Cardiac surgeries

about the heart valve surgeries and cabg

1. CARDIAC
SURGRIES
BY,
REVATHY.A,
LECTURER,
CCON.

2. •Cardiac surgery, or cardiovascular
surgery, is surgery on the heart or great
vessels performed by cardiac surgeons.

3. Approaches to heart surgery
•Open heart surgery deals with the
structures inside the heart, whereas
close heart surgery deals with the
structures outside the heart. In an open
heart surgery, a heart-lung machine is
required.

4. Closed heart surgery
•Closed heart
surgery refers to
the type of
surgery in which
heart lung
machine or
bypass machine
is not used.
Open heart surgery
•Open heart
surgery refers to a
type of surgery in
which the chest
wall is surgically
opened and heart
is exposed.

5. •The surgeons’
works on the
structures located
in the exterior area
of the heart.
Heart lung machine
•Not Required
Location of the scars
•Usually on the side
of the chest
•This surgery is
performed on the
muscles, valves, or
arteries of the
heart.
•Required
•Usually on the
centre on the chest

6. Time Spent in
Hospital
•Comparatively
shorter
Time to recover
•Comparatively
shorter
•Comparatively
shorter
•Comparatively
shorter

7. Types of Heart Surgery
•Aortic valve surgery. Surgery to repair or
replace an aortic valve that is not working
correctly.
•Arrhythmia surgery.
A surgical procedure to correct
irregular heart rhythms such as atrial
fibrillation or ventricular tachycardia.

8. •Congenital heart surgery
•Coronary artery bypass graft
(CABG) surgery.
•Heart transplant.

9. 1. VALVULAR
SURGERY.

10. TYPES
•Aortic valve surgery.
•Balloon valvuloplasty.
•Heart valve repair or replacement surgery.
•Mitral valve repair surgery.
•Tricuspid valve surgery.

11. INDICATIONS

13. VAVULOPLASTY
•Definition
Balloon valvuloplasty, also called
percutaneous balloon valvuloplasty, is a
surgical procedure used to open a
narrowed heart valve. The procedure is
sometimes referred to as balloon
enlargement of a narrowed heart valve

14. •Purpose
 The goal of the procedure is to improve
valve function and blood flow by enlarging
the valve opening.
It is sometimes used to avoid or delay
open heart surgery and valve replacement

15. •Types of Valvuloplasty
There are several types of
valvuloplasty:
I.Commissurotomy
Is the repair to commissures between
the leaflets.
The procedure used to separate the fused
leaflets.
It is in 2 type.

17. a) Closed commissurotomy
1.Balloon mitral valvuloplasty
Patients who have been diagnosed with
mitral valve stenosis, high-risk aortic
stenosis or certain blockages of the
plumonic valve may benefit from balloon
valvuloplasty.

18. These valvular obstructions are relieved
using highly specialized balloon catheters.
A balloon is threaded into the heart through
the vein (femoral) in the groin and
temporarily expanded across the narrowed
valve.
The goal of this procedure is to enhance
blood flow across the mitral valve.

21. 2. Balloon aortic valvuloplasty

Balloon aortic valvuloplasty (BAV) in
conjunction with optimal medical
management remains a safe and feasible
treatment option for some patients.

22. Interventional cardiologists perform BAV in
severe aortic stenosis patients, who require
urgent non-cardiac surgery and as a bridge
to transcatheter or surgical aortic valve
replacement in decompensated patients
who cannot tolerate more definitive therapy.

25. b) Open commissurotomy
The procedure is performed
under cardiopulmonary bypass, that is open
heart surgery.

26. •During this surgery, a person is put on a
heart-lung bypass machine. The surgeon
removes calcium deposits and other scar
tissue from the valve leaflets. The surgeon
may cut parts of the valve structure. This
surgery opens the valve.
•It is used for people who have severe
narrowing of the valve and aren't good
candidates for balloon valvotomy.

