What are the tests done before TKR

Preoperative - Postoperative

preoperative diagnosis

Clinical status with Allen test on both sides
We routinely perform the Allen test bilaterally in patients who are scheduled for aortic coronary bypass surgery to evaluate the usefulness of the radial artery as an additional bypass graft. In most cases we prefer arterial grafts over leg veins, which are only used in special situations.

Blood tests

Test blood, BB, small clots, electrolytes, liver and kidney values, CRP, heart enzymes

Imaging
The following examinations are carried out upon admission to hospital:
Thorax RX dv / ds (if the last is> 2 weeks old)
EKG always new
Carotid duplex in high-risk patients:> 70 years old, Stn CVI / TIA, diabetes mellitus, flow noise
Cardiac catheter: The heart catheter examination is carried out in most cases for diagnosis and indication. In patients with isolated non-coronary cardiopathies, it is usually carried out in addition to rule out CHD or to take measurements of the hemodynamics, for example to determine the severity of the PAHT or restricted CO. In individual cases, if the pretest probability for CHD is low, a cCT can be performed as an alternative. These examinations can be carried out on an outpatient basis or during a brief hospitalization or on the day of admission. In the case of impaired kidney function, poor AZ or advanced age, we then plan to start with HK 2 days before the heart operation.
Transthoracic echocardiography: Existing examinations (not only the written findings, but also the most important sequences on CD) are usually sufficient for valve vitia. A TEE upon admission is usually not necessary, because intraoperatively the operation is always carried out under TEE, so that relevant questions can still be answered there.
A preoperative TEE is only necessary for specific questions and if the TTE does not provide enough information on surgical planning, e.g. on the reconstructability of a valve or the degree of destruction in endocarditis.
CT / cCT(for special questions, e.g. aortic aneurysm, reoperations, non-invasive exclusion of CHD),
MRI / cMRI (for special questions, e.g. aortic aneurysm, reoperations, proof of viability, contractile reserve, etiology)
Lung function: with suspected or known advanced lung disease
OnVein duplex exams can in our opinion be dispensed with. Only in patients after complete stripping of the varices and pathological Allen tests bilaterally can the preoperative evaluation of the venous situation be useful for localizing vein segments that are still present (e.g. v. Saphena parva).


Dentist?
With regard to a heart operation, especially a valve operation, a systematic assessment of the teeth and, if necessary, rehabilitation by the dentist was recommended in the past. However, this approach has been abandoned. Today is a dental check-up and preoperative treatmentonly necessary if there are symptoms of active inflammation / infection and teeth that are obviously badly damaged by caries.
We advise against dental hygiene and dental elective interventions in the first 3-6 months postoperatively because of the increased risk of endocarditis and bleeding.
In contrast to the US and European guidelines for endocarditis prophylaxis, the guidelines of the Swiss Society for Cardiology continue to see oneEndocarditis protection for dental hygiene and dental interventions after surgerybefore (red card).

preoperative measures

Own medication

Should be taken unchanged until admission.


Exceptions

Antiplatelet agents and oral anticoagulation:

Before heart surgery, it must be considered whether an existing platelet inhibition or OAC should be discontinued.

Basically, antiplatelet agents are intended asMonotherapy (usually ASA) can be left in place until the procedure. With dual therapy after coronary stenting, you canDiscontinue clopidogrel, prasugrel (Efient), or ticagrelor (Brilique) 7-10 days before the procedure unless the proximal RIVA or a large RCA has been stented. If the coronary intervention was more than 1 year ago, the dual platelet inhibition can in any case be reduced to ASA.

Marcoumar can be stopped 2 days before admission to the hospital, regardless of the indication. Bridging with LMWH is unnecessary in the vast majority of cases. AQ> 40% on the day of entry is completely sufficient.

DOAK
The new oral anticoagulants likeDabigatran (Pradaxa) or rivaroxaban (Xarelto) can cause severe bleeding and cannot be directly antagonized. Therefore, caution should be exercised when dealing with this with regard to cardiac surgery.
In principle, NOAKDiscontinued 48 hours before a planned major surgery become atRenal failure better than 72 hours (with CrCl <50 ml / min even> 96h). Bridging with LMWH is usually not necessary.

Stop smoking
We strongly recommend patients to stop smokingat least 2 weeks to stop preoperatively. Even 2 days preoperatively is still better than not at all. However, the resuming ciliary cleaning function then leads immediately postoperatively to increased productive coughing, which is very painful for the patient after the sternotomy and increases the risk of secondary sternum instabilities.

alcohol
We systematically ask the patient about the type and amount of alcohol consumed preoperatively. Advice from your spouse or partner, or from you, is also helpful in the event of increased consumptionpreventive action take action against postoperative delirium and withdrawal symptoms.

postoperatively

General recommendations
The following recommendations are given to the patient as a leaflet:
Take a shower: Covering the chest wound with a waterproof adhesive bandage for the first 2 weeks after the operation. Remove the adhesive film after showering, do not stick any more plasters on.
Swimming:Do not bathe for 4 weeks (outdoor pool, bathtub, etc.)
Drive: Do not drive vehicles yourself for 4 weeks. Buckle up.
Carry and lift: No carrying or lifting of loads> 5kg or strength work with the arms for 8 weeks.
Medication:Medication as prescribed. Adjustments take place during rehabilitation. Reduce the pain medication gradually, first during the day, only at the end leave the dose off for the night.
Endocarditis prophylaxis (after valve replacement, after valve reconstruction): Think about endocarditis prophylaxis (red ID card) if necessary.
After rehabilitation: After the rehabilitation, your family doctor will be there for you again. The heart specialist (cardiologist) will automatically call you for a check-up after 3-6 months.

Medication
Ca antagonist (Norvasc) for 6 weeks when using the RA, RIMA for spasm prophylaxis
ASA, statin lifelong according to ACB; Statin only for <75y
ASS according to AKE bio, no Marcoumar
Marcoumar for 3 months after MKR: AF episodes occur more frequently during this time. In addition, there is increased thrombogenicity in the LA up to the endocardialization of the mitral annuloplasty ring.
Marcoumarfor 6 months according to MKR plus RFA. The endocardial lesions created by ablation are very thrombogenic. In addition, the ablation only has a fully electrically insulating effect after the scarring has healed, which takes about 6 months. AF episodes are still possible during this time.
Thereafter, the Marcoumar can be suspended at SR. Was the LAA closed during the operation? amputated, the OAC can also be suspended in AF and replaced by ASA.
Diuretics for 3-6 W postoperatively after surgery with atrial incision (MKR, TKR, atrial myxoma, etc.), mostly moduretic, no loop diuretics
Analgesics: Usually only paracetamol, for coronary patients no diclofenac, if NSAIDs, then preferably naproxen with PPI.
Beta blockersfor 3 W: For the prophylaxis of postoperative AF, we prefer to use Concor immediately postoperatively. In the phase of frequent AF episodes, prophylaxis makes sense.
Cordarone:If AF occurs intraoperatively or with beta blockers, or if it is hemodynamically effective, we use Cordarone. Often, after saturation and in SR, due to its long half-life, it can be stopped again when it leaves.