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Caring for Patients with Totally Endoscopic Coronary Artery Bypass: Special Considerations for the ED Nurse
CLINICAL
CARING
PATIENTS WITH TOTALLY ENDOSCOPIC CORONARY ARTERY BYPASS: SPECIAL CONSIDERATIONS FOR THE ED NURSE FOR
Authors: Ameera Chakravarthy, MS, CRNP, Eric J. Lehr, MD, PhD, FRCSC, and Susan L. Bindon, DNP, RN-BC, CNE, Baltimore, MD, and Seattle, WA
oronary artery disease remains a major cause of morbidity and mortality in the United States. As a surgical intervention for this disease, coronary artery bypass grafting (CABG) surgery has become commonplace. Often, emergency department (ED) nurses are familiar with post-CABG patient visits and the presentation of common postoperative complications, including atrial fibrillation, heart failure, pleural effusions, and surgical site issues. However, nurses may not be aware of emerging coronary surgical innovations that are less invasive, less painful, and promote a quicker functional recovery. Totally endoscopic coronary artery bypass (TECAB) is one such surgical innovation that is performed in a small number of centers of excellence in the United States. This surgery permits the bypass of coronary arteries through 5 dime-sized incisions in the chest. TECAB is achieved with the use of a telemanipulator machine that enhances surgical maneuvers through instruments performed by robotic arms controlled by the operator (surgeon) from a console located away from the operating table. 1 Endoscopic coronary surgery preserves the sternum and therefore avoids the risk of sternal wound complications, minimizes blood loss, and reduces the incidence of postoperative atrial fibrillation. Because TECAB is less invasive than standard CABG, the surgery is typically less painful and also preserves muscular and respiratory function. Because this relatively new surgery is currently performed in only a handful of medical institutions across the United States, many nurses and other health care providers may be
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Ameera Chakravarthy is Clinical Instructor, Department of Organizational Systems and Adult Health, University of Maryland School of Nursing, Baltimore, MD. Eric J. Lehr is Cardiac Surgeon and Director of Cardiac Surgery Research and Education, Swedish Heart and Vascular Institute, Division of Cardiac Surgery, Seattle, WA. Susan L. Bindon is Assistant Professor, Department of Partnerships, Professional Education & Practice, University of Maryland School of Nursing, Baltimore, MD. For correspondence, write: Ameera Chakravarthy, MS, CRNP, University of Maryland School of Nursing, 655 W Lombard St, Suite 342, Baltimore, MD 21201; E-mail: [email protected]. J Emerg Nurs ■. 0099-1767 Published by Elsevier Inc. on behalf of Emergency Nurses Association. http://dx.doi.org/10.1016/j.jen.2016.04.009
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unaware of its existence. Nurses who work in emergency departments may need to manage postoperative complications in patients who have undergone TECAB. Understanding the surgery, the postoperative course, and the potential complications of TECAB facilitates appropriate triaging and resource allocation to adequately manage the needs of this patient population (Table 1). The purpose of this article is to provide ED nurses with a primer on TECAB, along with the most common postoperative complications after this type of surgery. An ED nurse might be the first person to care for these patients after discharge from the hospital where they had the TECAB surgery. Historical Background
Goetz completed the first documented successful bypass graft in humans in May 1960. Since then, CABG has become standardized and predictable, with good long-term results despite some well-known postoperative and/or perioperative complications, including stroke, delirium, postoperative cognitive impairment, mediastinal infection, renal dysfunction, myocardial dysfunction, dysrhythmias, bleeding, and pericarditis. 2 Because of these potential complications, improvements to the surgery have been explored. Minimally invasive direct coronary artery bypass grafting (MIDCAB), typically performed via a left anterior mini thoracotomy, was proposed as a sternal-sparing approach. However, with this surgery, it can be challenging to harvest the entire left internal mammary artery, and this graft can be prone to twisting. Identification of the target vessel can also be difficult. Typically with MIDCAB, multi-vessel grafting is also not possible. To overcome the limitations of MIDCAB, in the mid 1990s, 3 surgeons investigated endoscopic techniques to provide coronary revascularization while maintaining sternal integrity and avoiding the use of cardiopulmonary bypass. The first TECAB was performed by Loulmet in 1998, requiring no graft revision and with no evidence of coronary ischemia for more than 12 years. 3 Initially, TECAB was performed for patients with lesions within the left anterior descending arterial circulation and later for those with right-sided cardiac lesions. Refinement of surgical robots further assisted cardiothoracic surgeons in performing 2-, 3-,
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TABLE 1
Indications and contraindications for totally endoscopic coronary artery bypass TECAB indications
TECAB contraindications
Hybrid candidate (TECAB with PCI)
Single-, double-, or triple vessel disease involving significant lesions to the left anterior descending artery, circumflex artery, left main, or left main equivalents associated with significant lesions to the right coronary artery system amenable to PCI
Absolute: Cardiogenic shock Hemodynamic instability Severely impaired lung function that would prevent single lung ventilation Relative: Pleural adhesions after previous thoracic surgery, trauma, radiation, inflammatory disease Significant space limitations (morbid obesity, significantly enlarged hearts) Chest deformities Intramyocardial, heavily calcified, and very small target vessels in beating heart approaches Ascending aortic diameter ≥35 mm and significant aortoiliac atherosclerosis in on-pump arrested heart approaches 1
Multivessel disease without concomitant valve or aortic disease, preserved left ventricular function, preserved lung function forced expiratory volume in 1 second N 60% 1,6 Coronary lesions suitable for percutaneous intervention (short lesion in larger vessel, not at bifurcation)
PCI, Percutaneous coronary intervention; TECAB, totally endoscopic coronary artery bypass.
