Percutaneous Revascularization
- minimally invasice procedure to treat coronary arterial atherosclerotic disease (CAD) by restoring coronary blood flow- balloon tipped catheter introduced into the peripheral artery to gain access to the coronary arteries- usually an outpatient procedure- types:1. percutaneous transluminal coronary angioplasty (PTCA)2. directional coronary atherectomy (DCA)3. endoluminal stenting
Angioplasty, Atherectomy, and Stenting
Angioplasty- balloon at the tip is inflated compressing the central potion of the atherosclerotic lesion outward against the wall of the arteryAtherectomy- mechanism is in the distal part of the catheter and placed over the lesion, the balloon is inflated to press it against the wall and the cutter is used to remove the plaqueStenting- introduced into the lesion and expanded to maintain the luminal diameter
PT Implications: Percutaneous Revascularization
- inpatient PT consultation rare (unless complications)- home health and outpatient rare, usually referred for other musculoskeletal issues- has higher mortality rate and higher odds ratio for liklihood for re-admission (important for PT to assess for red flags)- PT assessment/treatment1. catheter insertion site for bleeding and/or signs of infection2. consider distal pulses, skin color and temp3. avoid aggressive hip flexion activities very early (up to 48 hours after)4. inpatient promote early mobility and ambulation (monitor EKG changes and for cardiac symptoms (may have bed rest directly after procedure)5. home health/outpatient look for red flags, symptoms, and vitals
Coronary Artery Bypass Graft
- performed when artery becomes completely occluded or when percutaneous will not work with athero- occluded coronary arteries are bypassed with donor vessels- heart accessed through median sternotomy- my be performed with bypass (machine take blood out of body) or off-bypass- safest and most reliable method for revascularization- veins used are the saphenous vein or the left internal mammary artery- median sternotomy: incision from suprasternal notch to xiphoid. sternem is divided and spread with retractors and closed with wires
PT Considerations: CABG
Sternal Precautions:- no lifting/carrying greater than 5 lbs (about 1/2 gallon of milk)- no bilateral UE flexion- no pushing/pulling greater than 10 lbs (can't pull on bed to lift up)- usually last 6-8 weeks- pillow may be given to help with splinting and to remind of no use of armsIncisional Precautions- no submersion in water- no creams/lotions- no betadine unless MD prescribed
PT Implications: CABG
Inpatient:- early intervention: mobility, LE exercises, functional training, cognitive training, muscle power training- education: sternal precautions, safety at home, activity progression at home, goal is to prevent readmissionHome Health and Outpatient- consults occassionally- exercise progression- monitor vitals and sternal incision helps to prevent readmission
PT Considerations: Donor Site Complications
Saphenous Vein Donor Sites:- would complications- dehiscence (seperation), infection, cellulitis, osteolyelitis- LE edema (b/c of decrease in venous return)- nerve injury- protected weight bearing (rare)Radial Artery donor site:- parethesias- hand weakness- wound complications- hypersensitivity- hand ischemia
Aortic Aneurysm Repair
- abnormal widening/ballooning of a portion of an artery due to blood vessel wall weakness- named by location (ie thoracic aortic aneurysm- risk factors: hypertension, hypercholesterolemia, tobacco use, collagen vascular disease, family history, presence of athero- aneurysms greater than 5 cm or with rapid enlargement are considered for repair- for home health there may be no symptoms- abdominal aneurysm may present at pulse behind the belly button, back, or belly and pain in those regions, low BP, dizziness, trouble breathing
Repairs for Aneurysms
- Open repair: artery is clamped above and below aneurysm, aneurysm is cut transversely and a graft is sewn into place- endovascular repair: catheters allow for a stent graft to be put in which relieves pressure off of the aneurysm's wall
PT Application: Aortic Aneurysm (Repaired)
1. if repaired surgically:- you will want to do early rehabilitation interventions- open repair on TAA: sternal precautions- " " on AAA: incisional precaultions (log roll and splinting)-will need to monitor BP response to exercise- inspect incisions- pts are at higher risk for pulmonary complications- endovascular repair: restricted movement and no aggressive hip flexion
