CARDIAC SURGERY

Basically there are three major type of surgical procedure:

1. REPARATIVE PROCEDURES
These are likely to produce a cure or excellent improvement. For example:
 Closure of a PDA, ASD and VSD
 Repair of mitral stenosis
 Simple repair of TOF.
2. RECONSTRUCTIVE PROCEDURES
Not always curative, and reoperation may be needed.
 CABG
 Reconstruction of an incompetent mitral
 Tricuspid or mitral valve.
3. SUBSTITUTIONAL PROCEDURES
Not always curative.
 Valve and cardiac replacement.

OPEN HEART SURGERY

The cardiopulmonary bypass is achieved by inserting a large catheter (ie, cannula) into
two peripheral blood vessels, usually a femoral vein and an artery. Blood is diverted
from the body through the venous catheter to the cardiopulmonary bypass machine and
returned to the patient through the arterial catheter.
Cardio pulmonary bypass is used to divert the oxygenated blood to a machine in which
oxygenation and circulation occurs. Re-oxygenated blood is then returned to the client’s
circulation. This technique is called Extra-Corporeal Circulation (ECC or heart lung
machine) allows the surgeon to stop the heart during the time of surgery.

FUNCTIONS OF HEART LUNG MACHINE

 Diverts circulation from the heart and lungs, creating a bloodless operating field.
 Performs all gas exchange functions.
 Filters, re-warm or cool the blood
 Circulates oxygenated, filtered blood back into the arterial circulation

COMPONENTS OF CARDIOPULMONARY BYPASS

 Hemodilution
 Hypothermia
 Anticoagulation
Hemodilution occurs as the client’s blood becomes diluted with isotonic crystalloid
solution used to prime the bypass machine
Hypothermia (28-36deg C) is used to reduce tissue oxygen requirements by 50% to
protect the organs from ischemic injury.
Anticoagulation is necessary to prevent coagulation in the machine once the client’s
blood comes into contact with the machine
Ü These 3 components contribute to the clinical sequelae and the complications
associated with CPB, including coagulopathies. Excessive bleeding after surgery
is related to the hemodilution and excessive activation of the hemostatic system
because blood cells are injured as they contact the machine. The risk of
complications is high when the duration of CBP exceeds 2 hrs.

CORONARY ARTERY BYPASS GRAFT

It involves the bypass of a blockage in one or more of the coronary arteries using the
saphenous veins, mammary artery, or radial artery as conduits or replacement vessels.
Before surgery, coronary angiography locates lesions and points of narrowing within the
vessels.
During traditional CABG surgery, a median sternotomy incision is made so that the
heart and aorta can be seen. The client is placed on CPB while the bypasses are
performed. After this, the heart is stopped using a solution of iced saline containing
potassium. After the bypasses have been performed, the client is taken off the machine,
and the heart takes over again.
Saphenous veins were originally used. The distal end of the vein is sutured to the aorta,
and the proximal end is sewn to the coronary vessel distal to the blockage. The veins
are reversed so that their valves do not interfere with the blood flow. Nowadays used
less often.
The internal mammary artery is used commonly. It is used to revascularise the left
anterior descending artery. Disadvantage is, more time is required to remove the artery
and the artery is shorter. An advantage is greater chance for the artery to remain patent.
The radial artery is frequently used in clients having repeated CABG. The artery has
had excellent patency rates.
LESS INVASIVE CABG SURGERIES

 OFF –BYPASS CABG OR MID-CABG

In off-bypass CABG, OR MID-CABG (minimally invasive direct CABG) surgery is
performed through a median sternotomy with a smaller incision on a beating heart after
reduction in cardiac motion with medications and devices. The benefit is the avoidance
of CPB because of the many potential complications of CPB. It is a less invasive
approach.
OUTCOMES
 Ease the manifestations( but cannot halt the process of atherosclerosis )
 Improvement in quality of life ( improvement in physical & social functioning and
mood states)
 Reduce angina in 80 to 90% who do not respond to medical interventions ( so it
is an important treatment of CHD)
 Prolongation of life, increased exercise tolerance, and ability to perform former
activities.

COMPLICATIONS
 Postoperative bleeding
 Wound infection or dehiscence
 Intra operative stroke
 MI
 Multiple organ system failure
 Death
 Persistent hypotension(causes cerebral ischemia, renal shutdown, MI & shock)

NURSING MANAGEMENT
ASSESSMENT
The health assessment focuses on obtaining baseline physiologic, psychologic and
social information. The preoperative history and health assessment should be well
documented because they provide a basis for postoperative comparison.
1) Health history
 Past history of any major illness(hypertension, diabetes), surgeries, medication
therapies
 Present history includes reviewing of symptoms like chest pain, palpitations,
SOB, paroxysmal nocturnal Dyspnea and peripheral edema
 Personal history includes ill habits(drugs, smoking & alcohol).dietary & sleep
pattern
2) PHYSICAL ASSESSMENT
A complete physical examination is performed, with special emphasis on the following.
 General appearance and behavior
 Vital signs
 Nutritional and fluid status, weight, height
 Inspection and palpation of the heart, noting the point of maximal impulse,
abnormal pulsations, and thrills
 Auscultation of the heart(S3 & S4, snaps, clicks, murmurs & friction rub
 JVP
  Peripheral pulses
 Peripheral pulses
 Peripheral edema
3) PSYCHOSOCIAL ASSESSMENT
 Coping mechanisms
 Knowledge and understanding of the surgical procedure, postoperative course
and long term rehabilitation
 Support systems

