Right thoracotomy approach to mitral valve surgical procedures.

The right thoracotomy approach to mitral valve surgical procedures allows surgeons to achieve excellent, rapid exposures of mitral annuli; facilitates the excision of diseased mitral valves; avoids injury to previously placed coronary artery bypass grafts; and aids surgeons with the insertion of valve prostheses. This approach is especially appropriate for patients with anatomic deviations (e.g., deep chest cavities, counterclockwise rotations of the heart) and hostile mediastina (i.e., previously opened mediastina with severe adhesions around the heart and posterior side of the sternum). This article discusses mitral valve disease, compares the right thoracotomy approach to median sternotomy, describes perioperative nursing care of patients undergoing mitral valve surgical procedures, and presents a case study.

Marfan's syndrome and surgical repair of ascending aortic aneurysms.

Marfan's syndrome is an inherited, degenerative connective tissue disorder that affects many body systems (eg, skeletal, ocular, cardiovascular, cutaneous, pulmonary, abdominal, neurologic). The cause of Marfan's syndrome is unknown, but recent genetic studies have linked this disorder to chromosome 15q15-q21.3. The characteristics associated with Marfan's syndrome require a multidisciplinary approach to patient care. This article discusses one serious complication of Marfan's syndrome-aortic root dilatation- and composite graft repairs of ascending aortic aneurysms. Physicians and nurses must be more aware of Marfan's syndrome so that life-threatening medical conditions can be evaluated and followed by health care providers.

Effect of lateral position on arterial and venous blood gases in postoperative cardiac surgery patients.

BACKGROUND: Investigators have suggested that lateral position may have clinically significant effects on oxygenation in cardiac surgery patients. Presence of lung disease and type of cardiac surgery may be important considerations. OBJECTIVES: To determine the effect of position (left, right, supine) on blood gases in patients who have had coronary artery bypass or cardiac valvular surgery and to compare the effect of position on blood gases in cardiac surgery patients having preoperatively diagnosed lung disease with those having no lung disease. METHODS: A repeated measures design was used to study 120 mechanically ventilated, postoperative cardiac surgery patients. Subjects were randomly assigned a sequence of three positions (supine, and 45; right and left lateral) after cardiac surgery. Heart rate, respiratory rate, and arterial blood gas values were collected in each position. Venous blood gas values were collected from a subset of 40 subjects. RESULTS: A statistically significant effect of position on PaO2 was found in the group as a whole. The mean PaO2 in the left lateral position was lower than the value in the right or supine positions. No significant effects for position and pH, PaCO2, or bicarbonate were detected. No significant effects were found for type of surgery or the presence of absence of preoperative lung disease. A significant effect of position on venous pH was detected. No significant position effects were found for PvO2, PvCO2, bicarbonate, or venous saturation. No significant position effects were found for the calculated arterial-venous oxygen difference. CONCLUSIONS: The results of this study support those of previous research, which reported lower PaO2 in postoperative coronary artery bypass graft patients in the left lateral position. Mean differences in PaO2 were small, suggesting that the known benefits of lateral positioning in the early postoperative period outweigh the potential risks.

The octogenarian cardiac surgery patient.

As advances are made in medical-surgical technology and overall life expectancy increases, cardiac surgery previously done only in younger populations is now becoming common in older adult age groups. Most of the nursing literature regarding elderly cardiac surgery patients focuses on the 65- to 75-year-old age group; little has been written about the 80- to 90-year-old age group. Very elderly patients present unique and complex challenges to the interdisciplinary teams involved in their care. Nurses must recognize and anticipate the specialized needs of these frail individuals to optimally manage their care. Aortic valve replacement is the most common cardiac valve surgical procedure performed in very elderly persons. A case study and an integrated care plan for the aortic valve surgery patient are described.

Effect of position on selected hemodynamic parameters in postoperative cardiac surgery patients.