and even 4-vessel TECAB 4,5 and combined left and right coronary lesions. TECAB can be combined with percutaneous coronary intervention (PCI), a nonsurgical procedure used to open blocked coronary arteries using a catheter to deploy a stent or dilate a narrowed vessel. PCI can be performed either before, during, or after TECAB. Applied as a hybrid coronary revascularization concept, it simplifies the intervention while providing patients with the best coronary revascularization options from both the surgical field (internal mammary arteries) and interventional field (drug-eluting stents). Drug-eluting stents are polymer-coated stents that release an antiproliferative drug in the coronary artery to prevent restenosis. The hybrid coronary revascularization approach shows promising mid- to long-term results. 6 TECAB with or without PCI preserves the sternum, accelerates postoperative rehabilitation and return to work, and improves the patient’s quality of life. 7 The decreased length of stay and quicker return to baseline function is a highly valued benefit to a large aging population with multiple comorbidities. Older adults are at an increased risk for loss of muscle mass and function (sarcopenia), and postoperative bed rest accelerates this deleterious process, causing dependency, as well as increased morbidity and mortality. 8–11 In addition, a strong association exists between physical limitation and depressive symptoms in patients with coronary disease. 12 Given the less invasive nature of TECAB,
2
patients may avoid some of the potential physical and mental setbacks associated with more rehabilitation-intensive sternal-spreading cardiac bypass surgeries.
Surgical Procedure and Patient Preparation
Once a patient is identified as a suitable candidate for a TECAB (Table 1), a decision must be made regarding the use of cardiopulmonary bypass (CPB) during the surgery and how to protect the myocardium. If the patient is placed on CPB and the heart is stopped, the surgery is called an arrested heart (AH) TECAB. If CBP is not used, the surgery is called a beating heart (BH) TECAB. In a few cases, the patient is placed on CPB to provide increased working space or to manage hemodynamic challenges, but the heart is not stopped. This operation is “pump-assisted TECAB” and is the least common form of TECAB. Traditional BH CABG has inferior long-term graft patency compared with AH surgeries, and thus AH TECAB is preferred, unless contraindications exist. These contraindications include an ascending aortic diameter of greater than 35 mm, moderate to severe aortic and/or iliac vessel atherosclerosis, and small femoral vessels. 4 Depending on the extent of peripheral and central arterial disease, patients with these contraindications can be considered for BH TECAB or pump-assisted TECAB,
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in which systemic arterial perfusion for CPB is delivered via right or left axillary artery cannulation. 4 BH TECAB is contraindicated in patients with small-caliber coronary targets or arteries with intramyocardial coronary vessels requiring bypass and in some patients with morbid obesity. 13 In general, patients undergoing TECAB are typically placed in a 30-degree right lateral decubitus position with the telemanipulator device placed over the patient’s left side. General anesthesia is induced with single lung ventilation via a double lumen endotracheal tube or occasionally a single lumen endotracheal tube and a bronchial blocker. The collapsed left lung provides working space for the insertion of a 12-mm camera port through the left fifth intercostal space, with the addition of up to three 8-mm instrument ports placed between the midclavicular line and anterior axillary line. In some cases, an additional 12-mm port is placed in the left subcostal region near the midclavicular line for a myocardial stabilizer. The left internal mammary artery or right internal mammary artery or both can be harvested, clipped distally, and removed from the thoracic wall to be reimplanted beyond the obstructing coronary lesions. For AH TECAB, the left femoral artery and vein are typically cannulated, and for the BH TECAB, the left axillary artery and left common femoral vein are most commonly cannulated prophylactically for CPB as a safety net in the event of hemodynamic instability or other intraoperative challenges. 1
Postoperative Care
Postoperative care of the patient after TECAB generally follows the same practice guidelines as for patients undergoing standard CABG. 2 Patients undergoing TECAB may be extubated in the operating room or are often candidates for early extubation, usually within 2 to 4 hours after returning to the intensive care unit, unless problems arise from prolonged single lung ventilation, concomitant pulmonary disease, or surgical complications. Temporary pacing wires are not typically placed unless the patient has a strong need for pacing. Aside from port sites where one or two chest tubes are placed, there is the small groin incision where femoral CPB is engaged. Patients undergoing TECAB have incisions that vary from those of patients who undergo traditional CABG and may follow different in-hospital pathways, resulting in a shorter length of stay. Other differences may include an early initiation of patient-controlled analgesia to manage acute pain from telemanipulation at port sites and transition to oral medication once thoracostomy tubes are removed. Because the sternum is preserved, patients have no requirement for sternal precautions and can engage in immediate physical and occupational therapy postoperatively. No specific activities are proscribed, although it is recommended that patients
