need volume to increase
 Maintain Rate/Rhythm
Postop Considerations: AVR for AI
 Volume overload of LV
 Poor ventricular function
 Decreased myocardial contractility
 Inotropes = contractility = ventricle
emptying

 Abnormal heart rhythm

 Tachycardia - compensatory
 Inadequate preload
 Excessive afterload
 Needs peripheral dilatation
Postoperative Considerations: MVR for
MS
 Small LV cavity w Preserved LVF
 Adequate preload + sv
 RV dysfunction
 May need inotropic support for 1 – 2 days
 May not have sufficient cardiac reserve to
tolerate early extubation
 Pulmonary HTN, chronic volume overload
 EF may worsen due to increased afterload
postop
 Control of afterload is critical; IABP may be
needed
 Diuresis
Postoperative Considerations: MVR for MR
 Unmask LV dysfunction
 Reduces pressure in LV
 Volume overload
 Afterload mismatch = LV failure
 Intropic support
 Vasodilators
 Decrease LV compliance
 Maintain volume
 RV dysfunction
 High CVP, hypovolemic, cardiac output
 Maintain HR/Rhythm - Sinus
Preemptive Care
 Overall assessment of the patient
 More important than any single parameter.
 Warm, well-perfused extremities, normal mental status,
and good urine output (>0.5 ml/kg per minute).
 Trends in hemodynamics are usually more important
than isolated values

Vigilant monitoring enables care to be more

preemptive than reactive
Always on Your Mind

AHHH!!!
Acidosis
Hypovolemia
Hyper/hypo K
Hypoxia
Case Study
MG, 86 yo M presented to the ER s/p an episode of syncope precipitated by dyspnea
and chest pain

Reports 4yr history of AS followed by his PCP

 PMHx: HTN, anemia, scarlet fever at age 3, aortic stenosis

 PSHx: R Inguinal hernia repair, tonsillectomy
 Social Hx: No tobacco, occ ETOH, retired pharmacists
 Fam Hx: Negative for premature coronary disease
 Home meds: Cardizem, Lisinopril
Cardiac Cath: Severe 2 vessel CAD
(100% mid-LAD; 80% prox-Cx)
Cardiac Cath: Severe 2 vessel CAD (LAD; Cx)
SPAP: 40mmHg
Echo: EF 65%, No regional wall motion
abnormalities
MV: Moderate to severe MR
AV: Severe AS, mild AI

Peak Vel: 467 cm/s

Mean Vel: 362 cm/s
Peak Gradient: 87mmHg
Mean Gradient: 56mmHg
AVA 0.66 cm2
Intra Op
The aorta was extensively calcified from the aortic root to the transverse arch with evidence of calcific plaquing in the arch by visual
inspection, transesophageal echocardiogram, and preoperative CT scan. Epiaortic ultrasound was performed of the aortic root,
midascending aorta, distal ascending aorta, and proximal transverse arch. There was extensive calcification. The wall thickness was >
3 mm consistent with grade 3 atherosclerotic disease.

The right femoral artery was exposed for possible femoral arterial cannulation. The vessel was extensively calcified and judged to be
unsuitable for use for perfusion. This was suggestive of advanced aggressive atherosclerotic disease. The patient was judged to be at
advanced risk of stroke with extracorporeal circulation, and aortic valve intervention was deferred.
Procedure Performed: Off pump CABG x3; LIMA to LAD; SVG T-graft from LIMA to D1 to Cx
Referred for TAVI evaluation
Intra Op TEE Intra Op Epi Aortic US
Post Op
He continued to experience dizziness,
complicating his recovery.

TAVI evaluations take time.

In the interim he was referred for BAV and this

was undertaken with favorable results.

Post BAV Echo:

Peak Vel: 333 cm/s
Mean Vel: 245 cm/s
Peak Gradient: 44mmHg
Mean Gradient: 26mmHg
AVA 0.66 cm2
102 days Post CABG
TAVI was undertaken with 29mm Edwards
Sapien XT.
His post op course was uncomplicated. He was
discharged on POD #2 to home.

Post TAVI Echo:

Peak Vel: 135 cm/s
Mean Vel: 98 cm/s
Peak Gradient: 7 mmHg
Mean Gradient: 4 mmHg

Trivial perivalvular leak

30 days Post TAVI
July 2014 Echo:
Peak Vel: 128 cm/s
Mean Vel: 83 cm/s
Peak Gradient: 9 mmHg
Mean Gradient: 6 mmHg

Trivial perivalvular leak

107
Questions
Cardiac
Surgery
Jacqueline Redman MSN, RN, ACNP-BC, CCRN-CSC-CMC, FCCS-C