this is a continuation of chapter 13 cardiovascular alterations continuing our case study of Mr T he is a 54-year-old Asian male that was admitted yesterday through the emergency department for unstable angena and an inferior Walt stemi he was transported by EMS from the clinic to the emergency department his history is he's he's had mild angena for 2 years that was controlled by sublingual Nitro his pain episodes had started in increasing in frequency and then he started having pain at rest so the he visited his cardiologist and the Cardiology clinic called EMS and that's how he ended up in the Ed when he arrived to the hospital because the nearest hospital with PCI capabilities was over two hours away there was a decision made to go ahead and give him ropl the RL dose that was given was 10 units slow Ivy push over 2 minutes and the dose was repeated 30 minutes later another 10 units over 2 minutes why was Mr T treated with the thrombolytics rather than transported to the Center for PCI the answer is that in order to be effective the PCI should be done within the first 90 minutes after um initial contact with emergency medical staff so they if they had taken the time for granted transport that would have extended that window and PCI would no longer be an option remember that time is muscle he was still inside the window to give thrombolytics ideally the thrombolytics should be given within 30 to 60 Minutes of arrival to the hospital but the sooner the treatment is initiated the better because Mr T is having an inferior wmi What complications should be anticipated while getting him ready for the thrombolitic therapy go ahead and review table 13.7 pause the video and give this some thought the first thing we think about is whenever we're going to prepare to give thrombolytics we want to make sure that we start at least two large bore IVs and if anything else invasive needs to happen such as getting blood draws we want to go ahead and do those now before we give the actual thrombolitic therapy otherwise the risk of bleeding is going to be very extensive in addition if you look at the table the location of the MI being in inferior tells you that the primary side of occlusion could be either the right um coronary artery or the left circumflex and if those arteries are associated potential complications could be first or second degree heart block or rip ventricular infarction this morning Mr T's cardiac Rhythm suddenly dropped to 40 beats per minute and he's now very dizzy and breathless what do you think is occurring go ahead and pause this video take a moment to think about that and then I'll also review table 13.7 and then restart the video when you're ready you always want to worry about potentially Associated complications to the electrical conduction system the table says that people that are having inferior Mis the primary side of occlusion tends to be either the right coronary artery or the left circumflex so some complications that we would look for is first or second degree AV heart block and potentially right ventricular infarction that doesn't seem to be the case here in this instance something's happening that made this uh that made Mr teas very bardic and he is symptomatic Whenever there a successful reperfusion because of the uh clot Buster or the anti-thrombotic you can have a complication called reperfusion syndrome that's kind of an umbrella broader term that refers to there's a physiological response that occurs when you restore blood flow to that es schic tissue there's um one specifically a beasal ish reflex I'll write the name on the board there are several sensory receptors especially the in the inferior posterior wall so what happens is when they're stimulated by Stretch because we've reperfused now uh the reflex is going to be a brto cardia and hypotension so the es schic areas stretch they they're getting their profusion again the mechanical receptors then send signals to the vagus nerve uh from from the vagus nerve to the brain stem that's going to increase veal tone and decrease sympathetic activity as well so the result is AOC cardia and also uh potentially baso dilation that's going to drop the blood pressure this should be transitory however we do need to treat it because we don't want to cause more harm while we're sitting that uh for that to repair itself or or um for the patient to recover the additional information we need is probably a really quick full set of vitals do a neuro check on him super quick and we might be consider considering and getting ready to administer probably something to speed up the sinus nodes so we're probably going to give atropine potentially fluids because of that vasod dilation effect that's making the tank bigger so essentially they're all the Mr T is in a state of uh hypovolemia not actually in hypovolemia but relative to the vasil dilation that has occurred so again atropine probably likely and we may consider fluids as well or anticipate that order coming from the dock Mr TI has discharged from the hospital two days after his Mi and instructed to follow up with his cardiologist what discharge instructions are needed what meds is he going to be ordered what psychosocial support may be needed not only to Mr T but also his wife and their son Rie go ahead and pause the video and give that some thought he's definitely going to need to follow up with this cardiologist he can anticipate that he's probably going to get some medications like beta blockers and ACE inhibitors make sure that you review the drug table for treating an MI and having a post c a post cabbage also review your nursing care plan some of the potential psychosocial support issues that need to be attended to are going to be potentially issues related to guilt and also support uh if Mr T is a primary bread winner and he's going to be out of work in cardiac rehab for a while that's going to take some potentially add some stress to the home life as well the sun may be experiencing an extra layer of fear if he thinks that potentially this could be a condition that eventually could be the demise of his dad so some reass reassurance and some education is probably going to be needed as well let's move on to Circular revascularization procedures we're going to talk about three different types the first is coronary artery bypassing graph the traditional cabbage surgery then we'll talk about minimally invasive direct coronary artery bypass or midcab surgery then finally transmyocardial revascularization or TMR first let's talk about traditional cabbage surgery and you can watch this video here I believe it's about maybe a 4minute video that'll walk you through and shows you a nice illustration of the Cabbage procedure and so basically what we're doing here is we're rerouting blood blood flow to the areas that are no longer being perused because of the lesion such as here