1. Medical – Surgical Department
Master Program
2013-2014
CARDIAC SURGERY
( NUR 552 )
Presented by : AlJuhara AlMarzoog

2. Outlines
* History of cardiac surgery .
* Purpose of surgery .
* Who is at risk ?
* Surgical approaches .
* Types and techniques .
* Is your patient ready ?
* What is expected during post - op phase ( ASA
P OF S IONALNUR E)
R ES
S
* Potential complications of cardiac surgery and nursing
management ( CR
ITICALTH ING E E CIS )
INK
XR E

3. History of cardiac Surgery
*( Ludwig Rehn , Germany 1896 ) the first successful
repair of a stab wound to RV .
*( Theodore Tuffier , Paris 1912 ) surgery on the
aortic valve .
* ( Elliot Cutter , Boston 1923 ) surgery on the mitral
valve .
* ( Alfred Blalock , Baltimore 1945 ) systemic
pulmonary shunt for blue babies .
* ( John Lewis , Minnesota 1952 ) closure of arterial

4. History of cardiac Surgery
* ( Charles Hufnagel , Georgetown 1952 ) valve
substitute implantation .
* ( John Gibbon , Boston 1953 ) open heart
operation .
* ( Ake Senning , Sweden 1959 ) totally implanted
pacemaker .
* ( Michael DeBakey , Huston 1964 ) successful
CABG .

6. Purpose of surgery
* Revascularization , e.g. CABG .
* Correct congenital defects , e.g. ASD closure .
* Treat valvular disorders , e.g. MVR .
* Heart transplantation .
* Treatment of cardiac arrhythmias , e.g. Cox maze
procedure .
* Removal of cardiac tumors , e.g. Robotically
assisted surgery .

7. W is at risk ?
ho
* Elderly .
* Diabetic patients .
* Patients with COPD .
* Patients with ESRD .
* Reoperative patients .
* Concomitant PVD .
* Poor LV function .

8. Surgical Approaches
1- Open – Heart Surgery : thoracic cavity is opened to
expose the heart and the blood is recirculated and
oxygenated through CPB ( heart – lung machine )
e.g. CABG .
2- Off – Pump Heart Surgery : this approach is like
traditional open heart surgery . However , the heart
isn’t stopped , and a CPM isn’t used .
3- Minimally Invasive Heart Surgery : surgeon makes
small incisions in the side of the chest between ribs ,

9. Types & Techniques
I – CABG :
* CAD has been treated by myocardial
revascularization since 1960s , and the most
common CABG techniques have been performed for
more than 35 years .
* CABG is a surgery that increases blood flow to the
heart by creating a detour and re-routing the blood
flow around the blocked portion of the artery .

11. Types & Techniques
I – CABG :
* The major indications for CABG are alleviation of
angina that cannot be controlled with medication or
PCI , treatment of left main coronary artery stenosis
or multivessel CAD , prevention and treatment of MI
or heart failure , treatment for complications from
unsuccessful PCI .

12. Types & Techniques
I – CABG :
* Performed less frequently in women . Compared with
men , women referred for this surgery tend to be
older and have more comorbidities . In addition , they
have a higher risk of surgical complications such as
MI and stroke ( Puskas , Kilgo , Kutner , et al., 2007 )
. Furthermore , women have smaller coronary
arteries , which make the surgical procedure
technically more difficult .

13. Types & Techniques
I – CABG :
* The recommendation for CABG is determined by a
number of factors , including the number of diseased
coronary vessels , the degree of LV dysfunction ,
comorbidities , severity of symptoms and any other
previous treatment . Studies have shown that CABG
may be the preferred treatment for high – risk patients
such as those with sever three vessels CAD ,
ventricular dysfunction and diabetes ( Bravata ,
Gienger , McDonald , et la., 2007 ) . CABG to be
considered if occlusion 70 % approximately especially

14. Types & Techniques
I – CABG :
* Traditional technique : surgeon performs a median
sternotomy and connect patient to CPB machine .
Next , a blood vessel from either saphenous vein or
left/right internal mammary artery is grafted distal to
the coronary artery lesion by passing the obstruction .

