I.

Cardiac Catherization

Cardiac catheterization is the procedure of inserting a thin, hollow tube into a blood vessel in the
leg or, less often the arm, then passing it into or around the heart in order to obtain information about
cardiovascular anatomy and function. The procedure is most often performed to evaluate the blood
flow in the heart arteries and to identify any significant narrowing or blockages. If a significant blockage
is identified, the heart artery may be reopened non-surgically by another procedure called angioplasty
and/or stenting. Alternatively, the artery may require coronary artery bypass graft surgery. The test
can also measure pressures within the heart and lungs, measure the amount of oxygen in the blood
and heart chambers, identify abnormal heart chamber connections called shunts, assess heart valve
function, provide access through which samples of heart muscle tissue can be taken for analysis, and
provide an accurate assessment of the pumping ability of the heart.

A. Indication for the procedure

Cardiac catheterization is performed to find out if you have disease of the heart muscle, valves or
coronary (heart) arteries.

A cardiac catheterization provides information on how well your heart works, identifies problems
and allows for procedures to open blocked arteries.

(DAGDAGAN PA DITO)

What are the risks of cardiac catheterization?

Cardiac catheterization is usually very safe. A small number of people have minor problems.
Some develop bruises where the catheter had been inserted (puncture site). The contrast dye
that makes the arteries show up on X-rays causes some people to feel sick to their stomachs, get
itchy or develop hives.

B. Patient required preparation for the procedure

How long does the procedure take? Are there any other tests involved? Do the patient needs to
stay overnight in the hospital?

The catheterization itself normally takes 30 to 180 minutes; however, prior to your procedure
you will need to have some blood tests, chest X-rays and an electrocardiogram (ECG) performed
either the day before, or the day that the catheterization is performed. Patients do not usually
have to stay overnight for the catheterization, however, an overnight stay may be warranted if
your medical condition warrants it.

 The patient will be given instructions about what to eat and drink during the 24 hours
before the test.
  Usually, the patient will be instructed not to eat or drink anything for six to eight hours
before the catheterization procedure.
 Asks the patient for any medicines he/she was taking (including over-the-counter, herbs
and vitamins). The doctor may ask the patient not to take them before the catheterization
procedure.
 The patient will be ask for any are allergy to anything, especially iodine, shellfish, latex or
rubber products, medicines like penicillin, or X-ray dye.
 Instruct the patient to arrange or have someone to drive him/her home after the
procedure.
 Instruct if the patient usually wear a hearing aid; and advice to wear it during the
procedure. If he/she wears glasses, bring them to the appointment.

C. How the procedure was performed.

Cardiac catheterization takes place in a special cardiac catheterization laboratory. This is a

sterile environment (all medical personnel will wear gowns, masks and gloves), and there is
equipment present which is specific to this type of procedure. Some of the specialized equipment
includes an X-ray movie camera, which takes images of the chest from various angles; there also
will be a monitor present that will allow the doctors to see the heart as it functions. The heart
and blood pressure will be monitored throughout the procedure.

A doctor with special training performs the procedure with a team of nurses and technicians.
The procedure is done in a hospital cardiac catheterization (cath) lab.

Before the catheterization procedure, a nurse will put an IV (intravenous) line into a vein in
your arm so you can get medicine (sedative) to help you relax, but you’ll be awake and able to
follow instructions during the procedure.

The nurse will clean and shave the area where the doctor will be working. This is usually in the
groin area. A local anesthetic is usually given to numb the needle puncture site. The doctor will
make a needle puncture through the skin and into a large blood vessel.  A small straw-sized tube
(called a sheath) will be inserted into the vessel. The doctor will gently guide a catheter (a long,
thin tube) into the vessel through the sheath. A video screen will show the position of the
catheter as it is threaded through the major blood vessels and to the heart. The patient may feel
some pressure in the groin, but shouldn’t feel any pain.
Various instruments may be placed at the tip of the catheter. They include instruments to
measure the pressure of blood in each heart chamber and in blood vessels connected to the
heart, view the interior of blood vessels, take blood samples from different parts of the heart, or
remove a tissue sample (biopsy) from inside the heart.

There will be several periods when X-ray sensitive contrast media (dye) will be injected, through
the catheter. At these moments (approximately 30 seconds to 60 seconds each) the patient will
probably feel a warm sensation that spreads from head to toe.
 The doctor will remove the catheters and the sheath and the nurse will put pressure on the site
to prevent bleeding. Sometimes a special closure device is used. The procedure lasts about an
hour.

D. Nursing Care Management After the procedure

Puncture site assessment

Assess puncture site for: 
 Bleeding- check pressure dressing for any oozing or bleeding from puncture site and mark
the size of bleed if possible 
Note: check for bleeding immediately after vomiting or vigorous coughing.
 Haematoma- assess site for swelling, redness and pain and mark the size of haematoma if
possible                                                                                                
Note: A haematoma can indicate internal bleeding into the thigh, pelvis or retroperitoneal
space.
 Infection- assess site for heat, pain and redness.  Also assess for other signs of infection
including an increase in temperature, tachycardia, and rigors.  
 Ecchymosis- assess skin around site for purple discoloration.

Assessment of potential complications

Assess for retroperitoneal bleeding

 Assess vital signs- fluctuating BP response, bradycardia and hypotension are signs of
retroperitoneal bleeding.
 Assess for abdominal pain, groin pain and back pain.
Note:  Retroperitoneal haematomas are ipsilateral to the puncture site so pain on the
same side of the access site needs further investigations.
 Assess for diaphoresis.
 Assess for signs of bleeding - tachycardia, hypotension, decreased peripheral perfusion,
widening pulse pressure,  agitation, decreased haemoglobin level 

Assess for arrhythmias

Assess patient’s ECG rhythm on the cardiac monitor.  Ensure patient is in sinus rhythm
(Link- Sinus rhythm) or is in a rhythm deemed normal for the patient

Assess for thrombus

 Neurovascular observations: assess limb for colour, warmth, CRT, pulse strength,
sensation, movement and pain.
 In the presence of venous access site clot, the affected limb will appear red, swollen, the
patient will have an increase in pain levels and delayed CRT due to pooling of blood. 
  In the presence of an arterial access site clot, the affected limb will appear pale, cool,
have diminished or absent pulses distal to the insertion site, have decreased sensation
and delayed CRT due to lack of supply of arterial blood. 
Note: If you notice a limb with decreased perfusion assess pressure dressing to ensure it
is not too tight. 
Note: For accurate assessment of the pulse, mark the pulse position on the patient’s
foot. A doppler can be utilised if a pulse is not palpable. 

Assess and document intake and output.

Routine Management 
On arrival to the ward assess and record patient observations - these should include:
 Behaviour - alert, lethargic, irritable
 HR
 RR
 BP
 SpO2
 Oxygen requirements
 Temperature
 Neurovascular observation
Continue observations as per RPAO clinical guideline (Link).  Neurovascular observations
should be performed with every set of observations.
 Assess puncture site 30 minutely for 4 hours than hourly until ambulation.  Reassess site
after first ambulation and then a minimum of 4 hourly prior to discharge.
Note: the puncture site assessment commences from the time the patient enters the
PACU, not when they are transferred to the inpatient unit.
 Patient is required to remain on bed rest for:
o 4 hours for a diagnostic catheterisation.
o 6 hours for an interventional catheterization.   
Note: patient is permitted to move side to side while on bed rest to increase comfort.
 Ensure head of bed is no higher than 30 degree for duration of bed rest.  
 Do not remove dressing prematurely unless ordered to by RMO.  
 Dressing is to be removed prior to discharge for cardiac RMO to assess. 
Note: if a patient remains in hospital for longer than 24 hours, the dressing should be
removed 24 hours post procedure.
 Provide regular analgesia as ordered.
 Aspirin may be ordered for device closures - be aware if medical team has requested
such medications and when it should be commenced.

Management of Complication

Hematoma
 Apply manual compression over the hematoma to prevent further bleeding.
 If patient has a heparin infusion, stop infusion. 
  Assess for signs of intravascular volume depletion- tachycardia, widening pulse pressure,
hypotension, decreased peripheral perfusion, delayed CRT, agitation.  If insufficient
cardiac output seek urgent medical assistance (MET call 777).
 Auscultate hematoma for presence of pulse and a systolic bruit which indicates a
pseudoaneurysm.
 Notify physician (catheterization fellow- office hours: pager 5719, after hours: pager
5718)
 Bleeding at site 
 Apply pressure above insertion site with gauze to achieve hemostasis.  Hemostasis
should occur within 5-10 minutes.
 If patient has a heparin infusion, stop infusion.
 Reinforce pressure bandage. 
 Notify physician (catheterization fellow- office hours: pager 5719, after hours: pager
5718).

Arrhythmia
 Assess if this is a new arrhythmia for the patient. If new Notify physician (catheterization
fellow- office hours: pager 5719, after hours: pager 5718).
 Assess patient’s cardiac output- BP, peripheral perfusion, color and alertness.  If
insufficient cardiac output seek urgent medical assistance.
Note: regardless if the arrhythmia is new or deemed a normal occurrence for the
patient, if cardiac output is insufficient you must seek urgent medical assistance.
 Print rhythm strip or complete an ECG if patient is stable. 
 Continuous cardiac monitoring.

Thrombus
 Notify physician if any changes in neurovascular observations (catheterization fellow-
office hours: pager 5719, after hours: pager 5718). 
 Ultrasound to confirm clot.
 Antithrombotic agent as ordered by the medical team. First line of treatment for an
occluded vessel is a heparin infusion.  Thrombolysis may be used in rare circumstances. 

Retroperitoneal bleeding
 Notify physician if suspected
 Assess for signs of intravascular volume depletion.
 Bloods - FBE and Blood group and antibody screen. 
 Continuous monitoring. 
 CT scan. 
 Blood product transfusion. 

What happens after cardiac catheterization?

The patient will go to a recovery room for a few hours. During this time, he/she was instructed
to lie flat on bed.
Pressure will be applied to the puncture site to stop the bleeding.
 The patient will be asked to keep his/her leg straight and will not be able to get out of bed.
The heartbeat and other vital signs (pulse and blood pressure) will be closely monitored during
the patient recovery.
The patient was instructed to report any swelling, pain or bleeding at the puncture site, or any
have chest pain.
Before the patient leave the hospital, he/she will receive written instructions about what to do
at home.