uh you've got plaque that is completely occluded blood flow all this area of the heart the blowup version is right here so what'll happen is they Bridge blood flow and they put it just beyond where that lesion is so now this portion of the heart is now receiving oxygenated blood and so some the some popular graphs will be the sainis vein or they might reroute blood flow from the internal mamory artery uh and they could potentially even use the radial artery now the mamory artery and the radial artery they're both arteries and at risk for spasming the radial artery has slightly better long-term patency um over the saffin vein but again the risk that you need to consider is that because of the strong mus muscle muscular um aspects of the anatomy from the arteries that they're going to be at risk for spasming uh if the artery spasm of course that's not good because then blood flow to The myocardium is going to be interrupted which kind of defeats the point of having the bypass there are some cons to trying to use the radial artery or some contraindications first if they have if a patient has carpal tunnel syndrome and these are listed in your book so please review them um if the they have an abnormal Allen test review that uh you guys performed an allen test back in your assessment class if they have things like Rod phenomenon which is basically going to indicate that they've got compromised blood flow to that um the upper extremity any kind of trauma to the upper extremity history of vasculitis or braal plexus injury those are again are going to rule out um the the ability to use the radial artery for a Graft in a cabbage for a cabbage a couple of different variations will need to get a graft so this is just showing uh if they're going after the sainis vein they can use a traditional long incision and they'll go and they'll harvest the sainis vein or they could potentially go in and use a videos videoscopic approach so then the patient comes back with little puncture marks uh tends to be a little bit better for the patient's leg recovery or they can go in using a canula and dissect the saffin vein that way so you could get a patient that has a linear scar puncture marks or again more pranks remarks what are the indications for cabbage well first is refractory chronic stable angena so even somebody that has stable angena if it's like refractory to other therapies then they're going to start considering uh sending that patient for a cabbage if a patient has significant left man occlusion uh problems or lesion in the left man then and that means greater than 50% uh up until recently they're going to be a strong candidate for cabbage and so here if you can see in the graphic below it the left main coronary artery really supplies a large portion of The myocardium so they don't want to risk that the lesion could comp potentially just take out a big portion of the left ventricle uh that could be catastrophic for the patient the reason I said up to recently is because even just this morning I read an article that talks about they're revisiting excuse me revisiting sending everybody automatically for cabbage if they got left main occlusion so they're investigating other techniques it's actually pretty interesting how even in the past when sending patients to the cath lab to get stance placed uh if it bifurcated if the leion area bifurcated they wouldn't Place Sten and now they will so you'll see like a little y-shaped stent formation that's being used other indications are if somebody had a cath uh p with PCI in the past or the lesions did not either they failed or the lesions were just not amenable to PCI um if the patient has triple vessel disease um if they have unstable Anga and if they have left ventricular failure again those are indications to go ahead and refer them to get a cabbage the list of risks associated with cabbage are is very extensive and you're going to continue to see what those risks are as we move along through the slides it's a big surgery so there's increased mortality that is linked to left ventricular dysfunction uh the fact that we're doing an emergency surgery maybe the patient's not in the best shape um Advanced ages females tend to um have a little more trouble as well in the recoveries the number of diseased vessels um higher number of course is going to indicate higher risk and then there's potential considerations where uh the patients may suffer actually an MI on the table there could be a autm is immediately post off and additional concerns with decreased ejection fraction with congestive heart failure need to also consider all the associated risks from being under anesthesia for prol period of time and then there is the cooling and the rewarming phase that we'll talk about here in just a second traditional bypass procedure includes a median sternotomy or they split the sternum and then they'll excise the paric cardium and place the patient on cardiopulmonary bypass there are risks Associated concerns about bleeding potential clotting and then um they'll Institute they'll stop basically The myocardium so that's that's called myocardial preservation or cardioplegia the way that they do that is they inject a very high potassium cold solution so essentially they're stopping the heart then harvesting the graphs and then um assuming everything goes well um there's a lot of suturing in place and then weaning off of B bypass if the patient's heart does not automatically start pumping again they may need to Def defibrillate using internal defibrillator patient will likely come back out of the o with a few chest tubes there's quite a bit of trauma and inflammation that's occurring as well as a little bit of residual bleeding perhaps so the patient will come back with a medial chest tube and then if the plural was punctured or or sliced during the procedure they'll come back with bilateral chest tubes surgeon will re rejoin the sternum and then wire it together and the patient may also come back with epicardial pacing wires in Pace in place not all the patients come back with pacing wires in place uh but they will leave them just in case the the surgeon is concerned that there might be a rhythmia problems here down below this is a mediastinal chest tube the reason patients get cabbage surgery are to increase blood flow to The myocardium and that in of itself is going to help relieve the symptoms so if they were um not able to tolerate any kind of exertion hopefully those symptoms will relieve be relieved and then that also will prolong survival and improve overall their quality of life moving on to minimally invasive direct coronary artery bypass or midcab surgery there's an Associated branch of midcab the first is uh Port access coronary artery bypass or pack Cab in pack cab surgery the patient is still undergoing cardiopulmonary bypass but small incisions or small ports