29. II. Annuloplasty
An annuloplasty is a procedure to
tighten or reinforce the muscular ring around
a valve in the heart. This may be performed
during other procedures to repair a heart
valve.
Surgical repair typically involves the
implantation of a device surrounding the
valve, called an annuloplasty device, which
pulls the leaflets together to facilitate
coaptation and aids to re-establish valve
function.

31. •The aim of mitral valve annuloplasty is to
correct annular-to-leaflet mismatch by
restoring a normal ratio between the
annular size and leaflet surface area, in
order to increase the surface of
coaptation.
•In addition, the annular shape can be
adjusted to restore normal geometry or to
counteract leaflet or subvalvular
abnormalities..

32. •The role of annuloplasty is often
underestimated, and failure to perform a
well-conducted annuloplasty step can be a
reason for early as well as long-term
failures.
•The critical steps of the procedure are:
suture placement, sizing, and choice of
the type of ring

35. III. Chordoplasty
•Chordoplasty is the repair of the chordae
tendineae.
•The mitral valve is involved with
chordoplasty (because it has the chordae
tendineae); seldom is chordoplasty required
for the tricuspid valve.

36. •Regurgitation may be caused by
stretched, torn, or shortened chordae
tendineae.
•Stretched chordae tendineae can be
shortened, torn ones can be reattached to
the leaflet, and shortened ones can be
elongated.
•Regurgitation may also be caused by
stretched papillary muscles, which can be
shortened.

38. Before the Procedure
•Explain the procedure to the patient
•Patient will be asked to sign a consent form
that gives permission to do the test.
•Notify if the patient have ever had a
reaction to any contrast dye, or allergic to
iodine or seafood.

39. •Notify if the patient is sensitive to or are
allergic to any medications, latex, tape, or
anesthetic agents (local and general).
•Patient will be in NPO
•If the patient is pregnant or suspect that
may be pregnant, should notify the
physician.

40. •Notify the physician of all medications
(prescription and over-the-counter) and
herbal supplements that patient is taking.
•If the patient have heart valve disease, as
he may need to receive an antibiotic prior to
the procedure.

41. •Notify physician if he has a history of
bleeding disorders or if thy are taking any
anticoagulant (blood-thinning)
medications, aspirin, or other medications
that affect blood clotting. It may be
necessary to stop some of these
medications prior to the procedure.
•Do blood investigation priorly.

42. •Notify if have a pacemaker.
•The area around the catheter insertion
(groin area) may be shaved.

45. COMPLICATIONS
•Abnormal heart rhythms
•Narrowing of the valve opening
•Infection
•Bleeding
•Stroke
•Heart attack
•Death

46. BALLOON VAVULOPLASTY

47. MITRAL VALVE RPAIR..

48. 2.VALVE
REPLACEMENT

49. VALVE REPLACEMENT
•Valve replacement surgery is the
replacement of one or more of the heart
valves with either an artificial heart
valve(mechanical valve) or a bioprosthesis
(homograft from human tissue
or xenograft e.g. from pig). It is an
alternative to valve repair.

50. There are four procedures
•Aortic valve replacement
•Mitral valve replacement
•Tricuspid valve replacement
•Pulmonary valve replacement

53. MECHANICAL HEART VALVES
•Designed to mimic and function like a
natural, healthy heart valve.
•Mechanical valves open and close with
each heartbeat, permitting proper blood
flow through the heart.
•Mechanical valves are made from
manufactured materials and designed to
last a lifetime.
•They typically do not wear out or break
down.

54. •Mechanical valves are recommended
for patients:
1.With long expected life spans
2.With a mechanical valve already in place
at a different site than the new valve
3.In kidney failure, on hemodialysis or with
hypercalcemia (high blood calcium)
4.Already taking blood thinners because of
a risk of a blocked blood vessel
5.Older than 65

55. 6. Undergoing valve re-replacement for a
blocked tissue valve
7. Who can take blood thinners

56. Types of mechanical valves
There are three major types of mechanical
valves –
•caged-ball,
•tilting-disk and
•bileaflet valve

57. 1.caged-ball
•The first artificial
heart valve was
the caged-ball,
which utilizes a
metal cage to
house a silicone
elastomer ball.

