Cardiac Interventions


Fall 2025 — Lecture Follow-Along Notes

Slide 1 — Invasive Cardiovascular Procedures

Coronary Artery Reperfusion

  • Percutaneous transluminal coronary angioplasty (PTCA)

  • Coronary artery stent

Cardiac Surgery

  • Coronary artery bypass graft (CABG)

Control of Dysrhythmias

  • Pacemaker

  • Defibrillator placement

Big picture: This lecture covers procedures used to restore coronary blood flow and devices/procedures used to manage abnormal heart rhythms.

Slide 2 — Coronary Artery Reperfusion

Main topic:

Restoring blood flow through a blocked coronary artery

This leads into PTCA/PCI.

Slide 3 — Percutaneous Transluminal Coronary Angioplasty

PTCA

  • Large cannula inserted into an artery

    • Femoral

    • Brachial

  • Second cannula threaded up to coronary arteries

  • Balloon-tipped catheter opens the blocked coronary vessel

  • Balloon:

    • Compresses atheroma/plaque

    • Stretches the vessel to >90%

  • Can also:

    • Laser atheroma

    • Cut atheroma

    • Place a stent

  • Followed by anticoagulants

Complications During Procedure

  • Dissection

  • Perforation

  • Abrupt closure

  • Vasospasm

  • Acute MI

  • Arrhythmias

  • Cardiac arrest

Post-Procedure Complications

  • Re-occlusion

  • Arterial occlusion

  • Bleeding

    • Insertion site

    • Retroperitoneal

  • AKI

    • Dye/contrast is used

Know: After PTCA, bleeding, perfusion and renal function are major concerns.

Slide 4 — Percutaneous Coronary Intervention

PCI = Percutaneous Coronary Intervention

This slide is mainly visual.

Think:

Blocked coronary artery → catheter/balloon → artery opened → blood flow restored

Slide 5 — Post-Procedure Care: Assessment & Analysis

History

Assess the patient's history.

Assessments

  • Insertion site

  • Are sheaths still in place?

  • Medications

    • Heparin

    • IIb/IIIa agent

  • Perfusion

    • Peripheral circulation

  • Signs of complications

While listening: If your professor talks about checking the affected extremity, this goes under perfusion/peripheral circulation.

Slide 6 — Collaborative Care Priorities: Planning

Nursing

Risk for:

  • Impaired perfusion/cardiac function

  • Impaired gas exchange

  • Acute pain

  • Bleeding

  • Fluid imbalance

  • Anxiety

Patient education:

  • Disease

  • Self-care

Collaborative

Monitor/manage:

  • Perfusion

  • Gas exchange

  • Bleeding

  • Vascular occlusion

  • Renal function

Slide 7 — Collaborative Care Interventions: Implementation

Nursing

  • Pain assessment and management

  • Follow protocol

    • Vital signs

    • ECG

    • Peripheral pulses

    • Site checks

    • Immobility

    • Head-of-bed positioning

    • Repositioning

  • Monitor I&O

  • Medication administration and outcomes

  • Explore anxiety

  • Education

Collaborative

  • Review test results/labs

  • Initiate protocols

  • Medications

  • Detect/manage complications

  • Transitional care needs

Slide 8 — Collaborative Goals & Outcomes: Evaluation

Patient:

  • Maintains perfusion

  • Maintains gas exchange

  • Maintains fluid balance

  • Remains pain-free

  • Shows no signs of bleeding

  • Reports no/decrease/lower anxiety

    • Identifies ways to manage anxiety

  • Remains free of complications

  • Discusses self-care program

Slide 9 — CABG

Next major section:

Coronary Artery Bypass Graft

Slide 10 — CABG

Indications

  • Uncontrolled angina

  • Left main coronary artery blockage >50%

  • Multivessel disease: meaning multiple blockages in different coronary arteries, which may require surgical intervention for effective management.

  • Unsuccessful PTCA → choice in intervention is calculated (not under our scope) based on the severity of the blockages, patient's overall health, and the potential benefits versus risks associated with surgical options.