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avoid driving and other high-risk activities for several weeks in the event of postoperative arrhythmias or hypotension and until the patient has discontinued the use of narcotic medications. Submersion in water also should be avoided until all incisions have healed adequately. Patients may return to normal activities, including work when they feel ready, often within 1 to 2 weeks after surgery. Patients typically are discharged on postoperative days 3 to 5. Prior to discharge, cardiac surgery nurses educate patients and families about new and modified medications to be taken at home and related side effects or adverse reactions. Patients undergoing TECAB are instructed to contact the surgical team if they experience signs and symptoms of local or systemic infection, as well as graft failure (eg, return of previous angina, activity intolerance, shortness of breath, or nausea), fluid overload, and atrial fibrillation. ED nurses should be alert for these signs and symptoms when assessing and caring for patients who have undergone TECAB. Because the sternum is preserved in the TECAB procedure, the most dramatic difference between patients undergoing TECAB and traditional CABG is the lack of need for sternal precautions or lifting restrictions and immediate engagement in immediate physical and occupational therapy after surgery. The importance of returning to usual activity as soon as it is tolerated is also emphasized. A follow-up visit with the cardiac surgeon is scheduled in 4 weeks, and the patient is instructed to also schedule a postsurgical follow-up appointment with his or her cardiologist and primary care physician in 1 to 2 weeks. If the surgery precedes a PCI intervention that was not completed in the same hospital visit as the TECAB, an appointment for the PCI procedure is provided to the patient. Additionally, if the patient has a new prescription for warfarin (eg, postoperative atrial fibrillation) and a delay in enrollment in an anticoagulant management clinic occurs, a member from the surgical team may temporarily monitor international normalized ratio levels until the patient is enrolled into the clinic.
Postsurgical Complications Prompting an ED Visit
Patients most at risk for experiencing postoperative complications from a TECAB surgery are those who have multiple pre-existing comorbidities or prolonged operative times (N 7 hours), usually as a result of multivessel revascularization and use of BH TECAB. 14 These patients often have significant peripheral arterial disease, which adds to their risk of morbidity. Good evidence exists to support TECAB as a safe surgical intervention for patients with coronary artery disease with reduced major adverse cardiac and cerebrovascular events after 12 months. 15,16 Long-term graft patency after robotic-assisted CABG has been investigated and
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TABLE 2
Presenting symptoms in the emergency department related to totally endoscopic coronary artery bypass TECAB procedure
Possible adverse effects/complications
Presenting symptom/s
Initial ED management (in conjunction with primary cardiac surgery team when possible)
Single lung ventilation
Atelectasis, pleural effusion, unilateral pulmonary edema (increased risk with N 7-hr operative times) Stroke
Shortness of breath, activity limitation
Chest radiograph, diuresis, thoracostomy with pleural effusion evacuation
Heart lung machine use
Left groin femorofemoral or Hematoma, seroma, retroperitoleft axillary artery heart lung neal hemorrhage, pseudoaneurysm, cannulation arteriovenous fistula, arterial occlusion, femoral neuropathy, infection, aortic dissection Intraoperative transesopha- Rare complication of esophageal geal echocardiogram perforation Four port incisions placed in the third, fifth, and seventh left intercostal space and an assistance port site in the left parasternal region
Facial droop, arm weakness, diffi- Blood pressure, blood glucose, culty speaking oxygen, fluid, airway, intravenous thrombolytic therapy with tissuetype plasminogen activator and endovascular therapies considered Pain, swelling, erythema, tender- Vascular surgery consult, Doppler ness, purulent drainage at the studies, ultrasound, computed tocannulation site with or without mography angiogram, antibiotic fever, severe back pain, hypoten- treatment sion, tachycardia, abdominal pain Angina, melena, hematochezia, Thoracic surgery consult to evaluate dyspepsia, or gastroesophageal re- for surgical repair of the esophagus flux Left chest localized pain Opioid pain medications, initial chest radiograph to evaluate for pleural effusion, empyema
Pain related to surgical manipulation of robotic instruments at these sites Port site serosanguineous fluid drainage or superficial vessel bleeding Port site infection Pericardiotomy Pericardial effusion Chest pain, dyspnea, orthopnea, Nonsteroidal anti-inflammatory rapid heart rate drugs and prednisone if related to pericarditis Pericardiocentesis Pericardiectomy Electrocautery to liberate Graft failure, arrhythmias, myo- Palpitations, chest pain, short- Reoperation with graft repair, internal mammary artery, cardial infarction, heart failure ness of breath, hypervolemia medical management to improve robotic harvest of graft to cardiac output (e.g. diuresis) coronary artery anastomosis Hybrid TECAB plus PCI
Myocardial ischemia or infarc- Chest pain, shortness of breath, Cardiology and cardiac surgery tion from plaque destabilization heart failure symptoms consultation, cardiac catheterization with possible PCI with or without surgical replacement of coronary graft, dual antiplatelet treatment Conversion of TECAB to Sternal dehiscence, surgical site Localized chest discomfort, fe- Sternal repair, antibiotic treatment, sternotomy infection, protrusion of sternal ver, open surgical wound with wire removal, wound management wire or without drainage with topical dressings PCI, Percutaneous coronary intervention; TECAB, totally endoscopic coronary artery bypass.
