Transcript CORONARY ARTERY BYPASS GRAFTING

VALVULAR CARDIAC
SURGERY
Outline







Heart and Heart Valve A & P
Valvular Pathology
Valvular Diagnostics
Open Heart Patient Preparation
Supplies, Instrumentation, and Equipment
Valve Surgery (aortic, mitral, tricuspid)
Ventricular Aneurysmectomy
A&P
Your Heart’s Valves
Normal Circulation




Blood comes back to heart for reoxygenation via the superior
and inferior vena cava entering into the right atrium
Passes through the tricuspid valve into the right ventricle,
then through the pulmonic valve into the pulmonary artery
Blood is reoxygenated in the lungs and returns via the
pulmonic veins into the left atrium
There it goes through the mitral valve into the left ventricle
through the aortic valve pushing oxygenated blood into the
coronary ostia as it passes them and throughout the rest of
the body where oxygen is needed by all the organs and
tissues
CARDIAC VALVES


Tricuspid valve lies between the right atrium
and right ventricle
Blood returns to the heart through the
superior and inferior vena cavae into the
right atrium where it passes through the
tricuspid valve into the right ventricle where
it is pumped through the pulmonic valve into
the pulmonary artery to be taken to the
lungs for re-oxygenation
CARDIAC VALVES


Mitral Valve lies between the left
atrium and the left ventricle
Blood returns via the pulmonary veins
(after re-oxygenation) into the left
atrium, passes through the mitral valve
and into the left ventricle, where it is
pumped through the aortic valve
CARDIAC VALVES


Aortic valve lies between the aorta and
the left ventricle
Blood is pumped from the left ventricle
through the aorta to the coronary ostia,
head vessels, upper and lower
extremities, and the abdominal organs,
via the aorta





Clarification
The aortic and pulmonic are often referred
to as semi-lunar, meaning they have three
half moon shaped cusps
The mitral and tricuspid are often referred to
as atrioventricular valves, as they separate
the atria and ventricles
The tricuspid valve is “three-cusped”
The mitral valve is “two-cusped” or bicuspid





Mitral Valve
Has two cusps (a posterior and anterior
leaflet)
Often referred to as the bicuspid valve
Leaflets are attached and anchored to the
endocardial papillary muscles by cords
called cordae tendineae
Cordae tendinae keep the valve from
prolapsing
Cardiac Conduction






Coordinates cardiac conduction
SA Node (sinoatrial) “the pacemaker”
AV Node (atrioventricular)
Bundle of HIS or AV Bundle
Down R/L insulated branched bundles
in ventricular septum
Purkinge Fibers non-insulated and
feed into R/L ventricles
Cardiac Conduction


SA node initiates impulse > atria contract
(blood forced into ventricles)> stimulus
picked up by AV node > AV Bundle (signal
slightly delayed) > brnached bundles >
purkinge fibers > ventricles stimulated and
contract (blood forces atrioventricular valves
to close and semilunar valves to open)
These valves should go one-way
Pathology of Valves




Obstruction of the valves is usually caused by
stenosis or fusion of the leaflets causing diminished
blood flow resulting in poor oxygenation or backup
of blood into the respective ventricles
Backup of blood damages the ventricular
endocardium and myocardium over time, which can
cause ventricular aneurysm (thinning and
enlargement of the ventricle)
Can be regurgitant or insufficient due to leaflet
damage (may not necessarily be stenosed)
In the case of the mitral valve, damage can be to
the cordae tendineae, causing elongation, rupture,
or shortening
Aortic Stenosis



Calcification of the aortic valve cusps
LV hypertrophy develops as result of
restricted blood flow into the aorta
Sx: fatigue, DOE, palpitations,
dizziness, fainting, angina (chest pain)
Pulmonic Stenosis



Calcification of pulmonic valve cusps
Restricts flow into PA
RV hypertrophy
Mitral Regurgitation



