St.

Paul University Philippines

Tuguegarao City, Cagayan 3500
MASTER OF SCIENCE IN NURSING
ADULT HEALTH

PRESENTATION 1
CURRENT TRENDS IN THE MANAGEMENT OF CARDIOVASCULAR DISORDERS

KATHERINE B. ARELLANO, MAN

Faculty, Graduate School

Leonardo Jr Magtaan Uy, RN

MSN Student
Hi!

My Name is Leonardo Jr Magtaan Uy, not too young and never too old at 33.
I finished my Bachelor’s Degree in Nursing at Our Lady of the Pillar College in
Cauayan City and graduated year 2006 and passed the Local Board Exam
December of the same year.

I’m currently based in United Arab Emirates as a Staff Nurse and Supervisor in
Liwa Healthcare Services, a home healthcare facility here in Abu Dhabi.

I enrolled to Adult Health in order to gain in-depth knowledge of the current

trends, researches, best healthcare practices in care of Adult and Aging
population. For me, Nothing is more rewarding than Learning.

I’m expecting that this course Nursing in Cardiovascular Conditions will reiterate
basic principles and will provide learning opportunities in advanced theoretical
concepts and learn everything that is needed in this subject and that I would
likewise effectively make use of them in my practices in the future.
Candidate for Cardiac Catheterization
The primary reason for conducting a cardiac catheterization is to diagnose and manage
persons known or suspected to have heart disease, a frequently fatal condition that leads to
millions of heart attacks annually worldwide. Symptoms and diagnoses that may lead to
performing this procedure include:
• Chest pain, characterized by prolonged heavy pressure or a squeezing pain
• Abnormal treadmill stress test
• Myocardial infarction, also known as a heart attack
• Congenital heart defects or heart problems that originated from birth
• A diagnosis of valvular-heart disease
• A need to measure the heart muscle's ability to pump blood

Preparation for the Procedure

Prior to the cardiac catheterization procedure, it is important to relay information to the physi
cian or nurse regarding. allergies to shellfish (such as shrimp or scallops) which contain
iodine, iodine itself, or the dyes that are commonly used in other diagnostic tests.
Because this procedure is categorized as a surgery, the patient will be instructed not to eat or d
rink anything for at least.six hours prior to the test. Just before the test begins, the patient will
urinate and change into a hospital gown, then lie flat.on a padded table that may also be tilted
in order for the heart to be examined from a variety of angles.
Description of the Procedure
Catheterization is a valuable tool in detecting and treating abnormalities of the heart. Through
the use of fluoroscopic (x-ray) guidance, a catheter, which may resemble a balloon-tipped tube,
is strung through the veins or arteries into the heart, so the cardiologist can monitor a body's
various functions at each moment. Generally a test that lasts two to three hours, a patient
should expect the following prior to and during the catheterization procedure:
• A mild sedative maybe given that will allow the patient to relax but remain conscious during
the test.
• An intravenous needle will be inserted in the arm to administer medication. Electrodes will
be attached to the chest to enable the painless procedure known as an electrocardiograph.
• Prior to inserting a catheter into an artery or vein in the arm or leg, the incision site will be
made numb by injecting a local anesthetic. When the anesthetic is injected it may feel like a
pin-prick followed by a quick stinging sensation. Pressure may also be experienced as the
catheter travels through the blood vessel.
• After the catheter is guided into the coronary-artery system, a dye (also called a radio
contrast material) is injected to aid in the identification of any abnormalities of the heart.
During this time, the patient may experience a hot, flushed feeling or a quickly passing
nausea. Coughing or breathing deeply aids in any discomfort.
• Medication may be given during the procedure if chest pain is experienced, and nitroglycerin
may also be administered to allow expansion of the heart's blood vessels.
• When the test is complete, the physician will remove the catheter and close the skin with
several sutures or tape.
Management and Aftercare
While cardiac catheterization may be performed on an out-patient basis, a patient may require
close monitoring following the procedure while remaining in the hospital for at least 24 hours.
The patient will be instructed to rest in bed for at least eight hours immediately after the test.
If the catheter was inserted into a vein or artery in the leg or groin area, the leg will be kept
extended for four to six hours. If a vein or artery in the arm was used to insert the catheter,
the arm will need to remain extended for a minimum of three hours.
The patient should expect a hard ridge to form over the incision site that diminishes as the site
heals. Bluish discoloration under the skin at the point of insertion should also be expected but
fades in two weeks. It is also not uncommon for the incision site to bleed during the first 24
hours following surgery.
If this should happen, the patient should apply pressure to the site with a clean tissue or cloth
for 10-15 minutes
Candidate for Coronary Angioplasty
Angioplasty is used to treat peripheral arterial disease (PAD), which is the hardening of the arteries caused
by diabetes, smoking, high blood pressure, and elevated cholesterol. Often, angioplasty and stenting is
performed as an alternative to bypass surgery, a more invasive surgery used to treat PAD. Doctor may
recommend angioplasty if:
• You have chest pain or shortness of breath due to CAD.
• You have significant narrowing or blocking of only 1 or 2 coronary arteries. Your doctor may
recommend heart bypass surgery (coronary artery bypass graft surgery) instead of angioplasty.
• You have had a heart attack.
• You are not feeling better despite medicines and lifestyle changes to reverse atherosclerosis.
• You have a coronary bypass graft that has closed or narrowed.

