Cardiac surgeries

and Management

Gurjit kaur
Msc n 2
 Definition of cardiac surgery
 Types of cardiac surgery
 Open Heart Surgery
 Heart Lung Machine
 Conventional CABG
 Management
 Valvular replacement and its
management.
Cardiac surgery

 Definition:
Any surgical procedure involving the
heart, performed to correct acquired or
congenital defects, replace diseased
valves, open or bypass blocked vessels,
or graft prosthesis or a transplant.
Major Type of Surgical Procedure:
Reparative procedures
Curative or for
improvement.
For example:
Closure of a PDA, ASD
and VSD
Repair of mitral stenosis
Simple repair of TOF.
Contd..
 Reconstructive procedures
Not always curative, and reoperation
may be needed. For example:
CABG
Reconstruction of an incompetent mitral
Tricuspid or mitral valve.
Contd..
 Substitutional Procedures
Not always curative.
Valve and cardiac replacement
 Prior to 1930’s, heart surgery seen as impossible, with high
morbidity and mortality
 1937: Dr. John Gibbon designs heart-lung machine, which
enables cardiopulmonary bypass (CPB)
 1955: Vineburg and Buller implant internal mammary artery
into myocardium to treat cardiac ischemia and angina
 Dr.John Gibbon(Philadelphia) 1953 :
“performed ASD repair with the aid of CPB for the 1st time with
the survival of patient.”
 1958: Longmire, Cannon and Kattus at UCLA perform first
open coronary artery endarterectomy without CPB
 During 1960’s and 1970’s, CPB and cardioplegic arrest are
adopted, allowing Coronary Artery Bypass Graft (CABG) to
emerge as a viable surgical treatment
 Open Heart Surgery or
Cardio-Pulmonary Bypass
 The cardiopulmonary bypass is achieved
by inserting a large catheter (i.e.,
cannula) into two peripheral blood
vessels, usually a femoral vein and an
artery. Blood is diverted from the body
through the venous catheter to the
cardiopulmonary bypass machine and
returned to the patient through the
arterial catheter at appropriate
pressure and Flow rate.
 Chronic angina
 Unstable angina
 Acute myocardial infarction
 Acute failure of Percutaneous Transluminal
Coronary Angioplasty (PTCA)
 Severe coronary artery disease

BJ Harlan, et al; Manual of Cardiac Surgery

 function of Heart Lung Machine
 Diverts circulation from the
heart and lungs, creating a
bloodless operating field.
 Performs all gas exchange
functions.(ventilation and
oxygenation)
 Filters, re-warm or cool the blood
 Circulates oxygenated, filtered
blood back into the arterial
circulation
Contd..
 TEMP. REGULATION (Hypothermia)
 Low blood flowso ed blood trauma
 ses Body Metabolism.
Component of CPB
 TOTAL CPB : Systemic venous drainage
CPB Circuit  External oxygenator
heat exchanger External pump
arterial filter Systemic circulation.
 PARTIAL CPB : Portion of systemic
venous return (Rt. Heart)  CPB
.Undiverted blood  Rt. Atrium  Rt.
Ventricle  Pul. Circulation  Lt. Atrium
& Lt. Ventricle  Systemic Circulation.
Integral components of Extracorporeal
circuit
 PUMPS
 OXYGENATOR
 Heat exchanger
 Arterial filter
 Cardioplegia delivery system
 Aortic/atrial/vena caval cannulae
 Suction/vent
 PATIENT
ARTERIAL
LINE
FILTER
RESERVOIR

ROLLER
PUMP
OXYGENATOR
HEAT
EXCHANGER
Types of pump
 Roller pump(volume displacement and
non pulsative blood flow)
 Centrifugal pump
Oxygenator
 Bubble Oxygenator
 Membranous Oxygenator
DEFOAMING CHAMBER
 Defoaming of frothy blood.
 Large surface area coated with silicone
 This es the Surface Tension of the
bubbles causing them to burst.
Advantage of hemodilution