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shown to be 92.7% at a mean follow-up period of 16.3 months, 16 which is comparable with traditional CABG. Despite this safety profile, the possibility exists that a patient who has undergone TECAB surgery may seek emergent care for a postoperative complication, since TECAB is performed at only a few centers worldwide. As the surgery becomes more common, ED nurses may see patients returning for follow-up care in areas of the United States not yet involved in TECAB, and must be armed with knowledge of the surgery and its potential complications. Initial assessment of the patient presenting in the emergency department after a TECAB should include identifying the date and duration of the surgery, reviewing and managing pre-existing comorbidities, taking a history of postoperative complications, and verifying the ability of the patient to complete follow-up visits with the cardiac surgeon, cardiologist, and primary care physician since having the surgery. Additionally, if the patient was scheduled to undergo a stent along with TECAB surgery, ascertaining if the PCI portion was completed is critical. The coronary intervention is deemed incomplete and the patient is at risk for plaque destabilization and myocardial ischemia without the completion of this second stent-related component. Identifying if the patient is at therapeutic levels of anticoagulant therapy is important, especially if the patient received a drug-eluting stent as part of a hybrid surgical procedure or was prescribed an anticoagulant for atrial fibrillation or treatment for deep vein thrombosis. Patients may present to the emergency department with symptoms that can be associated with TECAB complications, including worsening shortness of breath, heart palpitations, inadequately treated pain, erythema, and/or drainage from the incision sites. Having an understanding of the specifics of TECAB surgery will be highly valuable when securing a leading diagnosis and developing a management plan (Table 2). For example, after undergoing TECAB surgery, a patient might seek care in an emergency department for persistent fevers, requiring inspection of axillary or groin cannulation sites, port hole incision sites, and conduit harvest sites, along with ordering of a standard chest radiograph and blood cultures. Similarly, a report of palpitations after undergoing TECAB surgery warrants a review of coronary lesions on the presurgery cardiac catheterization report, identification of grafts bypassed using TECAB surgery, and completion of pending hybrid PCI to differentiate between graft or stent failure and postoperative atrial fibrillation.
symptom and may include a complete blood cell count, chemistry panel, prothrombin time, partial thrombo plastin time, international normalized ratio, electrocardiogram, echocardiogram, chest radiograph, blood cultures, and urine cultures. In ideal circumstances, a cardiac surgery team experienced in robotic surgery techniques would be available to consult and oversee the care of a patient admitted to an emergency department after undergoing TECAB; however, for various reasons, this scenario may not be feasible. Consulting an in-house cardiac surgeon, as well as providing the phone contact of the original cardiac surgeon or surgery team, would be a way to enhance continuity of care and collaborative management. This communication will provide an opportunity to obtain an accurate patient history with regard to baseline data, specifics of intraoperative surgery, postoperative transition care concerns such as adverse reactions to medications, electrophysiology consultation for arrhythmias, and other pertinent issues. In some instances, the robotic surgical center can arrange for the patient to be transported back for specialized management of the presenting problem; this option should be explored if resources at the second medical institution are scarce or a significant delay in care might occur.
Conclusion
As cardiac surgery evolves, minimally invasive surgeries like TECAB will undergo further refinement and become the preferred surgical intervention to treat coronary artery disease while preserving patient function and quality of life. ED nurses’ increased knowledge and awareness of this surgery and how TECAB differs from traditional coronary artery bypass surgery via sternotomy will enhance hospital resource allocation and initiate timely health care team collaboration. Increased efficiency and preparedness will help prevent adverse health outcomes in patients who have undergone this specialized surgery. Acknowledgment
We thank Jo Ann Behounek, RN, for proofreading and verification of content for nurses working in the emergency department.
REFERENCES Treatment/Evaluation
1. Bonatti J, Schachner T, Bonaros N, Lehr EJ, Zimrin D, Griffith B. Robotically assisted totally endoscopic coronary bypass surgery. Circulation. 2011;124(2):236-244.
Initial laboratory and diagnostic assessment for a patient who has had a TECAB surgery would be tailored to the presenting
2. Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American
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College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;124(23):e652-e735. 3. Loulmet D, Carpentier A, d’Attellis N, et al. Endoscopic coronary artery bypass grafting with the aid of robotic assisted instruments. J Thorac Cardiovasc Surg. 1999;118(1):4-10. 4. Lehr EJ, Bonatti J. Totally endoscopic coronary bypass surgery robotic on pump (TECAB). In: Chitwood WR Jr, ed. Atlas of Robotic Cardiac Surgery London: Springer; 2014:79-86. 5. Bonatti J, Wehman B, de Biasi AR, Jeudy J, Griffith B, Lehr EJ. Totally endoscopic quadruple coronary artery bypass grafting is feasible using robotic technology. Ann Thorac Surg. 2012;93(5):e111-e112.
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9. Morley JE. Sarcopenia in the elderly. Fam Pract. 2012;29(Suppl. 1):i44-i48. 10. Allen C, Glasziou P, Del Mar C. Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet. 1999;354(9186):1229-1233. 11. Paddon-Jones D, Sheffield-Moore M, Cree MG, et al. Atrophy and impaired muscle protein synthesis during prolonged inactivity and stress. J Clin Endocrinol Metab. 2006;91(12):4836-4841.
