Cardiac surgery

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1. CARDIAC SURGERY

2. INTRODUCTION: The term CARDIOTHORACIC means "pertaining to the heart and chest." The term comes from the Greek word " kardiakos " which means pertaining to the heart, and " thorac " which is Latin for chest. In general terms, the term refers to the chest.  While the term does refer to the chest as a whole, in medicine it is most often used in the context of surgery.

3. DEFINITION: CARDIAC SURGERY , also called HEART SURGERY , involves surgical operations performed on the heart under to correct life-threatening conditions. The surgery can be either; OPEN HEART SURGERY CLOSED HEART SURGERY or MINIMALLY INVASIVE SURGERY depending on the conditions to be corrected.

4. HISTORY: The first successful surgery(Open heart) on the heart was performed by Dr. Daniel Hale Williams of Chicago, America in 1893. 1896: Ludwig Rehn : Suture cardiac stab. 1920: Cutlet and Beck : Mitral Valvotomy . 1925: Henry Souttar operated successfully on a young woman with mitral valve stenosis. 1937: Robert Gross : Ligation of PDA.

5. CONT… 1944: Alfred Blalock, Helen Taussig , and Vivien Thomas performed the first successful palliative paediatric cardiac operation, in a one-year-old girl with Tetralogy of Fallot . In 1947, Thomas Sellors operated on a Tetralogy of Fallot patient with pulmonary stenosis and successfully divided the stenosed pulmonary valve. Many thousands of these "blind" operations were performed until the introduction of cardiopulmonary bypass made direct surgery on valves possible

6. CONT… In 1948 : 4 surgeons carried out successful operations on mitral valve stenosis resulting from Rheumatic fever. 1952: The first successful intra cardiac correction of a congenital heart defect using hypothermia was performed by Dr’s . C. Walton Lillehei and F. John Lewis. In 1953, Alexander conducted the first cardiac surgery under local anaesthesia. 1953: Gibbon : Cardiopulmonary bypass.(open heart operation). In 1956, Dr. John Carter Callaghan performed the first documented open-heart surgery in Canada.

7. PURPOSE: The purpose of Cardiac surgery is to improve the quality of life of the patient and to extend the patient’s lifespan. PRECAUTIONS: Cardiac surgery involves substantial risk and is only done when the benefits outweigh the risk. Risks are highest for infants under one year of age and adults over age 60.

8. CONT… Risk increases with age and when the individual has other health problems such as DIABETES,CHRONIC KIDNEY FAILURE, CHRONIC LUNG DISEASE, PULMONARY EDEMA, CHF, ELECTROLYTE IMBALANCES, ALCOHOLISM and PRIOR HISTORY OF HEART ATTACK OR STROKE.

9. DESCRIPTION: To understand how cardiac surgery works, it is helpful to know something about the, ANATOMY OF THE HEART.

10. BLOOD CIRCULATION THROUGH THE HEART:

11. PURPOSE OF THE SURGERY: Cardiac surgery is done to correct many different types of heart conditions. The most common are: REVASCULARIZATION. ( Eg : CABG) TO TREAT, CONGENITAL HEART DEFECTS ( Eg : ASD CLOSURE) CORONARY ARTERY DISEASE VALVULAR DISORDERS ( Eg : MVR) ARRHYTHMIAS ANEURYSM REPAIR REMOVAL OF ANY CARDIAC TUMORS ( Eg : ROBOTICALLY ASSISTED SURGERIES) END STAGE HEART FAILURE REQUIRING HEART TRANSPLANTATION

12. TYPES OF CARDIAC SURGERY: OPEN HEART SURGERY. MODERN BEATING HEART SURGERY. CABG. MINIMALLY INVASIVE SURGERY. HEART TRANSPLANT. ROBOT ASSISTED SURGERY.

13. CONT: OPEN HEART SURGERY: Surgeon makes a large incision in the chest to open the rib cage and operate on the heart. “OPEN” refers to the chest, not the heart. Depending on the type of surgery, the surgeon also may open the heart. Later found that procedures involving opening the patient’s heart could be performed better in bloodless and motionless environment. Therefore, during such surgery, the heart is temporarily stopped, and the patient is placed on CARDIOPULMONARY BYPASS . ON PUMP SURGERY: USES HEART LUNG MACHINE (CPB).It is the traditional type of open heart surgery. It allows the surgeon to operate on a heart that is not beating and has no blood travelling through it.

