CABG , ANEURYSM REPAIR, CORRECTION OF CHD

1. CABG, ANEURYSM REPAIR
AND
CORRECTION OF CHD

2. CONTENTS
Anatomy of heart
CABG
oDefinition
oPurpose
oIndications &
Contraindications
oDiagnostic evaluation
oTypes of CABG
oTypes of Graft
oProcedure
oComplications
Aortic Aneurysm
oIndications of surgery
oSurgical management
Correction of CHD
oClassification of CHD
oSurgical management
oNursing management

3. ANATOMY OF THE HEART
• The heart contains 4 chambers
oRight atrium
oRight ventricle
oLeft atrium
oLeft ventricle

4. CABG
• A form of bypass surgery that can create new routes around
narrowed and blocked coronary arteries, permitting increased
blood flow to deliver oxygen and nutrients to the heart muscle.
• CABG surgery is one of the most commonly performed major
operations.

5. PURPOSE
Restore blood flow to the heart
Relieve chest pain and ischemia
Improves the patient’s quality of life
Enables the patient to resume a normal life cycle
Lower the risk of a heart attack

6. INDICATIONS &
CONTRAINDICATIONS
INDICATIONS
 Left main artery disease or
equivalent
 Triple vessel disease
 Abnormal left ventricular function
 Failed PTCA
 Immediately after MI
 Life threatening arrhythmias
caused by a previous MI
 Occlusion of grafts from previous
CABG
CONTRAINDICATIONS
 Aortic valve insufficiency
 Abdominal aortic aneurysm
 Hemorrhagic diseases
 Congenital heart diseases
 Cardiomyopathy
 Severe hypertension
 Uncontrolled arrhythmias
 Pregnancy

7. TYPES OF CABG
 Traditional/on pump Coronary Artery Bypass Grafting: It consists
of the placement of arterial or venous grafts to provide blood
between aorta or other blocked coronary arteries.
 Off-pump Coronary Artery Bypass Grafting (OPCAB): It uses a
median sternotomy to access all coronary vessels. It is performed
on a beating heart (no CPB) using mechanical stabilizers.
 Minimally Invasive Direct Coronary Artery Bypass (MIDCAB): It
offers patients with disease of the LAD & RCA. It requires several
small incisions between ribs or a mini-thoracotomy
 Robotic or Totally Endoscopic Coronary Artery Bypass(TECAB): It
uses a robot in performing CABG surgery. It is done with or
without use of CPB.

8. TYPES OF GRAFT
Internal mammary artery graft – LIMA & RIMA
Radial artery graft
Saphenous vein graft
Right gastro epiploic graft

10. PROCEDURE
• Pt is brought to OT
• Put IV & arterial lines
• Administer analgesics & induction agents
• Et tube is inserted and mechanical ventilation started
• GA is maintained with anesthetic agent such as isoflurane
• Chest is opened via a median sternotomy
• Bypass grafts are harvested
• When harvesting is done, the patient is given heparin to inhibit blood
clotting

11. PROCEDURE (cont….)
• In case of “on-pump” surgery, the surgeon sutures cannulae into
the heart and instructs the perfusionist to start CPB
• Protamine is given to reverse the effects of heparin
• Chest tubes are placed in the mediastinal and pleural space to
drain blood from around the heart and lungs
• Sternum is wired together and incision is sutured
• Dressing applied
• Pt is transferred to ICU
• Provide hemodynamic support & ventilator support

14. COMPLICATIONS
 Wound infection
 Bleeding
 Delay wound healing
 Reactions to anesthesia
 Fever
 Pain
 Stroke
 Heart attack
 Injury to arteries when graft harvesting time

15. AORTIC ANEURYSM
• Aortic Aneurysm are out pouching or dilation of the arterial wall and
are common problems involving aorta
• TYPES
oThoracic Aortic Aneurysm: Ballooning of the upper aspect of aorta,
above the diaphragm
oAbdominal Aortic Aneurysm: Enlargement in the area in the lower
part of the aorta

16. INDICATION OF SURGERY FOR
AORTIC ANEURYSM
Persistent pain
Aortic valve involvement
Coronary artery involvement
Diameter greater than 5.5 or rapidly expanding
Symptomatic patients
Acute rupture

17. SURGICAL MANAGEMENT
Open Aneurysm Repair (OARs)
Endo Vascular Graft Procedure (EVAR)

18. OPEN ANEURYSM REPAIR
 It involves large abdominal incision and cut into
diseased aortic segment
 Remove any thrombus or plaque
 Sutures a synthetic graft to the aorta
 Sutures the native aortic wall around the graft to
act as a protective cover
 It requires aortic cross clamping
 After which clamp is removed and blood is
restored

20. ENDO VASCULAR GRAFT PROCEDURE
• It is an alternative to conventional surgical repair
of AAA
• This technique involves the placement of a suture
less aortic graft into the abdominal aorta inside
the aneurysm via femoral artery cut down
• After the graft is delivered to the predetermined
point, the graft is pressed or implanted against
the vessel wall by balloon inflation
• Blood then flows through the vascular graft, thus
preventing the expansion of the aneurysm due to
pressure, and the aneurysm wall begin to shrink
over time

22. OPEN Vs EVAR
OAR EVAR
• Longer recovery time
• Longer hospital stay
• 90% long term success
• Younger patients typically
• Shorter length of stay
• Reduction in blood loss
• ICU utilization reduced
• Reduce morbidity/mortality rate
• Needs long term follow up
• May need secondary procedures for
end leaks