Description of the Procedure

A very small incision in the skin is made over a blood vessel in arm, leg, or wrist through which a small
thin tube is inserted. The surgery can take several hours depending on the number of blockages and if any
complications arise during the surgery.
Angioplasty is performed by a cardiologist and a team of specialized cardiovascular nurses and
technicians, mostly in a special operating room called a cardiac catheterization laboratory. This room is
often called the cath lab.
Most commonly an angioplasty is performed through an artery in the groin. Arms and wrists are less
common sites. The area is prepared with an antiseptic solution. Local anesthesia is injected to the site of
the catheter insertion. Your heart is carefully monitored throughout the procedure. You will receive fluids,
medications, and anticoagulants. After all this, the procedure begins:
Description cont.
1. You will lie on a padded table. After anesthetizing the area, the doctor will make a small incision over
the femoral artery in the upper part of the leg. A special needle is then inserted in the artery itself.
2. A guide wire is carefully passed through the needle and gently pushed into the artery and upwards
towards your chest.
3. A catheter is threaded along the wire until it has reached the coronary artery.
4. The doctor injects a harmless dye with help of the catheter. The dye shows up on a TV monitor and
helps to pinpoint the exact location of the blocked area. This dye breaks up later and leaves the body
as a waste.
5. Once the blocked area is identified, a thin wire is inserted through the catheter and guided all the way
to the blocked area and slightly beyond. This wire acts as a guide for the balloon catheter, which
allows the doctor to insert the deflated balloon to position precisely in the middle of the narrow
coronary artery.
6. The balloon is then inflated. As it expands, it squeezes the plaque deposits along the wall of the
artery. It also stretches the artery wall and enlarges the channel through which blood flows.
7. After satisfactory blood flow is achieved the balloon catheter is withdrawn and another catheter is
inserted. This balloon has a mesh stent wrapped around it.
8. Once this tube has been placed in the blockage area which has now widened, the balloon is inflated.
The stent is expanded and gets attached to the wall of the artery.
9. Finally after a careful inspection of the site, the catheter is withdrawn. The stent remains in place and
control the blood flow.
Preparation for the Procedure
Most people will need a routine blood test and electrocardiogram. You will be given detailed instructions
including a suggestion not to eat or drink after midnight the evening before. You need to discuss with the
doctor whatever medications you are on. Reporting about your allergies is also necessary especially
iodine, shellfish, x-ray die, latex or rubber products, and penicillin-type medications. You will be asked to
take aspirin before the procedure. You will be awake during the procedure and will be given medications
to relax.

Management and Aftercare

Vital signs, cardiac rate and rhythm, and neurovascular.status distal to the catheter insertion site are monito
red. A Doppler. Stethoscope should be used if peripheral pulses are difficult to palpate. The catheter site is
inspected periodically for hematoma formation,,ecchymosis, or hemorrhage. The dressing is marked, and
the health care. Provider is notified of any rapid progression. If bleeding occurs, direct.
Pressure is applied to the catheter site. The patient should keep the.punctured leg straight and limit head el
evation to no more than 15° to.prevent hip flexion and potential catheter migration. The patient is.assessed
for chest pain, which may indicate vasospasm or reocclusion of.the ballooned vessel. Intravenous fluids are
administered as Prescribed.to promote excretion of contrast medium. The patient is assessed for.signs and
symptoms of fluid overload, i.e., dyspnea, pulmonary crackles,distended neck veins, tachycardia, bounding
pulse, hypertension, galloprhythms. Pharmacological therapy is continued as prescribed (IV.nitroglycerin, he
parin). Catheter removal is explained to the patient, and.direct pressure is applied to the insertion site for 30
min, followed by a.pressure dressing. Vital signs continue to be monitored until it is certain.that no occult
hemorrhage is occurring. Discharge instructions are.provided to the patient and family regarding the schedu
led return visit.with the cardiologist, followup exercise, stress testing or angiography,and any exercise
prescriptions or activity restrictions (usually patients can.walk 24 hr after the procedure and return to work
in 2 weeks).
The importance of drug regimens, including desired effects and potential adverse reactions, is reinforced.
Candidate for Cardiac Bypass
The patient and the Doctor can consider whether coronary bypass surgery or another artery-opening
procedure, such as angioplasty or stenting, is indicated. Coronary bypass surgery is an option if:
• You have severe chest pain caused by narrowing of several of the arteries that supply your heart
muscle, leaving the muscle short of blood during even light exercise or at rest. Sometimes angioplasty
and stenting will help, but for some types of blockages, coronary bypass surgery may be the best
option.
• You have more than one diseased coronary artery and the heart's main pumping chamber — the left
ventricle — isn't functioning well.
• Your left main coronary artery is severely narrowed or blocked. This artery supplies most of the blood
to the left ventricle.
• You have an artery blockage for which angioplasty isn't appropriate, you've had a previous angioplasty
or stent placement that hasn't been successful, or you've had stent placement, but the artery has
narrowed again (restenosis).