What is CABG?

A blood vessel from another part of the body is grafted around the occluded coronary artery(ies)

Possible grafts:

  • Thoracic artery: A common choice for grafting, providing good blood flow due to its robust structure.

  • Saphenous vein : Often used for its accessibility, the saphenous vein can be harvested and utilized when the thoracic artery is not suitable.

Requires extensive:

  • Pre-op care

  • Intra-op care

  • Post-op care

Easy way to picture it: The blockage stays where it is. CABG creates a new route around it.

Slide 11 — Coronary Artery Bypass Grafts

Mainly visual.

Use this slide to remember:

Graft = new pathway around the coronary blockage

Slide 12 — CABG Procedure

  • General anesthesia

  • Surgical procedure

  • Sternotomy

  • Cardiopulmonary bypass (CPB) machine

    • Blood circulated through machine

    • Heart stopped

  • Vessels harvested and grafted

  • Chest tube placed

  • Epicardial wires placed

Slide 13 — Cardiopulmonary Bypass System

Mainly visual.

CPB

During cardiopulmonary bypass:

Blood circulates through CPB machine while heart is stopped.

Connect this slide back to the CABG procedure.

Slide 14 — Preoperative Management

Assessment & Analysis

CABG patients may be:

  • Older

  • Have multiple comorbidities: make sure these are addressed to optimize surgical outcomes and ensure comprehensive post-operative care.

    • Hypertension

    • Diabetes mellitus

    • Chronic obstructive pulmonary disease (COPD)

Medications That Improve Outcomes

  • Aspirin

  • Beta blockers

  • Statins

Testing

  • Chest X-ray

  • EKG

  • Labs:

    • Type & crossmatch

    • Coagulation studies

    • CBC

    • Metabolic panel

Assessment

  • Health history

  • Baseline assessment

  • Focused cardiovascular assessment

  • Glucose control: Maintaining optimal glucose levels is crucial in managing cardiac health, as uncontrolled diabetes can lead to increased rates of cardiovascular disease and complications.

  • Physiological:

    • Regular monitoring of heart function, including parameters such as blood pressure, heart rate, and rhythm, helps in early detection of potential issues and guides timely interventions.

  • Psychological:

    • Learning needs

    • Anxiety

  • Social:

    • Support available after surgery post operatively

Planning / Implementation / Outcomes

Patient education:

  • Reduce anxiety

  • Medication changes

  • Shower with antiseptic solution

  • What to expect during hospital course

  • Incentive spirometer

  • Exercises

  • Family/caregiver support

  • Transitional care

Slide 15 — Postoperative Management: Assessment & Analysis

Assessment minimum every 4 hours

Assess:

Neuro

  • Neurological status: Ensure alertness, orientation to person, place, and time, and evaluate pupil response and strength in all extremities.

Cardiac

  • Cardiac status: Monitor heart rate, rhythm, and blood pressure to assess cardiovascular stability and identify any abnormalities that may require intervention.

Respiratory

  • Respiratory status

Peripheral Vascular

  • Circulation/perfusion

Renal

  • Kidney function

Fluid/Electrolytes

  • Fluid status

  • Electrolytes

Family Needs

  • Assess family/support needs

Your professor has “WHY” on this slide, so listen for her explanation of why each body system needs to be closely monitored after CABG.

Slide 16 — Collaborative Care Priorities: Planning

Nursing

  • Impaired cardiac output

  • Impaired gas exchange

  • Risk for fluid/electrolyte imbalance

  • Risk for acute confusion

  • Acute pain

  • Risk for impaired renal function

  • Impaired thermoregulation

  • Risk of infection

  • Lack of knowledge

Collaborative

Watch for:

Fluid

  • Hypovolemia

  • Bleeding

  • Fluid overload

Cardiac

  • Cardiac tamponade

  • HTN

  • MI

  • Arrhythmias

  • Heart failure

Respiratory

  • Weaning from ventilator

Renal

  • AKI

Neuro

  • CVA

Other

  • Pain

  • Hypothermia

  • Infection

Slide 17 — Collaborative Interventions: Implementation

Collaborative

  • Monitor for complications

  • Ventilator settings

  • Wean from ventilator

  • ABGs

  • Follow protocols

  • Pacemaker settings

  • Labs

  • Warming devices

  • Physical therapy

  • Transitional care

Nursing

Monitor cardiac/perfusion:

  • VS

  • ECG

  • Hemodynamics

  • Signs of complications

Monitor pulmonary:

  • Ventilator

  • Chest tube care

  • Incentive spirometry

Monitor:

  • Labs

  • Urine output

  • Drainage

  • Electrolytes

Neuro/safety:

  • Manage pain

  • Monitor cognition

Infection/temperature:

  • Temperature

  • WBC

  • Drainage

Also:

  • Patient/family support

  • Education

Slide 18 — Collaborative Goals & Outcomes

Patient:

  • Maintains perfusion and cardiac output

  • Reestablishes/maintains gas exchange

  • Has controlled pain

  • Shows no signs of bleeding

  • Remains free of surgical-site infection

  • Is alert and oriented

  • Reestablishes thermoregulation

  • Remains free of complications

  • Has post-hospital care in place

Slide 19 — Pacemakers & Defibrillators

New section:

Implantable Cardiac Devices

Slide 20 — Think Back to Dysrhythmias

Your professor asks:

Why might someone need a permanent pacemaker?

  • To correct bradycardia: A condition characterized by an abnormally slow heart rate, which can lead to insufficient blood flow to the body.

  • To manage heart block: When the electrical signals in the heart are delayed or blocked, a pacemaker can ensure that the heart beats at a regular rhythm.

  • To treat certain types of heart failure: In cases where the heart's ability to pump blood is compromised, a pacemaker can help coordinate the heart's contractions.

Why might someone need a permanent defibrillator?

  • A permanent defibrillator may be necessary for individuals who are at high risk of life-threatening arrhythmias, as it can continuously monitor the heart's rhythm and deliver shocks to restore a normal heartbeat whenever dangerous irregularities are detected.

  • A person in afib

Slide 21 — Cardioversion & Defibrillation

Both treat tachyarrhythmias by delivering electrical current.

Electrical current:

  • Depolarizes a critical mass of myocardial cells

  • Essentially "resets" the heart

  • After repolarization, sinus node may recapture its role as pacemaker

Cardioversion

Synchronized with patient's ECG

Defibrillation

Unsynchronized

Main difference to memorize:

Cardioversion = synchronized

Defibrillation = unsynchronized

Slide 22 — Pacemakers

Definition

Electronic device that provides electrical stimuli to the heart muscle.

Used for:

  • Symptomatic dysrhythmias

  • Chronic dysrhythmias

  • Recurrent dysrhythmias

  • Dysrhythmias unresponsive to pharmacological therapy

Can be:

  • Transcutaneous

  • Transvenous

  • Implanted

Implanted: for men and women with atrial fibrillation or other cardiac arrhythmias such as:

, providing a long-term solution to manage heart rhythm effectively.

  • Below clavicle

  • Behind breast

Hardware

Generator

  • Circuitry

  • Batteries

Determines:

  • Heart rate

  • Strength of impulse from pacemaker to heart

    • Milliamperes

  • Sensitivity/detection of heart impulses

    • Millivolts

Electrodes

  • Attached to heart

  • Newer systems may be leadless

Slide 23 — Permanent Pacemaker

Mainly visual.

Use this slide to identify:

  • Generator

  • Leads/electrodes

  • Location of implanted device

Slide 24 — Pacemaker Programming

NASPE-BPEG Code

1st letter = Chamber PACED

  • A = Atrium

  • V = Ventricle

  • D = Dual

2nd letter = Chamber SENSED

  • A = Atrium

  • V = Ventricle

  • D = Dual

  • O = Off

3rd letter = TYPE OF RESPONSE from the pacemaker to what it senses

  • I = Inhibited

  • T = Triggered

  • D = Dual

  • O = None

4th = RATE ADAPTIVITY (dont really see)

  • O = None

  • R = Rate modulation

Also includes pacing-site capability and antitachycardia function.