are made inside the patient on the patient's chest the surgical team passes instruments through those ports to perform the bypass using the internal mamory arter the sainis vein or the radial artery so again the the goal is the same the approach is what's differing here so they're not slicing the patients and uh cutting the patient's sternum open the whole point of this approach is to avoid having the patient have to go on cardiopulmonary bypass the heart Contin to beat so this procedure this approach is used when only one or two arteries are going to be bypassed so they'll use a combination of small holes or ports in the chest and then a small incision directly over where the coronary artery needs to be bypassed so they'll use like a special device it looks like a Bent Fork uh to hold the portion of the heart still that they're actually working on at at at the time it's actually pretty interesting you'll see the rest of the myocardium beating but the device will hold that portion of The myocardium that they're working completely still and in this approach typically the internal mamory artery is the one that's commonly used for grafting I should mention one more approach for the previous slide there's a robotically assisted heart surgery that still falls under the category of minimally invasive heart surgery the surgeons use a computer console they control the instruments on thin robotic arms the benefits are that they're smaller incisions and hopefully quicker recovery times several complications can occur as a result result of cardiac surgery overall first of all the The myocardium is going to be affected because of the disease itself so that can result in low cardiac output and the sequella from that could be you know the the kidneys are very sensitive to perfusion so there could be renal impairment also if there's decreased blood flow to the mesentary there could be GI dysfunction and then also peripherally there could be impaired peripheral circulation mediastinal bleeding you that's where they did all the work and so that's a big concern always an infection especially they come back with you know they just did a big surgery big surgical procedure and they come back with a chest tube if the infection is is very serious and we don't catch it quickly or and start treating aggressively it could end up compromising the work that they did it could be very very serious if it's a sternal infection atrial dismas is going to be they're going to be a big concern as a result of this surgery and those occur because of the trauma from the surgery and the inflammation um especially if there's an atrial incision and then big electrolyte shifts specifically potassium and magnesium just the overall hemodynamic stress um the atrial changes during surgery you they going to be um shifts in fluid so there could be be like an acute atrial enlargement it's kind of going to stretch and cause a little bit of irritation so even up to like 15 to 40% of cabbage patients are going to have a fib in the early posttop period that's not an unusual usual arhythmia to see make sure that you review boxes 3-8 and 3-9 for related nursing care and because this is a very large surgery with um big massive blood flow shifts if they're going on pump and then off pump um and Associated bleeding the high risk of bleeding could result in hypovolemia we've already mentioned the complications of cabbage include dymas and then also they could p P they could have impaired contractility and a resulting low cardiac output intraoperatively you know they're working with vessels that already have compromised blood flow patients can suffer U myocardial infarction either on the table or immediately posttop then because of the entation and inflammation there could be blood or paracardial fluid buildup in the paracardial sack that could end up really causing a lot of pressure on the cardiac structure and cause paracardial tanod uh the failing heart could cause respiratory insufficiency overall pain big surgery again uh risk of emili and stroke risk of shock and even risk of death one month after Mr te's revascularization he develops chest pain and visits the cardiologist he's having t-wave changes now in the anterior leads he's referred to the tertiary Care Center for additional testing he under goes cardiac catheterization and angiography and they find a lesion of the left main coronary artery he scheduled for a cabbage why is a cabbage scheduled and not a PCI well we discussed about how the left main coronary artery supplies quite an extensive amount of The myocardium and they just don't want to take a chance and what are the psychosocial implications of having surgery at a tertiary Care Center he's basically going to have Specialists but they're probably not going to be in close proximity to where they live the implications are going to be maybe not being able to have their normal support systems right at hand it's going to add the additional stress of either Mrs T is going to have to drive back and forth or potentially have to get a room in a hotel if they don't have a roomin situation and um if their son is going to school the implications there are going to be you know who's going to stay with the son if he's underage while Mr and Mrs T are in the hospital and if you remember the beginning of the story they were talking about how the hospital was 2 hours away from their home of course the other alternative may be is it Mrs T decides to stay at home with Rie and then Mr T is all by himself in the hospital Mr T undergoes cabbage and the left internal memory artery the Lima is implanted to the left main coronary artery why is the Lima used the internal memory tends to have very good blood flow flow delivery and it also has long-term patency and if you think about it they're only kind of cutting on one end of the artery and rerouting it so they're not taking an entire graft it's almost like they're just rerouting from an existing vessel in the GE the same geographical area so the big benefit is ability to maintain long-term patency what are the post-operative priorities care for these patients is very extensive from the regular posttop concerns of anybody that's had general anesthesia you want to maintain pulmonary hygiene uh get them moving um their pain has to be under control uh there's certain Maneuvers that they have to do um they usually give them a pillow to brace to splint but we do want to keep them moving um they the surgeons generally are very aggressive unless the patients are in pretty bad shape where you've got organ s organ system failure um but if they're not and they're recovering just fine they'll want to get them up out of bed sometimes that same night um they want to wean them off the ventilator if they came back on the vent as quickly as possible patients could come back with pacing wires in place if all goes well