Description of the Procedure

The surgeon starts by making an incision in the middle of your chest. Your rib cage is then spread apart to
expose your heart. Or your surgeon may opt for minimally invasive surgery. This involves smaller cuts and
special miniaturized instruments and robotic procedures.
The patient is then hooked up to a cardiopulmonary bypass machine. Also known as the heart-lung
machine, it circulates oxygenated blood through your body while your surgeon operates on your heart.
Blood is pumped out of your heart by the machine to remove carbon dioxide, and the machine is then
filled with oxygen. The oxygenated blood is pumped back into your body without going through the heart
and lungs. This keeps oxygenated blood pumping throughout your body. Some procedures are performed
“off-pump,” meaning that connecting you to a heart-lung machine isn’t necessary.
Description cont.
Your surgeon will also use cooling techniques, sometimes called extreme cooling, to bring your body
temperature down to around 64.4°F (18°C). This technique suspends your body’s processes and makes
long heart surgeries possible. Your heart needs less oxygen when your body temperature is lowered. Your
doctor cools down your heart with the help of the heart-lung machine or by dousing your heart in cold,
salty water.
Cooling techniques allow your doctor to operate on your heart tissue for a few hours at a time. These
techniques decrease the risk of heart damage or brain damage from a lack of oxygen.
Your surgeon then removes a healthy blood vessel from inside your chest wall or leg to replace the
blocked or damaged portion of your artery. One end of the graft is attached above the blockage and the
other end below. When your surgeon is done, the heart-lung machine is removed, and the function of the
bypass is checked. Once the bypass is working, you’ll be stitched up, bandaged, and taken to the intensive
care unit (ICU) for monitoring.

Preparation for the Procedure

To prepare for coronary bypass surgery, the doctor will give specific instructions about any activity
restrictions and changes in diet or medications that should be followed before surgery. You'll need several
pre-surgical tests, often including chest X-rays, blood tests, an electrocardiogram and a coronary
angiogram. A coronary angiogram is a special type of X-ray procedure that uses dye to visualize the
arteries that feed your heart.
Most people are admitted to the hospital the morning of the surgery. Coronary bypass surgery may also
be performed in emergency situations, such as after a heart attack.
Be sure to make arrangements for the weeks following your surgery. It will take about four to six weeks
for you to recover to the point where you can resume driving, return to work and perform daily chores.
Management and Aftercare
After surgery, you'll typically spend 1 or 2 days in an intensive care unit (ICU). Your heart rate, blood pressure, and
oxygen levels will be checked regularly during this time. An intravenous line (IV) will likely be inserted into a vein
in your arm. Through the IV line, you may get medicines to control blood circulation and blood pressure. You also
will likely have a tube in your bladder to drain urine and a tube to drain fluid from your chest. You may receive
oxygen therapy (oxygen given through nasal prongs or a mask) and a temporary pacemaker while in the ICU. A
pacemaker is a small device that's placed in the chest or abdomen to help control abnormal heart rhythms.
Your doctor may recommend that you wear compression stockings on your legs as well. These stockings are tight
at the ankle and become looser as they go up the leg. This creates gentle pressure up the leg. The pressure keeps
blood from pooling and clotting. While in the ICU, you'll also have bandages on your chest incision (cut) and on
the areas where an artery or vein was removed for grafting.
After you leave the ICU, you'll be moved to a less intensive care area of the hospital for 3 to 5 days before going
home.
Care after surgery may include periodic checkups with doctors. During these visits, tests may be done to see how
your heart is working. Tests may include EKG (electrocardiogram), stress testing, echocardiography, and cardiac
CT. CABG is not a cure for coronary heart disease (CHD). You and your doctor may develop a treatment plan that
includes lifestyle changes to help you stay healthy and reduce the chance of CHD getting worse.
Lifestyle changes may include making changes to your diet, quitting smoking, doing physical activity regularly,
and lowering and managing stress. Your doctor also may refer you to cardiac rehabilitation(rehab). Cardiac rehab
is a medically supervised program that helps improve the health and well-being of people who have heart
problems. Rehab programs include exercise training, education on heart healthy living, and counseling to reduce
stress and help you return to an active life. Doctors supervise these programs, which may be offered in hospitals
and other community facilities. Talk to your doctor about whether cardiac rehab might benefit you.
Taking medicines as prescribed also is an important part of care after surgery. Your doctor may prescribe
medicines to manage pain during recovery; lower cholesterol and blood pressure; reduce the risk of blood clots
forming; manage diabetes; or treat depression.
Candidate for Procedure
Indications for pacemaker implantation are categorized into the following classes:
Class I - The procedure should be performed
Class IIa –It is reasonable to perform the procedure, additional studies with focused objectives are needed
Class IIb - The procedure may be considered, but additional studies with broad objectives are needed
Class III - The procedure should not be performed; it is not helpful and may be harmful
In 2008, the American College of Cardiology (ACC), the AHA, and the Heart Rhythm Society (HRS) jointly
published guidelines.
Class I indications include the following:
• Sinus node dysfunction
• Acquired atrioventricular block in adults
• Chronic bifascicular block
• After acute myocardial infarction
• Hypersensitive carotid sinus syndrome and neurocardiogenic syncope
• After cardiac transplantation
• Pacing to prevent tachycardia
• Patients with congenital heart disease