6. Ashby DT, Dangas G, Mehran R, et al. Comparison of clinical outcomes using stents versus no stents after percutaneous coronary intervention for proximal left anterior descending versus proximal right and left circumflex coronary arteries. Am J Cardiol. 2002;89(10):1162-1166.
12. Ruo B, Rumsfeld JS, Hlatky MA, Liu H, Browner WS, Whooley MA. Depressive symptoms and health-related quality of life: the Heart and Soul Study. JAMA. 2003;290(2):215-221. 13. Canale LS, Mick S, Mihaljevic T, Nair R, Bonatti J. Robotically assisted totally endoscopic coronary artery bypass surgery. J Thorac Dis. 2013;5(Suppl. 6):S641. 14. Wiedemann D, Bonaros N, Schachner T, et al. Surgical problems and complex procedures: issues for operative time in robotic totally endoscopic coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2012;143(3):639-647.
7. Bonaros N, Schachner T, Wiedemann D, et al. Closed chest hybrid coronary revascularization for multivessel disease—current concepts and techniques from a two-center experience. Eur J Cardiothorac Surg. 2011;40(4):783-787. 8. Alley DE, Koster A, Mackey D, et al. Hospitalization and change in body composition and strength in a population-based cohort of older persons. J Am Geriatr Soc. 2010;58(11):2085-2091.
15. Wang S, Zhou J, Cai JF. Traditional coronary artery bypass graft versus totally endoscopic coronary artery bypass graft or robot-assisted coronary artery bypass graft—meta-analysis of 16 studies. Eur Rev Med Pharm Sci. 2014;18(6):790-797. 16. Currie ME, Romsa J, Fox SA, et al. Long-term angiographic follow-up of robotic-assisted coronary artery revascularization. Ann Thorac Surg. 2012;93(5):1426-1431.
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CARING
PATIENTS WITH TOTALLY ENDOSCOPIC CORONARY ARTERY BYPASS: SPECIAL CONSIDERATIONS FOR THE ED NURSE FOR
Authors: Ameera Chakravarthy, MS, CRNP, Eric J. Lehr, MD, PhD, FRCSC, and Susan L. Bindon, DNP, RN-BC, CNE, Baltimore, MD, and Seattle, WA
oronary artery disease remains a major cause of morbidity and mortality in the United States. As a surgical intervention for this disease, coronary artery bypass grafting (CABG) surgery has become commonplace. Often, emergency department (ED) nurses are familiar with post-CABG patient visits and the presentation of common postoperative complications, including atrial fibrillation, heart failure, pleural effusions, and surgical site issues. However, nurses may not be aware of emerging coronary surgical innovations that are less invasive, less painful, and promote a quicker functional recovery. Totally endoscopic coronary artery bypass (TECAB) is one such surgical innovation that is performed in a small number of centers of excellence in the United States. This surgery permits the bypass of coronary arteries through 5 dime-sized incisions in the chest. TECAB is achieved with the use of a telemanipulator machine that enhances surgical maneuvers through instruments performed by robotic arms controlled by the operator (surgeon) from a console located away from the operating table. 1 Endoscopic coronary surgery preserves the sternum and therefore avoids the risk of sternal wound complications, minimizes blood loss, and reduces the incidence of postoperative atrial fibrillation. Because TECAB is less invasive than standard CABG, the surgery is typically less painful and also preserves muscular and respiratory function. Because this relatively new surgery is currently performed in only a handful of medical institutions across the United States, many nurses and other health care providers may be
C
Ameera Chakravarthy is Clinical Instructor, Department of Organizational Systems and Adult Health, University of Maryland School of Nursing, Baltimore, MD. Eric J. Lehr is Cardiac Surgeon and Director of Cardiac Surgery Research and Education, Swedish Heart and Vascular Institute, Division of Cardiac Surgery, Seattle, WA. Susan L. Bindon is Assistant Professor, Department of Partnerships, Professional Education & Practice, University of Maryland School of Nursing, Baltimore, MD. For correspondence, write: Ameera Chakravarthy, MS, CRNP, University of Maryland School of Nursing, 655 W Lombard St, Suite 342, Baltimore, MD 21201; E-mail: [email protected]. J Emerg Nurs ■. 0099-1767 Published by Elsevier Inc. on behalf of Emergency Nurses Association. http://dx.doi.org/10.1016/j.jen.2016.04.009
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unaware of its existence. Nurses who work in emergency departments may need to manage postoperative complications in patients who have undergone TECAB. Understanding the surgery, the postoperative course, and the potential complications of TECAB facilitates appropriate triaging and resource allocation to adequately manage the needs of this patient population (Table 1). The purpose of this article is to provide ED nurses with a primer on TECAB, along with the most common postoperative complications after this type of surgery. An ED nurse might be the first person to care for these patients after discharge from the hospital where they had the TECAB surgery. Historical Background
Goetz completed the first documented successful bypass graft in humans in May 1960. Since then, CABG has become standardized and predictable, with good long-term results despite some well-known postoperative and/or perioperative complications, including stroke, delirium, postoperative cognitive impairment, mediastinal infection, renal dysfunction, myocardial dysfunction, dysrhythmias, bleeding, and pericarditis. 2 Because of these potential complications, improvements to the surgery have been explored. Minimally invasive direct coronary artery bypass grafting (MIDCAB), typically performed via a left anterior mini thoracotomy, was proposed as a sternal-sparing approach. However, with this surgery, it can be challenging to harvest the entire left internal mammary artery, and this graft can be prone to twisting. Identification of the target vessel can also be difficult. Typically with MIDCAB, multi-vessel grafting is also not possible. To overcome the limitations of MIDCAB, in the mid 1990s, 3 surgeons investigated endoscopic techniques to provide coronary revascularization while maintaining sternal integrity and avoiding the use of cardiopulmonary bypass. The first TECAB was performed by Loulmet in 1998, requiring no graft revision and with no evidence of coronary ischemia for more than 12 years. 3 Initially, TECAB was performed for patients with lesions within the left anterior descending arterial circulation and later for those with right-sided cardiac lesions. Refinement of surgical robots further assisted cardiothoracic surgeons in performing 2-, 3-,
