presentation and management of cardiac surgical diseases division of cardiothoracic surgery...

Presentation and Presentation and management of cardiac management of cardiac surgical diseasessurgical diseases

Division of Cardiothoracic SurgeryDivision of Cardiothoracic SurgeryDepartment of SurgeryDepartment of SurgeryKing Khalid University Hospital, Riyadh.King Khalid University Hospital, Riyadh.

Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases

Objectives of the Lecture Objectives of the Lecture

Overview of diseases of heart, where surgery Overview of diseases of heart, where surgery can play a rolecan play a role

Understanding of the Basic Principles of Understanding of the Basic Principles of Cardiac SurgeryCardiac Surgery

Information regarding pre-operative, operative Information regarding pre-operative, operative and post-operative care in cardiac surgeryand post-operative care in cardiac surgery


Cardiac Diseases Cardiac Diseases

Coronary Artery DiseaseCoronary Artery Disease Valvular Heart DiseasesValvular Heart Diseases Congenital Heart DiseasesCongenital Heart Diseases Miscellaneous :Miscellaneous :

– Aortic DiseasesAortic Diseases– Pericardial DiseasePericardial Disease– Cardiac TumourCardiac Tumour– TraumaTrauma


Modes of Presentation Modes of Presentation of Cardiac Diseasesof Cardiac Diseases

Chest painChest pain Shortness of BreathShortness of Breath PalpitationsPalpitations Peripheral EdemaPeripheral Edema Congestive Cardiac FailureCongestive Cardiac Failure Cyanosis and Clubbing in Congenital DefectsCyanosis and Clubbing in Congenital Defects Uncommon presentationsUncommon presentations

– Pleural EffusionPleural Effusion – HaemoptysisHaemoptysis


Common Cardiac OperationCommon Cardiac Operation

Coronary Artery Bypass Grafting (CABG)Coronary Artery Bypass Grafting (CABG) Valve Replacement / Repair Valve Replacement / Repair Repair of congenital defects like of VSD or Repair of congenital defects like of VSD or

ASDASD Heart TransplantationHeart Transplantation


Ischemic Heart DiseaseIschemic Heart Disease

Clinical manifestations:Clinical manifestations: 1. Asymptomatic1. Asymptomatic 2. Symptomatic:2. Symptomatic:

-angina pectoris: stable- unstable-angina pectoris: stable- unstable

-myocardial infarction-myocardial infarction

-V.S.D., Ischemic mitral regurge, -V.S.D., Ischemic mitral regurge, Ventricular aneurysm, Heart failure, Ventricular aneurysm, Heart failure, Conduction defects.Conduction defects.


Risk factors:Risk factors: Smoking, Diabetes mellitus, Hypertension, Smoking, Diabetes mellitus, Hypertension,

Hyperlipedemia, Hereditary factors.Hyperlipedemia, Hereditary factors.

Laboratory Investigations:Laboratory Investigations: -Routine investigations-Routine investigations -Cardiac enzymes-Cardiac enzymes -E.C.G.-E.C.G. -Echocardiography-Echocardiography -Coronary angiography-Coronary angiography


Indications of surgery:Indications of surgery: 1. Failure of medical therapy or 1. Failure of medical therapy or

percutaneous intervention.percutaneous intervention. 2. Left main disease2. Left main disease 3. 3-vessel disease with left 3. 3-vessel disease with left

ventricular dysfunction ventricular dysfunction 4. Mechanical complications of 4. Mechanical complications of

myocardial infarction.myocardial infarction. 5. Associated valve disease5. Associated valve disease


Coronary conduits:Coronary conduits: 1. Arterial: Internal thoracic artery1. Arterial: Internal thoracic artery 2. Venous : Long saphenous vein.2. Venous : Long saphenous vein.

Types of surgery:Types of surgery: 1. Conventional: using the heart lung 1. Conventional: using the heart lung

machine, and cardioplegic arrestmachine, and cardioplegic arrest 2. Off-pump (beating heart surgery)2. Off-pump (beating heart surgery)


Coronary Artery Bypass Coronary Artery Bypass GraftingGrafting


Valvular Heart DiseasesValvular Heart Diseases 1. Mitral stenosis:1. Mitral stenosis:- Etiology: Rheumatic, CongenitalEtiology: Rheumatic, Congenital

- Investigations: E.C.G., X-ray chest, - Investigations: E.C.G., X-ray chest, EchocardiographyEchocardiography

-Indications for surgery:-Indications for surgery: Symptoms: exertional dyspnea, pulmonary Symptoms: exertional dyspnea, pulmonary

hypertension, hemoptysishypertension, hemoptysis Severe mitral stenosis: area less than 1 cm.Severe mitral stenosis: area less than 1 cm. Left atrial thrombus.Left atrial thrombus.