Class IIa indications include the following:

• Sinus node dysfunction
• Acquired atrioventricular block in adults
• Chronic bifascicular block
• Hypersensitive carotid sinus syndrome and neurocardiogenic syncope
• Patients with congenital heart disease
• Pacing to prevent tachycardia
• Permanent pacemakers that automatically detect and pace to terminate tachycardia
Candidate for Procedure cont.

Class IIb indications include the following:

Sinus node dysfunction
Acquired atrioventricular block in adults
Chronic bifascicular block
After acute myocardial infarction
Hypersensitive carotid sinus syndrome and neurocardiogenic syncope
After cardiac transplantation
Pacing to prevent tachycardia
Patients with congenital heart disease
Description of the Procedure

Before the procedure

Surgery to implant the pacemaker is usually performed while you're awake and typically takes
a few hours. Before the procedure, you are taken to a special room (called a preparation room
or holding area) to start an intravenous (IV) line. Most pacemaker implantations are done
using local anesthesia to numb the area of any incisions. You may receive additional IV
medication to help you relax. The implantation is done in a room with special X-ray
equipment. Your chest is cleaned with an antibacterial soap, and an IV line is placed in your
arm on the same side as the pacemaker.
During the procedure
During surgery, one or more flexible, insulated wires (leads, or electrodes) are inserted into a
major vein under or near your collarbone and guided to your heart with the help of X-ray
images. One end of each wire is secured to the appropriate position in your heart, while the
other end is attached to the pulse generator, which is usually implanted under the skin
beneath your collarbone.
Description of the Procedure

After the procedure

You'll usually stay in the hospital for one day after having a pacemaker implanted. Before you
leave, your pacemaker is programmed to fit your particular pacing needs. A return visit is
often scheduled to make sure your pacemaker's settings are correct. After that, most
pacemakers can be checked remotely using wireless technology. Using your cellphone or
radiofrequency signals, your pacemaker transmits and receives information between you and
your doctor's office, where your doctor can access the data — including your heart rate and
rhythm, how your pacemaker is functioning, and remaining battery life.
Remote transmissions can be made at scheduled intervals or at unscheduled times if your
pacemaker sends an alert, or you can send a transmission if you have a concern. Remote
technology means fewer trips to the doctor's office, but you'll still need to be seen by your
doctor in person for scheduled checkups.
After your procedure to implant your pacemaker, your doctor may recommend that you avoid
vigorous exercise or heavy lifting for about a month. You may have some aches and pains near
the area where your pacemaker was implanted. These pains can be relieved with over-the-
counter medicines, such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB,
others), but talk to your doctor before taking any pain relievers.
Preparation for the Procedure