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CLINICAL/Chakravarthy et al
TABLE 1
Indications and contraindications for totally endoscopic coronary artery bypass TECAB indications
TECAB contraindications
Hybrid candidate (TECAB with PCI)
Single-, double-, or triple vessel disease involving significant lesions to the left anterior descending artery, circumflex artery, left main, or left main equivalents associated with significant lesions to the right coronary artery system amenable to PCI
Absolute: Cardiogenic shock Hemodynamic instability Severely impaired lung function that would prevent single lung ventilation Relative: Pleural adhesions after previous thoracic surgery, trauma, radiation, inflammatory disease Significant space limitations (morbid obesity, significantly enlarged hearts) Chest deformities Intramyocardial, heavily calcified, and very small target vessels in beating heart approaches Ascending aortic diameter ≥35 mm and significant aortoiliac atherosclerosis in on-pump arrested heart approaches 1
Multivessel disease without concomitant valve or aortic disease, preserved left ventricular function, preserved lung function forced expiratory volume in 1 second N 60% 1,6 Coronary lesions suitable for percutaneous intervention (short lesion in larger vessel, not at bifurcation)
PCI, Percutaneous coronary intervention; TECAB, totally endoscopic coronary artery bypass.
and even 4-vessel TECAB 4,5 and combined left and right coronary lesions. TECAB can be combined with percutaneous coronary intervention (PCI), a nonsurgical procedure used to open blocked coronary arteries using a catheter to deploy a stent or dilate a narrowed vessel. PCI can be performed either before, during, or after TECAB. Applied as a hybrid coronary revascularization concept, it simplifies the intervention while providing patients with the best coronary revascularization options from both the surgical field (internal mammary arteries) and interventional field (drug-eluting stents). Drug-eluting stents are polymer-coated stents that release an antiproliferative drug in the coronary artery to prevent restenosis. The hybrid coronary revascularization approach shows promising mid- to long-term results. 6 TECAB with or without PCI preserves the sternum, accelerates postoperative rehabilitation and return to work, and improves the patient’s quality of life. 7 The decreased length of stay and quicker return to baseline function is a highly valued benefit to a large aging population with multiple comorbidities. Older adults are at an increased risk for loss of muscle mass and function (sarcopenia), and postoperative bed rest accelerates this deleterious process, causing dependency, as well as increased morbidity and mortality. 8–11 In addition, a strong association exists between physical limitation and depressive symptoms in patients with coronary disease. 12 Given the less invasive nature of TECAB,
2
patients may avoid some of the potential physical and mental setbacks associated with more rehabilitation-intensive sternal-spreading cardiac bypass surgeries.
Surgical Procedure and Patient Preparation
Once a patient is identified as a suitable candidate for a TECAB (Table 1), a decision must be made regarding the use of cardiopulmonary bypass (CPB) during the surgery and how to protect the myocardium. If the patient is placed on CPB and the heart is stopped, the surgery is called an arrested heart (AH) TECAB. If CBP is not used, the surgery is called a beating heart (BH) TECAB. In a few cases, the patient is placed on CPB to provide increased working space or to manage hemodynamic challenges, but the heart is not stopped. This operation is “pump-assisted TECAB” and is the least common form of TECAB. Traditional BH CABG has inferior long-term graft patency compared with AH surgeries, and thus AH TECAB is preferred, unless contraindications exist. These contraindications include an ascending aortic diameter of greater than 35 mm, moderate to severe aortic and/or iliac vessel atherosclerosis, and small femoral vessels. 4 Depending on the extent of peripheral and central arterial disease, patients with these contraindications can be considered for BH TECAB or pump-assisted TECAB,
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in which systemic arterial perfusion for CPB is delivered via right or left axillary artery cannulation. 4 BH TECAB is contraindicated in patients with small-caliber coronary targets or arteries with intramyocardial coronary vessels requiring bypass and in some patients with morbid obesity. 13 In general, patients undergoing TECAB are typically placed in a 30-degree right lateral decubitus position with the telemanipulator device placed over the patient’s left side. General anesthesia is induced with single lung ventilation via a double lumen endotracheal tube or occasionally a single lumen endotracheal tube and a bronchial blocker. The collapsed left lung provides working space for the insertion of a 12-mm camera port through the left fifth intercostal space, with the addition of up to three 8-mm instrument ports placed between the midclavicular line and anterior axillary line. In some cases, an additional 12-mm port is placed in the left subcostal region near the midclavicular line for a myocardial stabilizer. The left internal mammary artery or right internal mammary artery or both can be harvested, clipped distally, and removed from the thoracic wall to be reimplanted beyond the obstructing coronary lesions. For AH TECAB, the left femoral artery and vein are typically cannulated, and for the BH TECAB, the left axillary artery and left common femoral vein are most commonly cannulated prophylactically for CPB as a safety net in the event of hemodynamic instability or other intraoperative challenges. 1
Postoperative Care
Postoperative care of the patient after TECAB generally follows the same practice guidelines as for patients undergoing standard CABG. 2 Patients undergoing TECAB may be extubated in the operating room or are often candidates for early extubation, usually within 2 to 4 hours after returning to the intensive care unit, unless problems arise from prolonged single lung ventilation, concomitant pulmonary disease, or surgical complications. Temporary pacing wires are not typically placed unless the patient has a strong need for pacing. Aside from port sites where one or two chest tubes are placed, there is the small groin incision where femoral CPB is engaged. Patients undergoing TECAB have incisions that vary from those of patients who undergo traditional CABG and may follow different in-hospital pathways, resulting in a shorter length of stay. Other differences may include an early initiation of patient-controlled analgesia to manage acute pain from telemanipulation at port sites and transition to oral medication once thoracostomy tubes are removed. Because the sternum is preserved, patients have no requirement for sternal precautions and can engage in immediate physical and occupational therapy postoperatively. No specific activities are proscribed, although it is recommended that patients
