1. Tadsawiya Padkao, PT, M.Sc.
Faculty of Allied Health Sciences
University of Phayao

2. PURPOSES
• To learn definitions, cause, clinical manifestations
for cardiac diseases related to surgery
• To review the types and procedures for operations
• To study the post-operative complications
• To analyze the management of cardiopulmonary
dysfunction secondary to acute surgical conditions
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3. Heart Disease: in relation to cardiac structure
Myocardium Pericardium Coronary Valves Conduction
arteries system
Congenital -Atrial/ventricular -Anatimical -Bicuspid atresia -Abnormal
disease septal defects abnormalities pathway
-Atrioventricular -Homozygous -Wolff-Parkinson-
Canal Defect hypercholesterola White syndrome
-Hypertriphic emia -AV block
obstructive
myocardiopathies
Acquired -Myocardial -Pericarditis -Artheriosclerosis -Rhumatic fever -AV block
disease infarction -Tamponade -Syndrom X -Infective -Sick sinus
-Myocarditis -Malignancy -Stenosis syndrome
-Ventricular septal -Regurgitation -AV nodal re-
defect -Papillary muscle entrant
-Cardiomyopathies rupture tachycardia
-Chordae tendinea
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4. Heart Diseases: Other
Other Congenital Heart Disease
• Patent Ductus Arteriosus (PDA) (A)
• Coartation of Aorta (D)
• Total Anomalous Pulmonary
Venous Return
• Transport of Great Vessels (B)
• Tetralogy of Fallot (TOF or “Tet”)
(C)
Other Acquired Heart Disease:
• Congestive Heart Failure (HF):
Right HF or Lt HF
• Orthostatic Hypotension
• Arrhythmias
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5. • Coronary arteries become
narrowed or blocked, the area
of the muscle supplied by that
artery ischemic and injured,
and infarction may result.
• Pathogenesis
The exact mechanism by
which the development of
coronary artery disease (CAD)
can be explained has yet be
determined.
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6. Sign and symptom
• Symptom of CAD may not appear until the lumen of
coronary artery narrow by 75%
• Angina pectoris
• Breathlessness
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7. • MI, also know as a heart attack
or coronary, is the
development of ischemia with
resultant necrosis of
myocardial tissue
• Sign and symptom
 Angina Pectoris
 Breathlessness at middle of night
(women)
 Fever
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10. ECG demonstrating Ischemia. Note, ST-segment depression (I, V3–V6).
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11. ECG demonstrating anteroseptal myocardial infarction.
Note the ST-segment elevation.
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13. Describe and interpret this ECG
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14. Percutaneous Transluminal Angioplasty (PTCA)
• This means that, through the skin (percutaneous), a
procedure is performed inside an artery (transluminal)
of the heart (coronary) that reshapes (angioplasty) the
narrowed or blocked arteries.
• PTCA is performed with local anesthesia while you are
awake. This procedure is quite like the diagnostic
procedure called coronary angiography.
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15. Coronary angiography is
performed to detect
obstruction in the coronary
arteries of the heart. During
the procedure a catheter
(thin flexible tube) is
inserted into an artery in
your arm or groin and then
threaded carefully into the
heart. The blood vessels of
the heart are then studied
by injection of contrast
media through the catheter.
A rapid succession of X-
rays (fluoroscopy) is taken
to view blood flow
(Copyright 2007 The New York Times Company)
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16. PTCA: Procedure Overview
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17. Stenting
• A stent is introduced into
blood vessel on a balloon
catheter and advanced
into the blocked area of
artery.
• The stent stays in place
permanently, holding the
vessel open and
improving the flow of
blood.
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18. PTCA: Procedure Overview
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19. Coronary Artery Bypass Graft (CABG)
• Surgery may also be
indicated to improve long-
term survival by preserving
left ventricular function and
preventing MI
• There are three sources of
grafts that are used to bypass
stenosed coronary arteries:
the greater saphenous vein,
internal memory artery,
gastroepiploic artery
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20. Coronary Artery Bypass Graft
Surgery(CABG) creates new
pathways around narrowed or
blocked coronary arteries so that
more blood and oxygen flows to
the heart muscle. This surgery
uses segments of veins or arteries
taken from another part of the
body to bypass coronary arteries
on the heart that are blocked or
narrowed. It diverts blood flow past
the blockage allowing more blood
and oxygen to flow to the heart.
(Medmovie.com, 2007)
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21. (Family Doctor Publications, 2009)
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22. CABG : Procedure Overview
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23. (Healthwise, 2010)
CABG : Procedure Overview
2. The sternum is cut
1. A coronary artery is blocked (open heart surgery)
The surgeon makes a vertical incision in the
skin and muscle in the middle of the chest and
then cuts through the breastbone (sternum).
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24. (Family Doctor Publications, 2009)
CABG : Procedure Overview
Heart – Lung or Cardiopulmonary
Bypass Machine
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25. Padkao T 25