Treatment:Treatment: 1. Medical1. Medical 2. Balloon valvuloplasty2. Balloon valvuloplasty 3. Closed mitral commissurotomy3. Closed mitral commissurotomy 4. Open mitral commissurotomy4. Open mitral commissurotomy 5. Mitral valve replacement.5. Mitral valve replacement.


2. Mitral Regurgitation:2. Mitral Regurgitation: Etiology: Rheumatic, Degenerative, Endocarditis, Etiology: Rheumatic, Degenerative, Endocarditis,

Ischemic, TraumaticIschemic, Traumatic

Indications for surgery:Indications for surgery: Symptomatic, dilated left ventricle, diminished Symptomatic, dilated left ventricle, diminished

ejection fractionejection fraction

Treatment: Treatment: 1.Medical1.Medical 2.Mitral valve repair2.Mitral valve repair 3.Mitral valve replacement3.Mitral valve replacement


3. Aortic stenosis:3. Aortic stenosis: Etiology: Rheumatic, Congenital, Degenerative.Etiology: Rheumatic, Congenital, Degenerative.

Indications for surgery:Indications for surgery: Symptoms (angina, shortness of breath, syncopaal Symptoms (angina, shortness of breath, syncopaal

attacks)attacks) Severe aortic stenosisSevere aortic stenosis

Treatment:Treatment: MedicalMedical Aortic valve replacementAortic valve replacement


4. Aortic regurgitation:4. Aortic regurgitation: Etiology: Rheumatic, Endocarditis, Etiology: Rheumatic, Endocarditis,

Connective tissue disorders, Aortic Connective tissue disorders, Aortic dissectiondissection

Indications for surgery:Indications for surgery: Symptomatic patients, Progressive Symptomatic patients, Progressive

left ventricular dilatation.left ventricular dilatation.


Types of Prosthetic Valves Types of Prosthetic Valves and their merits and demerits and their merits and demerits

Tissue Valves (Bio prosthesis)Tissue Valves (Bio prosthesis)– No need to use long term anticoagulation.No need to use long term anticoagulation.– Limited and unpredictable durability.Limited and unpredictable durability.

Mechanical Valves Mechanical Valves – Anticoagulation Anticoagulation – Prolonged durability Prolonged durability


Complications of prosthetic valves:Complications of prosthetic valves: 1. Thrombosis1. Thrombosis 2. Bleeding complications2. Bleeding complications 3. Infective endocarditis3. Infective endocarditis 4. Paravalvular leak4. Paravalvular leak 5. Degeneration of biological valves5. Degeneration of biological valves


Types of Prosthetic Valves Types of Prosthetic Valves and their merits and demerits and their merits and demerits


Thoracic Aortic DiseaseThoracic Aortic Disease 1. Thoracic aortic aneurysm1. Thoracic aortic aneurysm Symptoms are usually due to Symptoms are usually due to

pressure on surrounding stuctures.pressure on surrounding stuctures.

2. Aortic dissection:2. Aortic dissection:Tear in the intima allowing blood to Tear in the intima allowing blood to

enter and flow in a false channel. enter and flow in a false channel. There are 2 lumens separated by the There are 2 lumens separated by the dissecting membranedissecting membrane


Pericardial effusionPericardial effusion

Progressive accumulation of fluid inside Progressive accumulation of fluid inside the pericardial cavity, may compress the the pericardial cavity, may compress the cardiac chambers.cardiac chambers.

Etiology:Etiology: -Traumatic-Traumatic -pericarditis-pericarditis -malignancy-malignancy -uremia, post irradiation-uremia, post irradiation -postoperative.-postoperative.


Investigations:Investigations: -Plain x-ray chest-Plain x-ray chest -Echocardiography-Echocardiography -CT scan-CT scan

Management:Management: - treat the cause- treat the cause -Aspiration -Aspiration -Pericardiostomy-Pericardiostomy


CardioThoracic EmergencyCardioThoracic Emergency

1. Chest pain:1. Chest pain: -Myocardial ischemia-Myocardial ischemia -Pulmonary embolism-Pulmonary embolism -Aortic dissection-Aortic dissection -Tension pneumothorax-Tension pneumothorax -Rupture esophagus-Rupture esophagus


2. Acute dyspnea:2. Acute dyspnea: -myocardial infarction-myocardial infarction -Pulmonary embolism-Pulmonary embolism -- spontaneous pneumothoraxspontaneous pneumothorax - bronchial asthma- bronchial asthma -F.B. aspiration-F.B. aspiration -stuck mechanical valve.-stuck mechanical valve.


