Cardiac Complications

1
Cardiac Complications

• Lynn McGugan Clark
• ACNP
• Duke University
• mcgug001_at_mc.duke.edu

2
Tamponade

• Heart too large for pericardial space
• Apparent immediately after chest closure
• r/t edema
• Fluid accumulation
• Pericardium or anterior mediastinum
• Un-drained blood and clots
• Correcting coagulopathy -gt pericardial clot
• Chest tubes unable to drain

3
Tamponade

• Delayed
• Occurs up to several weeks after operation
• May occur after pacing wire or LA catheter
  removal
• More common in anticoagulated patients
• Possibly from postpericardiotomy syndrome
• May be caused by chylopericardium
• Not prevented by prolonged drainage of
  pericardial space

4
Pathophysiology

• Stage 1 Accumulation of fluid causes increased
  ventricular stiffness - gt need higher filling
  pressures
• Stage 2 Pericardial pressure rises above
  ventricular filling pressure
• CO decreases
• Stage 3 Further decrease in CO occurs r/t
  equalization of pericardial and ventricular
  filling pressures
• Transmural distending pressures are insufficient
  to overcome pericardial pressures
• Septal shift
• Reduced diastolic filling

5
Widened Mediastinum
6
Signs and Symptoms

• Widened mediastinal silhouette
• Rapid increase in right and left atrial pressures
• Narrow pulse pressure
• Increased diastolic pressure an attempt to
  compensate for decreased CO by sending blood back
  to the heart
• Decreased CO
• Associated conditions (low UOP, low Sv02,
  acidosis)
• Tachycardia

7
Signs and Symptoms

• Prominent x descent on CVP waveform
• Pulsus paradoxus
• Drop in BP on inspiration by at least 10 mmHg
• Becks triad
• Hypotension (r/t decreased CO)
• Muffled heart sounds (r/t insulating fluid)
• JVD (r/t lack of forward blood flow
  accumulation in venous system)

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Pulsus Paradoxus
http//www.rhc.ac.ir/PTC/PDFs/PTCC73.pdf
9
CVP in Tamponade
http//www.rhc.ac.ir/PTC/PDFs/PTCC73.pdf
10
Diagnostic Tests

• Echocardiogram
• Hamid et al (2006) found only 20 of patients
  with tamponade met radiographic criteria for
  tamponade, while 100 of patients showed
  pericardial effusions on echo
• Unclotted blood appears as black space around
  heart, LV appears small and underfilled, vena
  cava appear distended, RA collapse in diastole
• CXR
• CT

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Regional Tamponade

• Clot anterior to R atrium/ventricle
• High CVP, low wedge
• Clot behind L atrium
• PAWP high, CVP low

12
Management

• Maintain perfusion
• give fluid and inotropes
• Reduce positive pressure ventilation
• Milk/strip CT
• Monitor for PEA
• Return to OR/emergent opening of the chest

13
Emergent Opening of the Chest
14
Indications

• Bleeding
• Cardiac Arrest
• Clinical Suspicion of Tamponade
• Hemodynamic Instability
• Peri-op MI
• Arrhythmias
• Graft malfunction

15
Post-Op Cardiac Surgery Arrest Statistics

• Incidence post cardiac surgery 1-5
• Survival of arrests occurring in ICU 33-79
• Most common causes VF, tamponade
• Chest reopening within 10 minutes improves
  survival

?
16
VF Post Cardiac Surgery

• Best Evidence Topic
• 15 papers reviewed
• Chance of successful defibrillation
• 1st attempt 75-78
• 2nd attempt 35
• 3rd attempt 14
• Conclusions Three shocks should be quickly
  delivered. If these do not succeed the chance of
  a 4th shock succeeding is likely to be lt10 and
  immediate chest reopening should be performed.
• Richardson, L., Dissanayake, A. Dunning, J.
  (2007). What cardioversion protocol for
  ventricular fibrillation should be followed for
  patients who arrest shortly post-cardiac surgery?
  Interactive Cardiovascular and Thoracic Surgery,
  6(6), pp 799-805. Retrieved January 7, 2008 from
  http//www.ncbi.nlm.nih.gov/pubmed/17693437?ordin
  alpos1itoolEntrezSystem2.PEntrez.Pubmed.Pubmed_
  ResultsPanel.Pubmed_RVDocSum

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Etiology and Precipitating Causes

• VF/VT
• Myocardial injury/infarction
• Reperfusion injury
• R-on-T with asynchronous pacing
• Acquired (hypokalemia/drug toxicity/long QT
  syndrome)
• Cardioversion with unsynchronized shocks