NURSING DIAGNOSES
Ü Fear related to the surgical procedure, uncertain outcome, and the threat to
wellbeing
Ü Deficient knowledge regarding the surgical procedure and the postoperative
course
Ü Potential for complications(angina, severe anxiety, cardiac arrest) related to
stress of impending cardiac surgery
POSTOPERATIVE NURSING MANAGEMENT
 The patient is usually managed in a critical care unit for the first 24 to 72 hours
after surgery.
 Care focuses on hemodynamic stabilization and recovery from anesthesia.
 Vital signs are assessed every 5 to 15 minutes and as needed until the patient
recovers from anesthesia or sedation and then every 2 to 4 hours and as
needed.
 Intravenous medications to increase or decrease blood pressure and to treat
dysrhythmias or altered heart rates are administered, and their effects are
monitored.
 The intravenous medications are gradually decreased until they are no longer
required or the patient takes needed medication by another route (eg, oral,
topical).
 Patient assessments are conducted every 1 to 4 hours and as needed, with
particular attention to neurologic, respiratory, and cardiovascular assessments.
After the patient has recovered from anesthesia and sedation, is hemodynamically
stable without intravenous medications, and assessments are stable, the patient is
usually transferred to a telemetry or surgical unit for continued postsurgical care and
teaching. The nurse provides wound care and patient teaching regarding diet, activity,
medications, and self-care. Patients are discharged from the hospital in 1 to 7 days.

Care of the Patient after Cardiac Surgery

Ü Decreased cardiac output related to blood loss and compromised myocardial

function

1. Monitor cardiovascular status.

a. Assess arterial blood pressure every 15 minutes until stable; then arterial or cuff
blood pressure every 1–4 hours ×24 hours.
b. Auscultate for heart sounds and rhythm.
c. Assess peripheral pulses (pedal, tibial, radial, carotid).
d. Measure left atrial pressure, pulmonary artery diastolic (PAD) pressure, and PAWP to
determine left ventricular end-diastolic volume and to assess
cardiac output.
e. Monitor PAWP, PAD, left atrial pressure, and CVP to assess blood volume.
f. Monitor ECG pattern for cardiac dysrhythmias
g. Assess cardiac enzyme test results when available.
h. Measure urine output every 1⁄2 hour to 1 hour at first, then with vital signs.
i. Observe buccal mucosa, nailbeds, lips, earlobes, and extremities.
j. Assess skin; note temperature and color.
2. Observe for persistent bleeding: steady, continuous drainage of blood; hypotension;
low CVP; tachycardia. Prepare to administer blood products, IV solutions.
3. Observe for cardiac tamponade: hypotension; rising PAWP, PAD, left atrial pressure,
or CVP; muffled heart sounds; weak, thready pulse; jugular vein distention; decreasing
urinary output. Check for diminished amount of blood in chest drainage collection
system. Prepare for pericardiocentesis. Assess for pulsus paradoxus.
4. Observe for cardiac failure: hypotension, rising PAWP, PAD, CVP, and left atrial
pressure, tachycardia, restlessness, agitation, cyanosis, venous distention, dyspnea,
moist crackles, ascites. Prepare to administer diuretics and digoxin.
5. Observe for myocardial infarction: ST-segment elevations, T-wave changes,
decreased cardiac output in the presence of normal circulating volume and filling
pressures. Obtain serial ECGs and isoenzymes

Ü Impaired gas exchange related to trauma of extensive chest surgery

1. Maintain mechanical ventilation until the patient is able to breathe independently.

2. Monitor arterial blood gases, tidal volumes, peak inspiratory pressures
3. Auscultate chest for breath sounds.
4. Sedate patient adequately, as prescribed, and monitor respiratory rate and depth .
5. Promote deep breathing, forced expiratory technique (FET, coughing), and turning.
Encourage use of the incentive spirometer and compliance with breathing treatments.
Teach incisional splinting with a “cough pillow” to decrease discomfort during deep
breathing and FET(coughing).
6. Suction tracheobronchial secretions as needed, using strict aseptic technique.
7. Assist in weaning and endotracheal tube removal.

