It will be helpful to overview cardiac surgeries like CABG, Valvular surgeries and heart transplant. It also enumerates the nursing diagnoses and its brief description.

1. NURSING MANAGEMENT OF PATIENT
UNDERGOING CARDIAC SURGERY.
1

2. MEANING-
Cardiac surgery, or cardiovascular surgery, is surgery on
the heart or great vessels performed by cardiac
surgeons. It is often used to treat complications of
ischemic heart disease (for example, with coronary
artery bypass grafting); to correct congenital heart
disease; or to treat valvular heart disease from various
causes, including endocarditis, rheumatic heart disease,
and atherosclerosis. It also includes heart
transplantation.
2

3. Historical
background for
Cardiac surgeries-
3

4. HISTORICAL BACKGROUND OF
CARDIAC SURGERIES-
19TH
CENTUARY
OPERATION
OF
PERICARDIUM
Francisco Romero (1801)
Dominique Jean Larry (1810)
Henry Dalton (1891)
Daniel Hale Williams (1893)
4

5. 19TH
CENTUARY
First surgery on the heart was on 14th September
1895 by Norwegian surgeon -Axel Capellen.
Ligation of bleeding coronary artery due to stabbed
injury to left axilla.
5

6. 6
British surgeon – Sir Henry Souttor
Operated on mitral valve stenosis
Made an opening in left atrium and inserted a finger into valve.

7. First surgeons who operated Tetralogy
of Fallot.
Performed successfully palliative pediatric cardiac surgery at
Johns Hopkins Hospital on November 29, 1944 in a one year old
girl for Tetralogy of Fallot.
7
Alfred Blalock
American surgeon
Helen Taussig
Pediatric cardiologist
Vivien Thomas
African- American
physiologist

8. First open heart surgery -
John Carter Callaghan was a Canadian cardiac surgeon who "pioneered open-
heart surgery in Alberta“
In 1955, he joined the Division of Cardiovascular and Thoracic Surgery at the
University of Alberta Hospital and performed Canada’s first successful open
heart surgery
8

9. Types of cardiac
surgeries-
9

10. Reparative cardiac surgeries-
Reparative cardiac surgeries are performed to cure the
condition with excellent and prolonged improvement.
 Closure of patent ductus arteriosus, atrial septal
defect(ASD) and ventricular septal defect(VSD).
 Repair of Mitral stenosis or Tetralogy of fallot.
10

11. Reconstructive cardiac surgeries-
 Reconstructive cardiac surgeries are not always
curative procedures. These procedures are complex
surgeries required re-operation.
 Coronary artery bypass graft
 Reconstruction of an incompetent mitral, tricuspid or
aortic valves.
11

12. Substitutional cardiac surgeries-
 Substitutional cardiac surgeries are valve
replacement, cardiac replacement by transplantation
or mechanical device ventricular replacement.
 Substitutional surgeries are not usually curative
procedures.
12

13. Another classification of cardiac
surgeries-
OPEN HEART SURGERIES
CLOSED HEART SURGERIES
13

14. CARDIO-PULMONARY BYPASS-
 Cardio pulmonary bypass is used during cardiac
surgery to divert the client unoxygenated blood to a
machine in which oxygenation and circulation
occurs.
 Reoxygenated blood is then returned to the client’s
circulation.
 This technique, called extra corporeal circulation ECC.
 Thus with the help of Heart lung machine, surgeon
can stop the heart and bypass the blood flow into
machine.
14

15. Functions of Heart Lung machine
 Diverts circulation from the heart and
lungs, providing the surgeon with a
bloodless operative field.
 Preforms all gas exchange functions.
 Filters, rewarms, or cools the blood.
 Circulates oxygenated, filtered blood
back into the arterial into the arterial
system.
15

16. Types of cannulations-
Venous cannulation-
A cannula may be placed in the right atrium,
superior vena cava, inferior vena cava or femoral
vein to drain the blood from the body to
cardiopulmonary bypass circuit ( heart lung
machine).
Arterial cannulation-
A cannula may be placed in ascending aorta or
femoral artery for returning of oxygenated blood
from the heart lung machine.
16

