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Cardiac surgeries

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PG Seminar presentation

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    Cardiac surgeries Cardiac surgeries Presentation Transcript

    • AMRUTA N. PAI
    • Cardio Pulmonary Bypass Machine
    • CPBM Also known as a heart-lung machine. It is a device that does the work of the heart & lungs when theheart is stopped for a surgical procedure, or for other reasons. Most patients are on the pump only as long as it takes to completeopen heart surgery.
    • Components of CPBM 2 main functional units- Pump Oxygenator Tubing (silicone rubber or PVC) Pumps (roller, centrifugal) Oxygenator (membrane oxygenators, oxygenation) Cannulae (Venous, Arterial)
    • Working schema of CPBMSpecial tubing connected tolarge blood vesselsAllows oxygen-depletedblood to leave the bodyTravels to CPBMMachine oxygenates the bloodReturns blood to the bodythrough a second set of tubing Constant pumping of the machinePushes the oxygenated bloodthrough the body
    •  Tubes- placed away from the surgical site- do not interfere with thesurgeon‟s work Placed in a blood vessel large enough to accommodate tubing & pressure ofpump. 2 tubes insure- blood leaves the body before reaching the heart & returns tothe body after the heart, giving a still & mostly bloodless area to operate. Third tube- inserted very near or directly into the heart, but not connected tothe CPBM- used to flush heart with cardioplegic, a potassium solutionwhich stops the heart. Once the cardioplegic takes effect, the CPBM is initiated and takes over theheart and lung function.
    • Purpose of CPBM To stop the heart without harming the patient (oxygenated blood mustcontinue to circulate through the body during surgery) The pump does the work of heart (pumping blood through body) andfulfils the function of lungs (oxygenates the blood while pumping) The CPBM is used for 2 primary reasons: Many cardiac surgeries would be impossible to perform with theheart beating- “moving target” - significant blood loss. The pump is used not for surgical need, but to help out if a patient hasheart failure. In some cases, a heart failure patient may be placed onthe pump to support the patient until a heart transplant becomesavailable.
    • Risks- CPBM Formation of small blood clots in blood processed by machine- canprobably cause stroke, MI or renal failure on returning to bodysbloodstream. The machine can also trigger an inflammatory process that can damagemany of the bodys systems and organs, called „post-pericardiotomysyndrome‟. Post-operative bleeding may be a serious complication, occasionallyrequiring a return to the operating room. Problems with temporary confusion or memory loss.
    • HistoryDefinition & IntroductionProcedureRecent advances in CABGIndicationsContraindicationsComplications
    • History of CABG John Gibbon- clinically useful cardiopulmonary bypass (CPBM)- 1953 William Mustard- first direct surgical approach to coronary circulation-1953 Dr. Robert Goetz & Dr. Michael Rohman- first successful surgeons toperform CABG with donor vessel anastomosed to the RCA. The actualanastomosis with the Rosenbach ring developed an atheromatous plaque-occluded the origin of the IMA used. Russian cardiac surgeon, Dr. Vasilii Kolesov- first successful IMA-Coronary artery anastomosis in 1964. 1970‟s- first full decade of CABG (relieved angina & improved QoL)
    • Alternative terminologies Heart Bypass Bypass surgery Aorto Coronary Bypass (ACB) “Cabbage” Single bypass, Double bypass, Triple bypass, Quadruple bypassand Quintuple bypass
    • DefinitionCABG is a surgical procedure in which oneor more blocked coronary arteries are bypassedby a blood vessel graft to restore normal bloodflow to the heart, with an intent to relieveangina & prevent death.Arteries or veins from elsewhere in thepatients body are grafted to the coronaryarteries to bypass atherosclerotic narrowingsand improve the blood supply to the coronarycirculation supplying the myocardium.