um nurses that are specifically trained and deemed competent um are you can get trained to DC pacing wires uh the chest tubes will watch and monitor for the drainage characteristics and the eyes and O's and we'll keep track hopefully the volume slowly decreases we definitely don't want it to increase too much and we want it it really pay attention to the color nothing should be super bright red especially a few hours after the surgery we'll do a very close look on Vital Signs especially temperature and any signs of compensatory mechanisms we'll look for signs and signs and symptoms of bleeding good neuro checks uh we'll do a thorough cardiovascular exam uh we'll make sure that we look at peripheral pulses listen very carefully to heart tones and examine the EKG Rhythm I already mentioned the posttop priorities are going to be weaning them from the mechanical ventilator getting them up and moving as much as possible avoiding any additional complications we're really concerned over things like atelectasis so we'll start them on incen topometry and in order for them to do that we have to assist the patient in getting a handle on pain control now let's talk about transmyocardial revascularization in TMR they use a high energy laser to create channels from the epicardial surface into the left ventricular chamber the goal is just like with cabbage to increase profusion to the heart muscle relief of symptoms occurs over time uh this can be done as an alternative for patients that are just not candidates for cabbage or poor candidates for cabbage and the clinical trials still are showing mixed results but at least it's an attempt to get revascularization for folks that are just not going to be able to have a cabbage and then enhanced external counter puls pulsation if youall want to have a little giggle take a look at this video and kind of fast forward until you can kind of see uh the in inflation of the actual cuffs it's actually pretty fun to watch uh this is a treatment for Ango when the patient again is not a candidate for bipass surgery and so the Cuffs go around the legs and they the inflation sinks to the patient's heart rate the intent is to increase arterial blood flow and it times with diast so that sequential pressure gets like that forward movement of blood flow hopefully the hope is to increase profusion back to The myocardium there's no definite data that it's actually going to reduce es schia but treatment does tend to show improved symptoms of angena and improved quality of life it takes a patient commitment there's usually going to be like 30 I think it's 35 treatments so they have to keep coming by daily to have the treatments done and now let's talk about different management strategies or treatment strategies for persistent dmas we're going to talk about radio frequency catheter abolition you've heard me use the term abolition before um overdrive pace makers or permanent pacemakers and then implantable implantable cardiovert defibrillators we'll talk about all these the first is radio frequency catheter abolition you've heard me heard the here you've heard me say the term abolition before an electrophysiologist will perform the study and this is typically done for supraventricular tardia um when we did our drimia you've heard me say there's a circuit re-entry phenomena where it's the same series of cells that just keep firing and firing so we don't want to let anybody sit as super ventricular Tac of cardia those are heart rates of 151 or greater um you know what the potential sequella are in the cardiac output's not going to be uh holding on for much longer and of course that increases myio cardial oxygen Di and which could also end up in an MI or extending an existing Mi so there's lots of many reasons we don't love patient sitting in an SVT Rhythm U so what the electrophysiologist will do is they'll introduce the catheter and using radio frequency they'll go in there and they're going to zap and interrup interrupt that electrical conductivity in that area that is behaving badly if you will just an illustration the electrophysiologist will introduce a catheter there they will Target the area that they believe is the cause for the SVT and they'll go in they'll zap that area and hopefully that'll stop the SVT episodes from happening moving on to Temporary and or permanent pacemakers temporary could be we put external pads on the patient or will the the doc will insert pacing wires and there'll be a little box external to that that we can control u based on whatever settings the doctor orders uh permanent will be they'll make a little sleeve usually the left upper chest and they'll tunnel the wires over so you'll see that little bulge from the small um size of the pacemaker and so the Pacers could be set by rate um will set voltage and sensitivity um then there's other settings that can occur what's important to note is the settings um are tailored to the patient they'll determine you know capabilities while the patient is is under anesthesia they're they could do these Al They insert these usually in the card in the cath lab they don't necessarily have to go to the Opera room anymore they'll have the rep there they'll have their device and they'll check all sorts of things from The myocardium they'll change uh the S the sensitivity the voltage and what they tend to do is the surgeon will implant the Pacers they'll place the wires in the the optimal locations that will take the least amount of voltage to establish capture uh and getting result depolarization from The myocardium you can have two wires where the both the Atria and then the ventricles will be paced um or you can have either or you can have a single wire that goes only into one Atria you can have two wires one in each Atria two wires one in each ventricle four wires one in every chamber or one in one Atria one in The ventricle so there's quite a variety and um it depends on what the issue is with the patient again these the wires are generally they're threaded in transvenously and then if they're going to have a permanent pacemaker they will tunnel the wires across the chest and they usually will make a little pouch underneath the skin for the Pacer and then they'll suture that shut the inter Society commission for heart disease or ichd they developed kind of a a code that describes which chamber is being paced the chamber that's being sensed and how the Pacer responds to sensing so it's like a recipe card that basically you can see um which P which chamber's being paced and you don't have to memorize that but just be aware that there's so many different settings and approaches um and the ICD is the one that that determines how to code and categorize the different modes that being used and this illustrates one of the examples that I gave so you've got a permanent Pacer this has been there's a little pouch this