Treatments

Ongoing technological advances in the treatment of cardiovascular disorders help patients live longer with a better quality of life than ever before.

Cardiovascular disorders: Balloon catheter treatments

Balloon catheter treatments for cardiovascular disorders include percutaneous balloon valvuloplasty and percutaneous transluminal coronary angioplasty (PTCA).

Cardiovascular disorders: Percutaneous balloon valvuloplasty

Percutaneous balloon valvuloplasty, which can be performed in the cardiac catheterization laboratory, seeks to improve valvular function. It does so by enlarging the orifice of a stenotic heart valve, which can result from congenital defect, calcification, rheumatic fever, or aging. A small balloon valvuloplasty catheter is introduced through the skin at the femoral vein. Although the treatment of choice for valvular heart disease remains surgery (valvuloplasty, valve replacement, or commissurotomy), percutaneous balloon valvuloplasty offers an alternative for those considered poor candidates for surgery.

Bursting the balloon

Focus Topic: Cardiovascular disorders

Unfortunately, elderly patients with aortic disease commonly experience restenosis 1 to 2 years after undergoing valvuloplasty. Also, despite the decreased risks associated with more invasive procedures, balloon valvuloplasty can lead to complications, including:

  • worsening valvular insufficiency by misshaping the valve so that it doesn’t close completely
  • pieces breaking off of the calcified valve, which may travel to the brain or lungs and cause embolism (rare)
  • severely damaging delicate valve leaflets, requiring immediate surgery to replace the valve (rare)
  • bleeding and hematoma at the arterial puncture site
  • MI (rare), arrhythmias, myocardial ischemia, and circulatory defects distal to the catheter entry site.

Patient preparation

Before the procedure, take the following steps:

  • Reinforce the doctor’s explanation of the procedure, including its risks and alternatives.
  • Restrict food and fluid intake for at least 6 hours before the procedure or as ordered.

Monitoring and aftercare

The patient undergoing balloon valvuloplasty will be monitored in the cardiac ICU or PACU after the procedure. He’ll be transferred to the medical-surgical unit when his condition is stable. After transfer to the medical-surgical unit, take these steps:

  • Monitor the effects of I.V. medications such as heparin.
  • Assess the cannulation site for bleeding or infection.
  • Monitor peripheral pulses distal to the insertion site and the color, temperature, and capillary refill time of the extremity. If pulses are difficult to palpate, use a handheld Doppler instrument.
  • Notify the practitioner if pulses are absent.

Home care instructions

Before discharge, instruct the patient to:

  • resume normal activity
  • notify the practitioner if the patient experiences bleeding or increased bruising at the puncture site or recurrence of symptoms of valvular insufficiency, such as breathlessness or decreased exercise tolerance
  • comply with regular follow-up visits.

Cardiovascular disorders: PTCA

PTCA offers a nonsurgical alternative to coronary artery bypass surgery. The doctor uses a balloon-tipped catheter to dilate a coronary artery that has become narrowed because of atherosclerotic plaque. (See Understanding angioplasty.)

Performed in the cardiac catheterization laboratory under local anesthesia, PTCA doesn’t involve a thoracotomy, so it’s less costly and requires shorter hospitalization. Patients can usually walk the next day and return to work in 2 weeks.

 

Best working conditions

Focus Topic: Cardiovascular disorders

PTCA works best when lesions are readily accessible, noncalcified, less than 10 mm, concentric, discrete, and smoothly tapered. Patients with a history of less than 1 year of disabling angina make good candidates because their lesions tend to be softer and more compressible. (See PCI: To intervene or not to intervene, page 280.) Complications of PTCA are acute vessel closure and late restenosis. To prevent restenosis, the patient may need to undergo such procedures as stenting, atherectomy, and laser angioplasty.