Before your doctor decides if you need a pacemaker, you'll have several tests done to find out the cause of
your irregular heartbeat. These could include:
Electrocardiogram. In this noninvasive test, sensor pads with wires attached, called electrodes, are placed
on your chest and sometimes your limbs to measure your heart's electrical impulses. Your heart's beating
pattern can offer clues to the type of irregular heartbeat you have.
Holter monitoring. Also known as an ambulatory monitor, a Holter monitor records your heart rhythms
for an entire 24-hour period. Wires from electrodes on your chest go to a battery-operated recording
device carried in your pocket or worn on a belt or shoulder strap.
While you're wearing the monitor, you'll keep a diary of your activities and symptoms. Your doctor will
compare the diary with the electrical recordings to try to figure out the cause of your symptoms.
Echocardiogram. This noninvasive test uses harmless sound waves that allow your doctor to see your
heart without making an incision. During the procedure, a small instrument called a transducer is placed
on your chest. It collects reflected sound waves (echoes) from your heart and transmits them to a
machine that uses the sound wave patterns to compose images of your beating heart on a monitor.
These images show how well your heart is functioning, and recorded pictures allow your doctor to
measure the size and thickness of your heart muscle.
Stress test. Some heart problems occur only during exercise. For a stress test, an electrocardiogram is
taken before and immediately after walking on a treadmill or riding a stationary bike. In some cases, an
echocardiogram or nuclear imaging may be done.
Other types of treadmill exercise tests also can be done to evaluate your heart, including an oxygen
consumption test that measures how much oxygen your body is using.
Management and Aftercare

The Patient will usually stay in the hospital for one day after having a pacemaker implanted.
The pacemaker is programmed to fit depending on patient’s particular pacing needs. A return
visit is often scheduled to make sure pacemaker's settings are correct.
After that, most pacemakers can be checked remotely using wireless technology. Using your
cellphone or radiofrequency signals, your pacemaker transmits and receives information
between you and your doctor's office, where your doctor can access the data — including your
heart rate and rhythm, how your pacemaker is functioning, and remaining battery life.
Remote transmissions can be made at scheduled intervals or at unscheduled times if your
pacemaker sends an alert, or you can send a transmission if you have a concern. Remote
technology means fewer trips to the doctor's office, but you'll still need to be seen by your
doctor in person for scheduled checkups.
After your procedure to implant your pacemaker, your doctor may recommend that you avoid
vigorous exercise or heavy lifting for about a month. You may have some aches and pains near
the area where your pacemaker was implanted. These pains can be relieved with over-the-
counter medicines, such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB,
others), but talk to your doctor before taking any pain relievers.
Candidate for Procedure

Cardiac ablation is a procedure that's used to correct heart rhythm problems.

When your heart beats, the electrical impulses that cause it to contract must follow a precise
pathway through your heart. Any interruption in these impulses can cause an abnormal
heartbeat (arrhythmia), which can sometimes be treated with cardiac ablation.
Ablation isn't usually your first treatment option. Ablation is a treatment option for people
who:
• Have tried medications to treat an arrhythmia without success
• Have had serious side effects from medications to treat arrhythmias
• Have certain types of arrhythmias that respond well to ablation, such as Wolff-Parkinson-
White syndrome and supraventricular tachycardia
• Have a high risk of complications from their arrhythmias, such as sudden cardiac arrest
Description of the Procedure

Catheter ablation is performed in the hospital. Before your procedure begins, a specialist will
insert an intravenous line into your forearm or hand, and you'll be given a sedative to help you
relax. In some situations, general anesthesia may be used instead to place you in a sleep-like
state. What type of anesthesia you receive depends on your particular situation.
After your sedative takes effect, your doctor or another specialist will numb a small area near
a vein on your groin, neck or forearm. Your doctor will insert a needle into the vein and place a
tube (sheath) through the needle.
Your doctor will thread catheters through the sheath and guide them to several places within
your heart. Your doctor may inject dye into the catheter, which helps your care team see your
blood vessels and heart using X-ray imaging. The catheters have electrodes at the tips that can
be used to send electrical impulses to your heart and record your heart's electrical activity.
This process of using imaging and other tests to determine what's causing your arrhythmia is
called an electrophysiology (EP) study. An EP study is usually done before cardiac ablation in
order to determine the most effective way to treat your arrhythmia.
Once the abnormal heart tissue that's causing the arrhythmia is identified, your doctor will
aim the catheter tips at the area of abnormal heart tissue. Energy will travel through the
catheter tips to create a scar or destroy the tissue that triggers your arrhythmia.
In some cases, ablation blocks the electrical signals traveling through your heart to stop the
abnormal rhythm and allow signals to travel over a normal pathway instead.
The energy used in your procedure can come from:
○ Extreme cold (cryoablation) ○ Heat (radiofrequency) ○ Lasers
Preparation for the Procedure

Always tell your provider what drugs you are taking, even drugs or herbs you bought without a
prescription.

During the days before the procedure:

• Ask your provider which drugs you should still take on the day of the surgery.
• Tell your provider if you are taking aspirin, clopidogrel (Plavix), prasugrel (Effient), ticagrelor
(Brilinta), warfarin (Coumadin), or another blood thinner such as apixaban (Eliquis),
rivaroxaban (Xarelto), dabigatran (Pradaxa) and edoxaban (Savaysa).
• If you smoke, stop before the procedure. Ask your provider for help if you need it.
• Tell your provider if you have a cold, flu, fever, herpes breakout, or other illness.