Ü Risk for deficient fluid volume and electrolyte imbalance related to alterations in
blood volume

1. Maintain fluid and electrolyte balance.

a. Keep intake and output flow sheets; record urine volume every 1 ⁄2 hour to 4 hours
while in critical care unit; then every 8 to 12 hours while hospitalized.
b. Assess the following parameters: pulmonary artery pressures, left atrial pressures,
blood pressure, CVP, PAWP, weight, electrolyte levels, hematocrit, jugular venous
pressure, breath sounds, urinary output, and nasogastric tube drainage.
c. Measure postoperative chest drainage (should not exceed 200 mL/hr for first 4 to 6
hours); Ensure patency and integrity of
the drainage system.
d.Weigh daily once patient is ambulatory.
2. Be alert to changes in serum electrolyte
levels.
a. Hypokalemia - Administer IV potassium replacement
as directed.
b. Hyperkalemia - administer an ionexchange
resin (sodium polystyrene sulfonate [Kayexalate]);or IV insulin and glucose.
c. Hypomagnesemia - Magnesium supplements may be given
d. Hypermagnesemia - dialysis and calcium gluconate administration.
e. Hyponatremia - administer sodium or diuretics as
prescribed.
f. Hypocalcemia – Administer replacement therapy as prescribed.
g. Hypercalcemia

Ü Acute pain related to surgical trauma and pleural irritation caused by chest tubes
and/or internal mammary artery dissection

1. Record nature, type, location, intensity, and duration of pain.

2. Assist patient to differentiate between surgical pain and anginal pain.
3. Encourage routine pain medication dosing for the first 24 to 72 hours

Ü Ineffective renal tissue perfusion related to decreased cardiac output, hemolysis,

or vasopressor drug therapy

1. Assess renal function:

a. Measure urine output every 1⁄2 hour to 4 hours in critical care then every
8–12 hours until hospital discharge.
b. Measure urine specific gravity.
c. Monitor and report lab results: BUN, serum creatinine, urine and serum electrolytes.
2. Prepare to administer rapid-acting diuretics or inotropic drugs (eg, dopamine,
dobutamine).
3. Prepare patient for dialysis or continuous renal replacement therapy if indicated

Ü Ineffective thermoregulation related to infection or postpericardiotomy syndrome

1. Assess temperature every hour.

2. Use aseptic technique when changing dressings, suctioning endotracheal tube;
maintain closed systems for all intravenous
and arterial lines and for indwelling urinary catheter.
3. Observe for symptoms of postpericardiotomy syndrome: fever, malaise, pericardial
effusion, pericardial friction rub, arthralgia.
4.Administer anti-inflammatory agents

Ü Deficient knowledge about self-care activities

1. Develop teaching plan for patient and family. Provide specific instructions for the
following:
• Diet and daily weights
• Activity progression
• Exercise
• Deep breathing, FET (coughing), lung expansion exercises
• Temperature monitoring
• Medication regimen
• Pulse taking
• Entry to the emergency medical system
• Need for MedicAlert identification
2. Provide verbal and written instructions; provide several teaching sessions for
reinforcement and answering questions.
3. Involve family in all teaching sessions.
4. Provide information regarding follow-up
5. Make appropriate referrals: home care agency, cardiac rehabilitation program,
community support groups
POTENTIAL COMPLICATIONS OF CARDIAC SURGERY

Cardiac Complications
Decreased Cardiac Output
 Preload Alterations (the amount of myocardial muscle fiber stretch at the end of
diastole)
1. Hypovolemia (most common cause of decreased cardiac output after cardiac
surgery)
• Blood loss (although some blood may be replaced to provide sufficient
hemoglobin to carry oxygen to the tissues)
• Surgical hypothermia (As the reduced body temperature rises after surgery,
blood vessels dilate, and more volume is needed to fill the vessels.)
• Intravenous fluid loss to the interstitial spaces because cardiopulmonary bypass
makes capillary beds more permeable
Management: Fluid replacement may be prescribed. Replacement fluids include: colloid
(albumin or protein), starch (hetastarch), packed red blood cells, or
crystalloid solution (normal saline, lactated Ringer’s solution).

2. Persistent bleeding
• Cardiopulmonary bypass procedure, which may cause platelet malfunction
(blood clots abnormally) and hypothermia, which alters clotting mechanisms
• Surgical trauma causing tissues and blood vessels to ooze bloody drainage
• Anticoagulant (heparin) therapy
Management: • Accurate measurement of wound bleeding and drainage tube blood is
essential. Bloody drainage should not exceed 200 mL/h for the first 4 to 6 hours.
Drainage should decrease and stop within a few days, while progressing from
sanguineous to serosanguineous and serous drainage.
• Protamine sulfate may be administered to neutralize unfractionated heparin; vitamin K
and blood products may be used to treat hematologic deficiencies.
• If bleeding persists, the patient may return to the operating room for corrective surgery.

3. Cardiac tamponade (may decrease preload to the heart by preventing available

blood from entering the heart)
• Fluid accumulates in the pericardial sac, which compresses the heart,
preventing blood from filling the ventricles.

Management: • Equipment is checked to eliminate possible kinks or obstructions in the

tubing.
• Drainage system patency may be reestablished by milking the tubing (taking care not
to strip the tubing, creating massive negative pressure within the chest, which may harm
the surgical repair or trigger a dysrhythmia).
• Chest x-ray may show a widening mediastinum.
• Emergency medical management is required; may include pericardiocentesis or return
to surgery.

4. Fluid overload
• High PAWP, CVP, and pulmonary artery diastolic pressures as well as crackles
indicate fluid overload.

Management: • Diuretics are usually prescribed and the rate of IV fluid administration is
reduced.
• Fluid restriction may be prescribed. Alternative treatments include continuous renal
replacement therapy, dialysis, and phlebotomy.