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Understanding angioplasty

Focus Topic: Cardiovascular disorders

Cardiovascular disorders

 

Patient preparation

Before the procedure, take the following steps:

  • Tell the patient that a catheter will be inserted into an artery and a vein in the groin area and that he may feel pressure as the catheter moves along the vessel.
  • Advise the patient that the entire procedure lasts from 1 to 4 hours and that he’ll have to lie flat on a table during that time.
  • Explain to the patient that he’ll be awake during the procedure and may have to take deep breaths to allow visualization of the radiopaque balloon catheter and answer questions about how he’s feeling during the procedure.
  • Tell the patient to notify the cardiologist if he experiences any chest pain or pressure during the procedure.
  • Tell the patient he will have to remain on bed rest while the catheter is in place.

PCI: To intervene or not to intervene?

Focus Topic: Cardiovascular disorders

Cardiovascular disorders

 

Monitoring and aftercare

The patient undergoing PTCA may be monitored in the cardiac ICU or interventional care recovery area after the procedure. The patient will be transferred to the medical-surgical unit when stable. After transfer to the medical-surgical unit, take these steps:

  • Monitor the effects of I.V. medications such as heparin.
  • Assess the cannulation site for bleeding or infection.
  • Monitor peripheral pulses distal to the insertion site and the color, temperature, and capillary refill time of the extremity. If pulses are difficult to palpate, use a Doppler stethoscope.
  • Notify the practitioner if pulses are absent.

Home care instructions

If the patient doesn’t experience complications from the procedure, he may go home in 6 to 12 hours. Instruct the patient to:

  • call his practitioner if he experiences any bleeding, bruising, or swelling at the arterial puncture site
  • return for a stress thallium imaging test and follow-up angiography, as recommended by his practitioner
  • report chest pain to the practitioner because restenosis can occur after PTCA.

Cardiovascular disorders: Emergency treatment for heart rhythm disturbance

Emergency treatment for heart rhythm disturbance may include defibrillation and pacemaker insertion.

Cardiovascular disorders: Defibrillation

With defibrillation, the heart receives a strong burst of electric current from defibrillator paddles applied to the patient’s chest. This brief electric shock completely depolarizes the myocardium, allowing the heart’s natural pacemaker to regain control of cardiac rhythm.

First choice

Focus Topic: Cardiovascular disorders

Defibrillation is the treatment of choice for ventricular fibrillation and pulseless ventricular tachycardia. For every minute that defibrillation is delayed, the patient’s chance of surviving ventricular fibrillation drops 7% to 10%. If ventricular fibrillation lasts for more than a few minutes, it causes irreparable brain damage. Note that patients with certain arrhythmias such as stable ventricular tachycardia may require a technique similar to defibrillation called synchronized cardioversion.

Cardiovascular disorders: Pacemaker insertion

Pacemakers are battery-operated generators that emit timed electrical signals to trigger contraction of the heart muscle, thus controlling heart rate. Whether temporary or permanent, they’re used when the heart’s natural pacemaker fails to work properly.

From the temp pool

Focus Topic: Cardiovascular disorders

Temporary pacemakers are used to pace the heart during CPR or open-heart surgery, after cardiac surgery, and when sinus arrest, symptomatic sinus bradycardia, or complete heart block occurs. Temporary pacing may also correct tachyarrhythmias that fail to respond to drug therapy. In emergency situations, the patient may receive a temporary transvenous or transcutaneous pacemaker if time or his condition doesn’t permit or require implantation of a permanent pacemaker. The doctor may also use a temporary pacemaker to observe the effects of pacing on cardiac function so he can select an optimal rate before implanting a permanent pacemaker. The method of pacing depends on the device.

Permanent position

Focus Topic: Cardiovascular disorders

Permanent pacemaker implantation is a common procedure; worldwide, about 110,000 people undergo it every year. Permanent pacemakers are inserted when the heart’s natural pacemaker becomes irreversibly disrupted. Indications for a permanent pacemaker include:

  • acquired atrioventricular (AV) block
  • chronic bifascicular and trifascicular block
  • AV block associated with acute MI
  • sinus node dysfunction
  • hypersensitive carotid sinus syndrome
  • hypertrophic and dilated cardiomyopathy.

The many types of pacemakers are categorized according to capabilities. Choice of a pacemaker depends on the patient’s age and condition, the cardiologist’s preference and, increasingly, the cost of the device, which can be several thousand dollars. (See Reviewing pacemaker codes.)

 

Cardiovascular disorders

 

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