E. References/ Sources

1. Applegate, R., Sacrinty, M., Kutcher, M., Kahl, F., Gandhi, S., Santos, R., & Little, W. (2008).
Trends in vascular  complications after diagnostic cardiac catheterization and percutaneous
coronary intervention via the femoral artery, 1998 to 2007. JACC. Cardiovascular Interventions,
1(3), 317-326.
2. Altiok, M., Yurtsever, S., & Kuyurtar, F. (2007). Review of the methods to prevent femoral
arteriotomy complications and contrast nephropathy in patients undergoing cardiac
catheterization: cardiac catheterization and care approaches in Turkey. Journal Of
Cardiovascular Nursing, 22(6), 452-458.
3. Chair, S., Yu, M., Choi, K., Wong, E., Sit, J., & Ip, W. (2012). Effect of early ambulation after
transfemoral cardiac catheterization in Hong Kong: a single-blinded randomized controlled trial.
Anadolu Kardiyoloji Dergisi: AKD = The Anatolian Journal Of Cardiology, 12(3), 222-230.
4. Ellis, S., Bhatt, D., Kapadia, S., Lee, D., Yen, M., & Whitlow, P. (2006). Correlates and outcomes
of retroperitoneal hemorrhage complicating percutaneous coronary intervention. Catheter
Cardiovasc Interv, 67, 541–545.
5. Farouque, H., Tremmel, J., & Shabari et al. (2005). Risk factors for the development of
retroperitoneal hematoma after percutaneous coronary intervention in the era of glycoprotein
IIb/IIIa inhibitors and vascular closure devices. J Am Coll Cardiol, 45 (1), 363–368.
6. Harper, J. (2007). Post-diagnostic cardiac catheterization: development and evaluation of an
evidence-based standard of care. Journal For Nurses In Staff Development: JNSD: Official
Journal Of The National Nursing Staff Development Organization, 23(6), 271-276.
7. Hockenberry, M., & Wilson, D. (2010). Wong’s Nursing Care of Infants and Children. (9th ed.).
St. Louis: Mosby
8. Karen, U. (2001). Therapeutic cardiac catheterization for congenital heart disease- a new era in
pediatric care.  Journal of Pediatric Nursing, 16 (5), 300-307.
9. Medical Dictionary. (2013). Retrieved from http://medical-dictionary.thefreedictionary.com/.
10. Pennsylvania Patient Safety Authority. (2007). Strategies to minimize vascular complications
following a cardiac catheterization. PA-PSRS Patient Safety Advisory, 4(2), 1-6
11. Rezaei-Adaryani, M., Ahmadi, F., & Asghari-Jafarabadi, M. (2009). The effect of changing
position and early ambulation after cardiac catheterization on patients' outcomes: a single-blind
randomized controlled trial. International Journal Of Nursing Studies, 46(8), 1047-1053.
12. Wilcoxson, V. L. (2012). Early Ambulation After Diagnostic Cardiac Catheterization via Femoral
Artery Access. Journal For Nurse Practitioners, 8(10), 810-815.
13. Yilmazer, M., Ustyol, A., Güven, B., Oner, T., Demirpençe, S., Doksöz, O., & ... Tavli, V. (2012).
Complications of cardiac catheterization in pediatric patients: a single center experience. The
Turkish Journal Of Pediatrics, 54(5), 478-485.
14. https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Care_of_the_patient_post_c
ardiac_catheterisation/
15. https://www.heart.org/en/health-topics/heart-attack/diagnosing-a-heart-attack/cardiac-
catheterization
II. Coronary Angioplasty

The heart’s arteries can become blocked or narrowed from a build-up of cholesterol, cells or other
substances (plaque). This can reduce blood flow to your heart and cause chest discomfort. Sometimes
a blood clot can suddenly form or get worse and completely block blood flow, leading to a heart attack.
Angioplasty opens blocked arteries and restores normal blood flow to your heart muscle. It is not
major surgery. It is done by threading a catheter (thin tube) through a small puncture in a leg or arm
artery to the heart. The blocked artery is opened by inflating a tiny balloon in it.

A. Indication for the procedure

People with blockages in their heart arteries may need angioplasty if they are having lots of
discomfort in their chest, or if their blockages put them at risk of a heart attack or of dying.

B. Patient required preparation for the procedure

People with blockages in their heart arteries may need angioplasty if they are having lots of
discomfort in their chest, or if their blockages put them at risk of a heart attack or of dying.

C. How the procedure was performed

How is it done?
1. A doctor numbs a spot on your groin or arm and inserts a small tube (catheter) into an
artery.
2. The catheter is threaded through the arterial system until it gets into a coronary (heart)
artery.
3. Watching on a special X-ray screen, the doctor moves the catheter into the artery. Next, a
very thin wire is threaded through the catheter and across the blockage. Over this wire, a
catheter with a thin, expandable balloon on the end is passed to the blockage.
4. The balloon is inflated. It pushes plaque to the side and stretches the artery open, so blood
can flow more easily. This may be done more than once.
5. In many patients a collapsed wire mesh tube (stent) mounted on a special balloon, is moved
over the wire to the blocked area.
6. As the balloon is inflated, it opens the stent against the artery walls. The stent locks in this
position and helps keep the artery open.
7. The balloon and catheters are taken out. Now the artery has been opened, and your heart
will get the blood it needs.
 Does angioplasty hurt?
No, angioplasty causes very little pain. The doctor will numb the place where the catheter
will be inserted.
You may feel some pressure as the catheter is put in.
You’ll be awake and alert but may be given medicine to help you relax.
The place where the catheter was put in may be sore afterwards.
Bruising is also common.
If you notice any bleeding or increasing pain or swelling, tell your doctor.

D. Nursing Care Management After the procedure

People with blockages in their heart arteries may need angioplasty if they are having lots of
discomfort in their chest, or if their blockages put them at risk of a heart attack or of dying.

What about afterwards?

 When the tube is removed from your leg or arm, a nurse or doctor will usually apply
direct pressure for 15 minutes or longer to the place where the catheter was inserted to
ensure there’s no internal bleeding.
 If angioplasty is done through the leg, for several hours you’ll lie quietly on your back
and the doctors and nurses will check for any signs of bleeding or chest discomfort. If
the procedure is done through the arm, you won’t need to remain in bed.
 You’ll almost always have to stay in the hospital for a night to rest. Sometimes a longer
stay is required.
 There’s a small risk that a blood clot will form inside the stent, blocking blood flow in the
artery. Your doctor will prescribe aspirin or other medicine to help prevent this.
 Avoid heavy lifting or vigorous physical activity for 1-2 days after the procedure.
 Learn about the risk factors you need to change to keep your heart healthy.

E. References/ Sources

III. Cardiac Bypass

Coronary artery bypass grafting (CABG) is performed for patients with coronary artery disease (CAD) to improve
quality of life and reduce cardiac-related mortality.

A. Indication for the procedure

Class I indications for CABG from the American College of Cardiology (ACC) and the American Heart Association
(AHA) are as follows:
 Over 50% left main coronary artery stenosis
 Over 70% stenosis of the proximal left anterior descending (LAD) and proximal circumflex arteries
 Three-vessel disease in asymptomatic patients or those with mild or stable angina
 Three-vessel disease with proximal LAD stenosis in patients with poor left ventricular (LV) function
 One- or two-Vessel disease and a large area of viable myocardium in high-risk area in patients with
 stable angina.
 Over 70% proximal LAD stenosis with either an ejection fraction (EF) below 50% or demonstrable
ischemia on noninvasive testing.

Other indications for CABG include the following:

 Disabling angina (class I)
 Ongoing ischemia in the setting of a non–ST segment elevation myocardial infarction (MI) that is
unresponsive to medical therapy (class I)
 Poor LV function but with viable, nonfunctioning myocardium above the anatomic defect that can be
re-vascularized

CABG may be performed as an emergency procedure in the context of an ST-segment elevation MI (STEMI) in
cases where it has not been possible to perform percutaneous coronary intervention (PCI) or where PCI has failed and
there is persistent pain and ischemia threatening a significant area of myocardium despite medical therapy.

Contraindications

CABG is not considered appropriate in asymptomatic patients who are at a low risk of MI or death. Patients
who will experience little benefit from coronary revascularization are also excluded.

Although advanced age is not a contraindication, CABG should be carefully considered in the elderly, especially
those older than 85 years. These patients are also more likely to experience perioperative complications after CABG. A
multidisciplinary heart team approach that emphasizes shared decision making in patients with complex CAD is
essential to offer the patient the best chance of a successful revascularization strategy.

B. Patient required preparation for the procedure

Preprocedural evaluation

Before performing CABG, clinicians should carefully examine the patient’s medical history for factors
that might predispose to complications, such as the following:

 Recent MI

 Previous cardiac surgery or chest radiation

 Conditions predisposing to bleeding

 Renal dysfunction

 Cerebrovascular disease including carotid bruits and transient ischemic attack (TIA)

 Electrolyte disturbances that might predispose the patient to dysrhythmias

 Infection, including urinary tract infection and dental abscesses

  Respiratory function, including the presence of chronic obstructive pulmonary disease (COPD)
or infection [3]

Routine preoperative investigations include the following [3] :

 Full blood count (abnormalities corrected)

 Clotting screen

 Creatinine and electrolyte levels (abnormalities corrected and discussed with the anesthetist)

 Liver function tests

 Screening for methicillin-resistant Staphylococcus aureus (MRSA)

 Chest radiography

 Electrocardiography (ECG)

 Echocardiography or ventriculography (to assess LV function)

 Coronary angiography (to define the extent and location of CAD)

Assessment of Risk

Risk models to predict 30-day mortality following isolated CABG is an active area of research. Risk
models such as the Euroscore system, [4]  and the Society of Thoracic Surgeons (STS) 2008 Cardiac
Surgery Risk Model, [5]  are the most commonly used predictors in cardiac surgery. Shared variables in
these two impressive models include age, previous MI, peripheral vascular disease (PVD), renal failure,
hemodynamic state and EF. In the STS model, 78% of the variance is explained by eight of the most
important variables, which include age, surgical acuity, reoperative status, creatinine level, dialysis,
shock, chronic lung disease, and EF.

C. How the procedure was performed

Premedication

The aims of premedication are to minimize myocardial oxygen demands by reducing heart rate and
systemic arterial pressure and to improve myocardial blood flow with vasodilators. Drugs that should be
continued up to the time of surgery are as follows:

 Beta-blockers, calcium channel blockers, and nitrates

 Aspirin
Administered agents are as follows:

 Temazepam immediately preoperatively

 Midazolam, a small intravenous (IV) dose in the operating room before arterial line insertion

Each patient should be cross-matched with 2 units of blood (for simple cases) or 6 units of blood, fresh
frozen plasma, and platelets (for complex cases). [3, 6, 7] Tranexamic acid (1-g bolus before surgical
incision followed by an infusion of 400 mg/hr during surgery) may be considered to reduce the amount
of postoperative mediastinal bleeding and the quantity of blood products used (ie, red blood cell and
fresh frozen plasma) [8]

Anesthesia

Cardiac surgery is most commonly performed under deep general endotracheal anesthesia.

Rarely used adjuncts make use of the following two forms of neuraxial blockade:

 Intrathecal opioid infusion

 Thoracic epidural anesthesia (generally a low-dose local anesthetic/opioid infusion)

Monitoring

In addition to the standard anesthetic monitoring (ECG, pulse oximetry, nasopharyngeal temperature,
urine output, gas analysis), specific monitoring requirements for cardiac surgery include the following:

 Invasive blood pressure

 Central venous access

 Transesophageal echocardiography (TEE)

 Neurologic monitoring

 Monitoring of bilateral cerebral saturations

 Pulmonary artery pressure monitoring with a Swan-Ganz catheter

Technique

Sites from which the conduit can be harvested include the following:

 Saphenous vein

 Left internal thoracic (mammary) artery (LITA)

  Radial artery

 Right internal thoracic (mammary) artery (RITA)

 Right gastroepiploic artery

 Inferior epigastric artery

 Short saphenous vein

 Cephalic vein and upper extremity vein

The usual incision used for CABG is a midline sternotomy (see the image below), although an anterior
thoracotomy for bypass of the LAD or lateral thoracotomy for marginal vessels may be used when an
off-pump procedure is being performed. Cardiopulmonary bypass, cardioplegic arrest, and placement of
the graft follows.

Alternative approaches to CABG include the following:

 Off-pump CABG
 Minimally invasive direct CABG (MIDCAB)
 Totally endoscopic CABG
 Hybrid technique (bypass plus stenting)
 Robotic-assisted CABG

Approach Considerations
The goal of coronary artery bypass grafting (CABG) is complete revascularization of the area of the
myocardium that is perfused by coronary arteries with a luminal stenosis of more than 50%. Several
methods may be used for this purpose. A durable conduit is vital for successful CABG. There are a
number of sites from which the conduit can be harvested, including the following:

 Saphenous vein

 Radial artery

 Left internal thoracic (mammary) artery (LITA)

 Right internal thoracic (mammary) artery (RITA)

 Right gastroepiploic artery

 Inferior epigastric artery

Harvesting of the Conduit

Saphenous vein

The great (long) saphenous vein (GSV) is located 2 cm anterior to the medial malleolus, traverses the
tibia, and ascends posteriorly up the tibial border before emptying into the femoral vein. It receives
numerous tributaries, notably at the knee, and contains 10-20 valves. Key associated structures are the
saphenous nerve, femoral cutaneous nerve, and saphenous branch of the genicular artery. The small
(short) saphenous vein (SSV) is located 1 cm posterior to the lateral malleolus, runs centrally up the
posterior calf, and drains into the popliteal vein.

As coronary artery bypass grafting (CABG) conduits, the saphenous veins have an 80-90% early
patency rate, which decreases to 50% at 10 years. The saphenous vein is generally acceptable as a
conduit in the absence of other vascular pathologies in the leg (varicosities in the vein, venous
insufficiency, previous deep vein thrombosis [DVT], or small lumen diameter) or overlying infection.