 Afterload Alterations (The force that the ventricle must overcome to move
blood forward. Alteration in the patient’s body temperature is the most common
cause of alterations in afterload after cardiac surgery.)

5. Hypothermia
• Blood vessel constriction, which increases afterload. (Blood vessel dilation from
fever or other hyperthermic condition decreases afterload.)
Management: Patient is rewarmed gradually, although vasodilators may be required if
the resistance is too great to wait for rewarming. The patient may require volume
support or vasopressors during a fever or severe vasodilation.
6. Hypertension
• Various causes. Some patients have a history of this condition and the nurse can
anticipate the need for treatment postoperatively. Other patients experience
transient hypertension.
Management: Vasodilators (nitroglycerin [Nitro-Bid], nitroprusside [Nipride, Nitropress])
may be used to treat hypertension. If patient had hypertension
before surgery, the preoperative management regimen resumes as soon as possible.

 Heart Rate Alterations

7. Tachydysrhythmias
• May or may not result from preload or afterload alterations
Management: • Rhythms are assessed to establish that they are not the result of
preload or afterload alterations.
• If a tachydysrhythmia is the primary symptom, the heart rhythm is assessed and
medications (eg, adenosine [Adenocard, Adenoscan], digoxin
[Lanoxin], diltiazem [Cardizem], esmolol [Brevibloc], lidocaine [Xylocaine], procainamide
[Procanbid, Pronestyl], propranolol [Inderal], quinidine [Cardioquin, Quinaglute,
Quinidex], verapamil [Calan, Corvera, Isoptin, Verelan]) are prescribed. (Patients may
be prescribed antiarrhythmics before CABG to minimize the risk of postoperative
tachydysrhythmias.)
• Carotid massage may be performed by a physician to assist with diagnosing or
treating the dysrhythmia.
• Cardioversion and defibrillation are alternatives for symptomatic tachydysrhythmias.
8. Bradycardias
• Many postoperative patients will have temporary pacer wires that can be attached to a
pulse generator (pacemaker) to stimulate the heart to beat faster. Less commonly,
atropine, epinephrine or isoproterenol may be used to increase heart rate.

9. Dysrhythmias (may or may not affect cardiac output)

• Abnormal heart rates
Management: it include medication, pacemakers (antibradycardiac, antitachycardiac),
carotid massage, cardioversion, or defibrillation.
Goal of treatment is to return the heart to a normal sinus rhythm.

 Contractility Alterations
10. Cardiac failure
• Possible when the heart fails as a pump and the chambers cannot adequately
empty
Management • The nurse observes for and reports falling mean arterial pressure; rising
PAWP, pulmonary artery diastolic pressure, and CVP; increasing tachycardia;
restlessness and agitation; peripheral cyanosis; venous distention; labored respirations;
and edema.
• Medical management includes diuretics and digoxin.

11. Myocardial infarction (may occur intraoperatively or postoperatively)

• Portion of the cardiac muscle dies, therefore contractility decreases. Until the infarcted
area becomes edematous, the ventricular wall moves paradoxically during contractions,
further decreasing cardiac output. Symptoms may be masked by the postoperative
surgical discomfort or the anesthesia–analgesia regimen.
• Careful assessment to determine the type of pain the patient is experiencing; MI
suspected if the mean blood pressure is low with normal preload. The systemic vascular
resistance (afterload) and heart rate may be elevated to compensate for poor
contractility.
• Serial ECGs and cardiac enzymes assist in making the diagnosis (alterations may be
due to the surgical intervention). Analgesics are prescribed in small amounts while the
patient’s blood pressure and respiratory rate are monitored (because
vasodilation secondary to analgesics or decreasing pain may occur and compound the
hypotension).
• Activity progression depends on the patient’s activity tolerance.

Pulmonary Complications
Impaired gas exchange
• During and after anesthesia, patients require mechanical assistance to breathe.
• Endotracheal tubes stimulate production of mucus and chest incision pain may
decrease the effectiveness of the forced expiratory technique (FET, cough).
Management : Pulmonary complications are often detected during assessment of
breath sounds, oxygen saturation levels, and end-tidal CO2 levels, and when monitoring
peak pressure and exhaled tidal volumes on the ventilator. Arterial blood gas results
and mixed venous saturations also are monitored when available.

Fluid Volume Complications

Hemorrhage
• Hemorrhage usually requires surgical intervention, and blood products are often
administered

Neurologic Complications
Cerebrovascular accident (brain attack, stroke)

Renal Failure and Electrolyte Imbalance

Renal failure
Acute tubular necrosis
Hypokalemia (low potassium level; normal level is 3.5 to 5.0 mEq/L [3.5 to 5.0 mmol/L])
Hyperkalemia.
Hypo calcemia & hypercalcemia
Hypomagnesemia & hypermagnesemia
Hypernatremia

Hepatic failure

• Most common in patients with cirrhosis, hepatitis, or prolonged right-sided heart failure
• Bilirubin, albumin, and amylase levels are monitored, and nutritional support must be
provided.
Infection
• Cardiopulmonary bypass and anesthesia alter the patient’s immune system. Many
invasive devices are used to monitor and support the patient’s recovery and may serve
as a source of infection.
• The following must be monitored to detect signs of possible infection: body
temperature, white blood cell counts and differential counts, incision and puncture sites,
cardiac output and systemic vascular resistance, urine (clarity, color, and odor), bilateral
breath sounds, sputum (color, odor, amount), as well as nasogastric secretions.
• Antibiotic therapy may be expanded or modified as necessary.
• Invasive devices must be discontinued as soon as they are no longer required.
Institutional protocols for maintaining and replacing invasive lines and devices must be
followed to minimize the patient’s risk for infection.