Blood flows back (regurgitates) into the
LA through the incompetent mitral
valve
LV hypertrophy
Sx: fatigue, palpitations, orthopnea
(need to sit up to breath), PND
(paroxysmal nocturnal dyspnea, after
sleeping wakes up needing air)
Mitral Stenosis




Calcified mitral valve
Impedes flow of blood into LV
LA hypertrophy or enlargement
Sx: fatigue, palpitations, DOE,
orthopnea, PND, pulmonary edema
Tricuspid Regurgitation


Blood flows back (regurgitates) into RA
due to incompetent tricuspid valve
Sx: engorged pulsating neck veins,
liver enlargement, RV hypertrophy,
thrill at left sternum
Tricuspid Stenosis



Calcification of tricuspid valve
Impedes blood flow into RV
Sx: diminished arterial pulse, jugular
venous prominence
Valvular Disease











Causes:
CAD and MI
Degenerative disease due to age
Rheumatic heart disease (a complication of bacterial strep)
Congenital disease
Obstruction results in left ventricular myocardial overload due
to backflow of blood, which stresses the myocardium over
time
IV Drug Abuse
Dental Infections
Lupus
Marfan’s Syndrome
Scleroderma
Symptoms of Valvular Disease







Fatigue
Weakness
Dyspnea with or without exertion, stress, or
pregnancy
Pulmonary edema
1° cause rheumatic fever
May go from mild to total disability in 5- 10
years
May be asymptomatic 10-20 years after
initial damage to valve
Diagnosis






NONINVASIVE
H&P
ECG/EKG
Exercise EKG (stress test)
Echocardiogram (echocardiography
is the Gold Standard for diagnosing
valvular disease)
Chest x-ray
Diagnosis



INVASIVE
Cardiac catheterization ( may be in
conjunction with echocardiogram)
Trans-esophageal echocardiogram
(usually done preoperatively in the OR
suite in conjunction with valve surgery)
Anesthesia

General
Medications





Warm saline with antibiotic solution
Topical hemostatic agents of choice: surgicel,
gelfoam and thrombin, gelfoam/thrombin/antibiotic
rolled into balls for sternal bone application, bone
wax for sternum with raytex underneath to prevent
surgeon from ripping gloves on rough edges
Extra NS for valve rinsing if is a xenograft
Will rinse x 3 in 250cc NS each rinse for 2 minutes
each or per manufacturer’s recommendations
Some surgeons may want antibiotic added to 2nd or
3rd rinse
Patient Positioning






Supine position
Arms padded and tucked
May want a shoulder roll to elevate the
sternum (optional)
Headrest
Pillow under knees (preferable)
Heel pads (preferable)
Prep





Begin at anterior thorax prepping outward in
a circular motion to the bedline, prep to top
of thighs/ bilateral groins, then pubis
With a separate sponge prep both legs to
knees to the bedline
Use betadine soap, then paint
May use gel or spray
Should do minimum of two coats of paint
PREP

For a CABG and valve replacement,
will prep sternum to neck, bedline to
bedline, groins, pubis, then each leg
circumferentially to ankles or feet
(institutional policy)
Equipment










Two large tables (back table and Mayfield)
Mayo stand (for saw)
Double ring
Prep tables x 2
Slush machine/warmer
ECU x 2
Cell saver
CPB machine
Off-table suction
External Pacing box
Instumentation









Open heart Trays
Valve Tray
Suture Guide Holder
Sternal retractor (Ankinney for aortic valve) and
(Cosgrove or Korous for mitral or tricuspid)
Finochetti
Sternal saw
Internal defibrillator paddles
Doctor’s specials
Micro instruments needed if CABG done with valve
surgery
Supplies









Valve Custom Pack (Coronary pack for CABG/Valve)
CV Drape Pack
Gloves
Chest tubes
Suture guide inserts
Valve Sizers for appropriate valve
Appropriate valves of surgeon request in the room
Misc. suture: pericardial suture, cannulation suture, aortic retraction
suture (for aortic valve only), valve repair or replacement suture,
suture to close aorta or atrium, pacing wires, suture to sew in pacing
wires, cutting needles to sew in chest tubes and pacing wires, sternal
wires, fascia suture, subcutaneous, subcuticular
Coronary ostia perfusion catheters (auto-inflating, gummy tip, or
spencers (for aortic only)
Supplies continued