On the day of the procedure:

• You will most often be asked not to drink or eat anything after midnight the night before
your procedure.
• Take the drugs your provider has told you to take with a small sip of water.
• You will be told when to arrive at the hospital.
Management and Aftercare
You’ll be moved to a recovery room to rest quietly for four to six hours to prevent bleeding at your
catheter site. Your heartbeat and blood pressure will be monitored continuously to check for
complications of the procedure. The sheath usually stays in your leg for several hours after catheter
ablation. During this time, you have to lie flat.

After the doctor or nurse removes the sheath:

• A nurse will put pressure on the puncture site to stop the bleeding.
• You should keep your leg straight for 6 to 8 hours after the doctor or nurse removes the sheath. The
nurse will tell you when you can get out of bed.
• The nurse will watch you carefully and check your heartbeat and vital signs (pulse and blood pressure).
• Tell your doctor or nurse right away if you notice any swelling, pain or bleeding at the puncture site, or
if you have chest pain.
• Before you leave the hospital, the nurse will give you written instructions about what to do at home.
• Aspirin is often prescribed for 2 to 4 weeks to minimize risk of clot formation at ablation sites.

Follow the instructions your nurse or doctor gave you. Most people can return to their normal activities
on the day after they leave the hospital.
• Don’t drive for 24 hours after you leave the hospital.
• Don’t drink alcohol for 24 hours after you leave the hospital.
• Avoid heavy physical activity for three days. Ask your doctor when you can return to strenuous
exercise.
• A small bruise at the puncture site is normal. If the site starts to bleed, lie flat and press firmly on top
of it. Have someone call the doctor or hospital.
Candidate for Procedure
A ventricular assist device (VAD) is a mechanical device that supports the lower left heart
chamber (left ventricular assist device, or LVAD), the lower right heart chamber (right ventricular
assist device, or RVAD) or both lower heart chambers (biventricular assist device, or BIVAD).
Your doctor may recommend you have a VAD implanted if:
You're waiting for a heart transplant. You may have a VAD implanted temporarily while you wait
for a donor heart to become available. A VAD can keep blood pumping despite a diseased heart
and will be removed when your new heart is implanted. When a VAD is implanted while you're
waiting for a heart transplant, it's referred to as a "bridge to transplant."
You're not currently eligible for a heart transplant because of other conditions. A VAD may
sometimes be implanted if you have heart failure, but you're not yet eligible for a heart
transplant due to other medical conditions. When a VAD is implanted for this reason, it's called
"bridge to candidacy" or "bridge to decision."
Your heart's function can become normal again. If your heart failure is temporary, your doctor
may recommend implanting a VAD until your heart is healthy enough to pump blood on its own
again. This is referred to as "bridge to recovery."
You're not a good candidate for a heart transplant. VADs are increasingly being used as a long-
term treatment for people who have heart failure but aren't good candidates for a heart
transplant. Generally if you're older than age 65, you may not be eligible for heart
transplantation. In that situation the VAD would be implanted as therapy for heart failure. A VAD
can enhance your quality of life.
When a VAD is implanted as a permanent treatment for heart failure, it's referred to as
"destination therapy."
Description of the Procedure

Ventricular assist device (VAD) surgery usually takes between 4 and 6 hours. The process is similar to that
of other types of open-heart surgery. The team for VAD surgery includes:
• Surgeons who do the operation
• Surgical nurses who assist the surgeons
• Anesthesiologists who are in charge of the medicine that makes you sleep during surgery
• Perfusionists who are in charge of the heart-lung bypass machine

Before the surgery, you're given medicine to make you sleep so you won't feel any pain. During the
surgery, the anesthesiologist checks your heartbeat, blood pressure, oxygen levels, and breathing. A
breathing tube is placed in your lungs through your throat. This tube is connected to a ventilator (a
machine that helps you breathe).

A cut is made down the center of your chest. The chest bone is then cut and your ribcage is opened so
that the surgeon can get to your heart.

Medicines typically are used to stop your heart during the surgery. This allows the surgeon to operate on
your heart while it's not beating. A heart-lung bypass machine keeps oxygen-rich blood moving through
your body during the surgery. (In some cases, LVAD surgeries have been done without using heart-lung
bypass machines.) When the VAD is attached properly, the heart-lung machine is switched off and the
VAD starts working. It supports blood circulation and takes over the pumping function of the heart.
Preparation for the Procedure

Before you get a ventricular assist device (VAD), you'll spend some time in the hospital to prepare for the
surgery. You might already be in the hospital getting treatment for heart failure. During this time, you'll
learn about the VAD and how to live with it. You and your caregivers will spend time with your surgeon,
cardiologist (heart specialist), and nurses to make sure you have all the information you need about the
VAD.
Before and/or after the surgery, you and your caregivers will learn:
• How the VAD works and Safety precautions.
• How to interpret and respond to alarms. How to provide care in case of emergency, such as the loss of
electrical power.
• How to wash and shower. How the VAD may affect travel.