VALVULOPLASTY

The repair, rather than replacement, of a cardiac valve is referred to as valvuloplasty.

The type of valvuloplasty depends on the cause and type of valve dysfunction.
Repair may be made
1) to the commissures between the leaflets in a procedure known as commissurotomy
2) to the annulus of the valve by annuloplasty
3) to the leaflets
4)to the chordae by chordoplasty
Most valvuloplasty procedures require general anesthesia and often require
cardiopulmonary bypass. Some procedures, however, can be performed in the cardiac
catheterization laboratory; these procedures do not always require general anesthesia
or cardiopulmonary bypass.
COMMISSUROTOMY
The most common valvuloplasty procedure is commissurotomy.
Each valve has leaflets; the site where the leaflets meet is called the
commissure. The leaflets may adhere to one another and close the commissure (ie,
stenosis) & the leaflets are also prevented from closing completely, resulting in a
backward flow of blood (ie, regurgitation). A commissurotomy is the procedure
performed to separate the fused leaflets.

Closed commissurotomy
Closed commissurotomies do not require cardiopulmonary bypass. The valve is not
directly visualized. The patient receives a general anesthetic, a midsternal incision is
made, a small hole is cut into the heart, and the surgeon’s finger or a dilator is used to
break open the commissure. This type of commissurotomy has been performed for
mitral, aortic, tricuspid, and pulmonary valve disease.

Balloon Valvuloplasty.
Balloon valvuloplasty is another type of closed commissurotomy.
 The procedure is performed in the cardiac catheterization laboratory, and the
patient may receive a local anesthetic. Patients remain in the hospital 24 to 48 hours
after the procedure.

Ü Mitral balloon valvuloplasty involves advancing one or two catheters into the right
atrium, through the atrial septum into the left atrium, across the mitral valve into the
left ventricle, and out into the aorta. A guide wire is placed through each catheter,
and the original catheter is removed. A large balloon catheter is then placed over the
guide wire and positioned with the balloon across the mitral valve. The balloon is
then inflated with a dilute angiographic solution. When two balloons are used, they
are inflated simultaneously. The advantage of two balloons is that they are each
smaller than the one large balloon often used, making smaller atrial septal defects.
As the balloons are inflated, they usually do not completely occlude the mitral valve,
thereby permitting some forward flow of blood during the inflation period.
Possible complications include some degree of mitral regurgitation bleeding from
the catheter insertion sites, emboli resulting in complications such as strokes, and
rarely, left-to-right atrial shunts through an atrial septal defect caused by the
procedure.
Ü Aortic balloon valvuloplasty also may be performed by passing the balloon or
balloons through the atrial septum, but it is performed more commonly by
introducing a catheter through the aorta, across the aortic valve, and into the left
ventricle.
Possible complications include aortic regurgitation, emboli, ventricular perforation,
rupture of the aortic valve annulus, ventricular dysrhythmias, mitral valve damage,
restenosis and bleeding from the catheter insertion sites.

OPEN COMMISSUROTOMY
Open commissurotomies are performed with direct visualization of the valve. The
patient is under general anesthesia, and a median sternotomy or left thoracic incision is
made. Cardiopulmonary bypass is initiated, and an incision is made into the heart. A
finger, scalpel, balloon, or dilator may be used to open the commissures. An added
advantage of direct visualization of the valve is that thrombus may be identified and
removed, calcifications can be seen, and if the valve has chordae or papillary muscles,
they may be surgically repaired.

Annuloplasty
It is the repair of the valve annulus (ie, junction of the valve leaflets and the muscular
heart wall). General anesthesia and cardiopulmonary bypass are required for all
annuloplasties. The procedure narrows the diameter of the valve’s orifice and is useful
for the treatment of valvular regurgitation.
An annuloplasty ring is used. The leaflets of the valve are sutured to a ring, creating an
annulus of the desired size. When the ring is in place, the tension created by the moving
blood and contracting heart is borne by the ring rather than by the valve or a suture line,
and progressive regurgitation is prevented by the repair.
Leaflet Repair
Damage to cardiac valve leaflets may result from stretching, shortening, or tearing.
  Leaflet repair for elongated, ballooning, or other excess tissue leaflets is removal
of the extra tissue. The elongated tissue may be folded over onto itself (ie,
tucked) and sutured (ie, leaflet plication). A wedge of tissue may be cut from the
middle of the leaflet and the gap sutured closed (ie., leaflet resection).
 Short leaflets are most often repaired by chordoplasty. After the short chordae
are released, the leaflets often unfurl and can resume their normal function of
closing the valve during systole. A piece of pericardium may also be sutured to
extend the leaflet.
 A pericardial patch may be used to repair holes in the leaflets.
Chordoplasty
Chordoplasty is the repair of the chordae tendineae.
The mitral valve is involved with chordoplasty (because it has the chordae
tendineae); seldom is chordoplasty required for the tricuspid valve. Regurgitation may
be caused by stretched, torn, or shortened chordae tendineae. Stretched chordae
tendineae can be shortened, torn ones can be reattached to the leaflet, and shortened
ones can be elongated.