The GSV can be procured either via an open harvest technique (see the image below), starting from
either the ankle or groin and using a vein stripper, or via an endoscopic technique. Likewise, the SSV
vein can be harvested either with an open procedure or endoscopically.

Published experience comparing open vein harvest (OVH) with endoscopic vein harvest (EVH) suggests
decreased wound-related complications, improved patient satisfaction, shorter hospital stay, and reduced
postoperative pain at the harvest site following EVH. [50, 51, 52]  Vein trauma is minimized by constant
visualization, proper countertraction, and careful hemostasis. The available evidence predominantly
confirms that EVH is no worse than OVH at short- and mid-term follow-up. [53]

The legs and groin should be shaved, prepared, and draped in the operating room. Care should be taken
to avoid getting skin preparation solution on the diathermy plate; this can result in diathermy burns.
Once the anesthetist is ready for surgery to start and the surgeon has confirmed the number of lengths
(25 cm) of vein required, the vein harvest can begin.

Internal thoracic (mammary) artery

The left internal thoracic (mammary) artery (LITA) and the right internal thoracic (mammary) artery
(RITA) arise from their respective subclavian arteries. The internal thoracic (mammary) artery can be
harvested either by itself or as a pedicle (see the figure below).

Whereas the LITA is most commonly harvested as a pedicle, the RITA is generally skeletonized,
because an RITA pedicle may interfere with sternal wound healing. The LITA is useful in left anterior
descending (LAD) artery anastomosis and has a good patency rate in this setting (98% at 1 year and
90% at 10 years). The RITA has a good patency rate when anastomosed to the LAD (96% at 1 year and
90% at 5 years) but a reduced rate when grafted to the circumflex or the right coronary artery (75% at 1
year).

Cardiopulmonary bypass

The first step in cardiopulmonary bypass is to cannulate the aorta and right atrium. The aortic area
selected for cannulation must be soft and nonatherosclerotic. To insert the aortic cannula, unfractionated
heparin is given, and the systolic blood pressure is lowered to below 100 mm Hg. At this point, two
purse-string sutures are placed into the aorta, and the aortic adventitia within the diameter of the purse-
string sutures is divided. An aortotomy is performed with a scalpel, the cannula is placed, and the purse-
string sutures are tightened around it.

The aortic cannula is then secured to a rubber tourniquet with a heavy silk tie. Once in place, the cannula
is de-aired and connected to the arterial pump tubing, where its position in the aorta can be confirmed by
watching the pattern of tube filling. The venous cannula is inserted into the right atrial appendage in a
similar fashion, with the end of the cannula positioned in the inferior vena cava. Adequate
anticoagulation is confirmed by assessing the activated clotting time; once this is done, cardiopulmonary
bypass can be commenced.

The aorta is cross-clamped distal to the cannula, and cold cardioplegia solution is infused via the aortic
cannula (some centers also cool the patient). Retrograde cardioplegia may also be administered via the
coronary sinus, especially in the patient who is undergoing repeat CABGs and has few or no patent
grafts for adequate perfusion with antegrade cardioplegia. Compared with crystalloid cardioplegia,
blood cardioplegia is associated with a lower incidence of intraoperative mortality, postoperative
myocardial infarction, shock, and conduction defects.

Placement of graft

After the initiation of cardiopulmonary bypass, the distal coronary bypass targets are identified. As a
rule, anastomoses to the right coronary artery and the marginal branches of the circumflex artery are
completed first.

The circumflex argery is accessed by retracting the heart laterally, whereas the posterior descending
artery and posterolateral circulation are accessed by retracting the heart cephalically. The left internal
thoracic (mammary) artery (LITA) is then usually anastomosed to the LAD if possible. In rare
circumstances (eg, CABG performed for acute anterior myocardial infarction), a saphenous vein graft
may be placed to the LAD artery for expediency.

To accomplish the bypass, an incision is made in the distal coronary artery, and the conduit ostium is
sutured around the full circumference of the anastomosis (see the image below). The conduit is then
infused with cold cardioplegia solution, and the end is tied with a polypropylene suture. A very fine
monofilament suture, commonly 7-0 or 8-0, is used to complete the distal coronary anastomosis. Most
often, it is an end-to-side anastomosis as shown in the picture below. Often, we can construct a side-to-
side anastomosis when a sequential anastomosis was performed with the same conduit.

When all the distal anastomoses are completed, rewarming of the heart is initiated, the aortic cross-
clamp is removed, and a partially occluding clamp is placed on the ascending aorta where the grafts are
to be anastomosed. Holes are punched in the ascending aorta, secured by the partially occluded clamp,
and the proximal ends of the anastomoses are sutured into place in the aorta (see the image below).
Before the cross-clamp is finally removed, air is evacuated from the grafts and ascending aorta. The
patient is then weaned off the bypass.
When normal rhythm is resumed, the patient is once again mechanically ventilated and electrolyte
abnormalities (commonly hypomagnesemia and hypokalemia) are corrected. If the patient is bradycardic
or experiences temporary heart block, temporary pacing is performed using wires placed to the right
atrium and right ventricle. When cardiopulmonary bypass has been successfully stopped, protamine is
given to reverse the heparin. [54]

Alternative Approaches to Coronary Artery Bypass Grafting

Off-pump CABG

The key to off-pump coronary artery bypass grafting (OPCABG) is the maintenance of blood pressure,
heart rate, and normothermia (with the use of warming blankets). Preload must be optimized during
manipulation of the heart to minimize hemodynamic instability. A number of techniques can be used to
prevent hypotension, including prophylactic intravenous (IV) fluid infusion, use of the Trendelenburg
and reverse Trendelenburg positions, and low-dose alpha-agonist infusion. [55]

A systematic review did not demonstrate any significant benefit of (OPCABG) compared with on-pump
CABG (ONCABG) regarding mortality, stroke, or myocardial infarction. [56]

Totally endoscopic CABG

Endoscopic surgical techniques with robotic assistance were developed to enable the performance of
surgery in difficult spaces; they are widely used across most surgical disciplines. The specific
application of these techniques to the treatment of coronary artery disease (CAD) is known as totally
endoscopic CABG. Totally endoscopic CABG, which aims to decrease postoperative morbidity,
duration of hospital stay, and overall cost, allows surgeons to perform endoscopic surgery on both the
beating and arrested heart. [57]

The first step in totally endoscopic CABG is to deflate the lung. Next, three small incisions are made at
the intercostal spaces, through which one robotic arm with an attached endoscope and two arms carrying
surgical accessories are passed. These arms are controlled by the operator from a unit located away from
the operating table. Grafts are then harvested from suitable sites, and an anastomosis is completed across
the affected coronary artery. [58]

Hybrid technique

Advances in surgical techniques and introduction of drug-eluting stents have provided a platform for a
hybrid combined strategy that involves grafting the left anterior descending artery with the left internal
thoracic (mammary) artery and then stenting the other coronary territories with drug-eluting stents
instead of bypassing them with saphenous vein grafts.

Although preliminary data indicate that such a hybrid strategy may be a reasonable alternative for some
patients with multivessel coronary artery disease, the real clinical utility of this approach will not be
known until results of randomized clinical trials are available.
 D. Nursing Care Management After the procedure

Medication Summary
The aims of premedication are to minimize myocardial oxygen demands by reducing the heart rate and
systemic arterial pressure and to improve myocardial blood flow with vasodilators.

See the 2017 European Association for Cardio-Thoracic Surgery (EACTS) guidelines on perioperative
medication in adult cardiac surgery [68] for more information.

Anxiolytics, Benzodiazepines
Class Summary
Administration of temazepam immediately before CABG can decrease the risk of tachycardia and
hypertension resulting from anxiety regarding the operation. In the operating room, intravenous (IV)
administration of a small dose of midazolam before arterial line insertion can also reduce anxiety,
tachycardia, and hypertension.

Temazepam (Restoril)

Temazepam depresses all levels of the CNS (eg, limbic and reticular formation), possibly by increasing
the activity of GABA.

Midazolam

Midazolam is a short-acting benzodiazepine with a rapid onset of action.

Opioid Analgesics
Class Summary
Induction of anesthesia is accomplished by using high doses of opioid (usually fentanyl or remifentanil)
to minimize the dose of propofol, etomidate, or thiopental and thereby maximize cardiovascular
stability.

Fentanyl citrate (Duragesic, Abstral, Actiq, Fentora, Onsolis)

Fentanyl citrate is a synthetic opioid that has 75-200 times more potency and a much shorter half-life
than morphine sulfate. It has fewer hypotensive effects than morphine and is safer in patients with
hyperactive airway disease because of minimal or no associated histamine release. By itself, fentanyl
citrate causes little cardiovascular compromise, although the addition of benzodiazepines or other
sedatives may result in decreased cardiac output and blood pressure.

Fentanyl citrate is highly lipophilic and protein-bound. Prolonged exposure to it leads to accumulation
of the drug in fat and delays the weaning process. Consider continuous infusion because of the
medication's short half-life.

Remifentanil (Ultiva)

Remifentanil binds mu-opioid receptors at various sites within the CNS.

Anesthetic Agents
Class Summary
After standard monitoring equipment is attached and peripheral venous access achieved but before the
arterial line is inserted, the midazolam dose is administered. Before placement of the arterial line, it
should be ensured that a radial artery graft will not be used for CABG.

Propofol (Diprivan)
Propofol is a phenolic compound unrelated to other types of anticonvulsants. It has general anesthetic
properties when administered intravenously. Propofol IV produces rapid hypnosis, usually within 40
seconds. The effects are reversed within 30 minutes, following the discontinuation of infusion. Propofol
has also been shown to have anticonvulsant properties.

Etomidate (Amidate)

Amidate is a nonbarbiturate imidazole compound with sedative properties. It is short-acting and has a
rapid onset of action; the duration of action is dose dependent (15-30 minutes). Its most useful feature as
an induction agent is that it produces deep sedation while causing minimal cardiovascular effects.

The major application of amidate is induction for endotracheal intubation, particularly in patients with,
or at risk for, hemodynamic compromise. Amidate has been shown to depress adrenal cortical function;
however, this effect is not significant clinically during short-term administration. Since the drug is
mixed in propylene glycol, continuous infusion is not recommended.

Thiopental
Thiopental is a short-acting barbiturate sedative-hypnotic with rapid onset and a duration of action of 5-
20 minutes. Like methohexital, it is most commonly used as an induction agent for intubation. To use
thiopental as a sedative, titrate in dosage increments of 25 mg (adjust to lower dose in children).

Isoflurane (Forane, Terrell)

Isoflurane is an inhalation anesthetic. It may have a myocardial protective effect and therefore is
especially useful in off-pump surgery. Isofluranse potentiates the effects of muscle relaxants. Small
doses of muscle relaxants can achieve complete paralysis when administered concomitantly with
isoflurane.

Neuromuscular Blockers, Nondepolarizing

Class Summary
Nondepolarizing neuromuscular blockers are used in combination with a sedative as part of the rapid-
sequence intubation process.
Pancuronium

Vecuronium may increase myocardial oxygen demand. It is used to facilitate endotracheal intubation
and provide neuromuscular relaxation during intubation and mechanical ventilation. It is given as an
adjunct to a sedative or hypnotic agent.

Vecuronium

Vecuronium may cause bradycardia in association with opioids. It is used to facilitate endotracheal
intubation and provide neuromuscular relaxation during intubation and mechanical ventilation. It is
given as an adjunct to a sedative or hypnotic agent.

Rocuronium (Zemuron)

Rocuronium may cause tachycardia. It is used to facilitate endotracheal intubation and provide
neuromuscular relaxation during intubation and mechanical ventilation. It is given as an adjunct to a
sedative or hypnotic agent.

Atracurium

Atracurium is not considered suitable for operations of long duration. It can cause hypotension
secondary to histamine release. It is used to facilitate endotracheal intubation and provide neuromuscular
relaxation during intubation and mechanical ventilation. It is given as an adjunct to a sedative or
hypnotic agent.

