Transcript Adult Cardiac Surgery

Adult Cardiac Surgery
Mahmoud ABU-ABEELEH
Associate Professor
Department of Surgery
Division of Cardiothoracic Surgery
School of Medicine
University Of Jordan
INTRODUCTION
INDICATIONS FOR CARDIAC SURGERY
HISTORY OF CARDIAC SURGERY
CORONARY ARTERY ANATOMY
ATHEROSCLEROSIS CAD
DIAGNOSIS
MANAGEMENT
SURGICAL INDICATIONS /TECHNIQUES
VALVULAR HEART DISEASES
Adult Cardiac Surgery: Ischemic Heart Disease (History)
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William Heberden- 1768- described angina pectoris.
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Claude Beck
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1930’s- sought to increase myocardial blood flow indirectly with
pericardial fat and omentum.
Arthur Vineberg
 1940’s- Mobilization of left internal mammary artery with implantation
of bleeding end into the left ventricle.
 1964- follow-up study on 140 patients
33% mortality
85% relief from angina
Adult Cardiac Surgery: Ischemic Heart Disease (History)
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John H. Gibbon, Jr.
Heart-lung machine
 May
1953- ASD closure
Adult Cardiac Surgery: Ischemic Heart Disease (History)
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KOLOSOV in Russia LIMA→LAD
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1962- David C. Sabiston, Jr.
Aortocoronary saphenous vein bypass
Adult Cardiac Surgery: Ischemic Heart Disease (CABG)
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Early and widespread acceptance of coronary bypass was
delayed.
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Best known cooperative studies (1970-80’s) were the;
VA
Coronary Artery Surgery Study
European Coronary Surgery Study
The Normal Heart - Coronary Artery Anatomy
Left Main CA
Layers of the Arterial Wall
Circumflex
Adventitia
Media
Intima
Right CA
Left Anterior Descending CA
Marginal Branch
Intima composed of
endothelial cells
Pathogenesis of ACS
ATHEROSCLEROSIS
Risk Factors
Uncontrollable
Controllable
•Sex
•High blood pressure
•Hereditary
•High blood cholesterol
•Race
•Smoking
•Age
•Physical activity
•Obesity
•Diabetes
•Stress and anger
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Indications for open-heart surgery
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Coronary heart disease: (CABG)
Triple vessel disease
 Lf main coronary artery disease
 Unstable angina ,failed Mx therapy
 Complications of PTCA
 Life threatening complications of MI
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Adult Cardiac Surgery: CABG Techniques
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Median sternotomy
Cardiopulmonary bypass
Cardioplegic arrest
Mammary artery, reversed saphenous vein, radial artery
Minimally access incisions (Port Access)
“Off-pump”
Heart Lung Machine
Arterial vs Venous conduits
Anatomy of heart valves
Anatomy
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MV:
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2Cusps, Anterior and posterior
The Ant is the larger
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AV:
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3 semilunar cusps, ant (RT), post. Wall (LT and post)
TV;
3cusps,
ant, septal ,post.
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PV;
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3 semilunar cusps one post. (lt) two ant( ant and rt)
AVS
tricuspid and bicuspid calcifications
Adult Cardiac Surgery: Valvular Heart Disease
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Aortic stenosis
Age-related degenerative
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Mild AS: AVA > 1.5cm2 ; Moderate 1-1.5cm2 ; Severe <1cm2
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Indications for surgery largely based on symptoms
 Syncope, angina, dyspnea and CHF
Aortic regurgitation
Calcific aortic disease, idiopathic degenerative disease, endocarditis,
rheumatic disease, bicuspid valve, aortic dissection, Marfan, etc.
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Indications for surgery
 Acute AR- inadequate time for ventricular compensation
 Chronic AR- symptoms, decreasing EF, LVEDD >75mm, LVESD
>55mm
Pathophysiolgy of AS
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Except in the congenital forms, AS develops slowly
The LV becomes increasingly hypertrophied, and
coronary blood flow may become inadequate
The fixed outflow obstruction limits the increase in C.O
required on exercise.
The progressive LV outflow obstruction results in
increased LV mass. This increase in wall thickness is a
compensatory mechanism to normalize LV wall stress
Symptoms of AS
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Exertional dyspnea
Angina
Pulmonary edema
Exertional syncope
Sudden death
Signs of AS
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Ejection systolic murmur
Slow rising carotid pulse
Reduce pulse pressure
LV hypertrophy
Signs of LV failure (crepitations, pulmonary
edema)
Investigations
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ECG
CXR
ECHO
CATH
ECHO criteria for assessment of aortic stenosis
severity
Mean gradient(mmhg)
Aortic valve area
(cm2)
mild
<25
>1.5
moderate
25-50
1-1.5
severe
>50
<1
critical
>80
<0.7
Recommendations for Aortic Valve Replacement in Aortic
Stenosis
Symptomatic patients with severe AS
Patients with severe AS undergoing
coronary artery bypass surgery
Patients with severe AS undergoing surgery on the aorta or
other heart valves
Patients with moderate AS undergoing coronary artery
bypass surgery or surgery on the aorta or other heart
valves
Asymptomatic patients with severe AS and the following;
Asymptomatic patients with severe AS and the following
LV systolic dysfunction
Abnormal response to exercise (e.g. hypotension)
Ventricular tachycardia
Marked or excessive LVH (>15 mm)
Valve area <0.6 cm2
Prevention of sudden death in asymptomatic patients with
none of the findings listed under asymptomatic patients
with severe AS
Adult Cardiac Surgery: Valve Prostheses
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Mechanical Valves
 Caged-ball valves
 Tilting disc valves
 single
leaflet
 bileaflet
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Tissue Valves
 Animal tissue (porcine aortic valves, bovine pericardium)
 Human tissue (Homografts, Autografts)
Mechanical valves
ball and cage
bileaflet
Mechanical valves
tilting-disc valve
Bioprosthetic Valves
Aortic homograft
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Human tissue valves
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autograft
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homograft
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Animal tissue valves
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Heterograft or xenograft
Adult Cardiac Surgery
How to choose a valve
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Mechanical valve in patients < 65years.
Tissue valves in patients > 65 years
Tissue valves in patients whose life expectancy is < 10 year
Tissue valve in patients who have problems which are likely to
cause life threatening bleeding.
Adult Cardiac Surgery: Aortic Valve Replacement
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Median sternotomy, hemi-sternotomy
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Cardiopulmonary bypass
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Cardioplegic arrest
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Excision of the valve
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Debridement
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Implantation
Adult Cardiac Surgery: ACC/AHA
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Aortic position
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Bileaflet- INR of 2-3
Other disk valves and Starr-Edwards- INR 2.5-3.5
In patients with higher risk of TE, INR 2.5-3.5 with addition of aspirin
80-100mg/d. (AF, ↓EF, prior TE, hypercoagulable state)
Mitral position
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All- INR 2.5-3.5
Adult Cardiac Surgery: ACC/AHA
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Tissue prosthesis Anticoagulation recommended in first 3
months, although aspirin alone in aortic
position in some centers. INR 2.5-3.5
 After 3 months, discontinue unless other
circumstances
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