You can ask to see what the device looks like and how it will be attached inside your body. You also may
meet with someone who already has a VAD who can give you information. This person can answer
questions about what it feels like to have a VAD implanted.
Your doctors will make sure that your body is strong enough for the surgery. If your doctors think your
body is too weak, you may need to get extra nutrition through a feeding tube before surgery. You also may
have tests to make sure you're ready for surgery. These tests may include:
• Blood tests. Blood tests are used to check how well your liver and kidneys are working. Blood tests also
are used to check the levels of blood cells and important chemicals in your blood.
• Chest x ray. This test is used to create pictures of the inside of your chest to help your doctor prepare
for surgery.
• EKG (electrocardiogram). This test is used to check how well your heart is working before the VAD
surgery.
• Echocardiography (echo). This test is used to create a detailed picture of your heart. Echo provides
information about the size and shape of your heart and how well your heart's chambers and valves are
working.
Management and Aftercare

After surgery to implant a VAD, you'll stay in the intensive care unit (ICU). You'll be given fluids, nutrition
and medications through intravenous (IV) lines. Other tubes will drain urine from your bladder and drain
fluid and blood from your heart and chest. Your treatment team will monitor you for signs of infection or
other complications.
Your lungs may not work properly immediately after your surgery, so you may need to remain connected
to a ventilator for a few days after surgery until you're able to breathe on your own.
After a few days in the ICU, you'll generally be moved to a regular hospital room. The amount of time
you'll spend in the ICU and in the hospital can vary, depending on your condition before the procedure
and how well you recover after your VAD is placed.
As you recover, your nurses and other members of your treatment team will help you become increasingly
active. They may help you sit up, get out of bed and walk in the hallways of the hospital. You may have
visits with a physical therapist to help you continue to increase your strength and get used to performing
daily life activities.
Your treatment team will work with you to help you gain strength and prepare you for going home. They
may explain how to live with a VAD and care for your VAD after you go home, and they can help answer
your questions about the VAD. Your treatment team may also discuss with you nutrition and cardiac
rehabilitation plans they may recommend during your recovery after you return home.
Management and Aftercare cont.

Your doctor will likely prescribe antibiotics and blood-thinning medications to prevent infection and other
complications while you're in the hospital. You'll usually need to continue to take blood-thinning
medications such as aspirin or warfarin (Coumadin, Jantoven) during the time you have a VAD to prevent
blood clots.
It's very important to follow the instructions for taking these medications carefully. You'll need to have
regular blood tests to monitor the effects of warfarin. Contact your doctor if you have any questions
about your medications or if you experience any side effects. You'll also need to continue to take any
medications you're taking for other conditions.
Your treatment team may encourage you to have visitors, such as family and friends, while you're
recovering in the hospital. Visitors may be able to help you perform some physical activities. Your nurses
and treatment team will also educate your family about many aspects of your care, such as how to care
for your VAD, how to watch for signs of infection after surgery, how to respond to emergencies related to
the VAD and how they can assist you at home.
Once you have recovered and gained your strength, your treatment team will determine when you're
healthy enough to be released from the hospital. If you need more time to recover your strength before
returning home, you may stay at a special care facility, such as a nursing home, for a period of time after
leaving the hospital.
Candidate for Procedure
Heart transplants are performed when other treatments for heart problems haven't worked, leading to
heart failure. In adults, heart failure can be caused by several conditions, including:
• A weakening of the heart muscle (cardiomyopathy)
• Coronary artery disease. Heart valve disease. A heart problem you're born with (congenital heart
defect)
• Dangerous recurring abnormal heart rhythms (ventricular arrhythmias) not controlled by other
treatments. Amyloidosis and Failure of a previous heart transplant
• Ischemic cardiomyopathy
• Congenital heart disease for which no conventional therapy exists or for which conventional therapy
has failed
• Intractable angina or malignant cardiac arrhythmias for which conventional therapy has been
exhausted

In children, heart failure is most often caused by either a congenital heart defect or a cardiomyopathy.