goes under the patient's skin the wires were threaded Venus transvenously and in this instance you've got four wires so you've got the atrial lead and then actually you've got Oneal lead here and then you've got two ventricular here's one going to the right ventricle here's one going to the left ventri ventricle now I want you to pay attention to the ventricular wire on the right ventricle look where the very end of the wire is connecting it's making contact at the Apex so in lead two the view is going to come from this area way down here looking in this direction okay so if the ventricular Pacer is the Pacer wire when it fires the conduction is going to start the apex of the heart so keep that in mind then it's going to start the depolarization wave traveling up in this direction go ahead and pause this video and think about what that's going to look like in lead 2 here are some examples about what paast rhythms should look like at the top you've got the patient own intrinsic rate for the Atria intrinsic beat so the SA node has fired here is the depolarization weight for for the atrial now you've got a Pacer Spike right in front of the QRS so that means this is a ventricular Pacer it's only got the wire in the ventrical fired and this is an example like the one in the previous slide where I said the Pacer wire is making contact in The ventricle way far down in the Apex so when it makes contact that deep down what's going to happen is it fires and then the depolarization wave is going to travel away from the positive side of lead 2 so you'll see an negative deflection and because this is cellto cell depolarization it's not following the right and the left bundle branches not following the super freeway so it's going to be slower so the QRS is going to be very wide and then same same happens again and again and again this Pacer this patient is 100% paced moving to the example below this patient has an AV or both an atrial and a ventricular Pacer here is the Atria the atrial Pacer Spike and then thankfully the Atria depolarized as a result and then now you've got the ventricular Pacer Spike and then here you've got that wide QRS that's the ventric the ventricles depolarizing as a result and then the next beat oh wait a minute look it's the patient's own intrinsic rate and then there's like a SM slight delay and so then the Pacer decides to fire again Pacer fires again and then here you got the the patient intrinsic beat so there you got a past Rhythm right here well wait a minute why is this happening the Pacer is not firing every single time well sometimes a Pacer could be set for example that it's not going to fire unless the patient's own intrinsic rate Falls below a certain certain certain threshold and that might be for example 60 so say the cardiologist says okay your Pacer's there but if your own intrinsic heart rate is at least 60 or greater the Pacer has no reason to fire so that means that there should the Pacer is going to sense that the the P patient should be firing its own their own beat at least one every six seconds or I'm sorry one every second sorry I almost I was thinking about respiratory rate for a second so if the patient's heart rate threshold is 60 then that means that every second the patient needs to show their own intrinsic beat if there's a delay of more than 1 second the Pacer is going to say ah took too long and then that that's what's going to cause the Pacer to fire so in this case the patient is not 100% paced and the telemetry tech can guess more or less what percentage that might be moving on to implantable cardioverter defibrillators or icds you might also see them called a icds the a stands for automated these are now they're implanted they look like little pacemakers or they could be an additional feature to a traditional Pacer like the one we just described and this is exactly what it means it's a defibrillator that's ready to fire if for some reason uh the patient is at high risk for having lethal dysmas so these icds are used to treat survivors of sudden Cardiac Arrest sudden Cardiac Arrest meaning that it's usually caused by something like vac that eventually uh dwindled to viib um so they deliver a high energy shock to defibrillate the patient when it senses that they're in one of those lethal rhythms the patient needs a lot of Education um and they will need to be card holding members or card carrying members they should also wear a Medic Alert bracelet as well even if the patient did not need a Pacer before and this is strictly an ICD function the icds have a pace function in case after they shock the patient the patient needs to if the the ICD senses that the patient needs to be paced um it can serve in that function indications for ICD therapy are listed in box 13-10 these are implanted by electrophysiologists big portion of the patient education is going to be that you do not want um to be with near large magnets I'm not sure what the current guidelines are as far as getting MRIs my suspicion is that hopefully it's not the ma it's not the magnetic properties it's the fact that these are reset and the settings are adjusted using a magnet so that would be catastrophic if they have a big magnet and it changes the settings causes potentially the system to malfunction you've already had content on heart failure in complex one so you'll review these next nine slides that are all in purple on your own again review on your own not sure have you covered BNP in complex one so as a quick review brain natural uretic peptide BNP it's a cardiac hormone that's secreted whenever the ventricular cells or the myocytes since that stretch so the higher the value the bigger the stretch the bigger the stretch the more the volume that's in the M the U Chambers so it's a direct reflection of um heart failure because the bigger the chambers get from stretch from fluid overload the higher the BNP will Mark will rise and the normal BNP value is 100 and that's picograms per milliliter again take a moment to review the assessment review diagnostic findings most of these should also be reviewed from last semester but take a moment at some of the medications they're listed in red those are coming from the list of the most frequently listed meds on the inlex as you look at the different categories of the medications and the treatment of heart failure make sure that you Target and understand what it is exactly that we're trying to fix or address with the heart failure patient so diuretic a Inhibitors uh arbs beta blocker xot tropes and then you've got the Arn I which is it's a combination of anenson receptive blockers plus an ayin inhibitor the benefits being is that the relaxation of the blood vessels is going to reduce blood pressure and then uh there's going to be an increase in the body's ability to increase sodium in water which is going to decrease overall fluid status