Remember the order:

Paced → Sensed → Response → Rate

Slide 25 — Which Is Which? - PRACTICE FOR EXAM

This appears to be an identification/practice slide.


Use what you learned from the previous slide:


a paced- do not measure

  • a paced rhythm — an electrical signal is delivered to the heart to stimulate contractions, while you do not measure the output visually in the same way as a natural rhythm.


dual paced: firesand gets response from A and V to coordinate contractions, ensuring proper timing between the atria and ventricles for effective blood pumping.

v paced: delivers electrical impulses to the ventricles, ensuring proper ventricular contraction and maintaining an adequate heart rate.

  1. What chamber is paced?

  2. What chamber is sensed?

  3. What is the response?

  4. Is there rate modulation?

Slide 26 — Pacemaker Complications

General/Insertion Complications

  • Dislodgement of pacemaker leads

  • Pneumothorax

  • Bleeding

  • Dysrhythmia

  • Infection

Device Problems

  • Electromagnetic interference

    • Can trigger alarms

  • Malfunction

  • Loss of capture/pacing

  • Under-sensing

  • Over-sensing

Patient

  • Medical alert ID!

Slide 27 — Implantable Cardioverter Defibrillator

ICD

Detects and terminates life-threatening episodes of:

  • V-tach

  • V-fib

Used for:

  • Post sudden cardiac death

  • CAD with LV dysfunction

    • EF <35%

  • Nonischemic dilated cardiomyopathy as listed on slide

Can be:

  • External/temporary

  • Internal/implanted

Can also provide: Pacing and Cardioversion

Slide 28 — Implantable Device Procedure Care

Assessment & Analysis

Assess:

  • Heart rate and Rhythm:

  • Incision site: infection risk

  • Chest X-ray: to make sure there is no pneumothorax or any other complications that could affect the procedure.

  • Medications:

    • Antiarrhythmics

    • Beta blockers

    • Diuretics

  • Anxiety

  • Depression

  • Anger

  • Body image: Negative body image can significantly impact a patient's willingness to participate in cardiac rehabilitation programs, potentially hindering recovery and overall quality of life.

  • Knowledge

Slide 29 — Collaborative Care Priorities: Planning

Nursing

  • Prevent infection

  • Pain

  • Bleeding

  • Mobility: not raising arm for about a week

  • Promote coping

  • Patient education

Collaborative

  • Cardiac output

  • Confirm lead placement

  • Device function

  • Protocols

  • Labs

Slide 30 — Collaborative Care Implementation

Nursing

Monitor:

  • Cardiac function

    • ECG

    • Perfusion: Assess peripheral pulses and capillary refill time, ensuring adequate oxygen delivery to tissues.

    • VS

  • Surgical site

  • Wound/dressing

  • Signs/symptoms of bleeding

  • Pain

Interventions:

  • Immobilize arm/use sling for about a week

  • Explore patient's perception of device

Patient Education

Teach:

  • Site care

  • Medications

  • Symptoms to report

  • Avoid electromagnetic interference (EMI)

  • Carry identification

Collaborative

  • Device settings

  • Chest X-ray

  • Labs

  • Medications

Slide 31 — Collaborative Care Goals & Outcomes

Patient:

  • Maintains cardiac output and perfusion

  • ECG reflects device settings

  • Remains free of infection

  • Remains free of bleeding

  • Is free of pain

  • Can discuss perceptions of device

  • Understands post-procedure precautions and care

End-of-Lecture Big Picture

For this PowerPoint, keep these four sections straight:

PCI/PTCA
→ Open the blocked coronary artery.

CABG
→ Create a new route around the blocked coronary artery.

Pacemaker
→ Provides electrical stimulation/pacing to the heart.

ICD
→ Detects and terminates life-threatening V-tach/V-fib.

And the electrical therapy distinction:

Cardioversion = synchronized

Defibrillation = unsynchronized