Anticoagulants, Hematologic
Class Summary
Anticoagulants prevent recurrent or ongoing thromboembolic occlusion of the vertebrobasilar
circulation.

Heparin

Heparin augments the activity of antithrombin III and prevents conversion of fibrinogen to fibrin. It does
not actively lyse but is able to inhibit further thrombogenesis. It prevents the recurrence of a clot after
spontaneous fibrinolysis.

E. References/ Sources

1. [Guideline] Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA guideline for coronary
artery bypass graft surgery: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011
Dec 6. 124(23):e652-735. [Medline]. [Full Text].

2. [Guideline] Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA 2004 guideline update for
coronary artery bypass graft surgery: summary article: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to
Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation. 2004 Aug
31. 110(9):1168-76. [Medline]. [Full Text].

3. Chikwe J, Beddow E, Glenville B. Cardiothoracic Surgery. Oxford: Oxford University Press;

2006.

4. Euroscore Scoring System. Available at http://www.euroscore.org/euroscore_scoring.htm.

Accessed: March 24, 2011.

5. Shahian DM, O'Brien SM, Filardo G, et al, for the Society of Thoracic Surgeons Quality
Measurement Task Force. The Society of Thoracic Surgeons 2008 cardiac surgery risk models:
part 1--coronary artery bypass grafting surgery. Ann Thorac Surg. 2009 Jul. 88(1 Suppl):S2-22.
[Medline].

6. Mackay JH, Arrowsmith JE. Core Topics in Cardiac Anaesthesia. Cambridge: Cambridge
University Press; 2007.

7. Gothard J, Kelleher A, Haxby E. Cardiovascular and Thoracic Anaesthesia. Edinburgh:

Butterworth Heinemann; 2004.
8. Wang G, Xie G, Jiang T, et al. Tranexamic acid reduces blood loss after off-pump coronary
surgery: a prospective, randomized, double-blind, placebo-controlled study. Anesth Analg. 2012
Aug. 115(2):239-43. [Medline].

9. Benjamin EJ, Blaha MJ, Chiuve SE, et al, for the American Heart Association Statistics
Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2017 update:
a report from the American Heart Association. Circulation. 2017 Mar 7. 135(10):e146-e603.
[Medline]. [Full Text].

10. World Health Organisation. Cardiovascular diseases (CVDs). Fact sheet no 317. Available at
http://www.who.int/mediacentre/factsheets/fs317/en/. May 2017; Accessed: October 25, 2017.

11. van Domburg RT, Kappetein AP, Bogers AJ. The clinical outcome after coronary bypass
surgery: a 30-year follow-up study. Eur Heart J. 2009 Feb. 30(4):453-8. [Medline].

12. Konstantinov IE. The first coronary artery bypass operation and forgotten pioneers. Ann Thorac
Surg. 1997 Nov. 64(5):1522-3. [Medline].

13. Veterans Administration Coronary Artery Bypass Surgery Cooperative Study Group. Eleven-
year survival in the Veterans Administration randomized trial of coronary bypass surgery for
stable angina. N Engl J Med. 1984 Nov 22. 311(21):1333-9. [Medline].

14. Carrel A. On the experimental surgery of the thoracic aorta and heart. Ann Surg. 1910 Jul.
52(1):83-95. [Medline].

15. Vineberg AM. Restoration of coronary circulation by anastomosis. Can Med Assoc J. 1946 Aug.
55(2):117-9. [Medline]. [Full Text].

16. Vineberg AM, Jewett BL. Development of an anastomosis between the coronary vessels and a
transplanted internal mammary artery. Can Med Assoc J. 1947 Jun. 56(6):609-14. [Medline].
[Full Text].

17. Vineberg AM, Niloff PH. The value of surgical treatment of coronary artery occlusion by
implantation of the internal mammary artery into the ventricular myocardium; an experimental
study. Surg Gynecol Obstet. 1950 Nov. 91(5):551-61. [Medline].

18. Vineberg A. Evidence that revascularization by ventricular-internal mammary artery implants

increases longevity. Twenty-four year, nine month follow-up. J Thorac Cardiovasc Surg. 1975
Sep. 70(3):381-97. [Medline].

19. Mueller RL, Rosengart TK, Isom OW. The history of surgery for ischemic heart disease. Ann
Thorac Surg. 1997 Mar. 63(3):869-78. [Medline].

20. Endo M. [The history and evolution of coronary artery bypass grafting] [Japanese]. Nihon Geka
Gakkai Zasshi. 2000 Dec. 101(12):827-32. [Medline].
21. Carpentier A, Guermonprez JL, Deloche A, Frechette C, DuBost C. The aorta-to-coronary radial
artery bypass graft. A technique avoiding pathological changes in grafts. Ann Thorac Surg. 1973
Aug. 16(2):111-21. [Medline].

22. Kappetein AP, Head SJ. 50th anniversary landmark commentary on Carpentier A, Guermonprez
JL, Deloche A, Frechette C, DuBost C. The aorta-to-coronary radial artery bypass graft. Ann
Thorac Surg 1973;16:111-21. Ann Thorac Surg. 2015 May. 99(5):1500. [Medline].

23. Alexander JH, Smith PK. Coronary-artery bypass grafting. N Engl J Med. 2016 May 19.
374(20):1954-64. [Medline].

24. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary-artery graft on 10-
year survival and other cardiac events. N Engl J Med. 1986 Jan 2. 314(1):1-6. [Medline].

25. Yi G, Shine B, Rehman SM, Altman DG, Taggart DP. Effect of bilateral internal mammary
artery grafts on long-term survival: a meta-analysis approach. Circulation. 2014 Aug 12.
130(7):539-45. [Medline].

26. Tatoulis J, Buxton BF, Fuller JA, et al. Long-term patency of 1108 radial arterial-coronary
angiograms over 10 years. Ann Thorac Surg. 2009 Jul. 88(1):23-9; discussion 29-30. [Medline].

27. [Guideline] Windecker S, Kolh P, Alfonso F, et al. 2014 ESC/EACTS guidelines on myocardial
revascularization. Rev Esp Cardiol (Engl Ed). 2015 Feb. 68(2):144. [Medline]. [Full Text].

28. Sinning JM, Welz A, Nickenig G. [The heart team in planning and performance of
revascularization: ESC guidelines versus clinical routine] [German]. Herz. 2016 Nov. 41(7):562-
5. [Medline].

29. Sipahi I, Akay MH, Dagdelen S, Blitz A, Alhan C. Coronary artery bypass grafting vs
percutaneous coronary intervention and long-term mortality and morbidity in multivessel
disease: meta-analysis of randomized clinical trials of the arterial grafting and stenting era.
JAMA Intern Med. 2014 Feb 1. 174(2):223-30. [Medline].

30. Verma S, Farkouh ME, Yanagawa B, et al. Comparison of coronary artery bypass surgery and
percutaneous coronary intervention in patients with diabetes: a meta-analysis of randomised
controlled trials. Lancet Diabetes Endocrinol. 2013 Dec. 1(4):317-28. [Medline]. [Full Text].

31. O'Riordan M. CABG reduces risk of death vs PCI in diabetic patients. Medscape News from
WebMD. September 13, 2013. Available at http://www.medscape.com/viewarticle/810953.
Accessed: September 23, 2013.

32. Benedetto U, Amrani M, Bahrami T, et al, for the Harefield Cardiac Outcomes Research Group.
Survival probability loss from percutaneous coronary intervention compared with coronary
artery bypass grafting across age groups. J Thorac Cardiovasc Surg. 2015 Feb. 149(2):479-84.
[Medline].
33. Dalen M, Ivert T, Holzmann MJ, Sartipy U. Coronary artery bypass grafting in patients 50 years
or younger: a Swedish nationwide cohort study. Circulation. 2015 May 19. 131(20):1748-54.
[Medline].

34. Velazquez EJ, Lee KL, Jones RH, et al, for the STICHES Investigators. Coronary-artery bypass
surgery in patients with ischemic cardiomyopathy. N Engl J Med. 2016 Apr 21. 374(16):1511-
20. [Medline].

35. Posenau JT, Wojdyla DM, Shaw LK, et al. Revascularization strategies and outcomes in elderly
patients with multivessel coronary disease. Ann Thorac Surg. 2017 Jul. 104(1):107-15.
[Medline].

36. Pi Y, Roe MT, Holmes DN, et al. Utilization, characteristics, and in-hospital outcomes of
coronary artery bypass grafting in patients with ST-segment-elevation myocardial infarction:
results from the National Cardiovascular Data Registry Acute Coronary Treatment and
Intervention Outcomes Network Registry-Get With The Guidelines. Circ Cardiovasc Qual
Outcomes. 2017 Aug. 10(8):[Medline]. [Full Text].

37. Khan MR, Kayani WT, Ahmad W, et al. Meta-analysis of comparison of 5-year outcomes of
percutaneous coronary intervention versus coronary artery bypass grafting in patients with
unprotected left main coronary artery in the era of drug-eluting stents. Am J Cardiol. 2017 Nov
1. 120(9):1514-20. [Medline].

38. Kulik A. Quality of life after coronary artery bypass graft surgery versus percutaneous coronary
intervention: what do the trials tell us?. Curr Opin Cardiol. 2017 Nov. 32(6):707-14. [Medline].

39. Karim MN, Reid CM, Cochrane A, et al. Mortality risk prediction models for coronary artery
bypass graft surgery: current scenario and future direction. J Cardiovasc Surg (Torino). 2017
Dec. 58(6):931-42. [Medline].

40. Harskamp RE, Bagai A, Halkos ME, et al. Clinical outcomes after hybrid coronary
revascularization versus coronary artery bypass surgery: a meta-analysis of 1,190 patients. Am
Heart J. 2014 Apr. 167(4):585-92. [Medline].

41. Kikuchi K, Mori M. Less-invasive coronary artery bypass grafting international landscape and
progress. Curr Opin Cardiol. 2017 Nov. 32(6):715-21. [Medline].

42. Iqbal J, Widmer R, Gersh BJ. State of the art: optimal medical therapy - competing with or
complementary to revascularisation in patients with coronary artery disease?. EuroIntervention.
2017 Aug 25. 13(6):751-9. [Medline].

43. Kulik A, Ruel M, Jneid H, et al, for the American Heart Association Council on Cardiovascular
Surgery and Anesthesia. Secondary prevention after coronary artery bypass graft surgery: a
scientific statement from the American Heart Association. Circulation. 2015 Mar 10.
131(10):927-64. [Medline]. [Full Text].
44. Ward HB, Kelly RF. OPCAB vs CABG: who, what, when, where?. Chest. 2004 Mar.
125(3):815-6. [Medline].

45. Moller CH, Penninga L, Wetterslev J, Steinbruchel DA, Gluud C. Off-pump versus on-pump
coronary artery bypass grafting for ischaemic heart disease. Cochrane Database Syst Rev. 2012
Mar 14. CD007224. [Medline].

46. Dewey TM, Mack MJ. Myocardial revascularization without cardiopulmonary bypass. Cohn L.
Cardiac Surgery in the Adult. New York: McGraw-Hill; 2008. 633-54.

47. Chocron S, Vandel P, Durst C, et al. Antidepressant therapy in patients undergoing coronary
artery bypass grafting: the MOTIV-CABG trial. Ann Thorac Surg. 2013 May. 95(5):1609-18.
[Medline].

48. Brooks M. Antidepressant prior to bypass may reduce postop pain. Medscape Medical News
from WebMD. June 05, 2013. Available at http://www.medscape.com/viewarticle/805336.
Accessed: June 11, 2013.

49. Khoshgoftar Z, Ayat Esfahani F, Marzban M, et al. Comparison of compression stocking with
elastic bandage in reducing postoperative edema in coronary artery bypass graft patient. J Vasc
Nurs. 2009 Dec. 27(4):103-6. [Medline].

50. Deppe AC, Liakopoulos OJ, Choi YH, et al. Endoscopic vein harvesting for coronary artery
bypass grafting: a systematic review with meta-analysis of 27,789 patients. J Surg Res. 2013
Mar. 180(1):114-24. [Medline].