3. Chest trauma:3. Chest trauma: -flail chest-flail chest -traumatic hemo/pneumothorax-traumatic hemo/pneumothorax -hemopericardium-hemopericardium


Congenital Heart DiseasesCongenital Heart Diseases

1. Acyanotic:1. Acyanotic: -Patent ductus arteriosus-Patent ductus arteriosus -Coarctation of the aorta-Coarctation of the aorta -Pulmonary stenosis-Pulmonary stenosis -Atrial septal defect-Atrial septal defect -Ventricular septal defect-Ventricular septal defect


2. Cyanotic:2. Cyanotic: -Tetralogy of Fallot-Tetralogy of Fallot -Transposition of the great vessels-Transposition of the great vessels -Tricuspid atresia -Tricuspid atresia -Total anomalous venous drainage-Total anomalous venous drainage -Truncus arteriosus-Truncus arteriosus


Basic Principles of Cardiac SurgeryBasic Principles of Cardiac Surgery

Adequate ExposureAdequate Exposure– Full or Partial Sternotomy / Thoracotomy / Robotic or EndoscopicFull or Partial Sternotomy / Thoracotomy / Robotic or Endoscopic

Bloodless Operative Field Bloodless Operative Field – Suction and re-transfusion / Snaring or clamping of bleeding vesselsSuction and re-transfusion / Snaring or clamping of bleeding vessels

Static Operative TargetStatic Operative Target– Cardiac Arrest / Ventricular Fibrillation / Mechanical StabilizersCardiac Arrest / Ventricular Fibrillation / Mechanical Stabilizers

Preservation of body perfusionPreservation of body perfusion– Use of Heart Lung Machine / Off-pump TechniquesUse of Heart Lung Machine / Off-pump Techniques

Preservation of MyocardiumPreservation of Myocardium– Off-pump Techniques / Hypothermia / Cardiac Arrest with Off-pump Techniques / Hypothermia / Cardiac Arrest with

cardioplegiacardioplegia


Heart Lung MachineHeart Lung Machine

Components :Components :– Roller pumpsRoller pumps– Blood Reservoir (cardiotomy reservoir)Blood Reservoir (cardiotomy reservoir)– OxygenatorOxygenator– Heater-cooler unit Heater-cooler unit – Tubing and Monitoring console etcTubing and Monitoring console etc

Limitation/Problems : Limitation/Problems : – Requires full anticoagulationRequires full anticoagulation– Can cause micro embolismCan cause micro embolism– Initiates Systemic Inflammatory Response Initiates Systemic Inflammatory Response


Heart Lung Machine Heart Lung Machine

Preoperative assessment of Preoperative assessment of cardiac surgical patientscardiac surgical patients

Evaluation of patients referred for Evaluation of patients referred for cardiac surgery aims to answer the cardiac surgery aims to answer the following questions:following questions:

Is surgery appropriate for the Is surgery appropriate for the conditioncondition

Is the patient fit to undergo the Is the patient fit to undergo the planned operationplanned operation

Is there any comorbidities that may Is there any comorbidities that may affect the operative managementaffect the operative management



Preoperative assessment of Preoperative assessment of cardiac surgical patientscardiac surgical patients

Approach:Approach: 1. History1. History 2. Physical examination2. Physical examination 3. Chest x-ray3. Chest x-ray 4. E.C.G.4. E.C.G. 5. Laboratory investigations5. Laboratory investigations


Pre-Operative Investigations for Pre-Operative Investigations for Cardiac SurgeryCardiac Surgery

Full Blood CountFull Blood CountBlood BiochemistryBlood BiochemistryECGECGChest X-rayChest X-rayPulmonary Function Tests.Pulmonary Function Tests.Other test according to systemic review of patientOther test according to systemic review of patient

EchocardiographyEchocardiographyAngiographyAngiographyCarotid Duplex Scan Carotid Duplex Scan Peripheral Duplex ScanPeripheral Duplex Scan


Usual Duration of Stay in HospitalUsual Duration of Stay in Hospital

One day before surgeryOne day before surgery 3-6 hours OR time3-6 hours OR time One day in ICUOne day in ICU 4-5 Days in Ward 4-5 Days in Ward Total 5-7 daysTotal 5-7 days

presentation and management of cardiac surgical diseases division of cardiothoracic surgery...

Documents

heart surgery slide

cardiac surgery slide

types of surgery

heart failure

lecture overview of

internal thoracic artery

associated valve disease

vessel disease