18
Etiology and Precipitating Causes

• PEA
• Hypovolemia
• Tamponade
• Massive MI
• Tension PTX
• Lung hyperinflation
• Drug toxicity
• Anaphylaxis

19
Exacerbating Factors

• Hypoxemia
• Hypercarbia
• Acidosis
• Hypokalemia
• Hypomagnesemia
• Hypothermia

20
Etiology and Precipitating Causes

• Asystole/Heart Block/Bradycardia
• Injured/edematous conduction system
• Hyperkalemia
• Acidosis
• Drug toxicity
• After prolonged VF
• Pacing problem (wires/connections/box)
• Discontinuation of overdrive pacing

21
Which Patients Benefit from Opening the Chest?

• 6 year prospective study
• Results 25 survival to discharge
• Favorable determinants of outcome were
• Arrest within 24 h of surgery
• Reopening within 10 minutes of arrest
• Arrest in intensive care unit (ICU)
• All patients who were reopened outside the ICU
  died
• Mackay, J. H., Powell, S. J., Osgathorp, J.
  Rozario, C. J. (2002). Six year prospective
  audit of chest reopening after cardiac arrest.
  European Journal of Cardiothoracic Surgery,
  22(3), pp. 421-425.

22
Patient Risk Factors

• Older
• Procedure other than CABG
• Urgent/emergent initial operation
• Reoperation
• Chronic renal insufficiency
• Longer CPB and aortic cross clamp time
• ?Pre-op ASA and prolonged bleeding times
• Pre-op myocardial infarction

23
Initial Evaluation

• Validate check for pulse, evaluate waveforms
• Ensure ETT patency and position
• Exclude ventilator as cause
• Manual bagging
• Paralyze if suspect ventilator dysynchrony
• Consider 30 second disconnect to exclude
  hyperinflation

Adapted from Sidebotham Gillham, 2007
24
Initial Evaluation

• Exclude tension PTX
• Auscultate chest
• Palpate trachea
• Consider re-opening early if tamponade suspected
• Stop sedatives and hypotensive agents
• Ensure vasoactive gtts are being delivered

25
Additional Evaluation

• What is the MAP?
• lt 30 mmHg gt initiate cardiac arrest algorithm,
  reopen chest

Adapted from Sidebotham Gillham, 2007
26
Additional Evaluation

• 30-50 mmHg
• evaluate treat for arrhythmias
• Fluid challenge
• Phenylephrine bolus 50-100 mcg or Epinephrine
  bolus 100-200 mcg
• Consider reopening chest if unresponsive to above
• If responsive, start/increase epi/vasopressin and
  evaluate cause with ECG, ABG, labs, CXR, CO, TEE,
  consider IABP

27
Additional Evaluation

• gt 50 mmHg gt
• Zero transducers, ensure gtts delivered,
  auscultate heart and lungs, examine CT
• Inform surgeon
• Consider paralysis and sedation, manually bag
  patient
• Pace at 90 bpm, fluid challenge, increase/start
  inotropes
• PA catheter placement/TEE

28
Preparation

• Decision made by surgeon/senior resident
• Sterile attire and field
• Drapes
• Caps, gowns, masks
• Prepped with betadine
• Hallway partitioned off
• OR nurse if available
• Light source
• Set up and get blood products to bedside
• Sterile suction tubing and catheters

29
Procedure

• Incision made beside staples/suture line
• Wires cut and removed
• Soft tissues and sternal edges inspected
• Clots evacuated
• Inspect all operative sites

30
Procedure

• Sutures, clips, thrombostatic material applied to
  bleeding sites
• Drainage tubes cleared of blood and clots, pacing
  wires re-attached
• Internal cardiac massage if needed
• Chest closed or packed and left open

31
Outcomes

• Median amount of blood removed 1L
• Chest bleeding found in gt 90
• Focal bleeding gt 55
• Diffuse ooze approximately 33
• Initiation of mechanical assistance possible
• 48 of patients with cardiac arrest responded to
  open chest CPR (Anthi et al., 1998) and survived
  to discharge

32
Complications

• Sternal Wound Infection
• Increased Mortality
• Renal Failure
• Respiratory Failure
• ARDS
• Sepsis
• Atrial Arrhythmias

33
Complications

• Stroke
• Longer ICU and hospital LOS
• Disadvantages
• No positive pressure ventilation systems, laminar
  air flow or restricted personnel entry