    • Introduction
    • 2 stages to bypass surgery: Stage 1: healthy blood vessel (the graft) is removed from leg or chest wall. Stage 2: Connecting graft to coronary artery, „bypassing‟ diseasedsegment, improving the blood supply to the heart.1 of the following technique is used:i) A heart-lung machine is used to circulate blood around the body, allowingthe surgeon to operate on the heart (“On-pump” surgery)ii) The „beating heart‟ technique, where the surgery is performed while theheart is still beating and working. This is called „off pump‟ surgery.The operation usually takes between3-6 hoursProcedure
    • General anaesthesia is administered Removes the veins or preparesthe arteries for graftingSaphenous vein or internal mammaryartery, incisions are madeIncision from patientsneck to navelSawed through breastbone Retracts rib cage & exposes heartConnected to CPBMCardioplegic solution injectedthrough coronary rootSmall opening- just below blockagein diseased coronary arteryBlood redirected through thisopening once the graft is sewn
    •  Cardioplegic solution avoids tissue damage, lowers the temperature ofheart Most patients who undergo CABG, have at least 3 grafts done. CABG builds a detour around one or more blocked coronary arterieswith a graft from a healthy vein or artery. The graft goes around the clogged artery (or arteries) to create newpathways for oxygen-rich blood to flow to the heart. Electric shocks start the heart pumping again after grafting The heart-lung machine is turned off & after the normal bloodflow isresumed, the chest cavity is closed.
    • Recent advances in CABG Totally endoscopic, minimally invasive CABG with use of a surgicalrobot, doesnt require an incision and patients can often return tonormal activities in few weeks. Keyhole surgery : requires 2-3 inch incision instead of splitting chestopen. Hybrid procedures (minimally invasive bypass surgery and stentedangioplasty in one operation). Off-pump or "beating heart" bypass
    • Difference- “Off-pump CABG” The bypass is sewed onto the heart, while heart continues beating.Various types of heart stabilizers are used to restrain the heart one sectionat a time so the surgeon can operate on it. The chest is opened through a midline sternotomy incision. After thetarget coronary vessel is exposed & stabilized, it is occluded & opened. A bridging plastic tube - which allows blood flow during suturing -- maybe placed. The bypass graft is then sutured to the coronary artery.
    • Advantages of off-pump over on-pump CABG Reduced need for blood transfusions Reduced risk of bleeding, stroke and kidney failure Potential for reduced psychomotor and cognitive problems High-risk patients with additional diseases like lung disease,kidney failure and peripheral vascular disease may benefit fromthis kind of operation.
    • Indications The 2004 ACC/AHA CABG guidelines state CABG is preferredtreatment for Disease of the left main coronary artery (LMCA). Disease of all three coronary vessels (LAD, LCX and RCA). Diffuse disease not amenable to treatment with a PCI. The 2005 ACC/AHA guidelines further state:CABG is preferred treatment with other high-risk patients such asthose with severe ventricular dysfunction (i.e. low ejection fraction), ordiabetes mellitus.
    • Indications….. contd….. Significant (>50%) left main stem stenosis. Disabling angina despite maximal medical therapy (surgery can beperformed with acceptable risk) 3 vessel disease (survival benefit greater when LVEF < 50%). 2 vessel disease with significant proximal LAD stenosis & eitherEF < 50% or demonstrable ischemia on non-invasive testing.
    • Contraindications Absence of an open major artery 1 mm or more in diameter beyond theobstructing lesion Absence of viable myocardium in the area supplied by the stenosed artery Co-existing severe non-cardiac condition with poor prognosis
    • ComplicationsImmediate Complications Bleeding Infection- chest and leg or arm wounds, or lungs Myocardial Infarction Pain Death Irregular heart beatLong Term Complications Stroke Renal failure
    • IntroductionIndicationsContraindicationsRepair, replacementTypes of valvular prosthesisComplications
    • Introduction 4 valves in the heart. Valves are strong, thin flaps oftissue, called leaflets. The leaflets open to allow bloodto move forward through theheart during half of theheartbeat, and close to preventblood from flowing backwardduring the other half of theheartbeat.
    •  The tricuspid valve allows blood to movefrom the upper chamber of the heart, theright atrium, into the lower chamber, theright ventricle. The pulmonic valve allows blood tomove out of the right ventricle, whichpumps blood to the lungs. Afterabsorbing oxygen from the lungs, theblood flows back into the heart to the leftatrium. The mitral valve allows blood to movefrom the left atrium into the leftventricle. The aortic valve allows the blood tomove out of the left ventricle, whichpumps the blood out of the heart, to therest of the body.