Another organ transplant may be performed at the same time as a heart transplant (multiorgan
transplant) in people with certain conditions at select medical centers. Multiorgan transplants include:
• Heart-kidney transplant. This procedure may be an option for some people with kidney failure in
addition to heart failure.
• Heart-liver transplant. This procedure may be an option for people with certain liver and heart
conditions.
• Heart-lung transplant. Rarely, doctors may suggest this procedure for some people with severe lung
and heart diseases, if the conditions aren't able to be treated by only a heart transplant or lung
transplant.
Description of the Procedure

Heart transplant surgery is an open heart surgery that takes several hours. If you've had
previous heart surgeries, the surgery is more complicated and will take longer. You'll receive
medication that causes you to sleep (general anesthesia) before the procedure. Your surgeons
will connect you to a heart-lung bypass machine to keep oxygen-rich blood flowing throughout
your body.

In this procedure, your surgeon will make an incision in your chest. Your surgeon will separate
your chest bone and open your rib cage so that he or she can operate on your heart.
Your surgeon then removes the diseased heart and sews the donor heart into place. He or she
then attaches the major blood vessels to the donor heart. The new heart often starts beating
when blood flow is restored. Sometimes an electric shock is needed to make the donor heart
beat properly.

You'll be given medication to help with pain after the surgery. You'll also have a ventilator to
help you breathe and tubes in your chest to drain fluids from around your lungs and heart.
After surgery, you'll also receive fluids and medications through intravenous (IV) tubes.
Preparation for the Procedure

Preparations for a heart transplant often begin long before the surgery to place a transplanted heart. You
may begin preparing for a heart transplant weeks, months or years before you receive a donor heart,
depending upon the waiting time for transplant. Once you decide where you would like to have your
heart transplant, you'll need to have an evaluation to see if you're eligible for a transplant. During an
evaluation, your doctors and transplant team will conduct a physical examination, order several tests, and
evaluate your mental and emotional health. The evaluation will check to see if you:
• Have a heart condition that would benefit from transplantation
• Might benefit from other less aggressive treatment options
• Are healthy enough to undergo surgery and post-transplant treatments
• Will agree to quit smoking, if you smoke
• Are willing and able to follow the medical program outlined by the transplant team
• Can emotionally handle the wait for a donor heart
• Have a supportive network of family and friends to help you during this stressful time
Your transplant team will also discuss the benefits and risks of a transplant and what to expect before,
during and after a transplant.

When a donor heart becomes available, the donor-recipient matching system considers several factors to
make a match, including:
• Medical urgency of potential recipients
• Blood type (A, B, AB or O)
• Antibodies the recipients may have developed
• Size of the donor
• Time spent on the waiting list
Preparation for the Procedure cont.

Evaluation of the heart transplant candidate includes laboratory tests, imaging studies, and
other tests as appropriate.

Closely monitor the heart transplant candidate for signs of clinical deterioration during the
waiting period for a suitable donor organ. Administer standard therapy for congestive heart
failure (CHF), and offer the patient the alternative of participating in experimental clinical
trials; such participation does not preclude listing for transplantation. Maintain close contact
with the transplant center, keeping the consultants informed of ongoing medical and social
issues pertaining to the candidate.

In the event of clinical deterioration, the transplant center may deem it appropriate to admit
the patient so that he or she can be evaluated for implantation of an artificial cardiac assist
device, an upgrade on the waiting list, or both. At times, the candidate may deteriorate to the
point where transplantation is no longer an option. Carefully discuss these issues with the
treating physicians, the patient, and the family.
Management and Aftercare
After you've had surgery to place your donor heart, you'll stay in the intensive care unit (ICU).
You'll generally be moved to a regular hospital room after a few days in the ICU, and you'll
usually remain in the hospital for a week or two. Endomyocardial biopsies are performed to
assess for allograft rejection. These may be performed as frequently as every week for the first
month, with the frequency decreasing over time. Follow-up visits are frequent for the first
month because regulation of immunosuppression is being adjusted during this time. The
frequency of visits gradually diminishes until the patient is generally seen on an annual basis.
You'll need to make several long-term adjustments after you've had your heart transplant. These
include
Taking immuno-suppressants. These medications decrease the activity of your immune system
to prevent it from attacking your donated heart. Because your immune system will most likely
never completely accept the new organ, you'll take some of these medications for the rest of
your life.
Managing medications, therapies and a lifelong care plan. After a heart transplant, taking all
your medications as your doctor instructs and following a lifelong care plan is important.
Cardiac rehabilitation. Cardiac rehabilitation programs incorporate exercise and education to
help you improve your health and recover after a heart transplant. Staff members trained in
cardiac rehabilitation may help you adjust to healthy lifestyle changes — such as regular exercise
and a heart-healthy diet — after your transplant.
Emotional support. Your new medical therapies and the stress of having a heart transplant may
make you feel overwhelmed. Many people who have had a heart transplant feel this way.