 Lowers Blood Viscosity  in

Hematocrit.
 Improves Microcirculation.
 Counteracts the  Viscosity by
Hypothermia.
Risks of hemodilution
 Viscosity -  SVR -  BP
 Low Colloid Oncotic Pressure - ed Fluid
Requirement & Tissue Edema.
 O2 carrying Capacity 
  Blood O2 content  Ischaemia of Critical
Organs.
 Mixed Venous PO2 is 
 Dilution of Coagulation Factors.
 Cardiac output :
flow rate at 2.2-2.4 l/m2/min at 370c.
 BP : 0-70 mm Hg.
 Most common arteries
bypassed:
 Right coronary artery
 Left anterior
descending coronary
artery
 Circumflex coronary
artery
 Saphenous vein used for bypassing right coronary artery
and circumflex coronary artery

 Internal mammary artery (IMA) used for bypassing left

anterior descending coronary artery
 Patency rate over 90% after 10 years
 If more veins are needed, alternative sites such as upper
extremity veins can be used
 Patency rate as low as 47% after 4.6 years
 Conduit removed
 Median sternotomy
 Sternum divided using electric saw
 Cold potassium cardioplegia
 Cardiopulmonary bypass
 Cannulation of:
 Ascending aorta
 Femoral artery
 Right atrium
 Heparin administered to minimize clotting
 Bypass of arteries:
 Incision in target artery:

 Anastamosis of graft with

artery:
 Positive:
 Relief of angina in 90% of patients
 80% angina free after 5 years
 Survival about 95% after 1 year
 Low chance of restenosis
 Negative:
 2-3 days in ICU, 7-10 day total hospital stay
 3-6 month full recovery time
 5-10% have post-op complications
 High cost
 Long time on CPB
 Depression of the patient's immune system
 Postoperative bleeding from inactivation of the blood clotting
system
 Hypotension
 Minimally invasive surgery does not use
CPB
 Smaller incision
 Emerging as a replacement for
conventional CABG
 MIDCAB CABG
Full sternotomy No Yes
CPB No Yes
Operating time 2-3 hrs 3-6 hrs
Recovery time 1-2 weeks 3-6 months
Effectiveness 90% 90%
Incision length 10 cm 30 cm

 Additionally, MIDCAB:
 Reduced need for blood transfusions, if any
 Less time under anesthesia: patients are moved out of
intensive care more quickly
 Less pain and discomfort
 Up to 40% savings over conventional CABG.
Thoracotomy incision (~10 cm)

Small incisions for video-assisted

LIMA harvest
 Small portion of front of 4th rib removed
 LIMA clipped and dissected

 MIDCAB retractor and

LIMA stabilizer
facilitates grafting
 LAD exposed  Anastamosis
preformed with
assistance of
mechanical stabilizer

Completed graft

RG Cohen, et al; Minimally Invasive Cardiac Surgery

 New instruments must be developed
 Requires highly skilled surgeon and learning
curve for surgeons limits number performed
 Small incision
 Beating heart
 Blood in field
 Can only be used with patients having
blockages in one or two coronary arteries on
the front of the heart
 Attempts at operating on other arteries have been
moderately successful, but requires even greater
skill and practice
 Uses CPB
 Balloon catheter system for aortic
occlusion and cardioplegic arrest
 5-8 cm left anterior thoracotomy
incision
 No sternotomy!!!
 LIMA harvested using
specialized retractor

