Redo cardiac surgery comes with increased risks compared to routine cardiac surgery due to adhesions from prior operations and potential for injury. Careful pre-operative planning is important, including reviewing prior surgery details and imaging. Cannulation choice is based on surgical risk factors. Cardiopulmonary bypass should be initiated early to prepare for any emergencies. Complications can include bleeding, difficulties with coronary sinus perfusion due to adhesions, low cardiac output syndrome, and vasoplegic syndrome. Close monitoring is needed for potential complications affecting cardiac function, lungs, brain, kidneys, and other organs.

1. REDO-CARDIAC SURGERY
GLORY MINI MOL. A
M.SC. PERFUSION TECHNOLOGY(II YEAR)
SRIHER

2. SYNOPSIS
• PRE-OP PLANNING
• RADIOGRAPHY
• CANNULATION STRATEGIES
• CARDIOPULMONARY BYPASSS
• COMPLICATIONS

3. INTRODUCTION
• REOPERATIONS FOR CARDIAC SURGERY FOLLOWING PRIOR STERNOTOMY ARE
ASSOCIATED WITH MORBIDITY AND MORTALITY
• REOPERATIONS ARE FUNDAMENTALLY DIFFERENT FROM ROUTINE SURGERIES
APPROACH OF PATIENTS
PREOP PLANNING
SURGICAL TECHNIQUES

4. PREOP PLANNING
(QUICK REVIEW)
• PREVIOUS HISTORY AND PHYSICAL EXAM
• EXTENSIVE CARDIOVASCULAR HISTORY
• DETAILED HISTORY OF PRIOR CARDIAC INTERVENTIONS AND PROCEDURE
• TYPE OF SURGERY AND DATE
• INCISION TYPES
• POST OP COMPLICATIONS INCLUDING INFECTIONS
• CARDIOPULMONARY DETAILS
• CANNULATIONS

5. RADIOGRAPHY
APART FROM PRE-OP DETAILS RADIOGRAPHY IS ALSO
IMPORTANT
• GRAFTS
• CONDUITS
• STENTING
• IMPLANTS

6. CANNULATION
• CHOICE OF CANNULATION IS DICTATED BY THE SURGICAL RISK OF THE CASE
• CANNULATION CHOICES ARE PREFERRED BY CONSIDERING:
• EXTENSIVE CALCIFICATION OF AORTA
• MULTIPLE BYPASS GRAFTS TO AORTA
• PRESENCE OF SIGNIFICANT ADHESIONS TO RA
• HIGH RISK OF CATASTROPHIC INJURY
Axillary or femoral
cannulation

7. CARDIOPULMONARY BYPASS
• CPB SHOULD BE INITIATED PRIOR TO STERNOTOMY OR THORACOTOMY
• CPB LINES SHOULD BE BROUGHT TO THE SURGICAL FIELD
• SHOULD BE PRIMED PRIOR TO STERNOTOMY IN THE EVENT THAT IT BECOMES
NECESSITY TO INITIATE EMERGENCY CPB.
• REDUCED OVERALL CPB DURATION

8. COMPLICATIONS
1. REDO- STERNOTOMY:
• HEMORRHAGIC INJURY
• INSTITUTION OF PRIOR BYPASS DON’T PROTECT RIGHT VENTRICLE FROM INJURY
(RIGHT VENTRICLE ADHERES TO UNDERSURFACE OF STERNUM WHEN LEFT
INTERNAL THORACIC ARTERY(LIMA) IS DISSECTED IN PRIOR SURGERY)
• PRIOR STERNOTOMY PREVENTS LESS BLEEDING

9. 2. CORONARY SINUS PERFUSION:
• CORONARY SINUS PERFUSION PROTECTS THE MYOCARDIUM AND FACILITATES THE
PERFORMANCE OF COMPLEX PROCEDURE.
• IN REDO SURGERY IT IS DIFFICULT TO APPROACH RETROGRADE CATHETER INTO
THE CORONARY SINUS BECAUSE OF DISTORTION OF THE ADHESIONS
• IN SUCH CASES, ANTEGRADE PERFUSION HAS TO BE MAINTAINED.
• IN SHORTER CROSS CLAMP TIMES, THE PROCEDURE CAN BE MANAGED WITH COLD
CARDIOPLEGIC SOLUTION.

10. 3. LOW CARDIAC OUTPUT SYNDROME
(TRANSIENT DECREASE IN SYSTEMIC PERFUSION SECONDARY TO MYOCARDIAL
DYSFUNCTION. THE OUTCOME IS AN IMBALANCE BETWEEN OXYGEN DELIVERY AND
OXYGEN CONSUMPTION AT THE CELLULAR LEVEL WHICH LEADS TO METABOLIC
ACIDOSIS)
• ONE OF THE MAIN PERIOPERATIVE COMPLICATIONS FOLLOWING REDO CARDIAC
SURGERY
• IT IS SEEN IN REPEATED REVASCULARIZATION PROCEDURE AND IN PATIENT WIT
PROLONGED MYOCARDIAL ISCHEMIC TIME.
• PATIENTS WITH EITHER PULMONARY HYPERTENSION OR MITRAL VALVE REPLACEMENT
FOR MITRAL REGURGITATION THIS OCCURS
• CARDIAC TAMPONADE
• POST OPERATIVE BLEEDING

11. 4. VASOPLEGIC SYNDROME
(HIGH-OUTPUT SHOCK STATE WITH POOR SYSTEMIC VASCULAR RESISTANCE)
• INCIDENCE OF VASOPLEGIC SYNDROME AFTER CARDIOPULMONARY BYPASS IS 5-
15%
• VASOPLEGIC SYNDROME MANIFESTS WHEN THE PATIENT IS MARKEDLY
HYPOTENSIVE AND REQUIRES LARGE DOSES OF VASOPRESSORS TO MAINTAIN
ADEQUATE BLOOD PRESSURE.
• SEPTIC CONDITIONS
• EXTREME DEGREE OF HEMODILUTION
• PATIENTS WHO RECEIVE MILRINONE BEFORE WEANING CPB
• IN PATIENTS VERY LOW EF OR PULMONARY HYPERTENSION MILRINONE IS
ADMINISTERED TO WEAN OFF

12. 1. DECREASED CARDIAC OUTPUT
• HYPOVOLEMIA
• BLEEDING
• CARDIAC TAMPONADE
• FLUID OVERLOAD
• HYPOTHERMIA
• HYPERTENSION
• TACHYARRHYTHMIAS
• BRADYCARDIAS
• CARDIAC FAILURE
• MYOCARDIAL INFRACTION
.2. PULMONARY COMPLICATIONS
• PLEURAL EFFUSIONS
• PNEUMONIA
• PULMONARY OEDEMA
• CARDIOGENIC PULMONARY OEDEMA
• ACUTE RESPIRATORY DISTRESS SYNDROME
• PULMONARY EMBOLISM
• PHRENIC NERVE INJURY
• PNEUMOTHORAX
• STERNAL WOUND INFECTION
3. NEUROLOGIC CHANGES
• STROKE
4. RENAL FAILURE AND ELECTROLYTE IMBALANCE:
• ACUTE RENAL FAILURE
• RENAL IMBALANCE
5. OTHERS
• HEPATIC FAILURE
• INFECTIONS
OTHER COMPLICATIONS

13. THANKYOU