Cardiac dysfunction management

Authors

Affiliations

Nate Yomogida, PT, DPT

Doctor of Physical Therapy

B.S. in Kinesiology

Chloë Kerstein, PT, DPT

Doctor of Physical Therapy

B.A. in Neuroscience

Revascularization and reperfusion of myocardium

• Thrombolytic therapy
• Percutaneous revascularization procedures
  • PTCA (percutaneous transluminal coronary angioplasty)
  • Balloon procedure
  • Vessel can not be fully occluded, only partially
  • Can place stent in valve (keeps vessels open)
  • A lesser intervention compared to bypass
  • Most common
  • Vessels cant be fully occluded
  • May place endoluminal stents

Transmyocardial Revascularization

• Catheter w laser tip
• Creates channels from patent arteries into ischemic area
• For chronic angina in pts unable to have PTCA or CABG
• Last line of defense for chronic angina, and unable to target full balloon or bypass (if not great surgical candidates for other procedures)

CABG

CABG: Coronary artery bypass graft

Reading CABG Documentation

• CABGx4 = A CABG with 4 vessels treated

Pump Head

Bypass machine → can cause pump head (STM loss, brain fog, cognitive issues)

• Coronary artery is completely occluded (can’t do balloon and stent at this point)
• Causes Ischemia NOT infarction
• Vascular graft used to revascularize myocardium
  • Saphenous vein (MOST times)
  • Radial artery
  • Left internal mammary artery
  • Right internal mammary artery
  • Artery to artery is nice, veins have valves
• Median sternotomy
  • Intense, big surgery
  • Balloon is first line of defense if possible
  • This will be a couple a day stay

Minimally invasive CABG

• Laparoscopic and robotic techniques
• Avoids median sternotomy
• Dec’d pain and infection in leg incisions
• Best for occlusions in ant coronary arteries
• May combine w/ PTCA for multiple blockages
• Infection is less common in this approach

Off Pump CABG

• Median sternotomy
• Grafting w beating, normothermic heart
• Regional ischemia for 5-15 min
• Reduced inflammatory response, suggests less myocyte injury

Median sternotomy

Sternal PRecautions

• Premise is to reduce dehiscence

• Limited evidence on how much this reduces risk of dehiscence

• If high risk for dehiscence be on sternal precautions for a longer period of time

  • Obesity: (obese,
  • women/men w larger breasts,
  • COPD (pressure of coughing), diabetes (delayed healing), smoke, vascular disease)

• 8 weeks

• Restrict UE lifting to < 10 pounds

• No pushing, pulling

• No scapular ADDUCTION

• No resistance or loading of UE past 90 in flexion or abduction

  • (don’t push thru arms out of chairs however if they must, tell them to move SLOWER →it minimizes forces)

• Minimal arm use for transfers

Ablation procedures

Catheter ablation

• Venous access usually
• Indications
  • SVT
  • AV node dysfunction
  • A fib
  • A flutter
  • V tach (certain types)
• Low power, high freq AC current to destroy cardiac tissue

Pacemaker

• Electrode placed to create AP to manage arrhythmias
• Temporary pacing post surgery

AICD: Automatic implantable cardiac defibrillator

• Automatic implantable cardiac defibrillator
  • Hx of life threatening ventricular arrhythmias
  • V tach
  • V fib
  • Should go off automatically

Life vest External defibrillator

• External defibrillator
• Sound alarm before shock (opportunity to stop it or sit down)
• Bridge to AICD or transplant
• Non surgical candidates
• If on heart transplant list or waiting for AICD or those who would not survive AICD surgery

Valve replacement

• Indications
  • Mitral or aortic stenosis
  • Mitral or aortic regurgitation
• Median sternotomy - unless TAVR (in thru femoral artery– no sternal precautions)
• Mechanical
• Durability, longer life
• Younger pts
• Downside:
  • Lifetime anticoagulation →If they have an allergy or they can not take meds →contraindication
• Biological valves
  • Older pts
  • Pig valves usually
  • Bleeding disorders

Mechanical circulatory Assist Devices (not in every hospital)

• Helps pump heart, blood
• Need additional training for these devices
• Percutaneous
  • TandemHeart
  • Impella
• Surgical
  • Multiple

Ventricular Assist Devices

• Mechanical pump that provides prolonged circulatory assistance in pts who have acute or chronic ventricular failure
• Temporary or permanent
• Temporary; bridge to heart transplantation
• Permanent: destination therapy
• Usually LVAD, may be RVAD or BiVAD
• 5 years to maybe a few decades
  • Averages are hard to report considering people die right after surgery

Total Artificial Heart

• 2 FDA approved devices
• Staff will need significant training

ECMO

• Extracorporeal membrane oxygenation
  • Direction oxygenation of blood and removal of CO2
  • Cardiac or respiratory failure not responding to max medical therapy and mechanical ventilation
  • Now PTs are starting to mobilize
  • Move slowly, ask for help, watch cannula