CHAPTER 2Cardiovascular: Cardiac Surgeries makes it hard to treat more than two coronary arteries
during the same surgery.
c. Robotic- assisted coronary artery bypass (RACAB), also called closed- chest heart surgery, may or may not require cardiopulmonary bypass. Robotic surgeries have been used for several dif fer ent heart- related procedures, including valve surgery, coronary artery bypass, cardiac tissue ablation, heart defect repair, and tumor removal.
d. Endoscopic coronary bypass (ECAB) enables the per for mance of bypass surgery in diffi cult spaces using a port access, which may be video and robotic assisted. This procedure is rare and typically reserved for one vessel revascularization.
e. Transmyo car dial laser revascularization (TMR) uses lasers to create channels in heart muscle to improve direct blood fl ow. This treatment is aimed at improving blood fl ow to areas of the heart that were not treated by angio- plasty or surgery. A special carbon dioxide (CO2) laser is used to create small channels in the heart muscle, improv- ing blood fl ow to the heart muscle.
IV. Statistics
a. Nearly 400,000 coronary artery bypass graft (CABG) surgery procedures are performed annually in the United States (Go et al, 2014). In 2010, 106,000 valve replacements were performed in the United States (Go et al, 2013).
b. One- year mortality is similar between CABG and percuta- neous coronary interventions (PCI), but 5- year survival is signifi cantly better for CABG (Go et al, 2013; Verma et al, 2013).
c. Cost: According to the Centers for Disease Control and Prevention (CDC), National Centers for Health Statistics (2014) reporting for 2012 total hospital costs for heart bypass were $6,170,000, with total hospital costs for heart valve replacement at $5,481,000.
hooked to the heart- lung machine without opening the chest, and the procedure is carried out using modifi ed instruments to fashion the connection between the graft and coronary artery inside the chest cavity.
iii. Aortic or mitral valve repair and replacement. The aortic valve and the mitral valve are the most com- monly replaced valves. Valves may be mechanical (synthetic materials) or tissue ( human or animal donor tissue). The procedure chosen will depend on the valve that needs replacement, the severity of symptoms, and the risk of surgery. With limited- access techniques for valve repair or replacement, the sternum does not need to be opened to gain access to the heart. For example, an aortic valve can be replaced through a small incision between the ribs on the side of the chest or through a 3- inch incision made in the middle of the chest. The mitral valve can be repaired or replaced through a 3- inch incision between the ribs, on the side of the chest. Robotic-assisted surgery may be employed (American Heart Association [AHA], 2016c; Texas Heart Institute, 2016).
b. Procedures that do not require the use of a CBP machine (sometimes called beating heart surgery [BHS]).
i. Off- pump coronary artery bypass (OPCAB) requires full sternotomy or limited access incisions. Surgeons use special equipment to hold parts of the beating heart still while they are constructing bypass grafts.
Meanwhile, the rest of the heart keeps pumping blood to the body.
ii. Minimally invasive direct coronary bypass (MIDCAB) requires that several small incisions are made in the chest to access only the sections of coronary arteries that require grafts. Note: The limited number of small incisions made using MIDCAB
Anastomosis: Surgical connection created between tubular structures, such as blood vessels, that are grafted into the coronary arteries to create a bypass channel for circula- tion around a blocked artery.
Cardioplegia: The intentional and temporary cessation of cardiac activity, primarily for cardiac surgery.
Cardiopulmonary bypass (CPB) (also called heart- lung machine): Mechanical means of circulating and oxygen- ating the blood through the body when it’s diverted from the heart and lungs. The heart’s beating is stopped so the surgeon can perform the bypass procedure on a still heart.
Coronary artery bypass grafting (CABG): Procedure in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood fl ow to the heart. These grafts usually come from the client’s own arteries and veins located in the leg (saphenous vein), internal mammary artery (IMA), or internal thoracic artery (ITA). The graft goes around the blocked artery (or arteries) to create new pathways for oxygen- rich blood to fl ow to the heart.
Minimally invasive direct coronary bypass (MIDCAB):
Requires a smaller incision and may be done for CABG and some valve remodeling and replacement procedures.
