I Device Implantation

This includes ASD/VSD occluders, PDA closure devices, coils, intravascular stents, and implantable valves.

General Nursing Interventions

• Monitor for symptoms of infection. Most patients receive a course of antibiotics during hospitalization and observe SBE prophylaxis as per American Heart Association Guidelines for up to 6 months after implantation (see section, Specific Diseases, Endocarditis, and Table 8-41).

• Patients with septal occluder devices, stents to the pulmonary artery circulation or venous system, or implantable heart valves often are discharged home on antiplatelet/anticoagulation therapy for up to 6 months (see Postoperative Care, Anticoagulation).

• A chest radiograph, echocardiogram, and CBC are often obtained and reviewed by the physician before patient discharge. Lung perfusion scans are often ordered after pulmonary artery stents are placed.

• Review discharge medications and necessary endocarditis prophylaxis (see Table 8-41). Include potential side effects of medications (i.e., increased incidence of bruising with anticoagulation), when to call provider (i.e., development of frequent nosebleeds, multiple bruises, bleeding with teeth brushing).

Nursing Interventions After ASD Device Closure

• Monitor for symptoms of device migration: Palpitations, ECG changes, chest pain, dyspnea, bleeding/low cardiac output, systemic or venous obstruction: venous congestion, jugular distension

• Monitor for aortic perforation, bleeding, device interference with AV valves, low cardiac output

• Patients may develop headaches after ASD closure. Include in discharge teaching

Nursing Interventions After VSD Device Closure

• Will likely require longer procedure times, and use of large sheaths, and may be associated with significant blood loss during procedure

• Obtain baseline hemoglobin/hematocrit, assess for hypovolemia, hypotension, hypothermia

• Monitor for arrhythmias: ventricular tachycardia, fibrillation, heart block

• Assess for loss of pedal pulses indicating possible vasospasm or thrombus

• Anticipate need for ventilatory support, inotropes, vasopressors, pacing, cardioversion660

Nursing Interventions After PDA Device Closure

• Monitor patient for symptoms of device migration

• If patient develops abdominal/flank pain/distension, chest pain, shortness of breath, hematuria, decreased lower extremity pulses, or signs of decreased cardiac output and perfusion, consider device migration into the aorta. Notify physician immediately and anticipate immediate return to catheterization suite or surgery for removal

• If patient develops hemoptysis, shortness of breath, arrhythmias, or decrease in oxygen saturation, consider device migration into pulmonary circulation or heart. Treat symptoms and notify physician immediately

• Coarctation and left pulmonary artery stenosis are known complications of PDA closure.

Nursing Care After Aortic Stent Implantation

These patients are considered at high risk of bleeding from catheterization site because of the use of a large arterial sheath and required anticoagulation.

• Perform frequent and vigilant assessment of entry site and extremity pulses (per order/routine)

• Maintain strict bed rest for 4-6   h as per orders/routine

• Monitor for device migration (see Symptoms in PDA Device closure section)

• Monitor neurologic status: Catheters in close proximity to head and neck vessels increase the risk of thrombus

• Patients may be discharged with beta-blocker or antihypertensive therapy

Nursing Care After Pulmonary Artery/Conduit Stent Implantation

Signs of stent migration dependent on location (pulmonary artery versus right ventricle)

• Monitor for signs of potential stent migration into the right heart: Congestive heart failure, jugular distension, hepatomegaly, dyspnea, ventricular arrhythmias, palpitations, tachycardia, cyanosis, and symptoms of low cardiac output.

• Monitor for evidence of coronary artery ischemia (can develop if device compresses the coronary arteries), specifically ST segment changes in ECG. Notify physician immediately, administer oxygen, obtain CXR, anticipate blood/fluid administration and emergent return to catheterization suite or surgery.

• Large sheath size: Monitor patient for retroperitoneal bleeding and symptoms of decreased cardiac output/shock

• Assess for reperfusion injury in patients with complex pulmonary artery disease/severe pulmonary artery stenosis as discussed under Respiratory Compromise.