14. OPEN HEART SURGERY:

15. Cont … MODERN BEATING-HEART SURGERY: Surgeons began to perform OFF-PUMP CORONARY ARTERY BYPASS SURGERY, which does not use a heart lung machine and surgeon operates on an actively beating heart. However, surgeon will slow the heart rate with medication or a device. This type of open heart surgery is limited to a few specific procedures.

16. MODERN BEATING HEART SURGERY:

17. Cont … CABG: Also called revascularization, is a common surgical procedure to create an alternative path to deliver blood supply to the heart and body, with the goal of preventing clot formation. The procedure is typically performed because of CORONARY ARTERY DISEASE. In ON- PUMP CABG the heart is stopped with the body's blood supply being maintained by the cardiopulmonary bypass (CPB) machine. On- pump Coronary artery bypass (ONCAB) is the more traditional method of performing bypass surgery .

18. CABG:

19. CONT… MINIMALLY INVASIVE SURGERY: An alternative to open-heart surgery, which involves a five to eight inch incision in the CHEST WALL, a surgeon may perform an ENDOSCOPIC procedure by making very small incisions through which a camera and specialized tools are inserted. ROBOT ASSISTED HEART SURGERY: A machine controlled by a cardiac surgeon is used to perform a procedure. The main advantage is it involves three small holes instead of a big incision.

20. MINIMALLY INVASIVE SURGERY:

21. ROBOT ASSISTED HEART SURGERY:

22. Cont … HEART TRANSPLANT: It is a surgical transplant procedure performed on patients with END STAGE HEART FAILURE or severe CORONARY ARTERY DISEASE when other medical or surgical treatments have failed.

23. HEART TRANSPLANT:

24. CARDIO THORACIC INCISIONS

25. A surgical incision is an aperture into the body to permit the work of the planned operation to proceed. In cardiothoracic surgery, the routinely used incisions are the midline sternotomy , thoracotomy and pacemaker incisions.

26. POSITION OF THE HEART INSIDE THE THORAX:

27. LAYERS OF THE HEART:

28. TYPES OF INCISIONS: MEDIAN STERNOTOMY. PACEMAKER INCISION THORACOTOMY : POSTEROLATERAL THORACOTOMY ANTEROLATERAL THORACOTOMY AXILLARY THORACOTOMY LATERAL THORACOTOMY SUBXIPHOID (PERICARDIAL WINDOW)

29. CHOICE OF INCISION: UNDERLYING PATHOLOGY. THE SITE (EG: LUNG,CHEST WALL, OESOPHAGUS). EXPERIENCE OF THE SURGEON. SURGERY : At the level of the 5 th rib for exposure of the upper thoracic area, At the level of the 6 th or 7 th rib for lower thoracic area ( eg : lower oesophageal or diaphragmatic surgery).

30. MEDIAN STERNOTOMY:

31. MEDIAN STERNOTOMY: The M edian sternotomy is the most common thoracic incision . It is the incision of choice for most cardiac surgical operations. It offers excellent exposure to the heart, pericardium, great vessels, anterior mediastinal structures. It is predominately used for open heart surgery, such as valve replacements, CABG, or cardiac transplant. Anatomy  – The incision is made from the substernal notch to around the xiphoid process Discussion – A widely used incision, which provides good access to the thoracic cavity and the mediastinum.

32. CONT… ADVANTAGE: The advantages of this incision are that it is quick to perform, especially in hemodynamic emergencies, and it produces less pain than a traditional thoracotomy. The main drawback is cosmetic, and a risk of sternal mal-union exists, which is usually associated with a postoperative infection. It can predispose to significant scar formation and chronic chest pain, also Brachial plexus injury may occur.