17. Types & Techniques
I – CABG :
* Alternative technique : Off – Pump CABG ( OPCAB )
involves a standard median sternotomy incision , but
the surgery performed without CPB , β – blocker
maybe used to slow the heart rate . The surgeon also
used a myocardial stabilization device to hold the site
still for the anastemosis of the bypass graft . Potential
benefits include a decrease in the incidence of stroke
and other neurological complications , renal failure .

19. Types & Techniques
I – CABG :
* Risks vs. Benefits : many benefits such as decrease
in angina , improved life – span , and providing an
effective route for blood with prevention of new
plaques formation . Some complications seen after
surgery are Atrial fibrillation , increased risk for
stroke , and cognitive dysfunction . Some researches
showed less than 2% chance of death , 5% stroke or
other neurological injury , and 20-40% Atrial fibrillation
.

20. Types & Techniques
II – Valve repair and replacement procedures :
* Valvuloplasty : the repair of cardiac valve , most
Valvuloplasty procedures requires general anesthesia
and often CPB . However , some procedures can be
performed in the cardiac catheterization lab . The type
of Valvuloplasty depends on the cause and the type
of valve dysfunction .

21. Types & Techniques
II – Valve repair and replacement procedures :
* Types of Valvuloplasty
1- Commissurotomy : each valve has leaflets , site
where leaflets meet is called commissure , so
Commissurotomy is the procedure performed to
separate the fused leaflets . There is two types open
and closed ( ballon Valvuloplasty ) .

22. Types & Techniques
II – Valve repair and replacement procedures :
* Types of Valvuloplasty
1- Commissurotomy :
a – Clo s e d : do not require CPB , valve not directly
visualized , performed in the OR with the patient
under GA , midsternal incision is made , a small hole
is cut into the heart , and the surgeon's finger or
dilator is used to open the commissure .

24. Types & Techniques
II – Valve repair and replacement procedures :
* Types of Valvuloplasty
1- Commissurotomy :
a – Clo s e d : percutanous balloon Valvuloplasty is the
technique most commonly performed in US . Balloon
Valvuloplasty is beneficial for mitral stenosis in young
patients , for aortic valve stenosis in elderly patients ,
and for patients with complex medical conditions that
place them at high risk for post-op complications .

27. Types & Techniques
II – Valve repair and replacement procedures :
* Types of Valvuloplasty
1- Commissurotomy :
b – O p e n : are performed with direct visualization of the
valve , the patient is under GA , CPB initiated , a
midsternal or left thoracic incision is made , the valve
is exposed and the surgeon uses a scalpel , finger ,
balloon , or dilator to open commissures

28. Types & Techniques
II – Valve repair and replacement procedures :
* Types of Valvuloplasty
2- Annuloplasty : is the repair of the valve annulus ( ie,
junction of the valve leaflets and the muscular heart
wall ) . GA and CPB are required . The procedure
narrows the diameter of the valve’s orifice and is
useful for the treatment of valvular regurgitation .

29. Types & Techniques
II – Valve repair and replacement procedures :
* Types of Valvuloplasty
2- Annuloplasty : there are two techniques . The first
one uses an annuloplasty ring , which may be
preshaped ( rigid / semirigid ) or flexible . The leaflets
of the valves 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 born by the ring rather than by the

30. Types & Techniques
II – Valve repair and replacement procedures :
* Types of Valvuloplasty
2- Annuloplasty : the second technique involves tacking
the valve leaflets to the atrium with sutures or tacking
tucks to tighten the annulus .

32. Types & Techniques
II – Valve repair and replacement procedures :
* Types of Valvuloplasty
3- Leaflet Repair : valve leaflets damage may result
from stretching , shortening , or tearing . The
elongated tissue may folded over onto self and
sutured . A wedge of tissue may be cut from the
middle of the leaflets and the gab suture closed .