Off- pump coronary artery bypass (OPCAB) (also called off- pump coronary revascularization): Off- pump procedures can offer certain advantages in low- risk populations, such as decreased cost, reduced length of stay, reduced postoperative complications, and avoidance of blood transfusions. They also reduce surgical trauma to the client as well as risk of stroke and kidney failure.
Percutaneous transmyo car dial revascularization (PTMR) (also called transmyo car dial laser revascularization, or TMR): Laser surgery that opens tiny new pathways within the heart muscle to treat the symptoms of angina in a client who cannot withstand more conventional
treatments such as bypass surgery or balloon angioplasty.
Robotic- assisted coronary artery bypass (RACAB):
Surgeon views the procedure on a video screen, uses a robot to perform the bypass, and has no direct contact with the client.
Sternotomy: Surgical incision made in the breastbone (mediastinum).
Totally endoscopic coronary artery bypass (TECAB):
Robotic- assisted procedure in which small- port incisions are made in intercostal spaces. TECAB is performed on the beating heart using a stabilization device that holds the anastomosis site steady and removes the need for CPB.
G L O S S A R Y
RELATED CONCERNS
Angina, chronic/stable, page 64 Dysrhythmias, page 85
Heart failure, page 38
Myo car dial infarction, page 72 Pneumothorax/hemothorax, page 169 Psychosocial aspects of care, page 835 Surgical interventions, page 873
CARE SETTING
Client is cared for at inpatient acute hospital on a surgical or post– intensive care unit (ICU) step- down unit.
****The preoperative data presented here depend on the specifi c disease pro cess and under lying cardiac condition and reserve.
D I A G N O S T I C D I V I S I O N
M A Y R E P O R T M A Y E X H I B I T
Activity/Rest
• Exercise intolerance
• Generalized weakness, fatigue
• Inability to perform expected or usual life activities
• Insomnia and sleep disturbances
• Abnormal heart rate, blood pressure (BP) changes with activity
• Exertional dyspnea
• Electrocardiogram (ECG) changes and dysrhythmias with activity
Circulation
• History of recent or acute MI (three or more), vessel coronary artery disease, valvular heart disease, hypertension
• Current use of antithrombotic drugs, including those that inhibit the production of clotting factors in the liver, such as warfarin (Coumadin); those that interfere with blood clotting by blocking thrombin activity, such as heparin and lepirudin (Refl udan); and antiplatelet drugs, such as aspirin, clopidogrel (Plavix), tirofi ban (Aggrastat), and eptifi batide (Integrilin), which keep platelets from aggregating into clots. Note: Cardiac patients taking these drugs preoperatively require vari ous interventions to ensure their safety for CPB and to reduce postoperative bleeding complications.
• Recent use of over- the- counter (OTC) drugs, such as NSAIDs, and dietary supplements, such as vitamin E, garlic, ginseng, and ginkgo (can inhibit clotting)
• Variations in BP, heart rate, and rhythm
• Abnormal heart sounds: S3/S4, murmurs
• Pallor and cyanosis of skin or mucous membranes
• Cool and clammy skin
• Edema, jugular vein distention (JVD)
• Diminished peripheral pulses
• Restlessness and other changes in mentation or sensorium (severe cardiac decompensation)
Ego Integrity
• Feeling frightened, apprehensive, or helpless • Apprehension, restlessness
• Facial or general tension
• Withdrawal and lack of eye contact
• Focus on self, irritability, anger, crying
• Distress over current events
• Fear of death or eventual outcome of surgery or pos si ble complications
• Fear about changes in lifestyle and role functioning
Food/Fluid
• Change in weight • Weight gain or loss
• Loss of appetite • Dry skin, poor skin turgor
• Nausea or vomiting • Postural hypotension
• Change in urine frequency or amount • Edema— generalized, dependent, pitting
Neurosensory
• Fainting spells, vertigo • Changes in orientation or usual response to stimuli
Pain/Discomfort
• Chest pain, angina
C L I E N T A S S E S S M E N T D A T A B A S E
M A Y R E P O R T (continued) M A Y E X H I B I T (continued)
Respiration
• Shortness of breath • Dyspnea
• Abnormal breath sounds, such as crackles
• Productive cough
Safety
Teaching/Learning
• Familial risk factors of diabetes, heart disease, hypertension, strokes
• Use of vari ous cardiovascular drugs
• Failure to improve