and then hopefully there's going to be an increase in contractility or the harps pumping function by increasing the natur Ric peptides and then finally the SGL t2s Inhibitors they inhibit reabsorption of glucose and sodium in the kidneys which is also going to lead to increase urine output so decrease overall fluid volume status in the heart failure patient M sah citrate IV can also be used for acute decompensation of the heart failure patient it mimics uh B type natural uretic peptide or BNP so that's going to help relax blood vessels increase blood flow and then reduce overall pressure uh cardiopulmonary wise let's talk about ways to reduce cardiac workload we'll talk about an anerotic balloon pump or just we just call it a balloon pump mechanical circulatory support devices mcsds biventricular pacing and then other nursing interventions that we can do uh that impact rest and activity and then cardiac rehab our primary goal for heart failure is going to be optimization of gas exchange so the interventions will Target Airway assessment um assessing the degree of their respiratory stress if that's present we'll position them semi because it's going to help um B basically promote gas exchange by lung expansion if they need supplemental oxygen we'll be prepared to do that they may require CPAP as well um you can anticipate orders to administer medications for diuresis and our goals are going to be our interventions are also going to Target controlling sodium and hopefully not fluid retention we will be doing daily weights because that's one of the the best ways to gauge um fluid retention and effectiveness of diuresis and then VTE prophylaxis DVT can potentially impact perfusion by a couple of different ways first of all it's going to stop blood flow which is going to stop impact also on the arterial side and then prolong venostasis will just add to congestion and increased pressure which also will impact perfusion as well perfusion meaning um delivery of oxygen and that's GNA potentially impact when we return blood flow back to through the right side of the heart to the pulmonary vasculature and we're not going to optimize gas exchange so I guess a short story is VTE prophylaxis dead feedback into gas exchange Mr T had his cabbage it was difficult to get him weaned from the B the bypass machine so a decision was made to insert an intraaortic balloon p pum or an iabp why was the iabp inserted and what are some related nursing interventions ABP was used to reduce cardiac workload it can be very helpful in the recovery of of cardiac surgery patients who have had hemodynamic compromise especially when trying to be removed from the bypass machine so we want to make sure that uh we keep the patient's leg immobile the insertion site for the balloon pump Cal um they will stay poniz to make sure that we prevent VTE and we'll have to gingerly check um distal pulses uh distal to the insertion site of the balloon pump catheter we'll be monitoring Vital Signs very closely and then any nurse that's um been that's been trained with taking care of patients with balloon pumps will know how to check certain parameters on the balloon pump itself to make sure that it's cycling a accordingly um and we'll make adjustments according to the doctor's orders thankfully Mr T only required the balloon pump for 24 hours and then it was weaned and removed the remainder of his posttop course was uneventful and he was discharged home 6 days after surgery so let's discuss his discharge teaching needs he's going to need to follow up with a surgeon and cardiologist he's going to uh make sure that we need to make sure that he understands his new medication regimen that he's following proper diet and lifestyle lifestyle changes he's not going to be able to jump back into normal activity right away and needs to keep his statins going to keep his LDL below 100 needs good nutrition and watch his incision sites and during the recovery phase mechanical circulatory support we're going to that um going to talk about these are temporary devices to reduce cardiac workload as we mentioned before increase profusion and at the end of the day to support end organ function we mentioned iabp or balloon pump and then we're going to also talk about uh extra Corporal life support or ecls these are examples of temporary mechanical circulatory support types uh this is an impella and then there's a heart mate to so these patients basically have a catheter that's inserted and and it's an assisant device so it travels all the way up to close to the aorta you got the outflow and the inflow sides and it's helping to propel blood flow forward out from the left ventricle so it's helping the left ventricle and the pump is external to the patient so they wear like a it's like a little bag or um a sash if you will almost like a satchel and they carry their pump wherever they go they will perform they're taught to perform their own dressing changes is a much larger device uh these patient this is done only on an inpatient basis so the catheter is inserted usually through the groin and it's a big catheter you kind of see here it's threaded up and it sits right after the aortic Arch and the way that it works is it's helping to propel blood forward so during syy the left ventricle is Contracting and ejection ejecting oxygenated blood into the aortic Arch the balloon pump is then cycled so that when blood flow gets to about the area of where the balloon P the balloon is sitting then it will inflate to help kind of push and Propel that blood forward it's almost like an extra ventricle it's called counter pulsation extra corporeal life support there's a couple of different types uh first the venovenous or the VV uh it's canulation that tends to lean towards more of respiratory support used for hypoxic hypercapnic respiratory failure for very severe pulmonary emilii uh ventilatory support that's needed for cardiac transplant um the other method is Veno arterial or VA and that is used most often for heart related or card uh issues like cardiogenic shock cardiac arrest in settings where uh cardiopulmonary bypass can't be weaned off after cardiac surgery um ecls is going to be indicate contraindicated in people that have irreversible brain injuries untreatable metastatic cancers uncontrol bleeding those are big canulas that are going in or if there's not going to be any additional bridging options available and U prog prognosis to come off that support is very very low um so if for example this is intended to be a place hard uh card holder and and uh the patient was hoping to get cardiac transplantation but they're not a candidate uh then it would be contraindicated to start them on ecls altogether they can't stay on this treatment strategy in definitely some heart failure patients are going to need long-term mechanical circulatory support or MCS patients that