    • IndicationsAcquired valvular diseases Infection Infective endocarditis Rheumatic fever Structural valve changes Stretching or tearing of thechordae tendineae orpapillary muscles Fibro-calcific degeneration Dilatation of the valveannulus.Congenital valvular diseases Improper valve size Malformed leaflets Irregularity in the way theleaflets are attached Congenital valve diseases Bicuspid aortic valve disease Mitral valve prolapse
    • Contraindications Manifestation of end-stage valvedisease Very poor LV function inassociation with a regurgitantlesion Severe fixed pulmonaryhypertension Extensive extra-annular tissuedestruction due to uncontrolledendocarditis Old age Presence of co-morbidities Renal failure Advanced pulmonary disease Severe haemolytic anaemia Severe generalizedarteriopathy Malignant disease Extreme overweight Serious infection untileradication
    • Valvular heartsurgeriesRepair Replacement
    • Valve repair V/S Valve replacementThe potential advantages of valve repair versus valve replacement are:Decreased risk of infectionDecreased need for life-long anticoagulant medicationPreserved heart muscle strength
    • Types of Valve Repair Surgeries Commissurotomy Decalcification Annulus support Creation of new chords Quadrangular resection of leaflet Patched leaflets and bicuspid aortic valve repair
    • Consists of separating mitral valve leaflets by mechanical means (valve “dilator”)
    • Valve Replacement SurgeryRemoval of faulty valve (native valve) and replace itby sewing a mechanical or biological valve to theannulus of the native valve.BiocompatibleAortic valve replacement- most commonly doneAnticoagulant medications (Warfarin) - rest of thepatient‟s life, depending on the type of valvereplacement that was used- reduces probability ofheart attack or strokeNeed to do regular blood test (PT, INR)
    • Types of Valvular prosthesisBIOLOGICAL VALVESMECHANICAL VALVES
    • Biological valve Biological valves (tissue orbioprosthetic valves)- made frombovine, porcine & allograft orhomograft. May have some artificial parts to givethe valve support and to aid placement Do not need life-long anticoagulanttherapy after Sx May last at least 17 years without adecline in function
    • Homograft valve• Human heart valve obtained from adonor after death, frozen & thentransplanted in recipient• Used to replace a diseased aortic valve,or pulmonic valve during the Rossprocedure• Well tolerated by the body as they aremost like native valves• Do not need to take anticoagulantmedications for rest of their lives
    • Mechanical ValvesMade totally of mechanical parts- toleratedwell by the body.Made of metal or carbon, designed to performfunctions of the patient‟s native valve.Very durable, designed to last a lifetime.The bi-leaflet valve is the most common typeof mechanical valveConsists of 2 carbon leaflets in a ring coveredwith polyester knit fabric.Need to take anticoagulant medications for therest of their livesSome patients who have a mechanical valvereplacement report a valve clicking noise attimes (opening and closing)
    • Types of mechanical valvesBall prosthesesNon-hooked single-disk prosthesesNon-hooked double-disk prosthesesDisadvantage - must be associated to prescription of an anticoagulant treatmentin long-term
    • Used to treat aortic valve diseasePatient‟s own pulmonic valve is removedand used to replace a diseased aorticvalve.The pulmonic valve is then replaced by ahomograft valve.Do not need to take anticoagulantmedications for rest of their lives.Ross Procedure
    • Smaller incisions than traditional heartvalve surgeryOther techniques- endoscopic or keyholeapproaches (also called port access,thoracoscopic or video-assisted surgery)and robotic-assisted surgeryBenefits-a smaller incision (3 to 4 inches-instead of 6- to 8-inch incision withtraditional surgery)smaller scars reduced risk of infection less bleeding less pain & traumadecreased length of stay in the hospital(3 to 5 days) & decreased recovery timeMinimally Invasive Valve Surgery
    • Full recovery from valve surgery takes about 2-3 monthsTo maintain cardiovascular health after surgery, making lifestyle changes& taking medications- strongly recommendedLifestyle changes include:Quitting smokingTreating high cholesterolManaging high blood pressure & diabetesExercising regularlyMaintaining a healthy weightEating a heart-healthy dietParticipating in a cardiac rehabilitation program, as recommendedFollowing up with your doctor for regular visitsRecovery process
    • Complications Structural valve deterioration(biological & bioprosthetic valves, deterioration is time-dependent) Valve thrombosis Thromboembolism Prosthetic endocarditis Major bleeding Paravalvular leak
    • Thank You…….