BACKGROUND: Indirect/noninvasive blood pressure, heart rate and central venous pressure are frequently monitored hemodynamic parameters in postoperative cardiac surgery patients. No previous studies have explored the effect of lateral position on these variables in this population. OBJECTIVES: To determine differences in (1) blood pressure, central venous pressure, or heart rate measurements among postoperative cardiac surgery patients due to position (supine, 45 degrees right lateral, and 45 degrees left lateral), (2) responses to position between patients having cardiac surgery in which the myocardium was opened (valvular replacement) and those in which it was not (coronary artery bypass graft), and (3) responses to position between cardiac surgery patients having preoperatively diagnosed lung disease and those without lung disease. METHODS: Phlebostatic axis in lateral positions was determined by echocardiography and geometric diagrams prior to the initiation of data collection. Postoperative cardiac surgery patients (N = 120) were studied in the three positions in random sequences. In each position, simultaneous blood pressure measurements were obtained from each arm, and central venous pressure and heart rate were recorded. RESULTS: Statistically significant differences were found in response to position in systolic and diastolic blood pressure, central venous pressure, and heart rate. Certain positions produced greater changes in selected variables, both in the total group and within specific subgroups. No differences were found between coronary artery bypass graft and valve (closed or opened myocardium) subgroups or between subgroups with and without lung disease. CONCLUSIONS: Lateral positioning of postoperative cardiac surgery patients appears to cause no detrimental effects on indirect/noninvasive blood pressure or heart rate measurements. However, significant differences in central venous pressure may occur and supine positioning for determination of central venous pressure is recommended.

Clinical paths for cardiac surgery patients: a multidisciplinary approach to quality improvement outcomes.

Implementation of clinical paths has resulted in a successful multidisciplinary approach for monitoring quality improvement outcomes in a select group of cardiovascular patients. This article defines clinical paths and explains their development, implementation, and evaluation. It also discusses how variances (which are defined as discrepancies between expected and actual events) were identified and how this information led to actions to improve patient outcomes. The roles of each health care professional are discussed in relation to clinical paths, and positive outcomes for the nurse, other health care professionals, and the institution are presented.

Caring for a Marfan patient with cardiovascular complications.

The Marfan syndrome is a heritable disorder of connective tissue associated with characteristic abnormalities of the skeletal, ocular and cardiovascular systems. Common cardiovascular manifestations of this syndrome are mitral valve prolapse with mitral regurgitation and dilatation of the ascending aorta resulting in aortic insufficiency, dissection, aneurysm and/or rupture. Although the prognosis for a patient with the Marfan syndrome is significantly more favorable than it was ten years ago, the cardiovascular complications continue to greatly reduce life expectancy. This article presents an overview of the Marfan syndrome including: history and epidemiology, clinical manifestations, diagnostic criteria, surgical intervention and follow-up. A case study is outlined which focuses on priority nursing diagnoses and a plan of care.

Indications, management, and patient education: anticoagulation therapy during pregnancy.

Anticoagulation is necessary in a variety of cardiovascular diseases to prevent thromboembolic complications. On a chronic basis, this type of therapy carries with it frustrations and challenges to both the woman and the health care provider related to monitoring, safety, and compliance. These problems are compounded during pregnancy by specific pharmacological considerations that often require substitution of a parenteral agent. Although at first this may seem an additional burden, the clinician can recruit the mother's naturally heightened awareness of health issues, as these extend beyond herself to the well-being of her child, to achieve therapeutic success.

Implications of prosthetic valve implantation: an 8-year follow-up of patients with porcine bioprostheses.

Nurses in cardiovascular critical care settings routinely care for patients with implanted valvular prostheses. The presence of an artificial valve substitutes a new disease state for the preexisting valvular disease. Five hundred nine patients who underwent cardiac valve replacement with porcine bioprostheses and who were followed for a total of 1633 patient-years provide the data base for discussion of long-term survival, functional capacity, and morbidity associated with valvular prostheses. Seventy-two percent of patients survived 5 years after operation. New York Heart Association functional class was improved in 84%. Three major types of morbidity were documented: thromboembolism, endocarditis, and valve failure. Cardiovascular nurses should be familiar with the implications of valvular prostheses to provide appropriate patient education and to facilitate the prompt detection and treatment of valve-related complications.