51. Kronick M, Liem TK, Jung E, Abraham CZ, Moneta GL, Landry GJ. Experienced operators
achieve superior patency and wound complication rates with endoscopic great saphenous vein
harvest compared with open harvest in lower extremity bypasses. J Vasc Surg. 2019 Nov.
70(5):1534-42. [Medline].

52. Luckraz H, Cartwright C, Nagarajan K, Kaur P, Nevill A. Major adverse cardiac and
cerebrovascular event and patients' quality of life after endoscopic vein harvesting as compared
with open vein harvest (MAQEH): a pilot study. Open Heart. 2018. 5(1):e000694. [Medline].
[Full Text].

53. Zenati MA, Bhatt DL, Bakaeen FG, et al, for the REGROUP Trial Investigators. Randomized
trial of endoscopic or open vein-graft harvesting for coronary-artery bypass. N Engl J Med. 2019
Jan 10. 380(2):132-41. [Medline]. [Full Text].

54. Parolari A, Alamanni F, Cannata A, et al. Off-pump versus on-pump coronary artery bypass:
meta-analysis of currently available randomized trials. Ann Thorac Surg. 2003 Jul. 76(1):37-40.
[Medline].
55. Song HK, Puskas JD. Off-pump coronary artery bypass surgery. Kaiser LR, Kron IL, Spray TL,
eds. Mastery of Cardiothoracic Surgery. 2nd ed. Philadelphia: Lippincott Williams & Wilkins;
2006.

56. Moller CH, Penninga L, Wetterslev J, Steinbruchel DA, Gluud C. Off-pump versus on-pump
coronary artery bypass grafting for ischaemic heart disease. Cochrane Database Syst Rev. 2012
Mar 14. 3:CD007224. [Medline].

57. Bonatti J, Schachner T, Bonaros N, et al. Technical challenges in totally endoscopic robotic
coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2006 Jan. 131(1):146-53. [Medline].

58. Mishra YK, Wasir H, Sharma KK, Mehta Y, Trehan N. Totally endoscopic coronary artery
bypass surgery. Asian Cardiovasc Thorac Ann. 2006 Dec. 14(6):447-51. [Medline].

59. Gongora E, Sundt TM III. Myocardial revascularization with cardiopulmonary bypass. Cohn LH,
ed. Cardiac Surgery in the Adult. 3rd ed. New York: McGraw-Hill; 2008. 599-632. [Full Text].

60. Roach GW, Kanchuger M, Mangano CM, et al. Adverse cerebral outcomes after coronary
bypass surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia
Research and Education Foundation Investigators. N Engl J Med. 1996 Dec 19. 335(25):1857-
63. [Medline].

61. Higgins R, Perez-Tamayo RA. Coronary artery bypass grafting using cardiopulmonary bypass.
Kaiser LR, Kron IL, Spray TL, eds. Mastery of Cardiothoracic Surgery. 2nd ed. Philadelphia:
Lippincott Williams & Wilkins; 2007.

62. [Guideline] Authors/Task Force members; Windecker S, Kolh P, Alfonso F, et al. 2014
ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial
Revascularization of the European Society of Cardiology (ESC) and the European Association
for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European
Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014 Oct 1.
35(37):2541-619. [Medline].

63. [Guideline] Fihn SD, Blankenship JC, Alexander KP, et al. 2014
ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and
management of patients with stable ischemic heart disease: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines, and the American
Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for
Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation.
2014 Nov 4. 130(19):1749-67. [Medline]. [Full Text].

64. [Guideline] 2012 Writing Committee Members; Jneid H, Anderson JL, Wright RS, et al, for the
ACC Foundation, AHA Task Force on Practice Guidelines. 2012 ACCF/AHA focused update of
the guideline for the management of patients with unstable angina/Non-ST-elevation myocardial
infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the
 American College of Cardiology Foundation/American Heart Association Task Force on practice
guidelines. Circulation. 2012 Aug 14. 126(7):875-910. [Medline]. [Full Text].

65. [Guideline] Amsterdam EA, Wenger NK, Brindis RG, et al, for the ACC/AHA Task Force
Members. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation
acute coronary syndromes: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. Circulation. 2014 Dec 23. 130(25):e344-426.
[Medline]. [Full Text].

66. [Guideline] Sousa-Uva M, Storey R, Huber K, et al, for the ESC Working Group on
Cardiovascular Surgery and ESC Working Group on Thrombosis. Expert position paper on the
management of antiplatelet therapy in patients undergoing coronary artery bypass graft surgery.
Eur Heart J. 2014 Jun 14. 35(23):1510-4. [Medline]. [Full Text].

67. [Guideline] Ferraris VA, Saha SP, Oestreich JH, et al, for the Society of Thoracic Surgeons.
2012 update to the Society of Thoracic Surgeons guideline on use of antiplatelet drugs in patients
having cardiac and noncardiac operations. Ann Thorac Surg. 2012 Nov. 94(5):1761-81.
[Medline].

68. [Guideline] Sousa-Uva M, Head SJ, Milojevic M, et al. 2017 EACTS guidelines on perioperative
medication in adult cardiac surgery. Eur J Cardiothorac Surg. 2018 Jan 1. 53(1):5-33. [Medline].
[Full Text].

69. Gheorghiade M, Bonow RO. Chronic heart failure in the United States: a manifestation of
coronary artery disease. Circulation. 1998 Jan 27. 97(3):282-9. [Medline].

70. Varnauskas E. Twelve-year follow-up of survival in the randomized European Coronary Surgery
Study. N Engl J Med. 1988 Aug 11. 319(6):332-7. [Medline].

71. Busko M. CABG trumps PCI for survival in CAD even without diabetes. Medscape Medical
News by WebMD. December 2, 2013. Available at
http://www.medscape.com/viewarticle/815245. Accessed: December 10, 2013.

72. Katz MH. Evolving treatment options in coronary artery disease. JAMA Intern Med. 2014 Feb 1.
174(2):231. [Medline].

73. Poi MJ, Echeverria A, Lin PH. Contemporary management of patients with concomitant
coronary and carotid artery disease. World J Surg. 2018 Jan. 42(1):272-82. [Medline].

74. Badri M, Abdelbaky A, Li S, Chiswell K, Wang TY. Precatheterization use of P2Y12 inhibitors
in non-ST-elevation myocardial infarction patients undergoing early cardiac catheterization and
in-hospital coronary artery bypass grafting: insights from the National Cardiovascular Data
Registry. J Am Heart Assoc. 2017 Sep 22. 6(9):[Medline]. [Full Text].
 75. [Guideline] Aldea GS, Bakaeen FG, Pal J, et al, for the Society of Thoracic Surgeons. The
Society of Thoracic Surgeons Clinical Practice Guidelines on Arterial Conduits for Coronary
Artery Bypass Grafting. Ann Thorac Surg. 2016 Feb. 101(2):801-9. [Medline].

IV. Pacemakers / Implantable Devices

A pacemaker is an electronic device, approximately the size of a pocket watch, that senses intrinsic heart rhythms
and provides electrical stimulation when indicated.

A. Indication for the 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, but 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. [5] For further details on the following indications, see the ACC/AHA/HRS
2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities.

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

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

Contraindications
Contraindications for permanent pacemaker insertion include the following:

 Local infection at implantation site

 Active systemic infection with bacteremia

 Severe bleeding tendencies (relative contraindication)

 Active anticoagulation therapy (relative contraindication)

  Severe lung disease and positive end-expiratory pressure ventilation (relative contraindication for
internal jugular and subclavian access)

Technical Considerations
Procedural planning

Cardiac pacing can be either temporary or permanent. Temporary pacing may be accomplished
transcutaneously (ie, placing 2 external pacing pads over the chest wall in the anteroposterior or
anterolateral location) or via transvenous placement of a temporary pacing wire in one or more of the
right heart chambers. In a patient who has recently undergone cardiac surgery, temporary epicardial
leads are often placed and removed before the patient is discharged from the hospital. [6]

Permanent pacing is most commonly accomplished through transvenous placement of leads to the
endocardium (ie, right atrium or ventricle) or epicardium (ie, to the left ventricular surface via the
coronary sinus), which are subsequently connected to a pacing generator placed subcutaneously in the
infraclavicular region. In a patient without appropriate venous access, epicardial leads can be placed via
a thoracotomy and tunneled subcutaneously to the pacing generator.

Complication prevention

Multiple studies have shown that infection rates can be reduced by employing maximal sterile-barrier
precautions, including mask, cap, sterile gown, sterile gloves, and large sterile drape.

Subclavian artery injury may occur during subclavian vein access, carotid artery puncture during jugular
vein access, and femoral artery puncture during femoral vein access. The subclavian artery cannot be
compressed; accordingly, the subclavian approach should be avoided in anticoagulated patients.

An air embolism may be caused by negative intrathoracic pressure during inspiration by the patient,
which sucks air into an open line hub. Be sure the line hubs are always occluded. Placing the patient in
the Trendelenburg position lowers the risk of this complication.

If air embolism occurs, the patient should be placed in the Trendelenburg position with a left lateral
decubitus tilt; this may prevent the movement of air into the right ventricle and onward into the left side
of the heart. In addition, 100% oxygen should be administered to speed resorption of the air. If a catheter
is located in the heart, aspiration of the air should be attempted.

Dysrhythmia is due to mechanical irritation of the heart by the wire or catheter tip. It can usually be
terminated by simply withdrawing the equipment into the superior vena cava. Placing a central venous
catheter without a cardiac monitor is unwise.

If the clinician is not conscientious about maintaining control of the guide wire, it may be inadvertently
inserted fully into the vein and have to be retrieved.

Patients who are allergic to antibiotics may experience anaphylaxis upon insertion of an antibiotic-
impregnated catheter.
B. Patient required preparation for the procedure

Equipment
Equipment required for permanent pacemaker insertion includes the following:

 Fluoroscope

 Instrument tray

 Pacing system analyzer

 Introducer kit

 1-2% lidocaine or bupivacaine

 Antimicrobial flush and saline for pocket irrigation

 Emergency crash cart with medications

 Battery or electric cautery

 Suture material

 External pacemaker/defibrillator

Fluoroscopy and electrocardiography (ECG) are essential. Single-plane fluoroscopy using

anteroposterior, 30° right anterior oblique, and 45° left anterior oblique views usually suffices for
transvenous implantation from either the right or the left pectoral approach. High-resolution digital C-
arm fluoroscopy is generally needed for implants performed in the operating room (OR). Currently,
initial lead sensing and capture measurements are obtained by system analyzers, which may be
freestanding or built into the pacer programmer.

Instrument requirements vary with surgical preferences. A minivascular tray from the OR provides an
excellent starting point and can be modified as needed. Suture materials include both nonabsorbable
material for lead and device anchoring and absorbable material for pocket closure. Antimicrobial flush
and saline for pocket irrigation should be available. If phlebography is to be performed, an appropriate
intravenous (IV) contrast agent must be available.

Pacemaker/defibrillator

Although pacemaker leads from different manufacturers vary significantly, they can be classified into 1
of 2 types on the basis of the fixation mechanism at the tip:
  Active fixation with a screw

 Passive fixation with tines

The pacemaker battery usually lasts about 6-12 years, depending on type, programming, frequency of
use, and lead characteristics. When the battery is depleted, the pulse generator must be replaced. The
previously placed leads can be used if they are functioning properly.

Patient Preparation
Anesthesia

Implantation of pacing systems usually involves a combination of local anesthesia and conscious
sedation. Infiltration of skin and subcutaneous tissue at the implant site with 1-2% lidocaine or
bupivacaine provides sufficient local anesthesia for the majority of implant procedures. Conscious
sedation may be administered in the form of carefully titrated IV midazolam and fentanyl by trained and
qualified personnel. On rare occasions, general anesthesia may be required in an extremely
uncooperative or high-risk patient.

Positioning

The patient is usually positioned on his or her back, with the arms tucked. If air embolism occurs, the
patient should be placed in the Trendelenburg position with a left lateral decubitus tilt; this may prevent
the movement of air into the right ventricle and onward into the left side of the heart.

Monitoring and Follow-Up

Patients should plan to have someone drive them home after discharge.

Routine oral antibiotics should be continued for 3-10 days after the time of discharge. Discharge
medications must be optimized after pacemaker implantation, especially atrioventricular blocking
medications.