 Aorta drawn into

operating field

RG Cohen, et al; Minimally Invasive Cardiac Surgery

 Aorta clamped, anastamosis performed

RG Cohen, et al; Minimally Invasive Cardiac Surgery

 Benefits:
 Bloodlessfield
 Heart arrested
 allows more accurate anastomoses than MIDCAB
 Smallerincision than CABG
 No sternotomy
 Drawbacks
 UsesCPB
 Technically very difficult
 COMPLICATIONS
 Postoperative bleeding
Wound infection
Dehiscence
Intra operative stroke
MI
Multiple organ system failure
 Death
Persistent hypotension(causes cerebral ischemia, renal
shutdown, MI & shock)
 Stent or Surgery Study (SOS) 2001
 Death rate for CABG in this study unusually low
PCI and Stenting CABG
n=480 n=487
Mortality at 1 2.5% 0.8%
year
Need for 13% 4.8%
additional PCI
Need for 9% 1%
additional CABG
Overall adverse 22.1% 12.2%
effects
 CABG results in a lower restenosis rate as compared
with stenting
 Drug-eluting stents will narrow this difference
 Due to repeat treatment, costs for stents and surgery are
approximately equal after 2 years
 Minimally invasive surgeries (MIDCAB and port-access)
will result in fewer complications from surgery and a
shorter hospital stay
 This leads to lower costs for surgery, essentially removing the
cost advantage of stenting
 Diabetics have a substantially better response to CABG
than to angioplasty and stenting
 Currently, stenting is recommended over surgery
for one-vessel disease
 In the future, drug-eluting stents will probably be
used
 Minimally invasive surgeries could be used in place of
stents in diabetic, and other high-risk patients
 For more than one-vessel disease, surgery is
substantially better at preventing restenosis and
so will likely continue to be used in the future
 Minimallyinvasive surgeries will expand and replace
most conventional CABG procedures
Nursing Management
 Health history(past, present & personal)
 Physical assessment
 Psychological assessment.
Nursing Diagnosis
(pre operative)
 Fear related to the surgical procedure,
uncertain outcome, and the threat to
wellbeing
 Deficient knowledge regarding the surgical
procedure and the postoperative course
 Potential for complications(angina, severe
anxiety, cardiac arrest) related to stress of
impending cardiac surgery
Nursing Diagnosis
(post operative)
 Acute pain related to surgical trauma and pleural
irritation caused by chest tubes and/or internal
mammary artery dissection
 Decreased cardiac output related to blood loss and
compromised myocardial function
 Impaired gas exchange related to trauma of
extensive chest surgery
 Risk for deficient fluid volume and electrolyte
imbalance related to alterations in blood volume
Contd…
 Ineffective renal tissue perfusion related
to decreased cardiac output, hemolysis, or
vasopressor drug therapy
 Ineffective thermoregulation related to
infection or post-pericardiotomy syndrome
 Deficient knowledge about self-care
activities
Potential Complication of cardiac
surgeries
 Decreased Cardiac Output.
 Hypovolemia or hypervolemia(Fluid Overload)
 Persistent Bleeding
 Cardiac Tamponade
 Hypertension
 Dysrhythmias
 Cardiac failure
 Myocardial Infarction
Contd..
 Pulmonary complication like impaired gas
exchange.
 Neurological complication like CVA,
stroke, brain attack.
 Renal failure and electrolyte imbalance.
 Hepatic failure
 Infection.
Valvuloplasty
 The repair, rather than replacement, of
a cardiac valve is referred to as
valvuloplasty.
 The type of valvuloplasty depends on
the cause and type of valve dysfunction.
Commissurotomy
 Open Commissurotomy
 Closed Commissurotomy(Balloon
valvuloplasty)
Possible Complication
 Some degree of regurgitation
 Bleeding from the catheter insertion sites
 Emboli resulting in complications such as
strokes
 Left-to-right atrial shunts through an
atrial septal defect caused by the
procedure.
Annuloplasty
 It is the repair of the valve annulus (ie,
junction of the valve leaflets and the
muscular heart wall).
Chordoplasty

 Chordoplasty is the repair of the chordae

tendineae.
Valve replacement
 Prosthetic valve replacement began in the 1960s.
 When valvuloplasty or valve repair is not a viable
alternative, such as when the annulus or leaflets of
the valve are immobilized by calcification.
 General anesthesia and cardiopulmonary bypass are
used for all valve replacements.
 Most procedures are performed through a median
sternotomy (ie, incision through the sternum).
Types of valve
 Mechanical valves
 Tissue or Biological valves