Aortic cannula
Venous cannula (need two for bicaval cannulation-need for
mitral valve surgery)
Antegrade cannula (may just use retrograde and place this
after aorta closed for aortic valve surgery/is placed for mitral
valve surgery)
Retrograde cannula
Medusa
Cardiac insulation pad
Myocardial temperature probe
Extra saline
Three cytals for washing valve if using a xenograft (porcine or
bovine)
Valve Replacement Options

Mechanical
Biological

Diseased valve excised and replaced

Valve Replacement Options
(Aortic and Mitral)






1. Mechanical:
St. Jude or Starr-Edwards
valve only
conduit/valve available for aortic
Durable
Used primarily in young patients
Patient requires long-term anticoagulant
therapy (not for elderly)
Complications: emboli and bleeding from
other injury due to anticoagulant therapy
Valve Replacement Options
(Aortic or Mitral)







2. Heterograft/Xenograft
Biologic
May be bovine or porcine
Bovine pericardium is the new rage
Old porcine has a duration of 15 years
Bovine pericardial are thought to last
longer/research inconclusive due to recent
development
No anticoagulant therapy needed
Valve Replacement Option
(Aortic)





3. Aortic Stentless
Biologic
Porcine
Durability good over age of 60
No anticoagulant therapy needed
Valve Replacement Options
(Aortic, Mitral, Pulmonic)








4. Allograft/Homograft
Biologic
Cadaver from organ donor
Will measure annulus size with TEE
Will choose graft before incision made or as
opening chest
Time will be required for proper thawing procedure
to be implemented to prevent damage to the graft
Long term
Limited availability
Valve Replacement Option
(Aortic)






5. Autograft (ROSS Procedure)
Requires expert valve surgeon
Excision of patient’s pulmonic valve to be
used as the patient’s new aortic valve
A pulmonic allograft will be used to replace
excised pulmonic valve
Long term
Limited availability of pulmonic allograft
Valve Repair Options

Annuloplasty rings

Mitral annuloplasty rings
Tricuspid annuloplasty rings

Replacement verses Repair




Aortic and Mitral are replaced
Tricuspid in extreme situations can be
replaced with a mitral valve
Mitral and tricuspid usually repaired
with annuloplasty rings
Mitral may have to be replaced if
attempted repair is unsuccessful
Annuloplasty Rings







Used for repairing of the mitral or tricuspid valves
Mitral rings are a near to complete circle
Tricuspid rings are an incomplete circle or half-circle
Sizers are half moon shaped and have T or M on them (will
come with a malleable handle-bend it slightly for ease of
sizing)
Are differentiated between by T or M on the tag (remove the
Minnie-Pearl tag before passing it to the surgeon)
Provide reduction of the dilated annulus
Often the tricuspid function will return to normal with the repair
of the mitral
Valve Repair/Replacement
Procedure









Incision with #10 blade
Cautery
May use curved mayo scissors to ream under the xiphoid to
loosen the fascia from the sternum
Sternal saw
Bone wax or gelfoam powder mixed with saline or thrombin to
make soft balls to spread on sternum
Wet laps folded in half (should have been soaked in antibiotic
NS and wrung out)
Sternal retractor
Cautery and debakeys to open/dissect the pericardium
Pericardial sutures (may use pop-off silk or neurolon)
Valve Repair/Replacement
Procedure






Dissect aorta from pulmonary artery to provide room to place
aortic cross-clamp
Purse-string cannulation stitches for aortic cannula (x2),
venous cannula, and retrograde cannula, each is rommeled
Heparin is administered by anesthesia at surgeon prompt
Cannulas are placed, aortic first, stab blade (#11), aortic
cannula, heavy tie or umbilical tape, tube clamp, bowl and
scissors to cut aortic pump line, hook to CPB tubing, make
sew cannula to patient/drape or clamp with non-penetrating
towel clip
Venous cannula placed, metz, cannula (some surgeons may
use a satinsky to clamp the atrial appendage before incising
it), heavy tie or umbilical tape, tube clamp or not and hook to
venous line from CPB machine
Surgeon will say to perfusion, “Go on bypass”
Valve Repair/Replacement
Procedure