The method and frequency of pacemaker checkup are determined by the physician involved in
pacemaker follow-up care and are based on the individual patient’s needs, the type of pacemaker used,
and any underlying medical conditions present.

Medicare-allowed pacemaker checks are as follows:

 Single-chamber pacemakers - 2 pacemaker checks in the first 6 months after insertion, then 1
every 12 months or during any pacer malfunction

 Dual-chamber pacemakers - 2 pacemaker checks in the first 6 months after insertion, then 1
every 6 months or during any pacer malfunction
There is a 90-day global period for pacemaker insertion; as a rule, any pacer checks during that time are
included in the global period.

Pacemakers can be followed via transtelephonic monitoring or remotely via wireless technology.
Although these technologies provide some comfort to the patient, they offer only limited interrogation
data and pacemaker information to the monitoring physician. One of the disadvantages of remote
monitoring is that it does not permit programming or changes to the pacemaker.

C. How the procedure was performed

Approach Considerations
Permanent pacemaker insertion is considered a minimally invasive procedure. Transvenous access to the
heart chambers under local anesthesia is the favored technique, most commonly via the subclavian vein,
the cephalic vein, or (rarely) the internal jugular vein or the femoral vein. The procedure is typically
performed in a cardiac catheterization laboratory or in an operating room (OR).

The pacing generator is typically placed subcutaneously in the infraclavicular region. Occasionally,
pacemaker leads are implanted surgically via a thoracotomy, and the pacing generator is placed in the
abdominal area. Single-chamber and dual-chamber pacer insertion can be accomplished from either left
or right pectoral sites. After appropriate sedation, the chest is prepared with an antiseptic solution, and
the area is covered with sterile drapes to keep the incision area as clean as possible.

In current practice, antibiotic prophylaxis is standard for device implantation. Preoperative antibiotic use
reduces the risk of pacemaker-related infections by approximately 80%. [8, 9]

Implantation of Pacemaker
Routinely, cefazolin 1 g is administered intravenously (IV) 1 hour before the procedure. If the patient is
allergic to penicillins or cephalosporins, vancomycin 1 g IV or another appropriate antibiotic may be
administered preoperatively.

Venous access

A central vein (ie, the subclavian, internal jugular, or axillary vein) is accessed via a percutaneous
approach. In patients in whom this is technically difficult because skeletal landmarks are deviated, an
initial brief fluoroscopic examination will greatly reduce the time and complications associated with
obtaining the access.

The subclavian vein is typically accessed at the junction of the first rib and the clavicle. On occasion,
phlebography may be required to visualize the vein adequately or to confirm its patency. Some centers
employ the first rib approach under fluoroscopy, with no or minimal incidence of pneumothorax.
After venous access is obtained, a guide wire is advanced through the access needle, and the tip of the
guide wire is positioned in the right atrium or the venacaval area under fluoroscopy. The needle is then
withdrawn, leaving the guide wire in place. If indicated, a second access will be obtained in a similar
fashion for positioning of a second guide wire.

Sometimes, a double-wire technique is used, whereby 2 guide wires are inserted through the first sheath
and the sheath then withdrawn, so that 2 separate sheaths can be advanced over the 2 guide wires. This
technique can cause some resistance or friction during sheath or lead advancement.

Creation of pocket

A 1.5- to 2-inch incision is made in the infraclavicular area parallel to the middle third of the clavicle,
and a subcutaneous pocket is created with sharp and blunt dissection where the pacemaker generator
will be implanted. Some physicians prefer to make the pocket first and obtain access later through the
pocket or via venous cutdown; once access is obtained, they position the guide wires as described above.

Placement of lead(s)

Over the guide wire, a special peel-away sheath and dilator are advanced. The guide wire and dilator are
withdrawn, leaving the sheath in place. A stylet (a thin wire) is inserted inside the center channel of the
pacemaker lead to make it more rigid, and the lead-stylet combination is then inserted into the sheath
and advanced under fluoroscopy to the appropriate heart chamber. Usually, the ventricular lead is
positioned before the atrial lead to prevent its dislodgment.

Making a small curve at the tip of the stylet renders the ventricular lead tip more maneuverable, so that it
can more easily be placed across the tricuspid valve and positioned at the right ventricular apex.
Techniques for positioning the ventricular lead have been described. [10, 11]

Once correct lead positioning is confirmed, the lead is affixed to the endocardium either passively with
tines (like a grappling hook) or actively via a helical screw located at the tip. The screw at the tip of the
pacemaker is extended or retracted by turning the outer end of the lead with the help of a torque device.
Adequate extension of the screw is confirmed with fluoroscopy. Each manufacturer has its own
proprietary identification marks for confirming adequate extension of the screw.

Once the lead is secured in position, the introducing sheath is carefully peeled away, leaving the lead in
place. After the pacing lead stylet is removed, pacing and sensing thresholds and lead impedances are
measured with a pacing system analyzer, and pacing is performed at 10 V to make sure that it is not
causing diaphragmatic stimulation. After confirmation of lead position and thresholds, the proximal end
of the lead is secured to the underlying tissue (ie, pectoralis) with a nonabsorbable suture that is sewn to
a sleeve located on the lead.

If a second lead is indicated, it is positioned in the right atrium via a second sheath, with the lead tip
typically positioned in the right atrial appendage with the help of a preformed J-shaped stylet.

In a patient who is without an atrial appendage as a result of previous cardiac surgery, the lead can be
positioned medially or in the lateral free wall of the right atrium. As with the ventricular lead, the atrial
lead position is confirmed, impedance is assessed, the stylet is withdrawn, and the lead is secured to the
underlying pectoralis with a nonabsorbable suture.

Positioning of pulse generator

When the leads have been properly positioned and tested and sutured to the underlying tissue, the
pacemaker pocket is irrigated with antimicrobial solution, and the pulse generator is connected securely
to the leads. Many physicians secure the pulse generator to underlying tissue with a nonabsorbable
suture to prevent migration or twiddler syndrome.

Typically, the pacemaker is positioned superficial to the pectoralis, but occasionally, a subpectoral or
inframammary position is required. After hemostasis is confirmed, a final look under fluoroscopy before
closure of the incision is recommended to confirm appropriate lead positioning.

Completion and closure

The incision is closed in layers with absorbable sutures and adhesive strips. Sterile dressing is applied to
the incision surface. An arm restraint or immobilizer is applied to the unilateral arm for 12-24 hours to
limit movement.

A postoperative chest radiograph is usually obtained to confirm lead position and rule out
pneumothorax. Before discharge on the following day, posteroanterior and lateral chest radiographs will
be ordered again to confirm lead positions and exclude delayed pneumothorax.

Pain levels are typically low after the procedure, and the patient can be given pain medication to manage
breakthrough pain associated with the incision site.

Complications
Access-related complications

Early access-related complications include the following:

 Bleeding
 Hematoma
 Phlebitis or thrombophlebitis of the vein
 Local infection
 Arterial injury or puncture
 Hemothorax
 Pneumothorax
 Catheter-related thrombosis (which may lead to pulmonary embolism)
 Air embolism
 Dysrhythmias
 Atrial wall puncture from guide wire (which may lead to pericardial tamponade)
 Lost guide wire
  Anaphylaxis
 Chylothorax (possible with left-side lead insertion)

A study by Armaganijan et al reported that age is a factor in early postimplant complications, with
elderly patients (older than 75 years) having an increased risk of pneumothorax and both atrial and
ventricular lead dislodgement/loss of capture. [12]

Late access-related complications include the following:

 Chylothorax
 Hematoma
 Venous thrombosis or occlusion
 Phlebitis
 Atrioventricular fistula
 Hemothorax
 Infection

Pocket-related complications

Early pocket-related complications include the following:

 Swelling
 Hematoma
 Bruising and local pain
 Infection

Late pocket-related complications include the following:

 Pocket erosion
 Pocket infection
 Chronic pain at the site

Lead-related complications

Early lead-related complications include the following:

 Atrial or ventricular arrhythmias

 Chamber perforation [13]
 Pneumothorax and pneumopericardium (with an atrial lead)
 Intercostal or diaphragm pacing
 Pectoral muscle stimulation
 Lead dislodgement
 Tricuspid valve laceration
 Cardiac tamponade
  Pericardial friction rub
 Hypotension
 Bleeding

Late lead-related complications include the following:

 Infection of pacer lead

 Endocarditis
 Systemic infection
 Perforation
 Access vein thrombosis
 Inferior vena cava thrombus
 Pectoral muscle stimulation
 Right atrial thrombus
 Loss of capture and sensing
 Tricuspid regurgitation
 Lead fracture
 Intercostal or diaphragm pacing

Pacemaker generator–related complications

Early pacemaker generator – related complications include the following:

 Infection
 Malfunction, including undersensing, oversensing, loss of capture, loss of output, inappropriate
rate, inappropriate mode, pulse generator failure, pacemaker-mediated tachycardia, and
pacemaker syndrome [14]

Late pacemaker generator – related complications include the following:

 Twiddler syndrome
 Pacemaker infection
 Pacer malfunction [14]
 Allergy or sensitivity to the device materials

Pacemaker device infection

Cardiac device infections can lead to longer hospital stays, increased costs, and higher mortalities . If
they are detected and treated at an early stage, device extraction may be avoided and patient morbidity
and mortality significantly reduced.

Pacemaker infections may be divided into 2 general types on the basis of the initial source of infection:

 Primary infections - The device or pocket itself is the source of infection, usually because of
contamination at the time of implantation
  Secondary infection - The leads, device, and the pocket are seeded by bacteremia derived from a
different source

Overall device infection rates range from 0.68-2.2%. [15, 16, 17, 18, 19] Independent risk factors for cardiac
device infection have been identified. These include the following:

 Pulse generator replacement

 Dual- or triple-chamber device implantation [16]
 Advanced patient age (older than 60 years) [19]
 Renal dysfunction
 Oral anticoagulation [18]

Complete device system extraction (either percutaneously or intraoperatively), antimicrobial therapy of

appropriate duration, and reimplantation of a new pacing system at a different site are the current
methods of treatment for device infection. The majority of patients discharged after such treatment will
be free of infection. [20]

Other complications

The patient may experience reactions to either a local anesthetic or an IV sedative. Radiation skin burns
have been reported to occur as a result of prolonged fluoroscopy in technically difficult cases.

Cardiac Resynchronization Therapy

Cardiac resynchronization therapy (CRT), also referred to as biventricular pacing or multisite ventricular
pacing, is a component of modern heart failure therapy for qualified patients. In CRT, there is a coronary
sinus lead for left ventricular epicardial pacing in addition to a conventional right ventricular endocardial
lead. By simultaneously pacing the right and left ventricles, CRT reduces the ventricular dyssynchrony
that is frequently present in patients with ventricular dilatation or conduction system defect.

CRT can involve either pacing (CRT-P) or defibrillation (CRT-D). The following discussion focuses on
CRT-P.

CRT is recommended for patients with a left ventricular ejection fraction less than 35%, a QRS duration
longer than 120 msec, sinus rhythm, and New York Heart Association (NYHA) functional class III or
ambulatory class IV heart failure symptoms with optimal medical therapy. [5] Trials suggest that CRT
may also reduce morbidity and mortality in patients with mildly symptomatic heart failure.
Consequently, the 2010 European guidelines and updated 2012 ACC/AHA/HRS guidelines now
recommend CRT for the NYHA class II patient population. [21, 22] The ACC/AHA/HRS guidelines also
now indicate CRT for patients with left-bundle-branch block with a QRS duration that is greater than or
equal to 150 ms. [22]

Biventricular pacing has been effective in improving symptoms and quality of life, reducing heart failure
hospitalizations, and reducing mortality because of its ability to achieve the following results:
  Reduction in ventricular electromechanical delay
 Improved ventricular function
 Reduced metabolic costs
 Improved functional mitral regurgitation
 Favorable remodeling
 Reduction of cardiac chamber dimensions
 Improved exercise capacity

Factors that influence the responsiveness of patients to CRT or that are used to identify patients who will
be responsive to CRT include the following:

 QRS complex duration

 Ventricular dyssynchrony (by echocardiography)
 Successful lead placement
 Physiologic atrioventricular delay

CRT requires left ventricular lateral wall pacing, which is achieved by placement of an epicardial lead
via the coronary sinus. Multiple-guide catheter systems are available for coronary sinus cannulation,
with most designs favoring a left pectoral approach. Coronary sinus phlebography facilitates placement
by demonstrating vessel size, position, and angulation. Left anterior oblique and right anterior oblique
projections are obtained with cine recording during injection of 10-15 mL of contrast in the coronary
sinus.