58. • Caged ball valves have a high tendency
to form blood clots, so the patient must
have a high degree of anti-coagulation,
usually with a target INR of 2.5-3.5.
• Edwards Lifesciences discontinued
production of the Starr-Edwards valve in
2007.

59. 2.Titling-disc valve
•The purpose in
creating the titling-
disc valve was to
restore the central
blood flow that was
lost with the ball
valve design.

60. •These valves consist of a single circular
disc restrained by two metal struts and a
metal ring.
•The struts are attached to the metal ring.
•The struts prevent the disc from escaping
the device in either direction.
•The disc opens and closes based on the
same principles used in the ball valve
design, except a disc is used instead of a
ball

61. •Tilting disc valves can open at an angle of
60° and at a rate of 70 beats per minute.
•The angular opening of this valve reduces
damage to blood cells.
•These are major improvements over the
ball design but the struts of the tilting disc
valves tend to fatigue and fracture over
long periods of time.

62. 3. Bileaflet valves
•The bileaflet valve
design consists of
two semicircular
leaflets which pivot
on hinges.

63. •Bileaflet valves have the best central flow
– the leaflets open completely, allowing
very little resistance to blood flow.
•These valves correct the problem of
central flow and blood cell damage;
however, they allow some backflow.
•The majority of mechanical heart valves
used today are bileaflet valves because
they allow the least resistance to flow and
the least blood damage.

64. TTK-CHITRA
ONLY INDIAN-MADE HEART VALVE  
•The first implant
was December 6,
1990 at Sree
Chitra
Institute ,Trivandru
m.
•TTK Chitra Heart
Valve has been in
Clinical use for
over 14 years.
•Complete Structural Integrity
•Absence of cavitation related damage
•Silent operation
•Rotatable within the sewing ring to assure
its freedom to rotate if repositioning needed.
•Low profile,most price-friendly

65. •More than 55,000 TTK Chitra Heart Valve
has been implanted so far in India, Nepal,
Sri Lanka, Bangladesh and South
Africa(250 CENTERS)

66. BIOPROSTHETIC VALVES
•Tissue valves are created from animal
donors’ valves or other animal tissue that's
strong and flexible.
•Tissue valves can last 10-20 years, and
usually don't require the long-term use of
medication.

67. •Tissue valves are recommended for
patients who:
1.Cannot or will not take blood thinners
2.Are younger than 65 years old and need
aortic valve replacement but do not have
risk factors for blocked valves or who are
younger than 70 years old and need mitral
valve replacement
3.Need to have a blocked mechanical valve
replaced

68. 4. Are in kidney failure, on hemodialysis or
have hypercalcemia (high blood calcium)
5. Who are in adolescence and still growing

71. Porcine (pig) Valves
•Two major brands
of porcine available
today, Hancock
and Carpentier-
Edwards
•Has good durability
and and good
hemodynamics

72. Materials: Porcine valve tissue, stents made
of wire, Elgiloy(cobalt-nickel alloy), sewing
ring-knitted Teflon

73. Pericardial (cow) Valves
•Lasts as long as
standard porcine
valves at 10 years

74. •The pericardial valve has excellent
hemodynamics, even in smaller
sizes(19mm to 21mm)and has gained a
large market share (about 40% of US
tissue valves) in this group of patients

75. Homografts(Human to Human)
•Homografts are valves transplanted from
one human to another
•After donation, valves are cyropreserved
until needed
•Since the valve must be thawed overnight,
the patient’s size must be known
beforehand.
•homograft availability is limited by donor
availability

76. •Advantages: resistance to infection, lack
of need for anticoagulation, excellent
hemodynamic profile (in smaller aortic root
sizes)
•More difficult surgical procedure limits its
use.