Hypothermia will begin by perfusion who
can cool the blood he is circulating
Cross Clamp will be placed across the aorta
Cardiac insulation pad may be placed
Myocardial temp probe may be placed near
the apex of the left ventricle
Ice may be applied to the heart as well
Aortic Valve Replacement




AORTIC
Once temperature is where surgeon wants
it, he will take a metz and cut the aorta open
above the aortic valve and below the aortic
cross clamp
He may want stay sutures or retraction
sutures
He may continue to perfuse the heart with
cardioplegia fluid directly into the coronary
ostia via the medusa and coronary perfusion
cannula that is attached (his/her preference)
Aortic Valve Replacement






He/She will begin to excise the valve using metz, a
pituitary ronguer, knife (#15c or #11)
Be prepared to wipe ronguer , metz, and forceps
frequently with a moist lap
Retraction may be provided by the assistant with a
hand-held aortic retractor
Off-table suction will be used to “vacuum” (tonsil
suction without tip) as plaque is removed
Care is taken NOT to get debris into the
ventricle as it could cause stroke later
Cold NS Irrigation provides thorough cleaning using
an asepto
Mitral Valve
Repair/Replacement







Caval tapes will be used with a ligature passer or right angle and long dacron
or polyester tapes and rommeled to provide a tight seal around the cavae and
their cannuli to prevent blood from coming into the field around the cannuli
Heart is turned over and left atrium is exposed
Surgeon will take an #11 or #15 blade to open the atrium, long metz to widen
the incision
Mitral retraction will be achieved with a hand-held mitral/atrial retractor or
placement of the arm attachments for the cosgrove or korous retractor
Two long, blunt nerve hooks will be passed to the surgeon for him to
manipulate the valve leaflets and determine location/extent of damage
Will repair by removing a leaflet, repairing the cordae tendineae with gortex
(PTFE) or prolene suture (have knife, metz, and nerve hooks available)
One of the leaflets may be left to maintain ventricular configuration (if one
passed to you, ask if it is the anterior or posterior for proper specimen
labeling)
Mitral Valve
Repair/Replacement





Once the annulus is cleaned or the cordae are
repaired, the annulus will be sized using mitral
sizers for the appropriate valve being used
Clarify the valve before obtaining it from the
circulator
Valve sutures will be placed (double load pledgeted
valve sutures)
Once valve sutures are in hand up three NH as you
will assist with loading the valve sutures in order to
place through the annuloplasty ring or valve
Be sure you keep up with how many sutures are
used
Valve Repair/Replacement
Procedure









Once valve annulus is clean, annulus is sized with appropriate sizer
Valve is passed to field after being verified by the circulator, scrub, and
surgeon
Bovine and porcine valves require a rinsing process (2 minutes in a minimum
of 250ml NS times three)
Baxter-Edwards only require one minute x 3
Sutures for valve are placed (pledgeted 2-0 RB-1 ethibond or CV-316 Ticron
Pledgeted sutures are used for valve replacement/Non-pledgeted for
Repair
Sutures will be passed double loaded as all pledgeted sutures should
Once sutures are in, if valve is ready, three short NH will be passed up and
the assistant, scrub, PA, and surgeon will work their way around the suture
guide loading each needle in sequence for the surgeon to pass through the
valve
The sutures should have been counted before valve is up so the surgeon
knows how far apart to place the sutures in the cuff of the valve
Valve Repair/Replacement
Procedure









