CARDIAC SURGERY

BY: PALAK KHANNA

BLOOD
SUPPLY
The pericardium is a membrane, or sac, that surrounds your
heart. It holds the heart in place and helps it work properly.
Routine tests / investigations in cardiovascular
diseases
Blood test (CBC)
Cardiac enzymes : Standard enzyme measurement such as troponin, creatine kinase MB
(CKMB) and lactate dehydrogenase (LDH) can aid diagnosis, as well as having prognostic
implications.
Electrolytes
Electrocardiogram (ECG)
urine tests
Exercise stress test : Exercise tolerance testing (ETT) is a valuable technique for assessing
myocardial ischaemia, both for diagnostic purposes and as a prognostic tool.
Chest x-ray : useful for showing the size and shape of the heart and detecting chest disorders.
It can also show any fluid in the lungs, which may be caused by heart disease.
Cardiac CT
Thyroid function test
Cardiac MRI : Cardiac magnetic resonance imaging (MRI) can be performed to evaluate the
ischaemic burden of coronary disease (using pharmacological agents to stress the heart) and to
provide details of tissue viability when using gadolinium as a contrast agent.
Echocardiography : Performed either through a transthoracic or transoesophageal approach,
echocardiography is valuable for the evaluation of ventricular function and regional wall motion
abnormalities, as well as valvular lesions.

Coronary angiography : Selective coronary angiography provides the means of accurately

diagnosing the presence and extent of CAD and remains the ‘gold standard’ diagnostic technique
CARDIOPULMONARY BYPASS
Cardiopulmonary bypass (CPB) was first used successfully in 1953 by Gibbon and has since
revolutionised cardiac surgery.

Arterial cannulation
Conventionally, the great vessels are exposed and an
aortic perfusion cannula is inserted into the ascending
aorta, held in place by the purse-string suture.

Venous cannulation
A purse-string suture is placed around the right atrial
appendage and a single ‘two-stage’ venous cannula is
placed to establish venous drainage. The venous pipe has
end holes that sit in the inferior vena cava and side holes
that sit in the right atrium (to take drainage from the
superior vena cava).
Cooling techniques let surgeons stop the heart for long periods without damaging the heart
tissue. Cool temperatures avoid damage to the heart tissue by reducing the heart’s need for
oxygen.
The heart may be cooled in 2 ways:
Blood is cooled as it passes through the heart-lung machine. In turn, this cooled blood lowers
body temperature when it reaches all of the body parts.
Cold salt-water (saline) is poured over the heart.
After cooling, the heart slows and stops. Injecting a special potassium solution into the heart
can speed up this process and stop the heart completely. The heart is then safe from tissue
injury for 2 to 4 hours.

