Post op Management of MVR & CABG

Mitral Valve Replacement-Introduction

• Mitral valve replacement is a procedure whereby the diseased mitral

valve of a patient's heart is replaced by either a mechanical or tissue
(bioprosthetic)
Mechanical Valves:

• They are artificial components that have same purpose as a natural

heart blood thinners for the rest of valve and are created from carbon
and polyester materials that human body tolerates well.

• The risk associated with it is blood clot, so the patient needs his life to
reduce stroke.
 Biological Valves: (Bioprosthetic Valves)

• They are made from human or • Biological valves don’t increase

animal tissues. the risk of developing blood clots
• An allograft or homograft (tissue but they don’t last as a
taken from a human donar’s mechanical valve.
heart).
• A porcine valve (made from pig
tissue).
• A bovine valve (made from cow
tissue).
 Indications of MVR

➢Mitral valve regurgitation:

• The flaps (leaflets) of the mitral valve don't close tightly, causing
blood to leak backward. Mitral valve regurgitation is common in
people with mitral valve prolapse.
➢Mitral valve stenosis:
• The valve leaflets become thick or stiff, and they may fuse together.
This causes the valve to become narrowed and reduces blood flow
through the area.
 Complications of MVR

• Infection. • Complications from anesthesia.

• Bleeding. • Continued leaking of the valve.

• Irregular heart rhythms. • Damage to nearby organs.

• Blood clots leading to stroke or • Memory loss or problems with

heart attack. concentration.
CABG (Coronary Artery Bypass Graft)
 CABG (Coronary Artery Bypass Graft)

• Coronary bypass surgery is a surgical procedure that diverts the flow

of blood around a section of a blocked or partially blocked artery in
heart.
• During CABG, a healthy artery or vein from the body is connected, or
grafted, to the blocked coronary artery.
• The grafted artery or vein bypasses (that is, goes around) the blocked
portion of the coronary artery.
 The goals of having the CABG surgery include:

• Improving r quality of life and decreasing angina and other CHD

symptoms
• Allowing patient to resume a more active lifestyle
• Improving the pumping action of heart if it has been damaged by a
heart attack
• Lowering the risk of a heart attack (in some patients, such as those
who have diabetes)
• Improving the chances of survival
 Types of Coronary Artery Bypass Grafting

1. Traditional /on pump CABG;

• This is the most common type of coronary artery bypass grafting
(CABG). It's used when at least one major artery needs to be
bypassed.
2. Off-Pump CABG;
• This type of CABG is similar to traditional CABG because the chest
bone is opened to access the heart. However, the heart isn't stopped,
and a heart-lung bypass machine isn't used. Off-pump CABG is
sometimes called beating heart bypass grafting.
 Types of Coronary Artery Bypass Grafting Contd…

3. Hybrid CABG;

• Combination of CABG and PCI

• CABG for left main artery and PCI to LCX and RCX
 Indications

• Over 50% left main coronary artery stenosis

• Over 70% stenosis of the proximal left anterior descending (LAD) and

proximal circumflex arteries

• Three-vessel disease in asymptomatic patients or those with mild or

stable angina
 Indications Contd…

• Ongoing ischemia in the setting of a non–ST segment elevation

myocardial infarction (MI) that is unresponsive to medical therapy

• CABG may be performed as an emergency procedure in an ST-

segment elevation MI (STEMI) and unable to perform percutaneous

coronary intervention (PCI) or where PCI has failed

 Contraindications

• In asymptomatic patients who are at a low risk of MI or death.

• Patients who will experience little benefit from coronary

revascularization

• Although advanced age is not a contraindication, CABG should be

carefully considered in the elderly, especially those older than 85
years.
 Preprocedural evaluation

➢Before performing CABG, clinicians should carefully examine the

patient’s medical history for factors that might predispose to
complications, such as the following:

• Recent MI

• Previous cardiac surgery or chest radiation

• Conditions predisposing to bleeding

 Preprocedural evaluation Contd…

• Renal dysfunction

• Cerebrovascular disease and transient ischemic attack (TIA)

• Electrolyte disturbances that might predispose - dysrhythmias

• Infection, including urinary tract infection and dental abscesses

• Respiratory function
 Complications

• Bleeding during or after the • Pneumonia

surgery • Renal dysfunction
• Blood clots that can cause heart • Breathing problems
attack, stroke, or lung problems
• Cardiac arrhythmias (abnormal
• Infection at the incision site heart rhythms)
(sternum and leg)
Post op Management
 Post Op Management

Goals:
• Rest, Comfort & Relief from pain
➢Promote;
• Early movement & Ambulation
• CVS function & tissue perfusion
• Psychosocial Adjustment
• Respiratory, Renal & Neurologic
➢Prevent;
functions
• Post-operative complications
• Fluid, Electrolytes & Nutritional balance
 Postoperative Care in the ICU