17. Components of Cardiopulmonary
bypass circuit-
Pump
Venous
reservoir
Oxygenator Heat exchanger
Filter
Cardiotomy
suction
Cardiotomy
reservoir
Left ventricle
venting
Cardioplegia
delivery system
17

18. Myocardial protection-
 Myocardial protection can be defined as the specific
intraoperative strategies designed to protect the myocardium,
from the tissue damage resulting from ischemic state that
occurs with extracorporeal circulation.
18

19. Cardioplegia -
 Cardioplegia is infused to arrest the
heart and provide a bloodless,
motionless operative field as well as
protect the heart during cardiac surgery.
 Cardioplegic solution is infused into
the aorta or coronary sinus or into the
coronary arteries themselves to cause
cardiac arrest.
19

20. Types of Cardioplegia-
Crystalloids
Potassium, magnesium and procaine –immediate
diastolic arrest
O2, glucose, glutamate- energy substrate
HCO3 and PO4- buffer acidosis
Calcium, steroids or procaine- stabilize the
membrane
Blood cardioplegia
¼th of cardioplegia ( crystalloid) and ¾th of
blood –
Provides oxygen carrying capability and maintain
oncotic pressure
Less myocardial edema
20

21. Temperature of Cardioplegia-
Hypothermia
15-280C
O2 demand
Normothermia
370C
Cardioplegic attack
21

22. Techniques of delivering Cardioplegia-
Antegrade
Retrograde
22
ANTEGRADE RETROGRADE
Coronary
sinus
Proximal
Aorta

23. CORONARY ARTERY BYPASS GRAFT
(CABG) SURGERY
Coronary artery bypass surgery is an open heart surgery
which involves the bypass of a blockage in one or more the
coronary arteries using saphenous veins, mammary artery,
or radial artery as conduits or replacement vessels.
23

24. Indications for CABG-
 Based on
1. Asymptomatic or mild angina,
2. Stable angina
3. Unstable angina
24

25. Asymptomatic or mild angina-
o Class I –
25
1.stenosis
2.Proximal stenosis
3. Triple
vessel
disease
4.Vessel disease (
+2) with LVEF <
50%

26. Asymptomatic or mild angina-
 Class II
26
Proximal LAD
stenosis and
+2 vessels
disease

27. Stable angina- 27
Triple
vessel
disease
2 vessels
disease +
LVEF <
50%
Myocardiu
m at risk
with LAD
stenosis
Angina
refractory
to
medicine

28. Unstable Angina 28
Ongoing
ischemia
+2 vessel
diseases and
PCI not
possible

29. PRE-PROCEDURAL EVALUTION:
 Patient medical history of patient properly examined for
factors that might predispose to complications.
 Routine pre-operative investigations
29

30. PATIENT PREPARATION -
 Premedication –
The aim of premedication are to minimize myocardial oxygen
demands by reducing heart rate and systemic arterial pressure
and to improve myocardial blood flow with vasodilators.
Patients on beta blocker and calcium channel blocker – sudden
withdrawal can cause tachycardia, rebound HTN and reduced
coronary dilatation.
Administration of temazepam immediately before CABG can decrease
the risk of tachycardia and hypertension resulting from anxiety
regarding the operation.
In operating room, intravenous administration of a small dose of
midazolam before arterial line insertion can also reduce anxiety,
tachycardia and hypertension.
30

31.  In patients referred for CABG, aspirin should be continued up to the time of
surgery, especially in those who present with an acute coronary syndrome. In
patients receiving a thienopyridine (e.g. clopidogrel) in whom elective CABG is
planned, the drug should be with held for either 5 days (clopidogrel) or 7 days
(for prasugrel) before the procedure.
 Each patient should be cross matched with 2 units of blood (for simple case) or
6 units of blood, fresh frozen plasma, and platelets.
 Administration of tranexamic acid may be considered to reduce post-operative
mediastinal bleeding and blood product (i.e. red blood cell and fresh frozen
plasma) use.
ANESTHESIA
 Cardiac surgery makes use of the following 2 forms of neuroaxial blockade
• Intrathecal opioid infusion
• Thoracic epidural anesthesia
31