33. PACEMAKER INCISION:

34. PACEMAKER INCISION: The pacemaker incision is utilised in the insertion of a pacemaker – a device that regulates the electrical activity of the heart. Typically , a 4-5cm incision is made in the left infraclavicular region. There are three main types of incision used – horizontal, oblique and deltopectoral . Once the incision is made, a subcutaneous ‘pocket‘ is created – in which the pacemaker is implanted.

35. THORACOTOMY: A Thoracotomy is an incision used to access the pleural space of the thorax. The three main subtypes are the; POSTERIOLATERAL INCISION, ANTEROLATERAL INCISION, AND AXILLARY INCISION.

36. POSTERIOLATERAL INCISION:

37. CONT… THE POSTERIOLATERAL THORACOTOMY : It is the gold standard for access to the thorax. It provides access to all the thoracic viscera, and is mainly used for pulmonary resections ( pneumonectomy or lobectomy), chest wall resection, or oesophageal surgery. The incision is made with the patient in the lateral decubitus position. It starts from between the scapula and mid-spinal line, and extends laterally to the anterior axillary line. Before reaching the thoracic cavity, the incision passes through the latissimus dorsi and serratus anterior muscles, then transects the rhomboids and trapezius

38. ANTEROLATERAL INCISION:

39. CONT… THE ANTEROLATERAL THORACOTOMY : I ncision can be used in a variety of operations for cardiac, pulmonary, and oesophageal pathology. The incision runs from the lateral border of the sternum to the mid-axillary line at the 4th or 5th intercostal space, dividing through the pectoralis major and serratus anterior in its approach.

40. LATERAL THORACOTOMY:

41. AXILLARY THORACOTOMY:

42. AXILLARY THORACOTOMY: An axillary thoracotomy is a muscle sparing approach to the thoracic cavity, used for pneumonectomy and pneumothorax operations. The incision is made between the posterior border of the pectoralis major and anterior border of latissimus dorsi muscles, through the 4th or 5th intercostal space. Choice in majority of PDA LIGATION,PULMONARY RESECTIONS,PA BANDING. T he incision reduces muscle damage and has good cosmetic outcomes, It has limited exposure to the thoracic viscera.

43. SUBXIPHOID (PERICARDIAL WINDOW):

44. CONT… INDICATIONS: pericardial effusion, pericardial biopsy, epicardial pacemaker. POSITION: supine. INCISION: Midline incision over the xiphoid or small incision between the ribs.

45. QUESTION: ANS: ① Midline sternotomy , ② Pacemaker scar, ③ Posterolateral thoracotomy, ④ Anterolateral thoracotomy, ⑤ Axillary thoracotomy

46. PREOPERATIVE ASSESSEMENT AND CARE

47. PREOPERATIVE ASSESSMENT AND CARE: Cardiac surgery is associated with significant morbidity, mortality, and socioeconomic costs. Preoperative assessment assists the clinician in identifying potential complications and facilitates discussion of these risks with the patient. Careful patient selection and preparation during preoperative evaluation may minimize morbidity, mortality, and resource use.

48. CONT… Preoperative care refers to health care provided before a surgical operation. The aim of preoperative care is to do whatever is right to increase the success of the surgery. At some point before the operation the health care provider will assess the fitness of the person to have surgery. This assessment should include whatever tests are indicated, but not include screening for conditions without an indication.

49. IT INCLUDES: Patient assessment. Specific preoperative problems and management. Risk assessment and consent. Medical, Surgical and Anesthetical aspects of patient assessment.

50. PATIENT ASSESSMENT: USUAL ASSESSMENT ALGORITHM H ISTORY E XAMINATION I NVESTIGATION

51. HISTORY TAKING: CHIEF COMPLAINTS (PRESENTING COMPLAINTS) HISTORY OF PRESENT ILLNESS( ONSET, DURATION, SEVERITY, COURSE, ALL FACTORS ) PAST MEDICAL HISTORY( EG: ANGINA, MI, STROKE, HTN… ) PERSONAL HISTORY ( OCCUPATION, MARITAL STATUS ) SURGICAL HISTORY(EG: BYPASS GRAFT, STENT… ) DRUG HISTORY( CVS, OTHER REGULAR MEDICATIONS,ALLERGIES ) FAMILY HISTORY SOCIAL HISTORY ( SMOKING, ALCOHOL, DIET, SLEEP, EXERCISE… )

