CV Procedures, Cardiac Catheterization

CV Procedures

• CV procedures fall under an open and percutaneous & endoscopic approach
• Open: Sternotomy, Thoracotomy, Thoracoabdominal, Abdominal
• Percutaneous & Endoscopic: small puncture holes in the skin, less invasive “non-surgical", "Closed" approach, and very small incisions which results in less recovery time
• Approaches used are based on the type of procedure, risk factors, and surgeon preference

Cardiac Catheterization

• Cardiac catheterization is used to evaluate or confirm presence of CAD, valve disease or disease of the aorta
• It determines need for treatment
• A catheter is inserted through introducer into a blood vessel, usually the groin/femoral artery
• Contrast dye is injected, and X-rays are taken as it moves through the chambers and valves

Interventional Procedures

• A non-surgical procedure opens narrowed coronary arteries and improves blood flow
• May be performed during diagnostic cardiac cath or after (performed via catheterization)
• Includes Percutaneous Transluminal Coronary Angioplasty (PTCA) / Percutaneous Coronary Intervention (PCI), Atherectomy, Stents, Bare Metal Stents, and Drug Eluting Stents

Percutaneous Transluminal Coronary Angioplasty (PTCA) or PCI

• Also known as balloon angioplasty and Percutaneous Coronary Intervention(PCI)
• With balloon inflation, fatty plaque is compressed against artery walls
• Widens blood vessel diameter, increasing blood flow to the heart
• Potential complications include vessel recoil

Stents – Bare-Metal (BMS)

• Small wire mesh tube helps prop the artery open and decreases narrowing
• It's often combined with angioplasty
• Patients take anti-clotting medications to avoid thrombosis/restenosis
• In-stent restenosis can still occur in over 20% of patients after stent placement

Drug Eluting Stents (DES)

• Medication on stents inhibits or prevents tissue growth
• Zotarolimus- and Everolimus-eluting stents (ZES, EES)
• Markedly reduces the rate of re-narrowing
• About 1 in 10 patients develops re-narrowing in the several years after drug-eluting stent implantation, a rate about half of bare-metal stents
• Anti-platelet therapy in conjunction with DES has been found to reduce restenosis

Atherectomy

• Percutaneous Transluminal Rotational or Directional Atherectomy is a plaque removal
• Special catheter with acorn shaped, diamond coated tip spins at high speeds
• It grinds away plaque on arterial walls
• Restenosis and acute complications are common

Brachytherapy

• It involves intracoronary radiation therapy
• Decreases rate of in-stent restenosis caused by tissue growth
• Radiation therapy is aimed at restenosis and treats existing restenosis and prevent further restenosis

Heart Valve Percutaneous Interventions

• Transcatheter Aortic Valve Replacement (TAVR)
  • Also known as Transcatheter Aortic Valve Implantation (TAVI)
  • Transcatheter Pulmonary Valve Implantations also occur
• This was recently FDA Approved and is performed on a beating heart
• Select patients with severe Aortic Stenosis or Pulmonary Valve Congenital Defects who are not candidates for traditional open chest or are high risk qualify for this procedure
• It uses a bovine and metal stent
• Transfemoral and Investigational Transapical approaches are used

Activity Guidelines & PT Considerations post PCI

• Generally, uncomplicated PCI patients are discharged from hospital after 24 hours
• Aerobic and resistance training can begin almost immediately, as long as the catheter site is healed or specific precautions/guidelines from the team are followed
• May progress more rapidly if there is no myocardial damage or little inactivity pre and post procedure
• Watch for recurrence of ischemic signs & symptoms

(Endovascular) Aneurysm Repair

• Refer to video examples to illustrate each procedure

Open Approach to Aneurysm Repair

• Sternotomy is the most frequently used incision for open heart surgery
• This used a saw or curved blade to open the chest
• A retractor is used to expand view

Surgeries via Sternotomy

• Cardiac surgeries: CABG (coronary artery bypass graft), valve (repair & replacement), aneurysm repair, ventricular assist devices, transplant

Activity Guidelines and PT Implications

• Avoid lifting heavy objects
• Avoid bilateral overhead activities or unilateral ROM if pain; ROM IS recommended to avoid adhesions
• Avoid pushing or pulling heavy objects
• Avoid sports and driving
• Avoid repetitive or sustained arm movements
• Sternal Click/Sternal Instability requires referring to articles on Brightspace for alternatives to traditional sternal precautions
• Splint when coughing

Coronary Artery Bypass Graft

• Blocked/Clogged coronary arteries are "bypassed"
• Revascularizes the myocardium
• Frequently uses Internal Mammary Artery (IMA), Saphenous Vein (SVG), Radial Artery
• Up to 5 vessels may be bypassed

Grafts

• Internal Mammary Arteries (IMA): most commonly used with best long-term results
• Radial Artery: Is also common
• Saphenous Vein (SVG): Minimally invasive surgery to harvest grafts
• Gastroepiploic Artery to stomach & Inferior Epigastric Artery to abdominal wall less commonly used

Heart-Lung Machine

• On-Pump Surgery performs the work of the heart & lungs, while they are stopped to allow work on a “still" heart
• Off-Pump surgery is surgery is performed where the heart remains beating

