The Ins and Outs of Cardiac Surgery. Stephanie Wold RN MN NP

The Ins and Outs of Cardiac Surgery Stephanie Wold RN MN NP 1

The Ins and Outs of Cardiac Surgery Cardiac Surgery in a Nutshell 2

Outline Wait Times and Referral Process for Cardiac Surgery Getting Ready for Cardiac Surgery - Preoperative Considerations A closer look at most common disease processes that require heart surgery and what each surgery entails Complications of cardiac surgery 3

Referral Process Cardiology Cardiac surgeon Discussed at CV Rounds Further referrals if needed 6

PREOPERATIVE PROCESS Once accepted for surgery, all patients require a detailed history and physical Pre-Admission i Clinic: i Baseline bloodwork CXR 12 lead ECG Interview with cardiac anesthetist Best Possible Medication History Pulmonary Function Tests Cross match Informed Consent 7

PREOPERATIVE CONSIDERATIONS Complete dental exam and treatment of any dental caries prior to any surgery during which prosthetic material will be placed (valves, grafts) 8

PREOPERATIVE CONSIDERATIONS 9

PREOPERATIVE CONSIDERATIONS Anti-anginal medications should be continued up to and including the morning of surgery Beta blockers have been demonstrated to lower perioperative mortality in cardiac surgery patients Anticoagulation Unfractionated heparin should continue up to the time of sugey surgery Low molecular weight heparin is usually stopped 18-24 hours prior to surgery to minimize bleeding risk 10

PREOPERATIVE CONSIDERATIONS ASA: Platelet function usually returns to normal within 3 days of stopping ASA For elective surgeries, ASA may be stopped 3 days prior to surgery For patients with an ACS or critical coronary disease, it may be continued up to the day of surgery as it has been shown to improve outcomes 11

PREOPERATIVE CONSIDERATIONS Plavix Has been shown to significantly increase the risk of bleeding and re-exploration for bleeding It is recommended that plavix be stopped 5-7 days before elective surgery ACE Inhibitors or ARBS should be held the morning of surgery Associated with reduced systemic resistance and a vasoplegic state during and after CPB 12

PREOPERATIVE CONSIDERATIONS Diabetics should refrain from taking oral hypoglycemics or insulin the morning of surgery Preoperative prophylatic antibiotics are administered before surgical incision (ancef or vancomycin) 13

CORONARY ARTERY DISEASE 14

Coronary Artery Disease caused by ATHEROSCLEROSIS - or a build up of cholesterol in the inner lining of the artery 15

Coronary Artery Disease Risk factors: hypertension dyslipidemia diabetes melitus cigarette smoking obesity family history Plaque rupture + thrombosis = Acute Coronary Syndromes 16

Referral Process Cardiology Cardiac surgeon Discussed at CV Rounds Further referrals if needed 18

Coronary Artery Bypass Grafting 19

Coronary Artery Bypass Grafting Requires a team approach Cardiologist Cardiology interventionalist Cardiac Surgeons Discussion with patients Consultation with other disciplines Nephrology Intensive Care The goal is to have all patients discussed d preoperatively during weekly CV Rounds 20

Coronary Artery Bypass Grafting Indications for Revascularization: Certain variables are considered: The clinical presentation Severity of angina The presence or absence of other prognostic factors Extent of medical therapy; and Extent of anatomic disease 21

From: ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate Use Criteria for Coronary Revascularization Focused Update: A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography J Am Coll Cardiol. 2012;59(9):857-881. doi:10.1016/j.jacc.2011.12.001 Figure Legend: Copyright The American College of Cardiology. All rights reserved. Method of Revascularization of Multivessel Coronary Artery Disease A = appropriate; CABG = coronary artery bypass grafting; CAD = coronary artery disease; CTO = chronic total occlusion; I = inappropriate; LAD = left anterior descending artery; PCI = percutaneous coronary intervention; SYNTAX = Synergy Between PCI With TAXUS and Cardiac Surgery; U = uncertain. Date of download: 1/27/2014 22

Coronary Artery Bypass Grafting 23

Coronary Artery Bypass Grafting Surgical Procedures - How do they do it? Traditional CABG performed using a median sternotomy using cardiopulmonary bypass 24

Coronary Artery Bypass Grafting The coronary blockages are bypassed with conduits Conduits used can be arterial or venous Usually the saphenous vein and the internal mammary artery are used Radial arteries are sometimes used with younger patients or patients with severe varicose veins 25

Coronary Artery Bypass Grafting 26

Coronary Artery Bypass Grafting Harvested Vein Graft 27

Coronary Artery Bypass Grafting 28

Coronary Artery Bypass Grafting 29

Coronary Artery Bypass Grafting 30

Cardiopulmonary Bypass (CPB) 31

Cardiopulmonary Bypass (CPB) Cardiac surgery is differentiated by all other surgeries by the use of CPB Often referred to as a heart lung machine or "the pump CPB temporarily takes over the function of the heart and lungs The goal is to have a still and blood free operating field The circulation of blood and the oxygen content of the body are maintained 32

Cardiopulmonary Bypass (CPB) Operated by perfusionists Medically directed by anesthesiologists Surgically directed by cardiac surgeons who connect the pump to the patient's body Provides the surgeon with a stable and relatively bloodless surgical field while maintaining adequate tissue perfusion 33

Cardiopulmonary Bypass (CPB) Blood is removed from the body by the venous cannula oxygenated and then returned to the body via the arterial cannula The heart and lungs are completely bypassed 34

Cardiopulmonary Bypass (CPB) Venous Cannulation Arterial Cannulation 35

Figure 2 Drawing shows several routes of cannulation: arterial cannulation of the distal portion of the ascending aorta, antegrade cardioplegia cannulation, retrograde cardioplegia cannulation, and bicaval venous cannulation. IVC = cannula into inferior vena cava, SVC = cannula into superior vena cava. (Reprinted, with permission, from the Cleveland Clinic Center for Medical Art and Photography.) RadioGraphics, http://pubs.rsna.org/doi/abs/10.1148/rg.331115747 Published in: Ahmed H. El-Sherief; Carol C. Wu; Paul Schoenhagen; Brent P. Little; Allen Cheng; Suhny Abbara; Eric E. Roselli; RadioGraphics 2013, 33, 63-72. DOI: 10.1148/rg.331115747 RSNA, 2013 36

Cardiopulmonary Bypass (CPB) Once CPB is initiated: aorta is cross-clamped cardioplegia solution is infused via the aortic cannula Retrograde cardioplegia may also be administered via the coronary sinus 37

Cardiopulmonary Bypass (CPB) Subclavian Cannulation 39

Cardiopulmonary Bypass (CPB) Femoral Cannulation http://www.edwards.com/products/cardiac/pages/cscategory.aspx 40

Cardiopulmonary Bypass (CPB) Complications of CPB: Vasodilatory Shock Hemolysis Emboli air or thrombotic Acute Kidney Injury Neurologic Effects (pump head) 41

Cardioplegia A method of myocardial protection during cardiac surgery Used to arrest the heart Failure to use cardioplegia results in anaerobic metabolism of the heart resulting in severe myocardial dysfunction A solution containing 20-25mEq/L of KCLis administered undiluted into the aortic root to achieve cardiac arrest The solution is readministered every 15-20 minutes to deliver potassium and wash out metabolic by-products 42

Cardioplegia 43

VALVULAR DISEASES 44

Aortic Stenosis Results from thickening or calcification of the valve leaflets creating an obstruction to left ventricular outflow» http://www.lucinafoundation.org/assets/aortic-stenosis.jpg 45

Aortic Stenosis May be caused by a congenital bicuspid valve or degenerative changes In older patients, it is likely caused by calcification and may be a manifestation of atherosclerosis http://www.heart-valve-surgery.com/images/calcified-aortic-valve-bicuspid.jpg https://science.nichd.nih.gov/confluence/download/attachments/35422393/aortic%20stenosis.png?api=v2 v2 46

Aortic Stenosis Indications for surgery predominately dictated by the 2008 ACC guidelines 1. AVR is indicated for symptomatic patients with severe AS. (Level of Evidence: B) 2. AVR is indicated for patients with severe AS undergoing g coronary artery bypass graft surgery (CABG). (Level of Evidence: C) 3. AVR is indicated for patients with severe AS undergoing surgery on the aorta or other heart valves.(level of Evidence: C) 4. AVR is recommended for patients with severe AS and LV systolic dysfunction (ejection fraction less than 0.50). (Level of Evidence: C) 47

From: 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons J Am Coll Cardiol. 2008;52(13):e1-e142. doi:10.1016/j.jacc.2008.05.007 Figure Legend: Management Strategy for Patients With Severe Aortic Stenosis Preoperative coronary angiography should be performed routinely as determined by age, symptoms, and coronary risk factors. Cardiac catheterization and angiography may also be helpful when there is discordance between clinical findings and echocardiography. Modified from CM Otto. Valvular aortic stenosis: disease severity and timing of intervention. J Am Coll Cardiol 2006;47:2141 51 (149). AVA indicates aortic valve area; BP, blood pressure; CABG, coronary artery bypass graft surgery; echo, echocardiography; LV, left ventricular; and Vmax, maximal velocity across aortic valve by Doppler echocardiography. Date of download: 2/25/2014 Copyright The American College of Cardiology. All rights reserved.

Aortic Regurgitation Results from abnormalities in the aortic valve leaflets that prevent the leaflet from closing Calcification, bicuspid valves, destruction from endocarditis Aortic root dilatation ti 49

Aortic Regurgitation - Indications for surgery Acute AR Usually due to a Type A aortic disection or to endocarditis The left ventricle will not be able to handle the sudden increase in blood volume Surgery is emergent 50

Aortic Regurgitation - Indications for surgery Chronic AR Symptomatic patients (regardless of LVEF) should undergo surgery Asymptomatic ti patients t must be follow closely l and are usually recommended for AVR as soon as LV functions begins to decline regardless of symptoms 51

Aortic Valve Replacement Types of Valves: Tissue or mechanical Patient preference is taken into account Tissue valves are generally preferred for patients over 65 to avoid the use of coumadin Stentless valves may be used to provide a larger orifice area Perimount Tissue Valve St Jude Mechanical Valve Freestyle Valve 52

Aortic Valve Replacement http://images.lifescript.com/images/ebsco/images/si55551515.jpg http://www.surgeryencyclopedia.com/images/gesu_01_img0025.jpg 53

Mini-Sternotomy 54

Aortic Valve Replacement Bentall Procedure: AVR with replacement of the aortic root 55

Aortic Valve Replacement Aortic Valve Replacement and Ascending Aorta Replacement 56

Mitral Valve Surgeries Performed for Mitral Stenosis or Mitral Regurgitation Mitral Stenosis: Nearly exclusively as a consequence of rheumatic fever Valve leaflets thicken, the cordae thicken and shorten and eventually the valve orrifice is reduced as well as LV filling 57

Mitral Valve Stenosis - Treatment Percutaneous Balloon Mitral Valvulopasty Mitral Valve Replacement 58

Mitral Valve Replacement (A) Left atrium is opened through the Left Atrial Appendage (B) The posterior leaflet is retained and used to reinforce the suture line (C) Mattress sutures are placed through the annulus. The valve is then tied into position 59

Left Atrial Appendage 60

Mitral Valve Regurgitation Results from: Dilatation of the annulous Damage to the valve leaflets Myxomatous changes Damage due to endocarditis Leaflet shrinkage due to rheumatic disease Chordae tendineae deficits Rupture Papillary Muscle deficits Rupture Ischemic dysfunction 61

Mitral Regurgitation 63

Mitral Regurgitation Indications for surgery: Symptomatic MR (CHF or cardiogenic shock) NYHA Class II-IV patients with chronic severe MR Acute endocarditis Patients with CAD undergoing CABG 64

Mitral Regurgitation Surgical Procedures: Repair or reconstruction is applicable to more than 90% of degenerative MR Replacement is indicated when a repair cannot be done satisfactorily t il 65

Mitral Valve Repair 66

The Future of Mitral Valve Surgery 67

Tricuspid Valve Surgeries Tricuspid Stenosis is rare and usually due to rheumatic heart disease or due to endocarditis Tricuspid Regurgitation is usually a consequence of something else Advanced d mitral disease Pulmonary hypertension Right ventricular systolic dysfunction 68

Tricuspid Valve Surgery Surgery is indicated for: class III-IV symptoms of heart failure When the patient is undergoing mitral valve surgery for mitral disease 69

Tricuspid Valve Repair 70

Post Operative Complications 71

Post Operative Complications Bleeding Post Cardiotomy Syndrome Air or Thrombotic Embolization Coronary Artery Graft Spasm Dysrhythmias Heart Block Atelectasis Renal Dysfunction 72

Thank you! Questions? 74