23. CONGENITAL HEART DEFECTS
• According to arterial oxygen saturation, congenital heart
diseases are classified into:
• ACYANOTIC CHD- Normal arterial oxygen saturation
oASD, VSD, PDA, Coarctation of aorta, Pulmonary stenosis
• CYANOTIC CHD- Reduced arterial oxygen saturation
oTOF, TGA, Tricuspid atresia, Truncus arteriosus,Total anomalies
pulmonary venous drainage

24. BASIS OF SURGERY FOR CHD
• Two main categories:
PALLIATIVE PROCEDURES: Aiming to increase pulmonary blood
flow
• Aortopulmonary shunt (Eg: TOF, Pulmonary atresia)
• Pulmonary artery banding
COMPLETE REPAIR:
• Repair of extra cardiac anomalies (Eg: PDA, and Coarctation of
Aorta)
• Repair of intra cardiac anomalies (Eg:VSD, ASD and TOF)

25. AORTOPULMONARY SHUNT
CLASSIC BLALOCK-TAUSSIG SHUNT (BT shunt) :
• Classically, it consists of anastomosing the subclavian artery to the
Pulmonary artery on the side opposite the aortic arch
• However, with some technical modifications the subclavian artery
can be anastomosed to the pulmonary artery on the same side of
aortic arch (Rarely used)
MODIFIED BLALOCK-TAUSSIG SHUNT (MBT shunt) :
• It consists of interposition of a polytetraflurothelene (GORE-TEX)
tube graft between the subclavian or innominate artery and the
right or left pulmonary artery

26. REPAIR OF EXTRA CARDIAC ANOMALIES
PDA:
• Approached through a limited left posterolateral thoracotomy and is
usually divide b/w clamps or ligated
COARCTATION OF AORTA:
• Approached through a left posterolateral thoracotomy
• Techniques – Resection and end – to- end anastomosis or dilatation
of the coarcted segment with subclavian flap or synthetic GORE-TEX
patch

27. REPAIR OF INTRA CARDIAC ANOMALIES
TOF
• Closure of VSD with a patch (Dacron) and relief of the obstruction
of the RV outflow tract and the stenosed pulmonary tract
ASD
• Closed by using pericardial patch
VSD
• Closed by using Dacron patch

28. NURSING MANAGEMENT
Risk for Decreased Cardiac output related to
changes in intravascular volume
INTERVENTIONS RATIONALE
Monitor vital signs
Assess mental status
Check peripheral perfusion
Auscultate lung sounds and Heart sounds
Monitor ABG
Monitor Urine output
Administer inotropic agents
• To evaluate cardiovascular status
• Decreased CO may lead to hypoperfusion to CNS
• Decreased CO may lead to hypoperfusion to
tissues
• To identify any abnormal heart sounds
• To rule out oxygenation level in body
• Decreased CO may lead to hypoperfusion to
kidney
• To improve cardiac output

29. NURSING MANAGEMENT
Risk for Bleeding related to the use of anticoagulation
therapy
INTERVENTIONS RATIONALE
• Assess for the signs and symptoms of bleeding
• Monitor chest drain and urine characteristics
• Monitor platelet counts and coagulation test
results (INR, PT, PTT)
• Convert from IV anticoagulation to oral
anticoagulation after the appropriate length of
therapy
• Stop heparin when bleeding occurs
• Bruises, epistaxis, and gum bleeding are early
signs of spontaneous bleeding
• Chest drain may increase and hematuria may
be seen
• Effects of anticoagulation therapy must be
closely monitored to reduce the risk of bleeding
• PT or INR levels should be in a therapeutic
range for anticoagulation before discontinuing
heparin
• Further administration of Heparin may lead to
bleeding

30. NURSING MANAGEMENT
Ineffective tissue perfusion related to increased
coagulability of blood
INTERVENTIONS RATIONALE
• Assess for contributing factors
• Assess for the signs and symptoms of deep
vein thrombosis
• Assess peripheral circulation status
• Monitor coagulation profile
• Administer anticoagulants as prescribed
• Apply below-knee compression stockings
• Encourage early ambulation after surgery
• Knowledge of high-risk situations helps in
early detection
• The signs and symptoms occur in the leg
affected by the deep vein clot
• To rule out thrombus formation
• These are used to measure the effectiveness
of anticoagulant therapy
• To prevent the formation of new clots
• Compression stockings enhance circulation
• To prevent venous stasis

31. NURSING MANAGEMENT
Deficient knowledge related to unfamiliarity in disease
condition & its management
INTERVENTIONS RATIONALE
• Assess the level of knowledge
• Instruct the client to take medications as indicated,
explaining their actions, dosages, and side effects
• Inform the client of the need for regular checkup of
INR while on oral anticoagulation
• Provide teaching regarding the safety measures
while on anticoagulant therapy such as the use of
an electric razor, the use of a soft toothbrush
• Advice the patient not sitting with the legs crossed
• To obtain base line information to plan
interventions
• Correct knowledge decreases future complications
• Routine coagulation monitoring is necessary to
ensure that a therapeutic response
• These precautionary measures help reduce the risk
of bleeding
• Sitting with legs crossed promotes vein
compression

32. REFERENCES
• Lewis, Bucher, Heitkemper, Harding, Kwong, Roberts. Lewi’s Medical
Surgical Nursing.3rd South Asia edition. Vol 2. New Delhi: Elseiver
publications; 2018.
• https://www.slideshare.net/AbhayRajpoot3/cabg-134836953
• https://www.slideshare.net/AnvinThomas/aneurysm-85794573
• https://www.slideshare.net/eimad0307/surgery-for-congenital-heart-
diseases
• https://nurseslabs.com/5-deep-vein-thrombosis-nursing-care-plans/5/

33. THANK YOU