VALVE REPLACEMENT
Prosthetic valve replacement began in the 1960s. When valvuloplasty or valve repair is
not a viable alternative, such as when the annulus or leaflets of the valve are
immobilized by calcifications, valve replacement is performed. General anesthesia and
cardiopulmonary bypass are used for all valve replacements. Most procedures are
performed through a median sternotomy (ie, incision through the sternum). After the
valve is visualized, the leaflets and other valve structures, such as the chordae and
papillary muscles, are removed. Some surgeons leave the posterior mitral valve leaflet,
its chordae, and papillary muscles in place to help maintain the shape and function of
the left ventricle after mitral valve replacement. Sutures are placed around the annulus
and then into the valve prosthesis. The replacement valve is slid down the suture into
position and tied into place. The incision is closed, and the surgeon evaluates the
function of the heart and the quality of the prosthetic repair. The patient is weaned from
cardiopulmonary bypass, and surgery is completed.

The signs and symptoms of the backward heart failure resolve in a few hours or days. If
valve replacement was for a regurgitant valve, it may take months for the chamber into
which blood had been regurgitating to achieve its optimal postoperative function. The
signs and symptoms of heart failure resolve gradually as the heart function improves.
Postoperative complications, such as bleeding, thromboembolism, infection,
congestive heart failure, hypertension, dysrhythmias, hemolysis, and mechanical
obstruction of the valve.

Types of Valve Prostheses

Two types of valve prostheses may be used: mechanical and tissue (ie, biologic) valves.

MECHANICAL VALVES
The mechanical valves are of the ball-and-cage or disk design. Mechanical valves are
thought to be more durable than tissue prosthetic valves and often are used for younger
patients.
Mechanical valves are used if the patient has renal failure, hypercalcemia, endocarditis,
or sepsis and requires valve replacement. The mechanical valves do not deteriorate or
become infected as easily as the tissue valves used for patients with these conditions.
Thromboemboli are significant complications associated with mechanical valves, and
long-term anticoagulation with warfarin is required.

TISSUE OR BIOLOGIC VALVES

Tissue (ie, biologic) valves are of three types: xenografts, homografts, and autografts.
Tissue valves are less likely to generate thromboemboli, and long-term anticoagulation
is not required.
Tissue valves are not as durable as mechanical valves and require replacement more
frequently.
1. Xenografts are tissue valves (eg, bioprostheses, heterografts); most are from
pigs (porcine), but valves from cows (bovine) may also be used. Their viability is
7 to 10 years. They are used for women of childbearing age because the
potential complications of long-term anticoagulation associated with menses,
placental transfer to a fetus, and delivery of a child do not exist. Xenografts also
are used for patients older than 70 years of age, patients with a history of peptic
ulcer disease, and others who cannot tolerate long-term anticoagulation. Useful
for tricuspid valve replacement.
2. Homografts, or allografts (ie, human valves), are obtained from cadaver tissue
donations. The aortic valve and a portion of the aorta or the pulmonic valve and a
portion of the pulmonary artery are harvested and stored cryogenically.
Homografts are not always available and are very expensive. Homografts last for
about 10 to 15 years, somewhat longer than xenografts. Homografts are not
thrombogenic and are resistant to subacute bacterial endocarditis. They are used
for aortic and pulmonic valve replacement.
3. Autografts (ie, autologous valves) are obtained by excising the patient’s own
pulmonic valve and a portion of the pulmonary artery for use as the aortic valve.
Anticoagulation is unnecessary because the valve is the patient’s own tissue and
is not thrombogenic. The autograft is an alternative for children (it may grow as
the child grows), women of childbearing age, young adults, patients with a history
of peptic ulcer disease, and those who cannot tolerate anticoagulation. Aortic
valve autografts have remained viable for more than 20 years. Most aortic valve
autograft procedures are double valve replacement procedures, because a
homograft also is performed for pulmonic valve replacement.