II Balloon Dilation/Valvuloplasty

Angioplasty and valvuloplasty is performed for stenotic vessels and valves. The narrowed area is stretched or may be torn. Severity of symptoms is dependent on the degree of stenosis before and after intervention (moderate, severe, or critical). With severe or critical valvular stenosis, the patient may be labile after catheterization and require support of ventilation and diuretic therapy.

General Nursing Interventions

• Monitor for bleeding, arrhythmias, signs of valvar insufficiency, and heart perforation/tamponade (low cardiac output)

• Monitor neurologic status: Balloon rupture during the procedure may cause air embolism or thrombus formation

• Assess and support systemic perfusion

• Anticipate postcatheterization chest radiograph, echocardiogram, and ECG before discharge

• Patient will require endocarditis prophylaxis for 6 months (see section, Specific Diseases, Endocarditis, and Table 8-41)

Nursing Interventions After Pulmonary Valvuloplasty

Manipulation of the right ventricular outflow tract may cause a hypercyanotic episode (see section, Common Clinical Conditions, Cyanotic Heart Disease).

• Monitor oxyhemoglobin saturation, color, heart rate and rhythm, respiratory effort, and serum pH and serum lactate for evidence of progressive hypoxemia.336

• Anticipate need for volume administration and support of oxygenation and ventilation

• Assess for symptoms of right heart failure

Nursing Interventions After Pulmonary Angioplasty

• Assess for reperfusion syndrome, support airway, oxygenation and ventilation

• Monitor patient for vessel rupture: Symptoms of low cardiac output

Nursing Interventions After Aortic Valvuloplasty

• Monitor arterial access site for bleeding

• Monitor for signs of neurologic impairment

• Monitor for symptoms of aortic insufficiency—widening pulse pressure, weak/thready pulse, hyperdynamic precordium, ventricular arrhythmias

III Radiofrequency Ablation

General Nursing Interventions

• Monitor access sites, including neck.

Monitor for bleeding/infection

• Monitor ECG for arrhythmias especially heart block or recurrent SVT

• Monitor for evidence of pericardial effusion/tamponade

• After left-sided pathway ablations patients are often discharged home on antiplatelet therapy. Review during discharge teaching.

IV Special Considerations

A Intervention/Access through Surgical Shunts to Pulmonary Arteries: Nursing Interventions

• Monitor for symptoms of shunt stenosis/occlusion:

image Increasing cyanosis, increasing O2 requirements, decreased respiratory and cardiac function

• Anticipate aggressive anticoagulation therapy, intubation, possible emergent return to cath lab/OR

B Hybrid Procedure for HLHS: Nursing Interventions

These procedures will alter hemodynamics significantly. Patients are often labile in the postcatheterization period.

Monitor for:

• Potential excessive cyanosis

• Restriction to pulmonary blood flow caused by excessively tight pulmonary artery band or ductal stent narrowing

• Restrictive atrial shunt, limiting pulmonary venous return; symptoms of heart failure

• Low cardiac output, excessively low mixed venous saturations

• Anemia, hematocrit <40%

• Heart failure, pulmonary edema caused by excessive pulmonary flow (indicated by arterial oxyhemoglobin saturation >85%)—typically the result of insufficient pulmonary banding

C Patients Critically Ill Before Procedure: Nursing Interventions

Monitor for and be prepared to treat pulmonary hypertensive crises, severe hypoxemia, arrhythmias (see appropriate sections in Common Clinical Conditions)

D Early Postoperative Intervention: High-Risk Patients: Nursing Interventions

• Monitor for internal bleeding caused by catheter crossing new suture lines

• Anticipate that patient may be hemodynamically unstable after procedure and will likely require support of circulation (e.g., inotropic or vasoactive support) and support of oxygenation and ventilation

• Monitor for cardiorespiratory instability, renal intolerance of contrast, infection

a Information in this box is intended to supplement that contained in Box 8-54. It highlights potential complications associated with specific catheterization interventions.

Box 8-56 Advanced Concepts: Care of the Child Undergoing Cardiac Catheterization

• Cardiac catheterization procedures in shunted patients may involve catheter manipulation through the surgical shunt with resultant elevated risk for shunt thrombosis. Systemic anticoagulation to avoid shunt thrombus is prescribed. Close monitoring for signs of altered shunt flow with increasing cyanosis is required.