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avoid driving and other high-risk activities for several weeks in the event of postoperative arrhythmias or hypotension and until the patient has discontinued the use of narcotic medications. Submersion in water also should be avoided until all incisions have healed adequately. Patients may return to normal activities, including work when they feel ready, often within 1 to 2 weeks after surgery. Patients typically are discharged on postoperative days 3 to 5. Prior to discharge, cardiac surgery nurses educate patients and families about new and modified medications to be taken at home and related side effects or adverse reactions. Patients undergoing TECAB are instructed to contact the surgical team if they experience signs and symptoms of local or systemic infection, as well as graft failure (eg, return of previous angina, activity intolerance, shortness of breath, or nausea), fluid overload, and atrial fibrillation. ED nurses should be alert for these signs and symptoms when assessing and caring for patients who have undergone TECAB. Because the sternum is preserved in the TECAB procedure, the most dramatic difference between patients undergoing TECAB and traditional CABG is the lack of need for sternal precautions or lifting restrictions and immediate engagement in immediate physical and occupational therapy after surgery. The importance of returning to usual activity as soon as it is tolerated is also emphasized. A follow-up visit with the cardiac surgeon is scheduled in 4 weeks, and the patient is instructed to also schedule a postsurgical follow-up appointment with his or her cardiologist and primary care physician in 1 to 2 weeks. If the surgery precedes a PCI intervention that was not completed in the same hospital visit as the TECAB, an appointment for the PCI procedure is provided to the patient. Additionally, if the patient has a new prescription for warfarin (eg, postoperative atrial fibrillation) and a delay in enrollment in an anticoagulant management clinic occurs, a member from the surgical team may temporarily monitor international normalized ratio levels until the patient is enrolled into the clinic.
Postsurgical Complications Prompting an ED Visit
Patients most at risk for experiencing postoperative complications from a TECAB surgery are those who have multiple pre-existing comorbidities or prolonged operative times (N 7 hours), usually as a result of multivessel revascularization and use of BH TECAB. 14 These patients often have significant peripheral arterial disease, which adds to their risk of morbidity. Good evidence exists to support TECAB as a safe surgical intervention for patients with coronary artery disease with reduced major adverse cardiac and cerebrovascular events after 12 months. 15,16 Long-term graft patency after robotic-assisted CABG has been investigated and
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TABLE 2
Presenting symptoms in the emergency department related to totally endoscopic coronary artery bypass TECAB procedure
Possible adverse effects/complications
Presenting symptom/s
Initial ED management (in conjunction with primary cardiac surgery team when possible)
Single lung ventilation
Atelectasis, pleural effusion, unilateral pulmonary edema (increased risk with N 7-hr operative times) Stroke
Shortness of breath, activity limitation
Chest radiograph, diuresis, thoracostomy with pleural effusion evacuation
Heart lung machine use
Left groin femorofemoral or Hematoma, seroma, retroperitoleft axillary artery heart lung neal hemorrhage, pseudoaneurysm, cannulation arteriovenous fistula, arterial occlusion, femoral neuropathy, infection, aortic dissection Intraoperative transesopha- Rare complication of esophageal geal echocardiogram perforation Four port incisions placed in the third, fifth, and seventh left intercostal space and an assistance port site in the left parasternal region
Facial droop, arm weakness, diffi- Blood pressure, blood glucose, culty speaking oxygen, fluid, airway, intravenous thrombolytic therapy with tissuetype plasminogen activator and endovascular therapies considered Pain, swelling, erythema, tender- Vascular surgery consult, Doppler ness, purulent drainage at the studies, ultrasound, computed tocannulation site with or without mography angiogram, antibiotic fever, severe back pain, hypoten- treatment sion, tachycardia, abdominal pain Angina, melena, hematochezia, Thoracic surgery consult to evaluate dyspepsia, or gastroesophageal re- for surgical repair of the esophagus flux Left chest localized pain Opioid pain medications, initial chest radiograph to evaluate for pleural effusion, empyema
Pain related to surgical manipulation of robotic instruments at these sites Port site serosanguineous fluid drainage or superficial vessel bleeding Port site infection Pericardiotomy Pericardial effusion Chest pain, dyspnea, orthopnea, Nonsteroidal anti-inflammatory rapid heart rate drugs and prednisone if related to pericarditis Pericardiocentesis Pericardiectomy Electrocautery to liberate Graft failure, arrhythmias, myo- Palpitations, chest pain, short- Reoperation with graft repair, internal mammary artery, cardial infarction, heart failure ness of breath, hypervolemia medical management to improve robotic harvest of graft to cardiac output (e.g. diuresis) coronary artery anastomosis Hybrid TECAB plus PCI
Myocardial ischemia or infarc- Chest pain, shortness of breath, Cardiology and cardiac surgery tion from plaque destabilization heart failure symptoms consultation, cardiac catheterization with possible PCI with or without surgical replacement of coronary graft, dual antiplatelet treatment Conversion of TECAB to Sternal dehiscence, surgical site Localized chest discomfort, fe- Sternal repair, antibiotic treatment, sternotomy infection, protrusion of sternal ver, open surgical wound with wire removal, wound management wire or without drainage with topical dressings PCI, Percutaneous coronary intervention; TECAB, totally endoscopic coronary artery bypass.