52. Cont … Cardiovascular –  (C/O CVS PROBLEMS) Chest pain / Palpitations  / Dyspnoea /  Syncope / Orthopnoea  / Peripheral oedema  Respiratory –(C/O RESP PROBLEMS) Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain GI  –  Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit  Urinary  –   Volume of urine passed / Frequency / Dysuria  / Urgency / Incontinence CNS  –  Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion Musculoskeletal –  Bone and joint pain / Muscular pain  Dermatology –  Rashes / Skin breaks / Ulcers / Lesions METABOLIC – DM, THYROID DYSFUNCTION. OTHER – HIV,HEPATITIS,TB,MALIGNANCY.

53. PHYSICAL EXAMINATION: GENERAL: Anaemia, jaundice, cyanosis, clubbing, nutritional status etc… Local: CVS; Pulse, BP, HR, Heart sound, Peripheral edema … (INSPECTION,PALPATION,PERCUSSION AND AUSCULTATION.) OTHER SYSTEM: Respiratory, Gastrointestinal, CNS, etc… PREOPERATIVE ASSESSMENT of site, side of surgery, specific imaging of site and related investigations. Presence of bacteriaemia can decrease the surgical results, so should check for and treat infection in pre op period. Airway assessment, assessment of dentition(for loose dentures).

54. Investigations: B lood tests(CBC): check for anemia (low iron) , chemical (electrolyte) imbalances in the blood, blood glucose level and HbA1C. Serum electrolyte. Urine analysis. Coagulation screening. (CLOTTING TIME AND BLEEDING TIME). ABG PFT Chest x ray: non-invasive test shows if fluid is building up in the lungs or if the heart is enlarged. E lectrocardiogram (EKG): non-invasive test helps detect abnormalities in heart rhythm and heart health by measuring the electrical activity of the heart

55. Echocardiogram: non-invasive imaging test that produces a picture of the heart in motion as it beats; extremely helpful in showing heart and valve damage K idney function tests: help pinpoint the cause of fluid retention S tress test: an electrocardiogram done while exercising or, for people who cannot exercise, while the heart is stimulated by medication. Transesophageal echocardiography: a diagnostic test using an ultrasound device that is passed into the esophagus of the patient to create a clear image of the heart muscle and other parts of the heart A ngiogram : an x-ray (radiographic) study of the blood vessels. An angiogram uses a radiopaque substance, or contrast medium, to make the blood vessels visible under x ray

56. PRE OPERATIVE PREPARATION IMMEDIATELY BEFORE SURGERY: INFORMED CONSENT. SURGEON AND ANAESTHETIST MEET PT PRIOR TO SURGERY TO IDENTIFY THE PT AND CONFIRM THE SURGERY. NPO FOR 6-8 HRS. PLACEMENT OF URINARY CATHETER. ANTIBIOTICS GIVEN AN HOUR PRIOR BEFORE SURGICAL INCISION. START OF IV LINEAND FLUID MGT. PREPARATION OF PARTS.

57. PRE OP MODIFICATION OF TREATMENT: Anticoagulants - These are tailed off over a few days prior to operation. Aspirin and Clopidogrel - This has a significant effect in diminishing platelet function and can lead to increased postoperative blood loss. Ideally it should be stopped 7-10 days before surgery, if not, should be stopped on the day of admission of the patient - unless there is unstable angina. Digoxin - Continued until the day before operation. Diuretics and Potassium Supplements - Continued until the day before operation B BLOCKERS -to continue them until the day before operation . Anti H ypertensives - Maintain until operation ANTI PLATELET: Should be withdrawn a week before surgery. CLOPIDOGREL, NSAIDs, BIGUANIDES : DISCONTINUE

58. Depending on the procedure after care is given. Complications: Excessive bleeding, infection, and a negative reaction to anaesthesia . Other complications include the development of kidney failure, heart arrhythmias , heart attack, blood clot formation, and stroke during or soon after the procedure. Death is possible and occurs in about 3% of patients who have cardiac bypass surgery and valve replacement surgery.

59. CONNEXIONS:

60. Connexions:

61. Connexions: