Adult Cardiac Surgery Mahmoud ABU-ABEELEH Associate Professor Department of Surgery Division of Cardiothoracic Surgery School of Medicine University Of Jordan
Adult Cardiac Surgery: Ischemic Heart Disease (History) William Heberden- 1768- described angina pectoris. Claude Beck 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) John H. Gibbon, Jr. Heart-lung machine May 1953- ASD closure
Adult Cardiac Surgery: Ischemic Heart Disease (History) KOLOSOV in Russia LIMA LAD 1962- David C. Sabiston, Jr.- Aortocoronary saphenous vein bypass Rene Favaloro Cleveland Clinic Frank Spencer/George Green Internal mammary artery
Adult Cardiac Surgery: Ischemic Heart Disease (CABG) Early and widespread acceptance of coronary bypass was delayed. 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 Circumflex Layers of the Arterial Wall Right CA Left Anterior Descending CA Marginal Branch Media Intima Adventitia Intima composed of endothelial cells
Pathogenesis of ACS
ATHEROSCLEROSIS
Risk Factors Uncontrollable Sex Hereditary Race Age Controllable High blood pressure High blood cholesterol Smoking Physical activity Obesity Diabetes Stress and anger 11
Indications for open-heart surgery 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
Adult Cardiac Surgery: CABG Techniques Median sternotomy Cardiopulmonary bypass Cardioplegic arrest Mammary artery, reversed saphenous vein, radial artery Minimally access incisions (Port Access) Off-pump
Adult Cardiac Surgery: CABG Techniques
Heart Lung Machine
Anatomy of heart valves
Anatomy MV: 2Cusps, Anterior and posterior The Ant is the larger Intervenes bet. A-V and aortic orifice AV: 3 semilunar cusps, ant (RT), post. Wall (LT and post) TV; 3cusps, ant, septal,post. PV; 3 semilunar cusps one post. (lt) two ant( ant and rt)
AVS tricuspid and bicuspid calcifications
Adult Cardiac Surgery: Valvular Heart Disease Aortic stenosis- Age-related degenerative Mild AS: AVA > 1.5cm 2 ; Moderate 1-1.5cm 2 ; Severe <1cm 2 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. Indications for surgery Acute AR- inadequate time for ventricular compensation Chronic AR- symptoms, decreasing EF, LVEDD >75mm, LVESD >55mm
Pathophysiolgy of AS 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 Exertional dyspnea Angina Pulmonary edema Exertional syncope Sudden death
Signs of AS Ejection systolic murmur Slow rising carotid pulse Reduce pulse pressure LV hypertrophy Signs of LV failure (crepitations, pulmonary edema)
Investigations ECG CXR ECHO CATH
ECHO criteria for assessment of aortic stenosis severity mild moderate severe critical Mean gradient(mmhg) <25 25-50 >50 >80 Aortic valve area (cm2) >1.5 1-1.5 <1 <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 Mechanical Valves Caged-ball valves Tilting disc valves single leaflet bileaflet 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 Human tissue valves autograft homograft Animal tissue valves Heterograft or xenograft
Adult Cardiac Surgery
How to choose a valve 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 Median sternotomy, hemi-sternotomy Cardiopulmonary bypass Cardioplegic arrest Excision of the valve Debridement Implantation
Adult Cardiac Surgery: ACC/AHA Aortic position 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 All- INR 2.5-3.5
Adult Cardiac Surgery: ACC/AHA 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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