PT Application: Aortic Aneurysm (not repaired)
1. if not repaired:- discuss with the team what to do- look at size- make sure the pt is cleared for PT and mobility- AVOID isometric exercises, heavy lifting, and valsalva maneuvers- pay attention to pain especially in the area of the aneurysm
Valve Repair/Replacement
- indicated for valve dysfunction (stenosis or insufficiency/regurgitation)- repair procedures modify the existing structures (usually repair or reshape the leaflet or decalcification)- replacements may be mechanical (last longer but blood can attach to it) or biological (not as strong but don't attract blood)- if a valve becomes stenotic (stiff) the heart muscll must work harder to pump the blood through the valve. May be caused by infection or age- insufficient (leaky) valves cause blood to leak back leaving less blood to be produced- done through a median sternotomy approach
PT Consideration: Valve Replacement
- Precautions: incisional and sternal if sternotomy- Bleeding risk if on anticoagulation therapy (INR)- monitor for arrhythmias- response to exercise
Cardiac Pacemaker Implantation
- Cardiac Pacemaker: electronic pulse generator used to control cardiac arrhythmias- used temporarily or permanently- indicated for SA node disorders, AV node disorders, complete heart block, and tachyarrhythmias- placed endocardial (inside heart wall) or epicardial (outside heart wall)- usually used temporarily after cardiac surgeries or to control transient arrhythmias after MI- use lithium batteries and last about 6 years
Pacemaker Placement
1. Transvenous: generator/battery is implanted under the skin and pacing wires are introduced through the subclavian, IJ, or cephalic veins and guided into the right atrium or right ventricule2. Surgical approach: generator/battery implanted under skin or remains external for temporary pacing- lead sutured to the myocardium- temporary wires exit from subxiphoid incision
Defibrillator Implantation
- implantable cardioverter defibrillator (ICD): used to correct life-threatening arrhythmias- detects and corrects tachycardias, ventricular fibrillation, and bradycardia- may be implanted with or without pacemaker- provides electric shock to heart if an irregular rhythm is detected- shock will reset rhythm- ICD is usually implanted endocardial, epicaridal patches, or subcutaneous electrodes (endo is most common)
PT Implications: Pacemaker/Defibrillator
- incisional precautions- observe response to exercise- no ipsilateral shoulder elevation, abduction >90 (2-4 weeks)- may have general cardiac precautions:1. no resistive exercise2. no isometric exercise3. no sustained full shoulder flex/abduction (4-6 weeks) - allows wires to adhere to the body4. limited lifting, pushing and pulling with UE- HR may not be responsive to increase in activity so need to focus on other measures to figure out fatigue
Ventricular Assist Device Implantation
- mechanical circulatory device used to partially or completely replace function of the heart- ST indications: following heart attack and revascularization, provide support to weakened myocardium during recovery, usually extracorporeal- LT indications: bridge to transplantation, replaces myocardial function for months/years for pts in heart failure waiting for transplant, usually intra- 3 types: LVAD, RVAD, and BiVAD- location of pump: extracorporeal (outside body) or intracorporeal (inside body)- no pulse or low pulsatility
VAD Implantation
- temporary VAD/ampulla- usually less than 6 hours- minimally invasive via femoral vessel- tiny pump in catheter that can drive 2.5 L blood per minute to body can be used for up to 7 days- used for transportation- parts to consider: driveline, controller, batteries, and variety of accessories
Types of VADS
- LVAD: inflow cannula that channels blood from the LV to the pump and an outflow cannula that channels blood from pump to ascending aorta- RVAD: the inflow cannula channels blood from the RV to the pump and the outflow cannula channels blood from the pump to the pulmonary artery
Important Parts of VAD
- batteries: 2 batteries or 1 battery with an AC?DC adapter are ALWAYS required, Never disconnect both power sources simultaneously- driveline: connects the controller to the pump through the pt's abdominal wall. It protects the wires powering the pump