Once full flow is established (the required

cardiac output depends on the body surface
area of the patient), the ventilator is stopped
and the heart can be isolated from the rest of
the circulation. Blood is drained from the
heart to the venous reservoir using the siphon
effect by gravity, as it is usually placed 50–70
cm below the level of the heart and
oxygenated using an oxygenator that allows
gas exchange across its membrane. Blood is
then pumped to the body by the bypass
machine via the aortic cannula.
The heart-lung machine carries blood from the upper-right chamber of
the heart (the right atrium) to a special reservoir called an oxygenator.
Inside the oxygenator, oxygen bubbles up through the blood and enters
the red blood cells. This causes the blood to turn from dark (oxygen-
poor) to bright red (oxygen-rich). Then, a filter removes the air bubbles
from the oxygen-rich blood, and the blood travels through a plastic tube
to the body’s main blood conduit (the aorta). From the aorta, the blood
moves throughout the rest of the body.
Discontinuing cardiopulmonary bypass
At the end of the procedure, air must be meticulously excluded from
the cardiac chambers.
Once perfusion is restored to the coronary arteries (by removing the
cross-clamp) the heart may beat spontaneously.
If ventricular fibrillation is present, cardioversion may be required.
Epicardial pacing wires may be placed to treat postoperative bradycardia
or heart block.
The patient is rewarmed, acidosis and hypokalaemia are corrected and
ventilation is restarted.
The heart gradually takes over the circulation while the arterial flow
from the CPB machine is reduced.
When the blood pressure is acceptable and the surgeon is confident
that the heart function is adequate, CPB is discontinued.
The cannulae are removed and the anticoagulation is reversed by
administering protamine.
Ischaemic heart disease
Ischaemic heart disease (IHD) is a major cause of morbidity and mortality in resource-rich countries. The
underlying pathology is mainly atherosclerosis of the coronary arteries.
Pathophysiology
Atherosclerosis is the process underlying the formation of focal obstructions or plaques in large- and
medium-sized arteries.
Atherosclerotic lesions can histologically be found at different stages in blood vessels including:
● The fatty streak. The first evidence of atherosclerosis can be found in children 10–14 years of age. This
appears as a yellow streak running along the major arteries. The streak consists of smooth muscle cells,
which are filled with cholesterol, and foam cells.
● Fibrous plaque. A fibrous plaque consists of large numbers of smooth muscle cells, foam cells, and
leukocytes. As the fibrous plaque grows, it projects into vessels leading to lumen narrowing that, in turn, can
lead to ischaemia or infarction.
● Complicated lesion. This occurs when the fibrous plaque ruptures provoking activation of the coagulation
cascade and the formation of thrombus
Indications for surgery
The decision to offer CABG is based on the balance between the
expected benefit and the potential risks to the patient. The two issues to
be addressed when deciding if a patient is suitable to have surgery are
the appropriateness of revascularisation and the relative merits of CABG
versus PCI. Current best evidence shows that revascularisation can be
readily justified on symptomatic grounds in patients with persistent
limiting symptoms (angina or angina equivalent) despite optimal
medical therapy and/or on prognostic grounds in certain anatomical
patterns of disease.
Surgery for the complications of myocardial
infarction
Ventricular septal rupture typically presents 3–7 days after infarction with
pulmonary oedema, a pansystolic murmur and haemodynamic instability. The
diagnosis is usually confirmed with echocardiography. Repair is with a pericardial or
artificial Dacron patch.
Mitral valve papillary muscle necrosis causes acute mitral regurgitation, a
pansystolic murmur and pulmonary oedema. Diagnosis is made by echocardiography
and right heart catheterisation (showing large V waves). Mitral valve replacement is
usually necessary, but the mortality rate is higher than in valve replacement for non-
ischaemic valvular diseases.

Acute failure of percutaneous coronary angioplasty

Since the advent of intracoronary stents, the need for emergency CABG following
complications of PCI is low at <1%. The mortality rate in this group is significantly
higher than for elective CABG.
Postoperative complications
Bleeding : Significant bleeding occurs in approximately 2–3% of patients. Rarely, acute cardiac
tamponade or profound hypotension may occur in the early postoperative period and requires
emergency resternotomy.
Arrhythmias : The most common postoperative arrhythmia is sinus tachycardia, closely
followed by atrial fibrillation (AF). It occurs in around 30% of patients undergoing CABG and
often spontaneously reverts to sinus rhythm. Treatment includes correction of potassium (>4.5
mmol/L), the use of β-blockers, amiodarone or digoxin and, if necessary, cardioversion.
Neurological dysfunction : Stroke leading to a focal neurological deficit occurs in
approximately 2% of patients following CABG.
Wound infection : Significant deep wound infection resulting in sternal dehiscence and
mediastinitis occurs in around 0.5–2% of patients.
VALVULAR HEART DISEASE
Heart valves function to maintain pressure gradients between cardiac chambers and so ensure
unidirectional flow of blood without reflux through the heart.
Types of prosthetic valves
Mechanical valves : Mechanical valves can be used in any age group to replace any valve . They
are extremely durable but the components of the valve are thrombogenic and, therefore, the
patient requires systemic anticoagulation, usually with warfarin.
Biological valves : Biological valves include homograft (or allograft) valves, removed from
cadavers; autografts, a patient’s own valve; and, most commonly, heterografts (or xenografts)
prepared from animal tissues.
P r o s t h e ti c v a l v e d y s f u n c ti o n a n d c o m p l i c a ti o n s
Structural valve failure : Bioprosthetic valves are vulnerable to degenerative changes. Structural
failure of a mechanical valve is generally uncommon.
Paravalvular leak : Early-onset paravalvular leaks usually result from technical difficulties at
insertion. Late-onset leaks can occur and may be related to an episode of endocarditis or, in the
presence of bioprostheses, leaflet degeneration.
Thrombosis and thromboembolism : Thrombus formation on a prosthetic valve remains the
most common complication of mechanical and biological valves. The risk of thromboembolism is
greater with a valve in the mitral position (mechanical or biological) than with one in the aortic
position.
Mitral valve regurgitation
INVESTIGATIONS
● ECG may show left atrial hypertrophy (bifid P
waves), left ventricular hypertrophy and atrial
fibrillation.
● Chest radiography. There may be
cardiomegaly with prominent pulmonary
vasculature.
● Echocardiography. This is often combined
with colour flow Doppler imaging, which shows
the severity of the regurgitant jet of mitral
regurgitation.
Mitral stenosis INVESTIGATIONS
● ECG may show left atrial enlargement (P-
mitrale) or AF. Right axis deviation and other
ECG signs of right ventricular hypertrophy (tall
QRS complexes in the right ventricular leads
V1–3) may also be present.
● Chest radiography. The left atrium is
enlarged (sometimes to an enormous degree)
along with upper lobe diversion as a result of
the raised pulmonary venous pressure. The
right ventricle also appears enlarged.
● Echocardiography, in combination with
colour flow Doppler imaging, allows
assessment of the flow across the valve and,
therefore, the degree of stenosis.
Transoesophageal echocardiography (TOE) may
be better at assessing valve morphology in
detail and excluding the presence of an atrial
thrombus.
● Coronary angiography. To investigate the
coronary arteries.
● Cardiac MRI.
● Right heart catheterisation.
MITRAL VALVE REPAIR
The restoration of normal valve function and preservation of the mitral apparatus is preferable
to replacement in specific groups of pathology, as it can be associated with improved long-term
ventricular remodelling and function. This approach reduces the bleeding complications
associated with anticoagulants.