have way Advanced heart failure and or cardiogenic shock uh they're going to need something to help assist ventricular function the the shortage of organ donors and the increase in heart failure incidents is going to and the has really increased demand for MCS and it's interesting to see just in the last 5 years how the number of patients that have MCS devices out in the community has really just escalated um the long-term therapy was previously known as destination therapy so they were it's used for patients who require long-term support the heart failure is not going to get better it's chronic and it hasn't basically responded it's refractory to Medical therapy and these patients are not going to be candidates for heart transplant and again this is an example of an MCS this is a heartmate 3 the patient wears the pump the device is external to the patient and they learn how to perform their dressing changes they come in only if there's complications these are all going to be review as well you had this in complex one the complications for heart failure include par pulmonary edema and cardiogenic shock and we're going to talk extensively about shock syndromes in an upcoming lecture as well the patients will be dnic they'll be cyanotic um the the term gurgles is really not the greatest way to describe it but we're talking about ranai and adventitious breath sounds they will exhibit pink froy sputum and refractory hypoxemia pulmonary edema is considered a life-threatening emergency because what's happening is the pulmonary vascular system is becoming absolutely full and engorged so what's happening is increasing volume and the pressure in the pulmonary vessels increasing pressure in the pulmonary capillaries which causes Le leing into the interstitial spaces of the lung they are classic symptoms listed so we're going to need to really rapidly administer diuretics along with supporting oxygenation uh we'll use Nitro and we're going to titrate that until the blood pressure is under control so that's going to reduce both pre-load and after load so we're reducing the volume coming in at the heart and reducing the workload of the heart because decreasing uh what what the ventricles are having to push against the patients that don't demonstrate an improvement and symptoms they're going to need a little bit more aggressive treatment so usually we'll start nitroglycerin at 10 to 20 mics per minute and we might have to TI titrate an increments of 10 mics per minute every 3 to five minutes depending on what the response is the max dose there is a maxos for Nitro we don't want to go above 200 mics per minute that's pretty darn High then cardiogenic shock um is the most ominous and acute form of pump failure and you can see that after a severe Mi you know we got got a big uh Mi with an a kinetic wall um that's going to result in a decreased contractility decreased stroke volume and an impact on cardiac output you'll also see dysrhythmias decompensated heart failure potentially a pulmonary embolis cardiac tampon you can even see a ruptured abdominal um aortic aneurysm that causes uh cardiogenic shock unfortunately the typical outcome for cardiogenic shock is death um we may have to assist with placement of mechanical devices such as a balloon pump or a vad vad when L else fails patients are worked up for a heart transplant and these are typical qualifications for heart transplant age less than 70 and Stage heart disease not treatable by other way means the criteria for medical urgency is used to classify patients as to who comes to the front of the line and then after transplant the management has to focus on optimizing heart function so you need to that patients need to go through an interview process to make sure that they have the support that they're going to need to be to have a successful organ transplant outcome infection tends to be the leading cause of morbidity and mortality after transplant so they have to be able to be um healthy enough to sus to survive the surgery and of course to be able to take care of themselves afterwards immunosuppressive medications are going to be absolutely critical to re re reduce the risk of rejection unfortunately that then increases the likelihood of infection so lifestyle modifications are going to have to uh be reviewed extensively with the patients moving on to inflammatory heart diseases pericarditis and infective endocarditis pericarditis is inflammation of the paric cardium it can be acute or chronic it can happen as a consequence of acute MI or it can happen secondary to kidney injury because of ureic pericarditis uh there there's infection radiation therapy and connective tissue diseases can that can also predispose patients to develop pericarditis the inflammation can result in cardiac tampones tanod so basically um the pressure increases Around The myocardium which deems contractility ineffective and can cause cardiovascular collapse uh there are classic EKG changes specifically Global St elevation in almost every single lead if not all leads um and then that classic chest pain P is typically described as sharp stabbing or piercing and it could radiate similar to an acute MI but it differs from Mi pain Mi is more pressure and dull whereas again pericarditis is sharp and stabbing infective endocarditis happens when microorganisms that are circulating in the bloodstream then attach on the endocardial surface it can be caused by microbes and then frequently involves the heart valves that can lead to valve dysfunction so we're going to observe osculate and listen be vigilant for the development of a new murmur so we tied pericarditis potentially after an MI could be related to uremia could be related to cancers and then it can lead to infusion and effusion tonot and scarring the patient with pericarditis typically has precordial pain other signs of pericarditis could be the new development of a paracardial friction rub uh patients pling of dmia weakness fatigue they may have a persistent temperature elevation and a bump in their white count and said rate as well as an increase in overall anxiety and uh a few things that I I forgot to mention in the previous slide um set this could also develop as bacterial or a fungal um issue or and infection and also as a result of trauma so here are the hmark marks paracardial friction rub a pulsus paradoxus which is basically during the respiratory cycle there is a natural flux of pressure in blood pressure um so your systolic blood pressure will naturally increase and decrease just by the mirror um changes in intrathoracic pressure usually the difference based on respiratory cycle or the state of the respiratory cycle is less than 10 millim of mercury in other words uh me just sitting here talking um while I'm just you know talking about the slides and not doing a whole bunch of activity my systolic blood pressure