32. PRE-PROCEDURE NURSING CARE
 Endo tracheal intubation needed
 Anesthetic agent
 Central venous access should be done
 Positioning- supine and roll in interscapular region
 Monitoring –
ECG, pulse oximetry, nasopharyngeal temperature, urine output, and gas
analysis
1. Arterial blood pressure monitoring
2. Central venous pressure monitoring
3. Transesophageal echocardiography
4. Neurological monitoring
32

33. Harvesting the conduit-
 The saphenous veins have an 80-90 percent of
patency rate.
 The saphenous vein is generally acceptable as a
conduit in the absence of other vascular
pathologies in the leg.
 The greater saphenous vein (GSV) can be
procured either via an open harvest technique,
starting from either the ankle or groin and using
a vein stripper, or via an endoscopic technique.
 The legs and groin should be shaved, prepared,
and draped in the operating room.
33

34. 34

35. Internal Mammary artery-
 The LIMA (left internal mammary artery) and the RIMA ( right
internal mammary artery) arises from respective subclavian
arteries.
35

36.  LIMA is most commonly harvested as a pedicle .
 RIMA is generally skeletonized because a RIMA pedicle may
interfere with sternal wound healing.
 The LIMA is useful in left anterior descending (LAD) artery
anastomosis and has good patency rate- 98 percent at 1 year
and 90 percent at 5 years.
 The RIMA has a good patency rate when anastomosed to the
LAD (96 percent at 1 year and 90 percent at 5 years) but a
reduced rate when grafted to the circumflex artery or the right
coronary artery (75 percent at 1 year).
36

37. Surgical procedures-
 Incision for CABG –
midline sternotomy by ant. Thoracotomy for bypass of the LAD.
Lateral thoracotomy for marginal vessels may be used when off
pump procedure is being performed.
37

38. Coronary artery bypass-
 First step – to cannulate the aorta and right
atrium
 Aortic area for cannulation must be soft and
non- atherosclerotic.
 Insertion of aortic cannula – unfractional
heparin given and
Systolic BP is lowered to 100 mm of Hg.
 Aortotomy- is done with a scalpel , the
cannula is placed and purse string sutures are
tightened around it.
38

39. Cont…
 Aortic cannula is secured and connected to arterial pump tubing.
 Venous cannula is tightened in right atrial appendage in similar
pattern.
 The aorta is cross clamped distal to cannula.
 Cold cardioplegia is infused via aortic cannula in antegrade
pattern.
 Blood cardioplegia is mostly infused as it has lower intra
operative mortality, postoperative myocardial infarction and
conduction defects.
39

40. Placement of graft-
 On initiation of cardiopulmonary bypass-
1. Distal to proximal
2. First – anastomosis of the right coronary artery and the marginal
branches of the circumflex artery.
3. The circumflex is accessed by retraction the laterally
4. The posterior descending artery and posterolateral circulation are
accessed by retracting the heart cephalically.
5. The LIMA is usually anastomosed with the LAD.
6. The saphenous vein can be grafted to all coronary artery except
LAD.
40

41. Understanding the graft to coronary arteries- 41
Anastomosis
of the 2
coronary
arteries done
first.
Graft is done
only by
LIMA pedicle

42. Techniques of anastomosis-
Distal anastomosis
Diseased coronary artery
to graft
Proximal anastomosis
Vein or artery graft to
Aorta
42

43. Weaning from cardiopulmonary
bypass -
 Rewarm the patient
 Initiation of mechanical ventilation
 In case of bradycardia and heart block, epicardial pacing.
 Once the heart start beating, the CPB is stopped.
 Effect of anticoagulation is reversed by administration of
Protamine.
43

44. Complications of CABG surgery-
44

45. Intra – Aortic Balloon Pump (IABP) –
 It augment the coronary perfusion during diastole and
reducing the afterload.
 It consist of a sausage shaped balloon that passed through
the femoral artery and positioned at descending thoracic
artery just distal to the subclavian artery.
 The catheter is attached to a power console that inflates and
deflates the balloon.
45
DiastoleINFLATION
• Blood is pushed back into the aorta, the coronary artery
perfusion is improved.SystoleDEFLATION
• Resistance is decreased and the workload of the heart is
reduced.