After sutures are in surgeon will ask for 2 kellys and you or he will cut
the needles
He will pass them to you attached to the other kelly
He will work the valve into the annulus of the excised valve (you
should moisten the strings with NS as he seats the valve)
He may take a knife at that point to release the insert holding the
valve to the handle
He will work his way around, tying in the interrupted sutures
When done, he will take long tenotomy scissors and cut the strands
just above the knots
He will test the valve leaflets with NS on an asepto (may use several)
May want a short piece of a red-rubber catheter attached to asepto
for visibility as he is squirting the NS to test the leaflets
If mechanical may use rubber shodded debakey forceps or long
cotton-tip applicator to test leaflets
Valve Repair/Replacement
Procedure




Will close aorta with 2 prolene sutures usually
pledgeted with a corresponding on a 3-0 or 4-0
tapered RB-1 or SH needle
Will close atrium with a 4-0 or 3-0 prolene on a
tapered SH or MH needle (usually non-pledgeted)
Air is vented via antegrade placement (if was not inaortic)
May need a 14 jelco on a 60 cc syringe to stab the
apex/ventricle of the heart to remove air within
before discontinuing bypass
Valve Repair/Replacement
Procedure








Topical hemostatic may be used (gelfoam pad strips with NS
or thrombin)
Patient may need to be defibrillated (have ready when closing
aorta or atrium)
CPB will be discontinued when patient is re-warmed (metz,
tube clamps, metz)
Pacing wires will be placed (atrial and ventricular)
Chest tubes will be placed (1 mediastinal and 1 substernal)
Sternal wires placed twisted and cut with wire cutter, irrigation
of NS with Antibx, fascial layer, subcutaneous, hook up
pleurevac after suctioning out the chest tubes, subcuticular
Dressing, steri-strips, telfa, 4x4s, primapore
Fluffs or 4x4s to chest tubes and tape
Ventricular Aneurysm Repair or
Ventricular Aneurysmectomy




Result of myocardial damage after an MI
causing myocardial replacement with scar
tissue
Scar stretches with pressure resulting in
aneurysm formation
Is the excision of the portion of the ventricle
that has become aneurysmic and reenforcing it with a patch of synthetic graft
material (may be PTFE or hemashield)
Often a tube graft is used and a circular
patch is cut with it
Ventricular Aneurysm Repair or
Ventricular Aneurysmectomy




May require CPB
Prep/Set up is as described for any Open
Heart surgery with exception of if being
done alone, you would not need a lot of the
previously described items
Most frequently done in conjuction with
CABG or Valve surgery
May hear referred to as the DOR
Procedure
Ventricular Aneurysm Repair or
Ventricular Aneurysmectomy





Procedure:
Incision made into the ventricle with a #15 or #11
blade extended with a metz
Will require retraction by the assistant with two
allises or babcocks (are usually part of a valve tray
of instruments)
Surgeon may remove or excise a part of the scar
tissue
A neck will be created in the rim of the scarring with
a prolene suture (2-0 or 3-0 on an SH, to pull the
tissue back together)
Ventricular Aneurysm Repair or
Ventricular Aneurysmectomy





Interrupted pledgeted ticron or ethibond sutures will
be placed (2-0 RB-1 or CV-316, SH or CV-305)
Patch will be passed up with 2 NH to place sutures
through the patch
Patch will be eased down to cover the created neck
Myocardium will be closed with another 3-0 prolene
SH
Epicardium will be closed with two thinly cut strips
of teflon felt and two running 3-0 or 2-0 Prolene
sutures on an SH or MH tapered needle
Ventricular Aneurysm Repair or
Ventricular Aneurysmectomy


Surgery proceeds with patient
rewarming if was cooled and
discontinuation of CPB
Routine open heart surgery closure
Complications







Hypothermia
Infection
Myocardial contusion
Bleeding
Cardiac tamponade
Embolus
Valve malfunction
Summary







Heart and Heart Valve A & P
Valvular Pathology
Valvular Diagnostics
Open Heart Patient Preparation
Supplies, Instrumentation, and Equipment
Valve Surgery (aortic, mitral, tricuspid)
Ventricular Aneurysmectomy