while I'm inhaling and exhaling it will change but it should change by no more than 10 millim of mercury pulses paradoxus means that there is a larger drop in blood pressure based on intrathoracic pressure so we've talked a lot about how that can how um intrathoracic pressure could influence cardiac output uh temporarily and how that would how you would be able to see that potentially um in your Vital Signs and again pulses paradoxes is that that flux is greater than 10 mm of mercury based on the respiratory cycle so now you know how to tailor your assessment our goals are going to be um if it's it's an infection that's suspected we're going to be administering Med um antibiotics uh the goals are going to be also to relieve pain uh the the providers may want to do something called a paracardial synthesis or a paracardial window so they're going to go in there and remove some of the inflammation some of the fluid if there's excess in there and uh if they leave a drain in then or they leave a little slit so that the whatever it is that's in there whether it's fluid or blood probably fluid um that it can continue to drain it's not completely open to air of course it's going to be open probably with a little um Sack or something to protect it from the environment but the window basically means is that they're leaving a slit open because they're expecting that the the in infectious state is going to continue for a little bit an infective endocarditis happens when microorganisms that are circulating in the bloodstream they attach onto an endocardial surface it's classified as one of three types it's either native valve endocarditis or nve that can be either acute or Subacute you can have a prosthetic valve endocarditis or PVE that can be either early or late and then intervenous drug abuse or ivda um some conditions increase the risk of developing endocarditis uh implantation of an artificial or prosthetic heart valve a history of previous endocarditis heart valves that are damaged by things such as rheumatic fever congenital heart defects or valve defects um infectious lesions those are referred to as vegetation if you see that term that's what what they mean that they're forming on the heart vves uh the vegetative process can grow to involve the cordio Tandon the papillary muscles and the conduction system so the patient could have dymas or acute heart failure because the cordat tendon and the papillary muscles are impacted the clinical presentation of patients that have acute infectious endocarditis includes high fever shaking chills other manifestations include night sweats cough weight loss General malays weakness fatigue headache muscular skeletal complaints then uh they have presence of new murmurs and other symptoms of heart failure there are some skin abnormalities that are associated with septic emilii these are janway lesions uh they're all they're typically hemorrhagic and they are on the palms and the soles and then um Osler nodes that can be red purple lesions that are going to be on the fingers or the toes there's also splinter hemorrhages that look like little vertical um hemorrhages on the nail beds and uh rth spots which of course we wouldn't see because they're retinal hem hemorrhages so the skin lesions are referred to as the peripheral Stig Stigmata of endocarditis Janeway lesions are typically not painful while Osler nodes are diagnosis is going to be done using a echocardiogram and that can also be trans esophageal or te and the treatment is going to be trying to diagnos the infective infective agent and then treating with the targeted appropriate IV antibiotics for four to six weeks so it's a long haul and then valve replacement surgery might be indicated for real severe cases and so patients are going to have to have um prevention strategies or prophylactic antibiotics before they visit the dentist or do anything where bacteria could be introduced into the the bloodstream such as with um oral basically um trips to the dentist excuse me um and those patients are at risk that have heart valve issues heart valve Replacements a history of endocarditis or they have microvascular pressure with regurgitation means there's increased pressure in the tiny or blood vessel or the microvascular because of a failing or leaking heart valve that causes the blood to flow backwards that's a regurge and this will be the last um disorder that we talk about Marfan syndrome it's um the most one of the most common inherited disorders that affects connective tissue it results from a mutation in Gene fbn1 and so um it's thought to be the result of structural abnormalities oric specifically disregulation of transforming growth factor B signaling the disease includes many different features you'll see here um anything ranging for my problems the next slide I'll talk a little bit more about that abnormal chest uh potential lung problems as well they'll have a short torso and then a tall thin body frame long long arms legs and fingers as the disease progresses in severity you'll start to see some of these changes um if you want to see like a 4-minute very interesting video there is um a college basketball player in 1990 Hank Gathers they have a nice summary of what happened and he had Marfan syndrome but if you watch this clip right here it'll talk about that here's the presentation of what a typical patient might see look like skeletal wise they'll have a very tall stature uh there'll be joint hypermobility they might have scoliosis um they'll have a sternum deformity this is Pectus excavatum but it could actually be both ways protruding or indented they'll have flat feet cardiovascular wise they could have aortic root dilation mitrov valve prolapse and aortic dissection and then they could also have a complicated um cardiac picture if they have mitro valve prolapse uh remember from your lectures from complex one some of the potential effects on The myocardium in general the skin they have stri they had rapid growth so they have that skin uh stretch marks if you will and they'll have skin elasticity defects on the ocular side they'll have glycom glaucoma and nearsightedness or myopia so the treatment is going to be tailored specific to the disease manifestation so you know they don't do a whole lot for like the tall stature um they might do pt for joint hypermobility and and scoliosis um if they have significant breathing problems or thoracic function problems because of the PEX PEX uh pectusexcavatum uh that would me that would be in extreme cases cardiovascular wise um if the aortic root is dilated so much so that they're concerned uh they might do something similar like they would for a an aneurysm repair uh mitro valve prolapse again you you potentially have a replacement so again they're they're looking specifically to the manifestations of the disease and that concludes this slide deck