46. Nursing care of patient with CABG
surgery-
The following are the goals to be achieve while caring CABG
patient in hospital-
1. To prevent the negative effects of prolonged bed rest.
2. To assess the client’s physiologic response to exercise.
3. To manage the psychological issues related to recovery from
CABG surgery.
4. To educate the client and family concerning recovery and the
adoption of risk reduction behaviors.
46

47. Nursing diagnosis -
1. Decreased cardiac output related to alteration in
preload/afterload/contractibility/heart rate.
2. Impaired gas exchange related to ventilation/perfusion mismatch or
intrapulmonary.
3. Ineffective airway clearance related to retained secretions and excess
secretions.
4. Risk for Hemorrhage related to inadequate hemostasis, disruption of
suture line or coagulopathy.
5. Acute pain related to tissue trauma secondary to sternotomy and leg
incision
6. Risk of post cardiotomy delirium or stroke
7. Risk of infection related to sternotomy incision, diabetes and obesity
47

48. Decreased cardiac output related to alteration in
preload/afterload/contractibility/heart rate-
Assess hemodynamic parameters (heart rate, CVP, RAP, BP, PAP, PAWP, CO)
Monitor potassium and magnesium levels.
Monitor weight daily and calculate change.
Monitor for peripheral edema.
Monitor I & O hourly.
Monitor heart sounds every 4 hourly- ventricular gallop S3 sign of heart failure.
Administer prescribed fluids, packed red blood cells, or colloids.
Administer prescribed vasodilators- reduce afterload
Warm the client to reduce shivering – hypothermia can lead to depressed contractility
Administer inotropic medication as prescribed – enhance myocardial contractibility
Protect external pacemaker wires from water and accidental exposure to electricity by
placing them in rubber gloves.
48

49. Ineffective airway clearance related to retained
secretions and excess secretions.
Monitor lung sounds- accumulation of fluid in alveoli
Monitor coughing efforts.
Administer supplemental oxygen to maintain saturation levels
above 93%.
Maintain the comfort using prescribed opioids.
Splint the incision with “heart pillows” or pillows.
Early ambulation
Use of incentive spirometry.
49

50. Risk for Hemorrhage related to inadequate
hemostasis, disruption of suture line or coagulopathy.
Monitor mediastinal chest tubes for output hourly.
Report excess volumes and/or institute prescribed treatments
for blood loss.
Retransfuse blood from mediastinum as ordered.
Keep chest tubes positioned without kinks and/or gently strip
them
Monitor for manifestation of cardiac tamponade- elevated
CVP, decreased CO, muffled heart sound and sudden cessation
of chest tube drainage.
50

51. Post CABG surgery health education and rehabilitative
programs:
The following are the goals to be met in this phase
• To restore clients to a desirable exercise capacity appropriate to their health
status, lifestyle, and occupation
• To provide additional education and support to the client and family for
adoption of risk-reduction behaviors
• To meet the psychosocial needs of clients and family, restore confidence
,and minimize anxiety and depression.
• To promote early identification of medical problems through close
observation and monitoring of clients during exercise.
• To assist clients in returning to occupational and leisure activities.
• To institute long term, follow up of risk reduction behavior change.
• To encourage clients to take responsibility for continuing lifestyle change.
51

52.  Outpatient exercise training usually takes place in a facility that provides
continuous ECG monitoring.
 Exercise therapy should be conducted three times weekly for 2-3
months.
 The duration of aerobic exercise ranges from 20 -30 minutes.
 After exercise heart rate, blood pressure, respiration is checked.
 A nutritionist may counsel for proper diet and psychologist for stress
management and adoption of risk prevention behaviors.
 In home visit periodic ECG examination is done.
 Cardiac rehabilitation.
52

53. VALVE SURGERY- 53

54. Valvuloplasty-
 Valvuloplasty is the reconstruction or repair procedure done for a
diseased heart valve.
 It is repair of the valve leaflet or related structure.
 The different methods of valvuloplasty includes patching the
perforated portion of the leaflet, resection of excess tissues and
debriding vegetation and calcification.
Advantage of valve repair are –
1. Higher survival rate
2. Fewer cardiac complication
3. Lesser mortality and morbidity
4. Reduced need for anticoagulation
5. Less costly
54