NURSING MANAGEMENT
Patients who have had valvuloplasty or valve replacements are admitted to the
intensive care unit; care focuses on recovery from anesthesia and hemodynamic
stability. Vital signs are assessed every 5 to 15 minutes and as needed until the patient
recovers from anesthesia or sedation and then assessed every 2 to 4 hours
and as needed. Intravenous medications to increase or decrease blood pressure and to
treat dysrhythmias or altered heart rates are administered and their effects monitored.
The intravenous medications are gradually decreased until they are no longer required
or the patient takes needed medication by another route (eg, oral,
topical). Patient assessments are conducted every 1 to 4 hours and as needed, with
particular attention to neurologic, respiratory, and cardiovascular systems. After the
patient has recovered from anesthesia and sedation, is hemodynamically stable without
intravenous medications, and assessment values are stable, the patient is usually
transferred to a telemetry unit, typically within 24 to 72 hours after surgery.
Nursing care continues as for most postoperative patients, including wound care and
patient teaching regarding diet, activity, medications, and self-care.
The nurse educates the patient about long-term anticoagulant therapy, explaining the
need for frequent follow-up appointments and blood laboratory studies, and provides
teaching about any prescribed medication: the name of the medication, dosage, its
actions, prescribed schedule, potential side effects, and any drug-drug or drug-food
interactions. Patients with a mechanical valve prosthesis require education to prevent
bacterial endocarditis with antibiotic prophylaxis, which is prescribed before all dental
and surgical interventions. Patients are discharged from the hospital in 3 to 7 days.
Home care and office or clinic nurses reinforce all new information and self-care
instructions with the patient and family for 4 to 8 weeks after the procedure.

Septal Repair
The atrial or ventricular septum may have an abnormal opening between the right and
left sides of the heart (ie, septal defect). Although most septal defects are congenital
and are repaired during infancy or childhood, adults may not have undergone early
repair or may develop septal defects as a result of myocardial infarctions or diagnostic
and treatment procedures.
Repair of septal defects requires general anesthesia and cardiopulmonary bypass. The
heart is opened, and a pericardial or synthetic (usually polyester or Dacron) patch is
used to close the opening. Atrial septal defect repairs have low morbidity and mortality
rates.
When the mitral or tricuspid valve is involved, however, the procedure is more
complicated because valve repair or replacement may be required and the heart failure
may be more severe.
Generally, ventricular septal repairs are uncomplicated, but the proximity of the defect to
the intraventricular conduction system and the valves may make this repair more
complex.

Heart Transplantation.
The first human-to-human heart transplant was performed in 1967. Since then,
transplant procedures, equipment, and medications have continued to improve. Since
1983, when cyclosporine became available, heart transplantation has become a
therapeutic option for patients with end-stage heart disease. Cyclosporine is an
immunosuppressant that greatly decreases the body’s rejection of foreign proteins, such
as transplanted organs. It also decreases the body’s ability to resist infections, and a
satisfactory balance must be achieved between suppressing rejection and avoiding
infection.

Indications
@ Cardiomyopathy
@ Ischemic heart disease
@ Valvular disease,
@ Rejection of previously transplanted hearts
@ Congenital heart disease
@ A typical candidate has severe symptoms uncontrolled by medical therapy, no
other surgical options, and a prognosis of less than 12 months to live.
Screening : A multidisciplinary team screens the candidate before recommending the
transplantation procedure. The person’s age, pulmonary status, other chronic health
conditions, psychosocial status, family support, infections, history of other
transplantations, compliance, and current health status are considered in the screening.
When a donor heart becomes available, a computer generates a list of potential
recipients on the basis of ABO blood group compatibility, the sizes of the donor and the
potential recipient, and the geographic locations of the donor and potential recipient;
distance is a variable because postoperative function depends on
the heart being implanted within 6 hours of harvest from the donor. Some patients are
candidates for more than one organ transplant: heart-lung, heart-pancreas, heart-
kidney, heart-liver.

Transplantation Techniques.

Orthotopic transplantation is the most common surgical procedure for cardiac

transplantation. The recipient’s heart is removed, and the donor heart is implanted at
the vena cava and pulmonary veins. Some surgeons still prefer to remove the
recipient’s heart leaving a portion of the recipient’s atria (with the vena cava and
pulmonary veins) in place. The donor heart, which usually has been preserved in
ice, is prepared for implant by cutting away a small section of the atria that corresponds
with the sections of the recipient’s heart that were left in place. The donor heart is
implanted by suturing the donor atria to the residual atrial tissue of the recipient’s heart.
Both techniques then connect the recipient’s pulmonary artery and aorta to those of the
donor heart.

Heterotopic transplantation is less commonly performed. The donor heart is placed to

the right and slightly anterior to the recipient’s heart; the recipient’s heart is not
removed. Initially, it was thought that the original heart might provide some protection
for the patient in the event that the transplanted heart was rejected. Although the
protective effect has not been proved, other reasons for retaining the original heart have
been identified: a small donor heart or pulmonary hypertension.
The transplanted heart has no nerve connections with the recipient’s body (ie,
denervated heart), and the sympathetic and vagus nerves do not affect the transplanted
heart. The resting rate of the transplanted heart is approximately 70 to 90 beats per
minute, but it increases gradually if catecholamines are in the circulation. Patients must
gradually increase and decrease their exercise
(ie, extended warm-up and cool-down periods), because 20 to 30 minutes may be
required to achieve the desired heart rate. Atropine does not increase the heart rate of
these patients.
Postoperative Course. Heart transplant patients are constantly balancing the risk of
rejection with the risk of infection. They must comply with a complex regimen of diet,
medications, activity, follow-up laboratory studies, biopsies (to diagnose rejection), and
clinic visits. Most commonly, patients receive cyclosporine
or tacrolimus (FK506, Prograf), azathioprine (Imuran) or mycophenolate
mofetil (CellCept), and corticosteroids (ie, prednisone) to minimize rejection.