A guide wire is inserted through the catheter positioned in the coronary sinus and maneuvered to the
target venous branch. The coronary sinus lead is advanced over the guide wire into the desired branch of
the coronary venous system.

The guide wire and guide catheter are withdrawn, leaving the coronary sinus lead in place. After
acceptable thresholds and impedance are ensured, the lead is secured to the pectoralis with a
nonabsorbable suture.

Identifying ideal sites for biventricular pacing has proven elusive when the criteria of latest epicardial
activation, cumulative biventricular-paced QRS width, and empiric placement on the posterolateral wall
are employed. Micromanometer recordings of the first derivative of left ventricular pressure (dP/dt) and
3-dimensional echocardiographic wall motion analysis provide superior information regarding lead site
placement, but they are not widely used in clinical settings.

Frequently encountered difficulties include problems in cannulating the coronary sinus, acute angulation
of the target venous vessels, and the absence of suitably sized veins in the left ventricular pacing region
of interest. Right pectoral positioning of the biventricular pacing leads is more difficult in the presence
of right subclavian–superior venacaval angulation and frequently requires the use of a deflectable guide
catheter.

Medication Summary
The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Antibiotics, Other
Class Summary
Routinely, cefazolin 1 g is administered intravenously (IV) 1 hour before the procedure. If the patient is
allergic to penicillins or cephalosporins, vancomycin 1 g IV or another appropriate antibiotic may be
administered preoperatively.

Cefazolin

 View full drug information

Cefazolin is a first-generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis,
inhibiting bacterial growth.

Vancomycin

 View full drug information

Vancomycin is a potent antibiotic that is directed against gram-positive organisms and that is active
against Enterococcus species. It is useful in the treatment of septicemia and skin structure infections.
Vancomycin is indicated for patients who cannot receive or have not responded to penicillins and
cephalosporins and for patients who have infections with resistant staphylococci.

Local Anesthetics, Amides

Class Summary
Local anesthetics block the initiation and conduction of nerve impulses.Anesthetics used for the
permanent pacemaker insertion include bupivacaine and lidocaine.
Bupivacaine (Marcaine)

 View full drug information

Bupivacaine decreases permeability to sodium ions in neuronal membranes. This results in the inhibition
of depolarization, blocking the transmission of nerve impulses.

Lidocaine (Xylocaine)

Lidocaine is an amide local anesthetic used in 1-2% concentration. The 1% preparation contains 10 mg
of lidocaine for each 1 mL of solution; the 2% preparation contains 20 mg of lidocaine for each 1 mL of
solution. Lidocaine inhibits depolarization of type C sensory neurons by blocking sodium channels.

To improve local anesthetic injection, cool the skin with ethyl chloride before injection. Use smaller-
gauge needles (eg, 27 gauge or 30 gauge). Make sure the solution is at body temperature. Infiltrate very
slowly to minimize the pain. The time from administration to onset of action is 2-5 minutes, and the
effect lasts for 1.5-2 hours.

D. Nursing Care Management After the procedure

E. References/ Sources

1. Zhan C, Baine WB, Sedrakyan A, Steiner C. Cardiac device implantation in the United States
from 1997 through 2004: a population-based analysis. J Gen Intern Med. 2008 Jan. 23 Suppl
1:13-9. [Medline].

2. Aquilina O. Brief history of cardiac pacing. Images Paediatr cardiol. 2006. 27:17-81.

3. Baddour LM, Epstein AE, Erickson CC, Knight BP, Levison ME, Lockhart PB. Update on
cardiovascular implantable electronic device infections and their management: a scientific
 statement from the American Heart Association. Circulation. 2010 Jan 26. 121(3):458-77.
[Medline].

4. Vardas PE, Auricchio A, Blanc JJ, Daubert JC, Drexler H, Ector H. Guidelines for cardiac
pacing and cardiac resynchronization therapy: The Task Force for Cardiac Pacing and Cardiac
Resynchronization Therapy of the European Society of Cardiology. Developed in collaboration
with the European Heart Rhythm Association. Eur Heart J. 2007 Sep. 28(18):2256-95.
[Medline].

5. Epstein AE, DiMarco JP, Ellenbogen KA, Estes NA 3rd, Freedman RA, Gettes LS.
ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities:
a report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline
Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) developed in
collaboration with the American Association for Thoracic Surgery and Society of Thoracic
Surgeons. J Am Coll Cardiol. 2008 May 27. 51(21):e1-62. [Medline].

6. Batra AS, Balaji S. Post operative temporary epicardial pacing: When, how and why?. Ann
Pediatr Cardiol. 2008 Jul. 1(2):120-5. [Medline]. [Full Text].

7. Bernstein AD, Daubert JC, Fletcher RD, et al. The revised NASPE/BPEG generic code for
antibradycardia, adaptive-rate, and multisite pacing. North American Society of Pacing and
Electrophysiology/British Pacing and Electrophysiology Group. Pacing Clin Electrophysiol.
2002. 25:260.

8. de Oliveira JC, Martinelli M, D'Orio Nishioka SA, et al. Efficacy of antibiotic prophylaxis
before the implantation of pacemakers and cardioverter-defibrillators: Results of a large,
prospective, randomized, double-blind, placebo-controlled trial. Circ Arrhythmia Electrophysiol.
2009. 2:29-34.

9. Costa AD, Kirkorian G, Cucherat M, etal. . Meta-analysis of Antibiotic prophylaxis for

Permanent Pacemaker Implantation A meta-Analysis Circulation. Circulation. 1998. 97:1796-
1801.

10. Rajappan K. Permanent pacemaker implantation technique: part I: arrhythmias. Heart. 2009
Mar. 95(3):259-64. [Medline].

11. Rajappan K. Permanent pacemaker implantation technique: part II. Heart. 2009 Feb. 95(4):334-
42. [Medline].

12. Armaganijan LV, Toff WD, Nielsen JC, Andersen HR, Connolly SJ, Ellenbogen KA, et al. Are
Elderly Patients at Increased Risk of Complications Following Pacemaker Implantation? A
Meta-Analysis of Randomized Trials. Pacing Clin Electrophysiol. 2012 Feb. 35(2):131-134.
[Medline].
 13. Hayes DL, Friedman PA. Implantation-related Complications. Cardiac pacing, Defibrillation
and Resynchronization. A Clinical Approach. 2nd. Wiley-Blackwell; 2008. Chapter 6.

14. Yarlagadda C. Pacemaker malfunction. February 18, 2009. [Full Text].

15. Klug D, Balde M, Pavin D, Hidden-Lucet F, Clementy J, Sadoul N. Risk factors related to
infections of implanted pacemakers and cardioverter-defibrillators: results of a large prospective
study. Circulation. 2007 Sep 18. 116(12):1349-55. [Medline].

16. Nery PB, Fernandes R, Nair GM, Sumner GL, Ribas CS, Menon SM. Device-related infection
among patients with pacemakers and implantable defibrillators: incidence, risk factors, and
consequences. J Cardiovasc Electrophysiol. 2010 Jul. 21(7):786-90. [Medline].

17. Margey R, McCann H, Blake G, etal. Contemporary management of and outcomes from cardiac
device related infections. Europace. 2010 Jan. 12(1):64-70. [Medline].

18. Lekkerkerker J, van Nieuwkoop C, Trines S, van der Bom J, Bernards A. Risk factors and time
delay associated with cardiac device infections: Leiden device registry. Heart. 2009. 95:715-20.

19. Cengiz M, Okutucu S, Oscioglu S, Sahin A, Aksoy H. Device-related infection among patients
with pacemakers and implantable defibrillators: incidence, risk factors, and consequences. Clin
Cardiol. 2010/07. 33(7):406-11.

20. Sohail S, Uslan D, Khan A, etal. Management and Outcome of Permanent Pacemaker and
Implantable Cardioverter-Defibrillator Infections. J Am Coll Cardiol. 2007. 49(18):1851-59.

21. Steffel J, Holzmeister J, Abraham WT. Recent advances in cardiac resynchronization therapy.
Postgrad Med. 2011 Mar. 123(2):18-26. [Medline].

22. Tracy CM, Epstein AE, Darbar D, Dimarco JP, Dunbar SB, Estes NA 3rd, et al. 2012
ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac
Rhythm Abnormalities: A Report of the American College of Cardiology Foundation/American
Heart Association Task Force on Practice Guidelines. Circulation. 2012 Sep 10. [Medline].

V. Cardiac Ablation

Cardiac ablation is a procedure that is used to scar small areas in your heart that may be involved in your
heart rhythm problems. This can prevent the abnormal electrical signals or rhythms from moving
through the heart.

During the procedure, small wires called electrodes are placed inside your heart to measure your heart's
electrical activity. When the source of the problem is found, the tissue causing the problem is destroyed.
A. Indication for the procedure

Why the Procedure is Performed

Cardiac ablation is used to treat certain heart rhythm problems that medicines are not controlling. These
problems may be dangerous if they are not treated.

Common symptoms of heart rhythm problems may include:

 Chest pain
 Fainting
 Slow or fast heartbeat (palpitations)
 Lightheadedness, dizziness
 Paleness
 Shortness of breath
 Skipping beats -- changes in the pattern of the pulse
 Sweating

Some heart rhythm problems are:

 AV nodal reentrant tachycardia (AVNRT)

 Accessory pathway, such as Wolff-Parkinson-White syndrome
 Atrial fibrillation
 Atrial flutter
 Ventricular tachycardia

Risks
Catheter ablation is generally safe. Talk with your provider about these rare complications:

 Bleeding or blood pooling where the catheter is inserted

 Blood clot that goes to arteries in your leg, heart, or brain
 Damage to the artery where the catheter is inserted
 Damage to heart valves
 Damage to the coronary arteries (blood vessels that carry blood to your heart)
 Esophageal atrial fistula (a connection that forms between your esophagus and part of your heart)
 Fluid around the heart (cardiac tamponade)
 Heart attack
 Vagal or phrenic nerve damage

B. Patient required preparation for the procedure

Before 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.

After the Procedure

Pressure to reduce bleeding is put on the area where the catheters were inserted into your body. You will
be kept in bed for at least 1 hour. You may need to stay in bed for up to 5 or 6 hours. Your heart rhythm
will be checked during this time.

Your doctor will decide whether you can go home on the same day, or if you will need to stay in the
hospital overnight for continued heart monitoring. You will need someone to drive you home after your
procedure.

For 2 or 3 days after your procedure, you may have these symptoms:

 Fatigue
 Achy feeling in your chest
 Skipped heartbeats, or times when your heartbeat is very fast or irregular.

Your doctor may keep you on your medicines, or give you new ones that help control your heart rhythm.

C. How the procedure was performed

There are two methods for performing cardiac ablation:

 Radiofrequency ablation uses heat energy to eliminate the problem area.

 Cryoablation uses very cold temperatures.
The type of procedure you have will depend on what kind of abnormal heart rhythm you have.

Cardiac ablation procedures are done in a hospital laboratory by trained staff. This includes cardiologists
(heart doctors), technicians, and nurses. The setting is safe and controlled so your risk is as low as
possible.

You will be given medicine (a sedative) before the procedure to help you relax.

 The skin on your neck, arm, or groin will be cleaned well and made numb with an anesthetic.
 Next, the doctor will make a small cut in the skin.
 A small, flexible tube (catheter) will be inserted through this cut into one of the blood vessels in the area. The
doctor will use live x-ray images to carefully guide the catheter up into your heart. 
 Sometimes more than one catheter is needed.

Once the catheter is in place, your doctor will place small electrodes in different areas of your heart.