77. Autografts (Ross Procedure)
•Autografts are valves taken from the same
patient in which the valve is implanted.
•Used for patients with diseased aortic
valves
•Advantages:
–patient receives a living valve in the
aortic position
- Better durability and hemodynamics
Leakage of the valve (aortic regurgitation)

78. Disadvantages:
Difficult procedure for the surgeon
and involves considerable skill

79. Ross Procedure
•The Ross
procedure (or
pulmonary autograft)
is a cardiac surgery
operation where a
diseased aortic valve
is replaced with the
person's own
pulmonary valve.

80. •A pulmonary allograft (valve taken from a
cadaver) is then used to replace the
patient's own pulmonary valve.
• Pulmonary autograft replacement of the
aortic valve is the operation of choice in
infants and children, but its use in adults
remains controversial.
[1]

81. •Advantages
i.Freedom from thromboembolism without
the need for anticoagulation.
ii.The valve grows as the patient grows (i.e.
children).
iii.Favourable hemodynamics.
iv.No foreign material present in the valve

83. •Procedure
•Before the surgery,
patient will
receive general
anesthesia.
•Surgeon will make
a 10-inch-long
(25.4 cm) cut in the
middle of the
chest.

84. •Separate
breastbone in
order to see heart.
•Most people are
connected to a
heart-lung bypass
machine or bypass
pump.

85. •Heart is stopped
while the patient is
connected to this
machine.
•This machine does
the work of heart
while the heart is
stopped.

86. •A small cut is
made in the left
side of heart so y
surgeon can repair
or replace the
mitral valve.
•Surgeon will
remove the mitral
valve and sew a
new one into place

89. •Once the new
valve is working,
surgeon will:
•Close the heart
and take off from
the heart-lung
machine.

90. •Place catheters
(tubes) around
heart to drain fluids
that build up.
•Close the
breastbone with
stainless steel
wires. It will take
about 6 weeks for
the bone to heal..

91. •The wires will stay
inside the body.
•Patient may have a
temporary
pacemaker
connected to the
heart until natural
heart rhythm
returns.
•This surgery may
take 3 to 6 hours

93. Complications
•Bleeding during or after the surgery
•Blood clots that can cause heart attack,
stroke, or lung problems
•Infection
•Pneumonia
•Pancreatitis
•Breathing problems
•Arrhythmias (abnormal heart rhythms)
•The replaced valve doesn't work correctly
•Death

95. TAVI

98. 3. CORONARY ARTERY
BYPASS GRAFT (CABG)

99. •Definition
A form of bypass surgery that can
create new routes around narrowed and
blocked coronary arteries, permitting
increased blood flow to deliver oxygen and
nutrients to the heart muscle.

100. •Purposes
Restore blood flow to the heart
Relieves chest pain and ischemia
Improves the patient's quality of life
Enable the patient to resume a normal
lifestyle
Lower the risk of a heart attack

101. •Indications
 Patients with blockages in coronary
arteries
 Patients with angina
 Patients who cannot tolerate PTCA
(Percutaneous transluminal coronary
angioplasty ) and do not respond well to
drug therapy
 Acute myocardial infarction
 Sever coronary artery disease

102. •Contraindications
Aneurysms
Valvular diseases
 Congenital diseases
 diseases of blood

103. Recent Advances in CABG
•Off-pump coronary artery bypass or
"beating heart" surgery
 A form of coronary artery bypass
graft (CABG) surgery performed
without cardiopulmonary bypass (heart-
lung machine).
Also known as OPCAB (Off-pump
Coronary Artery Bypass), the heart is still
beating while the graft attachments are
made to bypass a blockage

104. •Minimally Invasive Direct Coronary
Artery Bypass (MIDCAB)

 Surgical treatment for coronary heart
disease that is a less invasive method of
CABG.
 MIDCAB gains surgical access to the
heart with a smaller incision than other
types of CABG.