In addition to rejection and infection, complications may include accelerated

atherosclerosis of the coronary arteries (ie, cardiac allograft vasculopathy [CAV]or
accelerated graft atherosclerosis [AGA]).
Hypertension may be experienced by patients taking cyclosporine or tacrolimus; the
cause has not been identified.
Osteoporosis frequently occurs as a side effect of the anti-rejection medications and
pretransplantation dietary insufficiency and medications. Posttransplantation
lymphoproliferative disease and cancer of the skin and lips are the most common
malignancies after transplantation, possibly caused by immunosuppression. Weight
gain, obesity, diabetes, dyslipidemias (eg, hypercholesterolemia), hypotension, renal
failure, and central nervous system, respiratory, and gastrointestinal disturbances may
be caused by the corticosteroids or other immunosuppressants.
Other complications are immunosuppressant medication toxicities and responses to the
psychosocial stresses imposed by organ transplantation. Patients may experience guilt
that someone died for them to live, have anxiety about the new heart, experience
depression or fear when rejection is identified, or have difficulty with family role changes
before and after transplantation .
The 1-year survival rate for patients with transplanted hearts is approximately 80% to
90%; the 5-year survival rate is approximately 60% to 70% .

Mechanical Assist Devices and Total Artificial Hearts.

The use of cardiopulmonary bypass for cardiovascular surgery and the possibility of
performing heart transplantation for end-stage cardiac disease have increased the need
for mechanical assist devices. Patients who cannot be weaned from cardiopulmonary
bypass or patients in cardiogenic shock may benefit from a period of mechanical heart
assistance. The most commonly used device is the intra-aortic balloon pump. This
pump decreases the work of the heart during contraction but does not perform the
actual work of the heart.

Intra aortic balloon pumping

The IABP is a catheter with an inflatable balloon at the end. The catheter is usually
inserted through the femoral artery, and the balloon is positioned in the descending
thoracic aorta .IABP uses internal counterpulsation through the regular inflation and
deflation of the balloon to augment the pumping action of the heart. The device inflates
during diastole, increasing the pressure in the aorta during diastole and therefore
increasing blood flow through the coronary and peripheral arteries. It deflates just before
systole, lessening the pressure within the aorta before left ventricular contraction,
decreasing the amount of resistance the heart has to overcome to eject blood and
therefore decreasing the amount of work the heart must put forth to eject blood. The
device is connected to a console that synchronizes the inflation and deflation of the
balloon with the ECG or the arterial pressure (as indicators for systole and diastole).
Hemodynamic monitoring is essential to determine the patient’s response to the IABP.

Ventricular Assist Devices.

More complex devices that actually perform some or all of the pumping function for the
heart also are being used. These devices (VADs) can circulate as much blood per
minute as the patient’s heart, if not more. Each ventricular assist device is used to
support one ventricle. Some ventricular assist devices can be combined with an
oxygenator; the combination is called extracorporeal membrane oxygenation (ECMO).
The oxygenator– ventricular assist device combination is used for the patient whose
heart cannot pump adequate blood through the lungs or the body.
There are three basic types of devices: centrifugal, pneumatic, and electric or
electromagnetic.
 Centrifugal VADs are external, nonpulsatile, cone-shaped devices with internal
mechanisms that spin rapidly, creating a vortex (tornado-like action) that pulls
blood from a large vein into the pump and then pushes it back into a large artery.
 Pneumatic VADs are external or implanted pulsatile devices with a flexible
reservoir housed in a rigid exterior. The reservoir usually fills with blood drained
from the patient’s atrium or ventricle. The VAD then forces pressurized air into
the rigid housing, compressing the reservoir and returning the blood to the
patient’s circulation, usually into the aorta.
 Electric or electromagnetic VADs are similar to the pneumatic VADs, but
instead of pressurized air, one or more flat metal plates are pushed against the
reservoir to return the blood to the patient’s circulation.

Total artificial hearts

These are designed to replace both ventricles. Some require the removal of the
patient’s heart to implant the total artificial heart; others do not. All of these devices are
experimental. Although there has been some short-term success, the long-term results
have been disappointing. Researchers hope to develop a device that can be
permanently implanted and that will eliminate the need for donated human heart
transplantation for the treatment of end-stage cardiac disease.
Most VADs and total artificial hearts are temporary treatments while the patient’s own
heart recovers or until a donor heart becomes available for transplantation (ie, “bridge to
transplant”).
Bleeding disorders, hemorrhage, thrombus, emboli, hemolysis, infection, renal failure,
right heart failure, multisystem failure, and mechanical failure are some of the
complications of VADs and total artificial hearts.
The nursing care for these patients focuses on assessing for and minimizing these
Complications and involves providing emotional support and education.
References

1) Suzanne C. Smeltzer & Brenda Bare, Brunner & Suddarth’s textbook of medical
surgical nursing, 10th edition(2004) Lippincott Williams publications, New York, page
no 808, 733 – 755, 768 - 775
2) Joyce M. Black & Jane Hokanson Hawks, medical surgical nursing, 7 th
edition(2005)Saunders publication, page no 1599 – 1604, 1609 - 1612
3) www.google.com