55. Pre operative care-
 Review the patient’s condition.
 Rule out the medical, psychiatric and surgical history.
 Rule out whether patient is habitual to alcohol intake and
smoking.
 Pre operative lab investigations to be done.
 Evaluate the medication therapy of patient- digoxin, diuretics,
anti-hypertensive, psychotropic and herbal supplement.
 Preparation of events in the post operative period.
 Informed consent to be taken.
 Shave and preparation of surgical site.
 Give sedative before going to operating room if ordered.
55

56. Reparative procedures for diseased or defective
valves-
 Commissurotomy is an open-heart surgery that repairs a mitral
valve that is narrowed from mitral valve .It is also called open
commissurotomy.
 During this surgery, a person is put on a heart-lung bypass machine.
 Open commissurotomy is performed through median sternotomy
and right anterolateral thoracotomy.
 The surgeon removes calcium deposits and other scar tissue from the
valve leaflets.
 The surgeon may cut parts of the valve structure. This surgery opens
the valve.
 It is used for people who have severe narrowing of the valve and
aren't good for balloon valvotomy.
56

57. 57

58. Annuloplasty- 58
 Excessive leaflet tissue may be resected, elongated
chordae may shortened by incision of papillary
muscle and imbreating it with elongated chordae.
 Annular dilation is treated by tightening the annulus,
usually with placement of a support ring to remodel
annular shape without reducing orifice size.
 Annuloplasty is used for stenotic or regurgitant
valve.
Prosthetic rings used for
annuloplasty

59. Valve replacement -
Valve replacement is the excision of the valve leaflets and
replacement of it with mechanical or biological prothestic.
It is indicated, when valve is so stenosed and calcified and heart
circulatory function is seriously impaired.
The outcome of valve replacement is depend on patient general
condition , heart function at the time of surgery and type of valve
used.
59

60. Intra operative procedures-
 Incision of median sternotomy or in some case
right thoracotomy incision.
 Initiation of cardiopulmonary bypass .
 The diseased valve leaflets are excised at the
annulus.
 The margin of the valve annulus are retained and
sutured with prosthesis.
60

61. Post operative complication of valvular surgeries-
Thromboembolism
Bleeding
Infection
Congestive cardiac failure
Hypertension
Dysrhythmias
Hemolysis
Mechanical obstruction of the valve
61

62. Post operative care-
Achieve and maintain normal body temperature .
Monitor and optimize vital signs and hemodynamic status
Monitor for presence of dysrhythmias
Monitor drainage from the chest tube
Reposition patient every 2 hours and increase activity level when stable
Monitor the patient’s respiratory rate and promote deep breathing
exercise and coughing to prevent atelectasis
Monitor for and report any neurological changes from baseline
Maintain adequate renal perfusion. Document daily weight and fluid
intake and output.
Monitor serum electrolyte level
Avoid preload reduction
62

63. Patient education-
Teach the patient about long term use of anticoagulant
(warfarin) and its importance
Teach the patient about importance antibiotic prophylaxis to
prevent bacterial endocarditis before dental and surgical
interventions.
Advice the patient to have regular follow up with surgeon
Advice the patient to check PT INR value monthly it should in the
range of 2.5 to 3.5
Counsel the patient against the pregnancy.
63

64. Cardiac transplantation ( heart transplant)
Christiaan Neethling Barnard was a South African cardiac
surgeon who performed the world's first highly publicized
heart transplant at Groote Schuur Hospital, South Africa.
On 3 December 1967, Barnard transplanted the heart of
accident-victim Denise Darvall into the chest of 54-year-
old Louis Washkansky, with Washkansky regaining full
consciousness and being able to easily talk with his wife,
before dying 18 days later of pneumonia.
After the Transplantation of Human Organs Bill finally
received the President’s assent on 7 July 1994, a group of
surgeons led by P. Venugopal successfully performed
India’s first heart transplant at the All India Institute of
Medical Sciences (AIIMS) on 3 August 1994.
64