Xenograft
Allograft
Autograft
Nursing Management....
 Admitted to the intensive care unit
 Care focuses on recovery from anesthesia
and hemodynamic stability.
 Vital signs are assessed every 5 to 15 minutes
and as needed until the patient recovers from
anesthesia or sedation and then assessed
every 2 to 4 hours and as needed.
 Contd...
 Intravenous medications to increase or decrease blood
pressure and to treat dysrhythmias or altered heart
rates are administered and their effects monitored.
 The intravenous medications are gradually decreased
until they are no longer required or the patient takes
needed medication by another route (eg, oral, topical).
 Patient assessments are conducted every 1 to 4 hours
and as needed, with particular attention to neurologic,
respiratory, and cardiovascular systems.
Contd...
 Nursing care continues as for most postoperative
patients, including wound care and patient teaching
regarding diet, activity, medications, and self-care.
 The nurse educates the patient about long-term
anticoagulant therapy, explaining the need for frequent
follow-up appointments and blood laboratory studies, and
provides teaching about any prescribed medication: the
name of the medication, dosage, its actions, prescribed
schedule, potential side effects, and any drug-drug or
drug-food interactions.
Heart transplantation
 The first human-to-human heart transplant was performed in
1967.
 Since 1983, when cyclosporine became available, heart
transplantation has become a therapeutic option for patients
with end-stage heart disease.
 Cyclosporine is an immunosuppressant that greatly decreases
the body’s rejection of foreign proteins, such as transplanted
organs.
 It also decreases the body’s ability to resist infections, and a
satisfactory balance must be achieved between suppressing
rejection and avoiding infection.
Indications
 Cardiomyopathy
 Ischemic heart disease
 Valvular disease,
 Rejection of previously transplanted hearts
 Congenital heart disease
 A typical candidate has severe symptoms uncontrolled
by medical therapy, no other surgical options, and a
prognosis of less than 12 months to live.
Transplantation technique
 Orthotopic transplantation is the most common
surgical procedure for cardiac transplantation. The
recipient’s heart is removed, and the donor heart is
implanted at the vena cava and pulmonary
veins.The donor heart is implanted by suturing the
donor atria to the residual atrial tissue of the
recipient’s heart. Both techniques then connect the
recipient’s pulmonary artery and aorta to those of
the donor heart.
 Heterotopic transplantation is less commonly
performed. The donor heart is placed to the right and
slightly anterior to the recipient’s heart; the recipient’s
heart is not removed. Initially, it was thought that the
original heart might provide some protection for the patient
in the event that the transplanted heart was rejected.
Although the protective effect has not been proved, other
reasons for retaining the original heart have been
identified: a small donor heart or pulmonary hypertension.
 Mechanical Assist Devices and Total Artificial Hearts.
 References:
 Cohen, Robbin G, et al. Minimally Invasive Cardiac Surgery. St. Louis: Quality Medical
Publishing, Inc, 1999.
 Gravlee, Glenn P, at al. Cardiopulmonary Bypass: Principles and Practice. Philadelphia:
Lippincott Williams & Wilkins, 2000.
 Holmes Jr, David R. “Debate: PCI vs CABG: a moving target, but we are gaining,” Current
Controlled Trials in Cardiovascular Medicine. December 2001 Vol 2 No 6.
 Harlan, Bradley J, et al. Manual of Cardiac Surgery. New York: Springer-Verlag, 1995.
 Mehran, R, et al. “One-Year Clinical Outcome After Minimally Invasive Direct Coronary
Artery Bypass,” Circulation. December 2000 Vol 102 Issue 23 Pages 2799-2802
 Salerno, Thomas A, at al. Beating Heart Coronary Artery Surgery. Armonk: Futura
Publishing Company, Inc, 2001.
 Serruys, Patrick W, et al. “Comparison of coronary-artery bypass surgery and stenting for
the treatment of multivessel disease,” New England Journal of Medicine. April 12, 2001 Vol
344 No 15.
 Stables, RH, et al. “Coronary artery bypass surgery versus percutaneous coronary
intervention with stent implantation in patients with multivessel coronary artery disease (the
Stent or Surgery trial): a randomised controlled trial,” The Lancet. September 28, 2002 Vol
360 Issue 9338 Pages 965-970.
 American College of Cardiology
 Medscape.com
 TCTMD.com
 WebMD.com
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