➢Admission
Keyword: communication! Direct information from OR
team/anesthesiologist/surgeon to intensivist team on arrival in the unit
about:
• Operation
• Complications during op; bleeding, need for transfusion
• Responsiveness to volume, inotropes, and drugs
• Planned care and expected problems
 Initial Review of the Postoperative Patient

• ABC • Drain catheters and urinary

• Hemodynamic Monitoring catheter

• IV lines and sites • Temperature

• Pumps and infusions • Physical examination

 Postoperative Management Contd…

• Time on CPB

• Ventilation/oxygenation/airway management

• Vasopressor/inotropic support

• Surgical considerations for postop period

 Postoperative Management Contd…

➢Ventilation; ➢Circulation;

• CXR for ETT and chest tube • Vasopressor needs? Inotropes?

placement and pulmonary • CO output
functions
• Peripheral perfusion
• ABG for ventilation assessment
• Kidney function
and support
 Postoperative Management Contd…

➢Coagulation;

• Output in chest tube/wound per time unit

• TEG/ACT/PT/APTT/platelet count for coagulation status

• Observe drug effects on platelet function (i.e., milrinone)

 Risk Factors for Postoperative Pulmonary Dysfunction

• Age < 2 or > 60 yrs • Long CPB time

• COPD • Type of oxygenator

• Pulmonary hypertension • Use of ice for cardioplegia

• Congenital pulmonary pathology (damage to phrenic nerve)

• Down’s syndrome
 Graft Spasm Prevention

➢Several therapies to maintain graft patency after CABG has been used,
side effects and surgeon preference decide choice;

• Nitroglycerin

• Ca2-channel antagonists

• Phosphodiesterase inhibitors

• α-adrenergic antagonists
 Preventable Postoperative Complications

➢Arrhythmia ➢Hyperglycemia;
• Decreased organ perfusion
• Increased mortality and morbidity
• Increased risk for MI or fatal
arrhythmia • Impaired wound healing

• Prolonged ICU care and hospital stay • Decreased cardiac function

 Postoperative Complications-Management

➢Hypertension; ➢Pain;

• Increased risk of stroke and MI • Secondary hypertension

• Increased risk of surgical • Reduced pulmonary function

bleeding • Impaired wound healing

• Use multimodal approach:

acetaminophen, NSAID, opioid
 Postoperative Complications-Management

➢If there is significant amount of ➢Inform doctor for re-exploration if

bleeding from chest tube drain; the amount increase more than;

• Identify its cause(medical or • 400ml in first hour

surgical cause )/Heparin effect? • Or 3ml/kg/h in first 3 hours
• Check coagulation profile i.e. ACT, • Or continued bleeding of more than
PT/INR, platelets count, bleeding 200ml/hr
disorder.
 Postoperative Complications-Management

➢If there is no significant amount of bleeding from chest tube drain,

• check for patency of tube.

• signs of cardiac tamponade, like increased CVP, decreased BP,

tachycardia.

• Hemoglobin level, lactate etc.

 Postoperative Complications-Management

➢Coronary ischemia;
• Increased risk of MI/arrhythmias/circulatory arrest
➢Renal failure;
• 1 - 2% of CPB patient, associated with high mortality especially if
ARF is associated with dialysis
• Dopamine – improves outcome in patients with low CO
➢Prolonged ventilation;
• Increased risk of VAP
 Problem Directed Management

- ß-blocker if tachycardia and

➢Hypertension
good LV function
• Pain?
- Vasodilators if hypovolemia is
- PCA, iv/po medications or
excluded
epidural

• Postoperative stress response?

 Problem Directed Management

➢Hyperglycemia;

• Insulin infusion to maintain blood glucose @ 140-180mg/dl

 Problem Directed Management

➢Arrhythmias;

• Amiodarone has good prophylactic effect and shown good rhythm

control on postoperative AF

• ß-blockers should be continued if started, but keep in mind the

negative effect on a “stunned” myo-cardium.
 Coagulopathy

➢Hypothermia?

• Rewarm!

➢Residual heparin effect?

• Give 50-mg protamine

➢Intraoperative major bleed?

• Supply missing components – platelets, coagulation factors

 Nutrition

• NPO while intubated

• Sips 2 hours of extubation, followed by clear liquid and soft diet

• Diet as tolerated afterwards

• (Note; if long time intubation, patient needs enteral or parenteral

feeding)
 Special Cases

➢Pacemaker and ICD (pre-, intra-,

and postop); possibility to turn off
during and before surgery. Backup
needed?
➢Mechanical support for failing
heart postoperatively: IABP, VAD
• IABP improves coronary
circulation during diastole and
reduces LV afterload (check DPP
2hrly & watch for signs of DVT)
 Special Cases

➢Postoperative vasodilatory shock

• Use vasopressin on infusion
➢SIRS
• Use of low-dose steroids seems to attenuate cytokine response post
bypass and improve outcome.
 Special Cases

➢Pulmonary hypertension;

• PVR increased or RV overload/failure?

✓Use of milrinone, prostaglandin analogs, diuretics or sildenafil (or

combinations) to improve RV function

 Patient education

• Reinforce preop teaching. • Smoking cessation

• Incision care. • New medication.

• Activity restrictions. • Pulmonary hygiene.

• Sternal precaution. • Personal hygiene.

• Diet. • Chest physiotherapy and

spirometry
 Specific Considerations (MVR)

➢Medications;

• Inj. Heparin and tab. Warfarin (Anticoagulation)

• Others; cough expectorants, beta blockers, ACE inhibitors, diuretics,

cardiac glycosides and antiarrhythmics
 Specific Considerations (MVR)

➢Investigations; • APTT, PT/INR

• Hb • Chest X-ray

• Platelets • Others as needed

• BSR • ABG as per need

• RFT (INR; 2.5-3.5)

 Specific Considerations (MVR)

➢Patient education; • Prophylactic antibiotics prior to

• Anticoagulation Therapy dental procedures

• Therapeutic level of INR • Transthoracic echocardiography

for prosthetic valve and
• Safety measures from injury
ventricular functions
• Prevention of endocarditis

• Dietary restrictions
 Specific Considerations (CABG)

❑Medications;
➢Aspirin(Antiplatelet);
• Start within first 24 hrs of post op. (Reduces risk of early occlusion of
grafts)
➢Β-blocker;
• Reduces risk of cardiovascular death and AF/arrhythmia
➢Ca-channel blocker;
• Reduces mortality after cardiac surgery
 Specific Considerations (CABG) Contd…

➢Lipid lowering therapy;

• Lowers cholesterol and triglyceride levels

➢ ACE-inhibitors/ARB;

• Reduces risk of stroke, MI and death in diabetic and vascular patients

 Specific Considerations (CABG) Contd…

❑Investigations;

• Lab investigation; CBC, BSR, RFT

• Chest X-ray

• ECG (0 hours, 1st POD, 2nd POD and 3rd POD) and as needed.

• Cardiac Enzymes (CPK, CPK-MB); 0hrs, 6 hrs, 12 hrs and 24 hrs

• ABG as per need

 Specific Considerations (CABG) Contd…

❑Others;
• If patient on IABP machine, check for DPP 2 hourly and watch for
DVT

• If only femoral sheath is present watch for DPP 2 hourly and 6 hourly
once sheath is removed till ICU stay.

• Apply antiembolism stocking.(remove BD)

 Specific Considerations (CABG) Contd…

➢Patient education; • Stop smoking and alcohol intake

• Apply antiembolism stocking for
• Control blood pressure.
3 months on graft site leg.
• Keep grafted site leg slightly • Maintain cholesterol level.
elevated for 3 months. • Begin exercising regularly.
• Take antiplatelet and lipid
• Maintain weight.
lowering medicines regularly.
• Reduce stress.
 Nursing Management

➢Nursing Assessment:
• Abnormal breathing sounds
• Thick secretions and unable to spell out it
• Pain at incision site
• Hypercapnia
• Hypoxemia
• Confined on bed
 Nursing Management Contd…

➢Nursing Diagnosis;
1. Ineffective airway clearance related to presence of thick secretions
2. Ineffective breathing pattern related to pain at surgical site
3. Acute pain related to surgical incision
4. Impaired physical mobility related to activity intolerance
5. Impaired skin integrity related to diminished circulation and surgical
incision
6. Risk for infection related to surgical procedure
 Nursing Management Contd…

➢Nursing Interventions;
• Administer oxygen
• Remove secretions by suctioning
• Keep on fowler’s position
• Give analgesics
• Encourage for deep breathing and coughing exercise
• Encourage for early mobilization
• Maintain hand hygiene
 Questions

1. All of the followings are expected to be present in a post op. cardiac

patient having cardiac tamponade, except;

i. Hypotension

ii. Bradycardia

iii. Increased CVP

iv. Tachypnea
 Questions Contd…

2.What is the therapeutic level of INR For a patient underwent mitral

valve replacement?
i. 1.5-2.5
ii. 2-3
iii. 2.5-3.5
iv. 3-4
 Questions Contd…

3. You are a cardiac nurse and assigned for the care of a patient underwent
mitral valve replacement and under inj. Heparin 12,5000 iu /500cc on
infusion. Now APTT is 56/30, then, what will you do?

i. Hold inj. Heparin

ii. Increase Heparin by 2 iu/kg

iii. Decrease Heparin by 2 iu/kg

iv. Continue Heparin as it is

 Questions Contd…
4. You are a morning shift nurse caring for a patient wit Dx. of S/P-
CABG*2 having 1 Rt. Pleural and 1 Mediastinal chest tube separately.
Suddenly, your patient pulled out Rt. Pleural chest tube, then, what will
you do at first?
i. Call the doctor
ii. Assess the chest tube insertion site
iii. Gently press the chest tube insertion site with sterile gauze
iv. Call for x-ray