65. Cardiac transplantation-
Cardiac transplantation is the effective treatment of choice for client
with end stage heart disease and significantly prolongs the life of the
patient.
 There is an acute shortage of hear donors.
 While 50,000 need transplants every year, only 340 done in last 24
years.
 Delhi alone needs 1000 heart transplants every year.
 Based on activity data analyzed from 2008 for 104 countries,
representing nearly 90% of the worldwide population, it is shown
that around 100, 800 solid organ transplants are performed every
year worldwide: 69 400 are kidney transplants (46% from living
donors), 20 200 liver transplants (14.6% from living donors), 5 400
heart transplants, 3 400 lung transplants and 2400 pancreas
transplants.
65

66. 66

67. Indications for cardiac transplantation-
1) Severe heart failure refractory to medical therapy
2) Ischemia heart disease with not amenable to
revascularization
3) Recurrent symptomatic ventricular tachyarrhythmias
refractory to medical therapy, devices, or surgery
4) Cardiac tumors
5) Dilated cardiomyopathy
67

68. Contra indication -
• Amyloidosis
• HIV infection
• Cardiac sarcoma
• Age greater than 70 years
• Fixed pulmonary hypertension
• Systemic illness that will limit survival despite transplantation
• Neoplasm other than skin cancer (less than 5 years disease- free
survival)
• HIV/AIDS (CD4 count less than 200 cells/mm3)
• SLE or sarcoidosis that has multisystem involvement or is still active
• Irreversible renal or hepatic dysfunction
68

69. Selection of heart donor
• Brain death- Healthy young patients with complete
unresponsiveness, unreceptive, without reflex and spontaneous
movements of breathing.
• Age – Younger than 55 years of age and in smoker less than 45
years of age.
• No cardiac arrest or profound hypotension after injury.
• Normal echo function
• No valvular lesion
• No wall movement abnormality
• No sepsis, HIV, Hepatitis C, active malignancy, drug abuse, carbon
monoxide poisioning
• No injury to heart or concussion to heart.
69

70. Selection of recipient -
• No pulmonary artery hypertension
• No infection – HIV, Hepatitis, Pneumonia, Sepsis
• No pulmonary infarction
• Age below 60 years
• No renal failure
• No malignancy for 5 years
70

71. Procedures – Orthotopic transplantation 71
Technique 1 Technique 2

72. Assisted circulation and Mechanical hearts –
 It consists of a pump which is implanted in the abdominal wall and
connected to the left ventricle of the heart.
 It assists weak ventricles to draw blood into it and circulate
throughout the body.
 The surgeon connects the VAD to the bottom of the heart and an
aorta .
 Blood then flows into the heart and out the aorta by mean of small
electrically driven motor placed in VAD.
 The VAD is also consist of battery and controller that place beneath
skin thus is easier to carry.
 It bridges the time until a donor heart become available.
72

73. Post operative care-
Monitor
Bleeding
hypovolemi
Heart
Pul. HTN
Arrhythmias
Rejection
73

74. BIBLIOGRAPHY-
 HARIPRASAD P, TEXT BOOK OF CARDIOVASCULAR & THORACIC NURSING,
1ST EDITION, YEAR OF PUBLICATION- 2006, JAYPEE PUBLICATION, PAGE NO
300 – 334
 BLACK JOYCEE , HAWKS JANE, MEDICAL SURGICAL NURSING – CLINICAL
MANAGEMENT FOR POSITIVE OUTCOME ,VOLUME- 2 , 7TH EDITION ,
ELSEVIER PUBLICATION, PAGE NO 1609-1611,1640-1649
 GEORGE REENA, TEXTBOOK OF CARDIAC NURSING, 1ST EDITION, JAYPEE
PUBLICATION, PAGE NO 292- 331
 VENKATESON B, TEXTBOOK OF CARDIOTHORACIC NURSING, 1ST EDITION,
2017, JAYPEE PUBLICATION, PAGE NO 231-252
 www.googleimage.com
 www.wikipedia.com
 www.pubmed.com
 www.youtube.com
74

75. 75