• Hybrid Stage I procedures for hypoplastic left heart syndrome result in single ventricle physiology postcatheterization. Bilateral pulmonary artery bands and a stent within the ductus arteriosus are placed.

• Hybrid Stage I procedures for HLHS may develop restrictive atrial septum with elevated left atrial pressures, pulmonary hypertension, cyanosis, and inadequate cardiac output, requiring re-intervention.

• Distal pulmonary artery intervention provides treatment for stenosis inaccessible to surgical treatment.

Endomyocardial biopsy

Definition

An endomyocardial biopsy is a diagnostic procedure that removes a small piece of the heart muscle for laboratory analysis. This procedure aids in making the diagnosis of specific myocardial disorders that are seldom diagnosed by noninvasive tests.198 Diagnosis of these myocardial disorders guides treatment.

Endomyocardial biopsy remains the standard for diagnosing acute viral myocarditis and for diagnosing myocardial disease seen in hyperplastic obstructive cardiomyopathy, mitochondrial disorders, and storage diseases.165,188 (Please refer to the section, Myocarditis and the section, Cardiomypathy.)

Endomyocardial biopsy is also used to obtain tissue for rejection surveillance after cardiac transplantation (see Chapter 17).475

Because patients with myocardial disorders often present with new-onset heart failure and cardiogenic shock, early diagnosis is vital to guide treatment.198

Procedure

Endomyocardial biopsy is usually performed in the cardiac catheterization suite under fluoroscopic guidance. Fluoroscopy is preferred over two-dimensional echocardiography because it provides detailed information about the course of the catheter and the biopsy sites.198 Hemodynamic data are often obtained with the myocardial samples.

Specimens of heart endocardium and myocardium are obtained using a flexible bioptome. A bioptome is a solid catheter that has sharpened cusps that are opened and closed by the cardiologist to pinch off a piece of heart tissue. The bioptome is introduced through a long sheath directing the bioptome cusps to the biopsy site in the ventricular wall, as illustrated in Fig. 8-72. A variety of sizes of bioptomes and sheaths allow access even in small infants. Percutaneous access is obtained through right and left jugular or subclavian veins, right and left femoral veins, and right and left femoral arteries. The right internal jugular vein is the most common site used for posttransplant surveillance biopsies.198

image

Fig. 8-72 Endomyocardial biopsy technique showing the bioptome in place in the right ventricle.

(Redrawn from Copeland JG, Stinson EB. Curr Probl Cardiol 4:1-5, 1979.)

Potential Complications

Acute complications of endomyocardial biopsy include perforation and resultant pericardial tamponade, ventricular or supraventricular arrhythmias, heart block, pneumothorax, puncture of central arteries, pulmonary embolization, nerve paresis, venous hematoma, damage to the tricuspid valve, and creation of an arteriovenous fistula.198 The risk of complications varies with the skill and experience of the operator and the clinical condition of the patient. The use of the long sheath has reduced the risk of damage to the tricuspid valve.

Delayed complications include those seen with cardiac catheterization. These involve bleeding at the access site, pericardial tamponade, and deep vein thrombosis. The overall complication rate is less than 1% in greater than 4000 biopsies, with the major complications resulting from sheath insertion and biopsy procedure. Reported deaths have resulted from perforation and pericardial tamponade.198

Nursing Interventions

The nurse must monitor the child's appearance, electrocardiographic rhythm, blood pressure, and pulse oximetry throughout the procedure and during the postprocedure period. Signs of poor systemic perfusion, respiratory distress, bleeding, or arrhythmias must be immediately reported to the physician.

The nurse must have a high sensitivity to signs of cardiac tamponade and venous and arterial thrombosis and/or emboli. These include muffled or diminished heart sounds; pulsus paradoxus; distended neck veins; systemic hypoxemia; decreased cardiac output with tachycardia, hypotension, and poor perfusion; decreasing oxygen saturation; neurologic changes; and decreased perfusion and/or absent pulses distal to the catheter insertion site.721 Because the sheath used is large and long, the insertion site must be closely monitored for bleeding. If site bleeding occurs, immediate pressure must be applied and the physician notified.806

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