Inpatient PT Application: VAD
- pay attention to specific alarms at the facilities- precautions: incisional and sternal- secure all lines and parts to prevent pulling/dislodgeing- closely monitor exercise response and tolerance during physical activity- watch for "suction event" - any event that causes no blood in the heart (positional or from other problems like tampanade)- frailty test (pre-heart workup)- early interventions, progression of exercises- education on VAD function/battery
Home and Outpatient PT implications: VAD
- Precautions: incisional and sternal for 6-8 weeks- driveline is a site for infection - monitor and educate- vitals and response to exercise (BP and pulse will be impacted by the pump)- prehab for transplant- higher level exercise and training- increase risk for bleed and CVA
Heart Transplant
- last treatment option for indys with end-stage heart disease (heart failure/cardiomyopathy) and with less that one year life expectancy- Types:1. orthotopic: "total transplantation" where recipient's heart is removed and replaced by donor heart (more common)2. heterotopic: "piggyback" procedure where the donor heart is connected to the recipient's failing heart3. total artificial heart- can be use as a bridge to transplant, used when LVAD isn't an option
Inpatient PT Implications: Heart Transplant
- Precautions: incisional and sternal (up to 12 weeks)- early interventions and mobility- caution with syncopal events early- delayed response to increased exercise/workload- allow adequate warm up and cool down time- HR may not accurately reflect exercise response- total transplants will have no nerves so they will have a delayed response to the increase workload
Home health and outpatient PT Implications: Heart Transplant
- sternal precautions: education will reduce complications and re-admission- higher level exercise and functional training- education on heart transplant (especially with delayed response due to no vagus nerve)
Intra-Aortic Ballon Pump (IABP)
- catheter with balloon tip inserted into LV from artery- temporary- balloon inflates with diastole and deflates with systole- assist in pump blood to coronary arteries and body- improves myocardial profusion reducing O2 demand and decrease overload on heart
PT Implications: IABP
- only in ICU- femoral placement = bedrest, limit ipsilateral hip/knee ROM- PROM and AROM of other extremities- work on cognitive training b/c pts are on bedrest
Extracorporeal Membrane Oxygenation (ECMO)
- gas exchange and perfusion- bridge to recovery- bridge to LT device (VAD)- bridge to transplant- most significant form of life support- primary goal for PT: prevent LT injury from mechanical vent while facilitating lung/heart recovery- venous-venous ECMO: respiratory support via oxygenation and/or CO2 removal
PT Implications: ECMO
- dependent on ECMO strategy and cannulation location- pre-rehab for transplant- exercise and aerobic to facilitate vent/ECMO weaning- cognition/delirium (bed bound)- prevention of PICS- will have altered pulse activity
In-Patient Post Op PT
- facilitate and assist with airway clearance- aid in positioning, bed mobility, and early ambulation- monitor physiologic responses to activity and exercise (new symptoms of poor cardiac function, bleeding, and stroke symptoms)- lines and tubes management- aid in discharge planning and education
Home Health and Outpatient Post Op PT
- monitor physiologic responses to activity and exercise (new symptoms of cardiac function, bleeding, and stroke symptoms)- home safety and energy modifications- progression to higher level activity and exercise (aerobic, resistance, muscle power training)
Contraindications for PT
- unstable angina/chest pain at rest- hemodynamic instability- serious arrhythmias or conduction block- uncontrolled hypertension- lab values from previous lecture
Abnormal Response to Exercise
- HR increases greater than 20-30 bpm above resting- HR decrease below resting- systolic BP increases 20-30 above resting- systolic BP decreases more than 10 below resting- SPO2 decreases below prescribed level- abnormal ECG changes- PT becomes SOB or RR increases markedly
Abnormal Response Non-Verbal Signs
- color change (cyanosis/pallor)- diaphoresis- increased use of accessory muscles- agitation and or confusion- dizziness- excessive fatigue