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Wire Cutters
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Wire Cutters
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Forceps/Pickups
41
Chest Retractor/Finochetto/Baby Chest
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43
Lisch Blade/ Lepsche Knife
Hammer
44
Vascular Clamp/Big Kelley/Mayo Clamp
45
Aortic Side Biting Clamp/Satinsky Clamp
46
Vascular Cross Clamp
47
Vascular Cross Clamp
48
Needle Holders/Drivers
Scissors
Kocher Clamps
Kelly Clamps
49
DELAYED STERNAL CLOSURE
50
Delayed Sternal Closure

• Occurs more often in combined procedures
• Rationale
• Provides space for edematous heart
• Minimizes harmful effects of tamponade
• Arrhythmias
• Hemodynamic instability
• /- stabilizers
• Concerns re infection
• Anticipate broad spectrum antibiotics

51
Delayed Sternal Closure

• 4.2 of 3373 cardiac surgery patients
• Occurs approximately 2.0 (range 0.5-8 days) post
  op
• More frequently after combined cardiac surgery
  (9.6) than after CABG alone (3.7) or valve
  operation (2.6)
• COMPLICATIONS
• Superficial sternal wound infection 1.6
• Mediastinitis 0.8
• Sternal dehiscence in 3 (2.4) patients
• Christenson, J., Maurice, J., Simonet, F.,
  Velebit, V. Schmuziger, M. (1996). Open chest
  and delayed sternal closure after cardiac
  surgery. European Journal of Cardio-Thoracic
  Surgery, (10), pp. 305-311

52
Delayed Sternal Closure

• RESULTS 78.9 survived and were discharged an
  average of 8.6 days after closure. Mortality was
  related to indications for OC
• low cardiac output 38.6
• hemodynamic collapse on closure 0
• diffuse bleeding 33.3
• arrhythmias 27.3
• Christenson, J., Maurice, J., Simonet, F.,
  Velebit, V. Schmuziger, M. (1996). Open chest
  and delayed sternal closure after cardiac
  surgery. European Journal of Cardio-Thoracic
  Surgery, (10), pp. 305-311

53
Lynn McGugan Clark, ACNP, CTICU mcgug001_at_mc.duke.e
du
54
References

• Anthi, A., Tzelepis, G. E., Alivizatos, P.,
  Michalis, A., Palatianos, G. M., Geroulanos, S.
  (1998). Unexpected cardiac arrest after cardiac
  surgery incidence, predisposing causes, and
  outcome of open chest cardiopulmonary
  resuscitation. Chest, 113(1), pp. 15-19.
• Charalambous, C. P., Zipitis, C. S. Keenan, D.
  J. (2006). Chest reexploration in the intensive
  care unit after cardiac surgery a safe
  alternative to returning to the operating
  theatre. Annals of Thoracic Surgery, 81(1), pp.
  191-4.
• Dulak, S. B. (2005). Hands-on help. Cardiac
  tamponade. RN, 68(4), pp 32ac1-4.
• Hamid, M., Khan, M. U. Bashour, A. C. (2006).
  Diagnostic value of chest X-ray and
  echocardiography for cardiac tamponade in post
  cardiac surgery patients. Journal of the Pakistan
  Medical Association, 56(3), pp. 104-107.
• Lewis, A. M. (1999). Cardiovascular emergency!
  Nursing, 29(6), pp. 49-51.
• Moulton, M. J., Creswell, L. L., Mackey, M. E.,
  Cox, J. L. Rosenbloom, M. (1996).
  Reexploration for bleeding is a risk factor for
  adverse outcomes after cardiac operations.
  Journal of Thoracic and Cardiovasc Surgery, 111,
  pp. 10371046.
• Mackay, J. H., Powell, S. J., Osgathorp, J.
  Rozario, C. J. (2002). Six year prospective
  audit of chest reopening after cardiac arrest.
  European Journal of Cardiothoracic Surgery,
  22(3), pp. 421-425.
• Richardson, L., Dissanayake, A. Dunning, J.
  (2007). What cardioversion protocol for
  ventricular fibrillation should be followed for
  patients who arrest shortly post-cardiac surgery?
  Interactive Cardiovascular and Thoracic Surgery,
  6(6), pp 799-805. Retrieved January 7, 2008 from
  http//www.ncbi.nlm.nih.gov/pubmed/17693437?ordina
  lpos1itoolEntrezSystem2.PEntrez.Pubmed.Pubmed_R
  esultsPanel.Pubmed_RVDocSum
• Wahba, A., Gotz, W. Birnbaum, D. E. (1997).
  Outcome of cardiopulmonary resuscitation
  following open heart surgery. Scandinavian
  Cardiovascular Journal, 31(3), pp. 147-149.