MITRAL VALVE REPLACEMENT

When valve repair is not feasible, mitral valve replacement is necessary. This usually involves a
median sternotomy and access to the left atrium on CPB. The diseased valve is exposed, excised
and a suitably sized mechanical or bioprosthetic valve is implanted.

PERCUTANEOUS MITRAL VALVE REPAIR (MITRACLIP®)

The MitraClip® is a device used to reduce mitral valve regurgitation. The method involves
suturing of the leaflets of the mitral valve together so that regurgitation into the left atrium is
prevented. The valve continues to open through the sides of the suture and therefore blood
continues to flow into the left ventricle. Although this method is less invasive, associated with
rapid recovery and reduced in-hospital stay, it is however technically demanding and long-term
durability of the results of the device is unknown.
Aortic valve disease
Aortic stenosis

INVESTIGATIONS
● ECG. There is left ventricular
hypertrophy with tall R waves in the
lateral leads and sometimes a ‘strain
pattern’ (S–T depression with inverted T
waves in the lateral leads).
● Echocardiography confirms the
diagnosis and, together with colour flow
Doppler imaging, allows assessment of
the aortic valve gradient, calculation of
valve area and evaluation of left
ventricular dimensions and wall
thickness.
● Coronary angiography. To investigate
the coronary arteries in patients >40
years of age.
Aorti c regurgitati on
INDICATIONS FOR SURGERY
The indications for surgery include
severe regurgitation in symptomatic
patients.
Asymptomatic patients with severe
aortic regurgitation and left ventricular
dysfunction should be offered surgery.
Valve replacement should also be
considered in asymptomatic patients
with severe regurgitation if they are
undergoing cardiac surgery for any
other reason, or when there is
evidence of progressive left ventricular
dilatation (left ventricular end-systolic
diameter >50 mm).
Aortic valve replacement is
recommended if there is a decrease in
systolic function.
CONGENITAL HEART DISEASE
Cyanoti c congenital heart disease
Tetralogy of Fallot
This is the most common cyanotic congenital heart disease
found in children surviving to 1 year and accounts for about 4–
6% of all congenital heart diseases.
The four intracardiac lesions originally described were:
● VSD; ● overriding aorta; ● pulmonary (typically infundibular or
subpulmonary) stenosis;
● right ventricular hypertrophy.

Transposition of the great

vessels
Acyanotic congenital heart disease
Patent ductus arteriosus
The ductus arteriosus, a normal fetal
communication, facilitates the transfer of
oxygenated blood from the pulmonary artery
to the aorta, shunting blood away from the
lungs.
Normally, functional closure of the ductus
occurs within a few hours of birth; it is
abnormal if it persists beyond the neonatal
period.
Coarctation of the aorta
This accounts for 6–7% of congenital heart
disease and is defined as a haemodynamically
significant narrowing of the aorta, usually in
the descending aorta just distal to the left
subclavian artery, around the area of the
ductus arteriosus .
The coarctation typically puts a pressure load
on the left ventricle, which can ultimately fail.
Coarctation usually affects boys and, if it occurs
in girls, is suggestive of Turner syndrome.