105. MIDCAB is sometimes referred to as
"keyhole" heart surgery because the
operation is analogous to operating
through a keyhole.
MIDCAB is a form of off-pump coronary
artery bypass surgery
 The surgeon enters the chest cavity
through a mini-thoracotomy (a 2-to-3 inch
incision between the ribs).

106. •MIDCABG

107. •Robotic CABG
 Relatively new minimally invasive surgical
technique.
It is a less invasive alternative to
conventional open heart surgery where
the breastbone, or sternum

108.  It uses surgical instruments and a camera
attached to the arms of a robotic machine,
which are controlled by the heart surgeon
via a computer console

111.  Double bypass means two coronary
arteries are bypassed (e.g. the left anterior
descending (LAD)coronary artery and right
coronary artery (RCA)
Triple bypass means three arteries are
bypassed(e.g. LAD, RCA, left circumflex
artery (LCX)
Quadruple bypass means four vessels
are bypassed (e.g. LAD, RCA, LCX, first
diagonal artery of the LAD)
 Bypass of more than four coronary
arteries is uncommon.

113. •PREOPERATIVE NURSING
MANAGEMENT
 The preoperative nursing management
usually begins before hospitalization.
Patients with non acute heart disease
may be admitted to hospital the day
before or the day of their surgery.

114. •PREOPERATIVE ASSESSMENT
 History
 Physical examination
 Radiographic examination
 Electrocardiogram
 Laboratory analysis
 Typing and cross-matching of blood.
 Assessing patient’s functional level
 Psychosocial assessment.
 Family support system

115. PROCEDURE
•An endotracheal tube is inserted and
secured by the anaesthetist and
mechanical ventilation is started. General
anaesthesia is maintained by a continuous
very slow injection of Propofol.
•The chest is opened via a median
sternotomy and the heart is examined by
the surgeon involves creating a 6 to 8 inch
incision in the chest (a thoractomy) .

116. •The bypass grafts are harvested –
frequent conduits are the internal thoracic
arteries, radial arteries and saphenous
veins. When harvesting is done, the
patient is given heparin to prevent the
blood from clotting.
• "on-pump", the surgeon sutures cannulae
into the heart and instructs the perfusionist
to start cardiopulmonary bypass (CPB).

117. •Once CPB is established, the surgeon
places the aortic cross-clamp across the
aorta and instructs the perfusionist to
deliver cardioplegia to stop the heart and
slow its metabolism.
•One end of each graft is sewn on to the
coronary arteries beyond the blockages
and the other end is attached to the aorta.
•Chest tubes are placed in the mediastinal
and pleural space to drain blood from
around the heart and lungs.

118. •The sternum is wired together and the
incisions are sutured closed.
•The patient is moved to the intensive care
unit (ICU) to recover.

129. Post operative nursing
management
A.Preparation of the setting for patient
arrival
B.Immediate assessment & safe transition
from portable to bedside equipments.

130. Post operative assessment
•Hemodynamic monitoring
continuous assessment is needed.
continuous ECG,ABP, CVP,PAP,CO
record the vs frequently
•Care of chest tubes
assess the mediastinal & pleural
chest tubes hourly.
connect to suction of 20cm of H2O

131. prevent air leak by tightening all the
connection.
•Care of temporary pacemaker
examine the connection and function
of pacemaker.
inform the physician if bradycardia
present.
•Laboratory tests
check Ca, K, Mg, Na ect in q 2hrly
administer electrolyte supplements
check RBS regularly

132. •Ventilator management
assess ABG, pulse oxymetry & breath
sound.
suction the ETT as necessary.
•Administration of medication
inotropic agents
vasodilators
analgesics
anxiolytics
anticoagulants
other medications

133. •Other assessments
urine output
peripheral vascular assessment
neurological assessment
sternal dressing
•Identify & manage complications