 These electrodes are connected to monitors that allow the cardiologist to tell what area in your heart is
causing problems with your heart rhythm. In most cases, there are one or more specific areas.
 Once the source of the problem has been found, one of the catheter lines is used to send electrical (or
sometimes cold) energy to the problem area.
 This creates a small scar that causes the heart rhythm problem to stop.

Catheter ablation is a long procedure. It can last 4 or more hours. During the procedure your heart will
be monitored closely. A health care provider may ask you if you are having symptoms at different times
during the procedure. Symptoms you may feel are:

 A brief burning when medicines are injected

 A faster or stronger heartbeat
 Lightheadedness
 Burning when the electrical energy is used

D. Nursing Care Management After the procedure

E. References/ Sources

Calkins H, Hindricks JG, Cappato R, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert

consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm.
2017;14(10):e275-e444 PMID: 28506916 www.ncbi.nlm.nih.gov/pubmed/28506916.

Ferreira SW, Mehdirad AA. The electrophysiology laboratory and electrophysiologic procedure. In:
Kern MJ, Sorajja P, Lim MJ, eds. The Cardiac Catheterization Handbook. 6th ed. Philadelphia, PA:
Elsevier; 2016;chap 6.
Miller JM, Tomaselli GF, Zipes DP. Therapy for cardiac arrhythmias. In: Zipes DP, Libby P, Bonow
RO, Mann DL, Tomaselli GF, Braunwald E, eds. Braunwald's Heart Disease: A Textbook of
Cardiovascular Medicine. 11th ed. Philadelphia, PA: Elsevier; 2019:chap 36.

VI. Use of Ventricular Assisted Devices

A. Indication for the procedure

B. Patient required preparation for the procedure
C. How the procedure was performed
D. Nursing Care Management After the procedure
E. References/ Sources

VII. Heart Transplant

A heart transplant gives a patient with congenital heart disease the opportunity to have a normal
heart with normal blood circulation. If the transplant goes well, heart function and blood flow will be
better than ever.
A heart transplant replaces the patient's heart with a donor heart. Doctors remove the patient's
heart by transecting the aorta, the main pulmonary artery and the superior and inferior vena cavae,
and dividing the left atrium, leaving the back wall of the left atrium with the pulmonary vein openings
in place. The surgeon connects the donor heart by sewing together the recipient and donor vena
cavae, aorta, pulmonary artery and left atrium. In patients with congenital heart disease, the surgeon
may simultaneous transplant the lungs and the heart.

A. Indication for the procedure

The most common reason is that one or both ventricles have aren't functioning properly and severe heart failure is
present. Ventricular failure can happen in many forms of congenital heart disease, but is more common in congenital
defects with a single ventricle or if long-standing valve obstruction or leakage has led to irreversible heart
failure. Patients who as children had the Fontan procedure (involves redirecting blood flow from the
lower body to the lungs.), which helps complex congenital heart defects, may need a heart transplant
because the blood flow through the venous system is slow and the veins are congested, which can lead
to swelling, fluid accumulation, and protein loss.

How does it affect the heart?

The donor heart is matched to the recipient by blood type and body size. As the heart transplant
recipient, you must take medications to prevent his or her immune system from rejecting the new
heart. These drugs are called immunosuppressive medication. Your medical team will balance the
amount of immunosuppressive medication you need to prevent rejection of your new heart with the
risk of side effects, which include infection or cancer.

B. Patient required preparation for the procedure

C. How the procedure was performed

Heart transplant surgery

When a donor becomes available the prospective recipient is rushed to hospital as an emergency and prepared for
theatre. There follows an anxious period, waiting to hear whether the donor heart is suitable. If it is acceptable, the
patient is transferred to theatre and given an anesthetic, intubated, and has lines inserted.

The operation is performed via a median sternotomy. Cardiopulmonary bypass is instituted once the donor heart is 15
minutes from the hospital and the diseased heart explanted. Implantation begins with anastomosing the left atrium,
followed by the pulmonary artery, then the aorta. The heart is de-aired and right atria anastomosis is then completed.
The patient is then weaned from cardiopulmonary bypass, with the heart paced at 100-120 beats per minute, the
chest is closed and the patient moved to intensive care supported with inotropic infusions.

D. Nursing Care Management After the procedure

What will I need in the future?

After the heart transplant, the medical team will monitor the patient closely for heart rejection, which
can happen in the heart muscle cells or in the heart's arteries. They will also watch for side effects of
the immunosuppressive medications, which include diabetes, infection, kidney disease, cancer or high
blood pressure. If any of these problems arise, the doctor will change the medication type or dose. The
doctor may also decide to change your immunosuppressive medications as new drugs become
available.

Medical Follow-up

The patient will require regular checkups after the transplant by a transplant cardiologist. At these
visits, the cardiologist will do blood tests to check the levels of your immunosuppressive drugs and look
for side effects. He or she may also order electrocardiogram, echocardiogram and Holter monitoring to
help monitor the heart rhythm and function, or an endomyocardial biopsy, which is a diagnostic
procedure that surveys the sufficiency of your immunosuppressive therapy. The doctor will evaluate
the coronary arteries yearly or every other year to monitor for signs of narrowed coronary arteries in
the transplanted heart. The patient should also have routine medical checkups to maintain overall
health.
Activity Restrictions

Heart transplant recipients have no specific activity restrictions. Discuss activity ideas with the
transplant cardiologist.

Endocarditis Prevention

Endocarditis is an infection of the inner layer of the heart. While some people who have congenital
heart disease must take antibiotics prior to some medical and dental procedures to prevent
endocarditis, most heart transplant recipients don't need them unless they also have significant heart
valve disease.

Pregnancy
Women who've had a transplant could have complications during pregnancy. Depending on the type,
immunosuppressive medications may negatively affect the fetus. You may also have a greater risk of
rejection once the baby is born. If you are considering pregnancy, discuss the pros and cons with your
transplant cardiologist and obstetrician

Will I need more surgery?

A transplant heart can help the patient lead a more active, fulfilling life, but there may be times when
additional surgery is required. For instance, if the rhythm of the transplant heart becomes slow, you
may need to have a pacemaker. Rarely, the tricuspid valve can become damaged by the
endomyocardial biopsy procedure; if that happens it will need to be repaired or replaced. Patients with
congenital heart disease who have had a coarctation repair or problems with narrow or small
pulmonary arteries may need surgery or interventional catheterization after the transplant to increase
the size of these areas. Sometimes, a transplanted heart may fail because of rejection, damage to the
heart cells or coronary arteries of the heart, which leads to heart failure. If this happens, doctors can
sometimes transplant another heart
Postoperative care

In the immediate postoperative period - until hemostasis and hemodynamic stability are achieved - the
patient will be nursed in a designated cardiac ICU. Extubation is usually rapid, and done once arterial
blood gases are found to be satisfactory. Management of the patient usually includes monitoring intra-
arterial blood pressure, central venous pressure (CVP), left atrial pressure (LAP) and pulmonary artery
pressures (PAP).

Intravenous infusions may include inotropic support, fluid and volume replacement, anti-rejection
therapy and analgesia. Mediastinal drains and a urinary catheter will also be in situ. A prolonged stay in
ICU may be necessary if the patient has complications such as bleeding, right-sided cardiac dysfunction
or bi-ventricular failure requiring multiple inotrope therapy, an intra-aortic balloon pump or
ventricular-assist device. Patients will be transferred to the transplant unit when extubated six to 24
hours after surgery, where they will usually remain until discharge.

Continuing care

Following transfer, ECG monitoring and routine observations will be sustained. In addition, invasive
blood pressure and CVP monitoring will continue for a day or two. Mediastinal drains are usually
removed soon after transfer when drainage is minimal.

Hemodynamics

Maintenance of a heart rate of 100-110bpm is an important aspect of early postoperative care (Kuo,
2001) that enables optimal cardiac output and adequate renal perfusion to be achieved. In addition,
reduction of pulmonary vascular resistance is beneficial for right ventricular function. Isoprenaline is
administered to achieve both of these, although temporary pacing via epicardial wires may be
required. Additional inotropes/vasodilators such as milrinone/adrenaline or glyceryl trinitrate may be
used, depending on the patient.

If the patient’s cardiac function is satisfactory and adequate hydration is achieved, maintaining
adequate blood pressure is not usually a problem in the early postoperative period. Hypertension is
common following cardiac transplant; this is often drug-induced and generally caused by anti-rejection
therapy: ACE inhibitors and calcium channel blockers are common treatments. Life-threatening
arrhythmias are rare postoperatively, even during acute rejection episodes (Forni et al, 1996). Atrial
flutter/fibrillation is occasionally seen in patients and, if problematic, can be treated with overdrive
atrial pacing, amiodarone or, more rarely, DC cardioversion.
Respiratory care

Patients rarely experience respiratory problems. Intense physiotherapy, observation of respiratory

rate, oxygen saturations, and regular chest X-rays will allow early identification of pulmonary
atelectasis. Precise fluid management will help prevent pulmonary edema. Oxygen therapy will be
weaned as the patient’s clinical condition allows.
Fluid balance/renal function

The assessment and management of a patient’s fluid balance following heart transplant can be
challenging. It is essential to keep a fluid balance record, to check the patient’s weight daily, as well as
make regular checks of their urea and electrolyte levels, and do clinical examinations. Patients are
often edematous, and this is caused by a combination of fluid overload and having low albumin levels
preoperatively. Diuretics are frequently used but care must be taken not to cause hypovolaemia.

Most patients will present with renal dysfunction at the time of transplant, secondary to heart failure.
The insult of surgery, potential hypotensive episodes perioperatively and nephrotoxic anti-rejection
therapy usually worsens renal function in the early days.

Regular monitoring of urea and electrolyte levels, maintenance of optimal fluid balance and avoidance
of unnecessary nephrotoxic drugs will help. Dialysis may, occasionally, be necessary. Renal-dose
dopamine is no longer used routinely for all patients, as many studies have questioned its value
(Kellum et al, 2001).

Mobility

All patients are assessed for the risk of deep-vein thrombosis and will usually be prescribed low
molecular weight anticoagulants once a day until they are mobile. Patients who develop
thromboembolic problems may require formal anticoagulation therapy.

Mobility and independence are encouraged as the patient’s condition and confidence improve: they
are encouraged to sit out of bed on day two, start walking around at four to five days postoperatively
and attend the gym on day eight, following a satisfactory cardiac biopsy result. Each patient will require
an individual exercise plan tailored to his or her needs (Thompson, 1995).
Nutrition and hydration

As soon as adequate gastrointestinal function is established, patients are encouraged to eat and drink,
and intravenous fluids are discontinued. A good fluid intake of 2L in 24 hours is optimal.

In the early postoperative period, a diet high in protein and calories is encouraged to aid recovery and
tissue repair (Verity, 1996). Early dietetic input is established, as patients may require advice on low-
potassium, low-sugar or high-magnesium needs. Long-term advice will recommend patients adhere to
a low-saturated fat diet, to prevent obesity and raised lipid levels. Constipation will be treated with
basic interventions.

Patients will usually be mobile and independent about one week postoperatively, inotropes and
monitoring will normally have been discontinued, and the focus of care will shift to education and
rehabilitation. It is often around this time that a patient’s emotional and psychosocial needs increase.
Postoperative psychological issues
Rehabilitation and outpatient care

Rehabilitation and education are ongoing processes following the operation, culminating in discharge
into hospital accommodation or home within two to three weeks of transplantation. Outpatient visits
are frequent in the early postdischarge period, and medications, investigations and follow-up are
adjusted on an individual basis.

Within three months, the majority of patients will be able to lead a normal lifestyle and many consider
returning to work. In this time of surgical and medical miracles, it is important to recognise that for the
well-being and long-term survival of transplant patients, the multidisciplinary input of transplant
coordinators, nurses, social workers, psychologists, physiotherapists, chaplains and even ward
domestics is paramount. Despite the worry and upheaval of having a transplant, the recipients see the
process as worthwhile (Greaves, 1997). Transplantation is a specialty that depends not only on the
medical staff, but on the team as whole. Furthermore, none of this would be possible without the
courage of the donor families and the dedication of the teams that support them.

E. References/ Sources