Considerations After CABG Surgery

• The heart starts beating on its own
• Temporary Pacing Wires are required
• Mediastinal Chest Tube
• Sternal Wires
• Patient intubated
• ICU monitoring for 1-2 days
• Mobilization as early as 24-48 hours post operation
• Aerobic training occurs within 20-25 bpm of Resting HR (NYP); 30 (ACSM)

Valve Surgeries

• Valve repair options include commissurotomy, decalcification, triangular resection, annulus support, and patched leaflets
• Valve replacement should be considered if repair is not an option
• The types of valves are tissue (human or animal) and mechanical
• Types of mechanical valves are durable but require the use of lifelong anticoagulants; tissue valves have a lifespan up to 10 years, now extending

Activity After Valve Surgery

• Generally same guidelines as post-CABG
• However, these patients may have had greater prior activity restrictions or longer periods of symptoms
• Valve surgery patients MAY require starting at a lower functional level with slower progression

Aortic Arch Aneurysm Repair

• Refer to video examples in notes

Left Ventricular Assist Device

• LVAD does the work of the Left ventricle and helps left ventricle pump blood to the aorta
• Allows for resumption of ADLs and exercise
• LVAD is Indicated when there is Severe hemodynamic compromise despite medication & other interventions, as a Bridge to transplant, until the heart is able to pump effectively or during surgery, or for Long term treatment
  • Has been nicknamed ("Destination therapy")
• Right Ventricluar Assist devices and Bilateral Ventricular Assist devices also exist

PT Considerations for LVAD

• Sternal Precautions Apply
• Patients are usually severely deconditioned & weak with prolonged hospitalizations
• Patients are often non-pulsatile (Heartmate II LVAD or Heartmate 3 or Centrimag or ...)
  • The Mean Arterial Pressure (MAP) must be used https://www.youtube.com/watch?v=5SPrFP9GTOM
• Need Borg scale to monitor level of exertion (NYP 11, others 13-14)
• Patients get "dry" and need to drink water, especially prior to exercise, to maintain CO
• Watch out for the driveline, sutured in, and patients may wear an abdominal binder
  • Can't get wet
• Batteries last 10 hours.

Heart Transplant

• There is an obvious shortage of donors, which requires an extensive matching process
• Patients are given Massive anti rejection drugs
• PPM may placed during surgery
• Heterotopic "piggyback" or Orthotopic "switcheroo” which is More common are the two main types

Heart Transplant PT Considerations

• Increased 1 and 3 year survival rates to 86% and 80% respectively
• Biggest risk is rejection
• Problems Include: Exercise Intolerance, Loss of muscle mass and strength, Decreased or diminished autonomic cardiac innervation
• Side effects of immunosuppressive medication: Dyslipidemia, HTN, obesity, diabetes
• Patients have a Delayed Response To Exercise; in response to sub-maximal exercise CO increase is achieved by increase in SV, not HR; At higher work rates, myocardium responds with tachycardia
• Post exercise HR remains elevated for longer period because of lack of parasympathetic innervation
• Use RPE or dyspnea as guidelines
• Longer periods of warm-up and cool-down
• Progressive aerobic exercise
• Long term resistive exercise
• Monitor BP, side effects of meds, signs of exercise intolerance, signaling rejection

Thoracotomy

• Approach used for lung surgery and Aneurysm repair
• Could be Lateral, Anter-Lateral, Postero-Lateral, and Axillary
• Between the ribs with muscle sparing

Video Assisted Thoracoscopy

– VATS is “minimally invasive" and used for "smaller" lung surgeries

• Similar concept as done with joints which allows for Faster recovery time

Thoracoabdominal Approach

• It Enhances visualization of thoracic and abdominal area such as from TAA to AAA
• Requires a large incision
• Patients are often considered “sawed in half"
• Recovery involves increase in pain with movement and coughing which requires getting in fast

Open AAA Repair

• Refer to video examples

PT Considerations Post Thoracotomy and Thoracoabdominal Approaches

• Shoulder and Trunk ROM should be included
• Deep Breathing Exercises
• Incentive Spirometry
• Splinted Coughing
• Functional Mobility is key

Endarterectomy

• A surgical procedure where a blockage is removed from an artery
• Carotid endarterectomy videos:
• Can be done open or endovascularly

Vascular Bypass

• Common procedure for PAD is the Vascular Bypass
• Saphenous vein handles ~10% venous return
• SVG is also harvested for CABG
• Bypass grafts are named for where it is being bypassed to
• The Fem-pop and aorto-bifemoral are examples of Vascular Bylass

Pacemaker

• Permanent Pacemaker (PPM) creates an artificial action potential to maintain a suitable HR or stimulate ventricles
• May be used to treat syncope, CHF or hypertrophic cardiomyopathy
• May have leads or be leadless, which may result in fewer precautions

Automatic Implantable Cardioverter Defibrillator

• AICD/ICD is place similarly to PPM
• It May Pace and Defibrillate
• Detects Vtach and/or Vfib and delivers a "shock"
• Tries to "reset" the conduction system with an Endocardial lead attached to inside of the heart

PPM and AICD Activity Guidelines

• Limited UE ROM immediately post implantation, patient may be in a sling for 1-2 days
  • This may ve modified or not relevant if the device is leadless
• Limited UE ROM above shoulder for first 2 weeks, which may also not ne relevant if device is leadless
• Use Borg Scale, Monitor systolic BP, and Extended warm-up and cool-down
• Closely monitor for safe exercise and Know limits and cutoff rates so that patient doesn't receive shocks at high HRs