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shown to be 92.7% at a mean follow-up period of 16.3 months, 16 which is comparable with traditional CABG. Despite this safety profile, the possibility exists that a patient who has undergone TECAB surgery may seek emergent care for a postoperative complication, since TECAB is performed at only a few centers worldwide. As the surgery becomes more common, ED nurses may see patients returning for follow-up care in areas of the United States not yet involved in TECAB, and must be armed with knowledge of the surgery and its potential complications. Initial assessment of the patient presenting in the emergency department after a TECAB should include identifying the date and duration of the surgery, reviewing and managing pre-existing comorbidities, taking a history of postoperative complications, and verifying the ability of the patient to complete follow-up visits with the cardiac surgeon, cardiologist, and primary care physician since having the surgery. Additionally, if the patient was scheduled to undergo a stent along with TECAB surgery, ascertaining if the PCI portion was completed is critical. The coronary intervention is deemed incomplete and the patient is at risk for plaque destabilization and myocardial ischemia without the completion of this second stent-related component. Identifying if the patient is at therapeutic levels of anticoagulant therapy is important, especially if the patient received a drug-eluting stent as part of a hybrid surgical procedure or was prescribed an anticoagulant for atrial fibrillation or treatment for deep vein thrombosis. Patients may present to the emergency department with symptoms that can be associated with TECAB complications, including worsening shortness of breath, heart palpitations, inadequately treated pain, erythema, and/or drainage from the incision sites. Having an understanding of the specifics of TECAB surgery will be highly valuable when securing a leading diagnosis and developing a management plan (Table 2). For example, after undergoing TECAB surgery, a patient might seek care in an emergency department for persistent fevers, requiring inspection of axillary or groin cannulation sites, port hole incision sites, and conduit harvest sites, along with ordering of a standard chest radiograph and blood cultures. Similarly, a report of palpitations after undergoing TECAB surgery warrants a review of coronary lesions on the presurgery cardiac catheterization report, identification of grafts bypassed using TECAB surgery, and completion of pending hybrid PCI to differentiate between graft or stent failure and postoperative atrial fibrillation.
symptom and may include a complete blood cell count, chemistry panel, prothrombin time, partial thrombo plastin time, international normalized ratio, electrocardiogram, echocardiogram, chest radiograph, blood cultures, and urine cultures. In ideal circumstances, a cardiac surgery team experienced in robotic surgery techniques would be available to consult and oversee the care of a patient admitted to an emergency department after undergoing TECAB; however, for various reasons, this scenario may not be feasible. Consulting an in-house cardiac surgeon, as well as providing the phone contact of the original cardiac surgeon or surgery team, would be a way to enhance continuity of care and collaborative management. This communication will provide an opportunity to obtain an accurate patient history with regard to baseline data, specifics of intraoperative surgery, postoperative transition care concerns such as adverse reactions to medications, electrophysiology consultation for arrhythmias, and other pertinent issues. In some instances, the robotic surgical center can arrange for the patient to be transported back for specialized management of the presenting problem; this option should be explored if resources at the second medical institution are scarce or a significant delay in care might occur.
Conclusion
As cardiac surgery evolves, minimally invasive surgeries like TECAB will undergo further refinement and become the preferred surgical intervention to treat coronary artery disease while preserving patient function and quality of life. ED nurses’ increased knowledge and awareness of this surgery and how TECAB differs from traditional coronary artery bypass surgery via sternotomy will enhance hospital resource allocation and initiate timely health care team collaboration. Increased efficiency and preparedness will help prevent adverse health outcomes in patients who have undergone this specialized surgery. Acknowledgment
We thank Jo Ann Behounek, RN, for proofreading and verification of content for nurses working in the emergency department.
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