Minimally-Invasive Cardiac Surgery (Non-Sternal Approach)

Definition/Etiology:

• MIDCAB – Minimally Invasive Direct Coronary Artery Bypass
  • Addresses Perfusion (Hose) Problem that cannot be fixed with a stent but cannot have a full procedure CABG (many reasons)
    • No water = No garden. No Blood no organs!
    • Reroutes hose around the blockage
    • Perfusion restored
  • NON-STERNAL Bypass surgery
    • 2-4 hours instead of 3-6 hours
    • Performed on a beating heart
      • NO BYPASS MACHINE
• CABG indications
  • Non-Emergent/Planned Left Coronary Artery “Left Main disease”
• Surgery → CVSICU → POD#1
  • Step Down (PCCN Care)

Pathophysiology:

• NO Sternotomy “Crack the Chest” & NO Bypass
• 2 small Incisions = Left 5th intercostal space
  • 2.5 inches
• Vessels Harvested
  • During surgery
  • Left Internal Mammary Artery
    • It is a paired artery, with one running along each side of the sternum
• Open Pericardium & locate LAD
  • Stabilization device applied
  • Artery repaired

Noticing: Assessment & Recognizing Cues:

• Subjective Cues (Monitoring for signs ↓ Perfusion)
  • #1 Concern = Chest pain
    • PQRST
• Objective Cues
  • Concern = ↓ Cardiac Output /Bleeding
    • Vital Trend
    • Q 2- 4 hours in PCU
      • Hypotension/Tachycardia/MAP >65
  • Concern Heart Failure
    • S3/crackles/rales = heart failure
  • Concern Infection
    • 2 Small Incisions
      • Dehiscence unlikely
      • Infection – drainage/fever
  • Tubes/Drains
    • Chest tube= > 70cc/hr & slow decrease
    • Many times no foley

Interpreting: Analyzing & Planning:

• Labs
  • Baseline Labs
    • CBC, BMP, Renal Panel
  • Electrolytes
    • Replace KCL/MAG/Calcium
• ECG/Telemetry
  • Q Waves – Signs of scar tissue. Common.
  • Atrial Tachyarrhythmias
    • Afib/Aflutter/SVT
      • AFIB =most common = Rate Control

Responding: Patient Interventions & Taking Action:

• Low incidence of Post-Op complications (2%)
• Pharmacological Interventions
  • Pain management PRN
    • IV → PO
  • Electrolyte replacement IVPB
  • Fluid Replacement
    • Albumin for low MAP
• Non-Pharmacological
  • Incentive Spirometry
    • Q1 hour while awake
  • Cough & Deep breath
  • Incision Care/Tube Care
    • Chest tube
      • Output reducing
• Adjunct Medical Therapy
  • Rehabilitation Services: PT/OT
    • EARLY MOBILITY

Reflecting: Evaluating Patient Outcomes:

• ABCs & Post OP Watch (Infection/Bleeding)
  • Vitals closely
• Chest Pain Free
  • Sign of good perfusion
• ECG/Telemetry
  • Baseline
• Heart & Lung sounds
  • No sign of Heart Failure
• Kidney Output
  • 30ML/hr
• Skin/Tubes/Drains
  • Incision Care
    • 2.5 inch incision

Linchpins (Key Points):

• Notice
  • Symptoms of decreased perfusion
• Interpret
  • ECG/Labs
• Respond
  • Monitor Post Op Complication
    • Bleeding & Infection
• Reflect
  • Perfusion/Hemodynamically stable first