33. Types & Techniques
II – Valve repair and replacement procedures :
* Types of Valvuloplasty
4- Chordoplasty : is the repair of Chordae tendineae .
Mitral valve is involved with Chordoplasty , tricuspid
valve seldom requires Chordoplasty .

34. Types & Techniques
II – Valve repair and replacement procedures :
* Valve Replacement : GA and CPB are used ,
procedure performed through median sternotomy .
Two types of valves may be used .

35. Mechanical vs. Tissue valve
Mechanical
1st generation
Tissue
2nd generation
Descriptio Metal or plastic , bileaflet , Biological , most come from pigs
n
ball – and – cage , tilting – ( porcine ) or cows ( bovine ) .
disk design .
Xenografts , homografts,
autografts .
Advantag
es
Most durable , very low
calcification risk ;
therefore , are often used
for younger patients
Disadvant Risk for thromboemboli
ages
,require long tern
anticoagulation , sewing
leaflets has potential to
Eliminate the need of long term
anticoagulation therapy in most
patients , low mortality rate
associated with re-do procedures
Moderate to high calcification
risk , life expectancy improving
but still shorter than former
mechanical valves .

37. Is your patient ready ???

40. Post Operative phase nursing
* Neurologic status : assessment
LOC , pupil size and reaction to light , facial symmetry ,
movement of the extremities , and hands grip strength
.
* Cardiac status :
HR , rhythm , heart sounds , pacemaker status , ABP ,
CVP , hemodynamic parameters ( PAWP , CO ,
cardiac index , systemic and pulmonary vascular

41. Post Operative phase nursing
* Respiratory status : assessment
Chest movement , breath sounds , ventilator settings ,
RR , SaO2 , SpO2 , pleural chest tube drainage , and
ABGs .
* Peripheral vascular status :
Peripheral pulses , color of skin , nail beds , mucosa
lips , earlobes , skin temperature , edema .

42. Post Operative phase nursing
assessment
* Renal function :
Urinary output , urine specific gravity and osmolality .
* Fluid & electrolyte :
I & O , all CO parameters , electrolytes .
* Pain :
Nature , type , duration , response to analgesia .

44. Nursing management of potential
complications of cardiac surgery
* Neurologic complications :
Stroke .
Impaired cerebral circulation .
* Cardiac complications (  CO ) :
Hypovolemia .
Persistent bleeding .
Cardiac tamponade .
Fluid overload .
Hypothermia .

45. Nursing management of potential
complications of cardiac surgery
* Cardiac complications (  CO ) :
Hypertension .
Tachydysrhythmias .
Bradycardias .
Cardiac failure .
MI .

46. Nursing management of potential
complications of cardiac surgery
* Pulmonary complications :
Impaired gas exchange .
* Renal and electrolyte imbalance :
Acute renal failure .
Electrolyte imbalance .
* Other complications :
Hepatic failure .
Infection .

47. Case study
• A 72 year old gentleman is admitted to cardiac
surgery ICU following 4 vessel CABG surgery . On
endotracheal tube , Foley cath , Swan Ganz
catheter , arterial line , mediastinal and plural chest
tubes attached to suction , nasogastric tube . On
assessment his BP 164/88 , O2 saturation 94 % ,
bilateral crackles , K= 2.9 , urine output 25 ml/hr .
* Based on the assessment what is the nursing

48. Case study
* After few minutes his BP drops to 92/60 mmHg , ECG
shows sinus tachycardia , and his cardiac output
decreased .
* W is the most likely reasons for the drop in
hat
BP ?
* W other parameter should be assessed ?
hat
* Describe your interventions for this

49. References
Suzanne C. Smeltzer , et al . 2010 . Brunner & Suddarth's
textbook of Medical – Surgical Nursing 12 th edition , chapter
26 .
Mervyn Singer , Andrew R. Webb , et al. 2009 . Oxford
handbook of critical care 3rd edition , cardiovascular
monitoring section .
Luca M. Bigatello , et al. 2006 . Critical Care Handbook of
Massachusetts General Hospital 4 th edition , chapter 38 .