26. (Healthwise, 2010)
CABG : Procedure Overview
3. The heart is exposed 4. Blood flow is rerouted
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27. (Healthwise, 2010)
CABG : Procedure Overview
5. Oxygen-rich blood flows to heart muscle
Regardless of which type of blood
vessel is used, oxygen-rich
blood from the aorta is
rerouted around the blocked
section of the coronary artery
to feed the heart muscle.
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28. Showing Bypass Grafts
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29. Incision Lines
Traditional Sternotomy
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30. Minimal Invasive Cardiac Surgery (MICS):
CABG Surgery Update
Kenneth Herskowitz, M.D.
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31. Congestive Heart Failure (CHF)
• CHF is a condition in which
the heart is unstable to pump
sufficient blood to supply the
body needs.
• CHF happens when the heart
weak pumping action causes
a buildup of fluid called
congestion in your lungs and
other body tissue.
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32. Risk Factors for CHF include:
 Previous heart attack
 Coronary artery disease
 High blood pressure (hypertension)
 Irregular heartbeat (arrhythmia)
 Heart valve disease (especially of the aorta and mitral
valves)
 Cardiomyopathy (disease of the heart muscle)
 Congenital heart defects (defects you are born with)
 Alcohol and drug abuse
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33. Padkao T 33

34. Signs and Symptoms
• If the LEFT side of your heart is not
working properly (left-side heart
failure), blood and fluid back up into
your lung. You will feel
- shortness of breath
- be very tried
- have a cough (especially at night)
- cough up pinkish, blood-tinged
sputum
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35. Padkao T 35

36. Signs and Symptoms
• If the RIGHT side of your heart is
not working properly (right-side
heart failure), the slowed blood flow
causes a buildup of fluid in your
veins involved
- feet, legs and ankles swelling
- the lungs, liver and stomach
edema
- Fluid buildup is also hard on your
kidneys. It affects their ability to
dispose of salt (sodium) and water,
which can lead to kidney failure.
- Jugular vein distension
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37. Orthostatic Hypertension
• In standing from a supine or sitting position, signifies a decrease of 20
mmHg or greater in systolic BP or drop of 10 mmHg or more of
both systolic and diastolic arterial BP with concomitant pulse
increase of 15 bpm or more on.
• Etiology
 Volume depletion
 Venous pooling
 Side effects of medication
 Prolong immobility
 Starvation
 Performing valsava’s maneuver
 ANS dysregulation
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38. Sign and Symptom
• Signs and symptom
 Falls or mobility problem
 Acute or chronic mental confusion
 Cardiac symptom
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39. Arrhythmia
• Arrhythmias are disorder of the regular rhythmic
beating of the heart
• Symptoms
 Palpitations or rapid thumping
in your heart
 Feeling tired or light-headed
 Passing out
 Shortness of breath
 Chest pain
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40. What are some of the types of arrhythmias?
• Atrial fibrillation
The heart beats too fast and irregularly. This type of
arrhythmia requires treatment and can increase your risk
of stroke.
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41. What are some of the types of arrhythmias?
• Paroxysmal atrial tachycardia
The heart has episodes when it beats fast, but regularly.
This type of arrhythmia may be unpleasant but is usually
not dangerous.
Atrial 160-250/min: may conduct to ventricles 1:1, or 2:1, 3:1, 4:1 into the
presence ofTa block.
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42. What are some of the types of arrhythmias?
• Ectopic beats
The heart has an extra beat. Treatment usually is not
needed unless you have several extra beats in a row
and/or other problems with your heart (such as heart
disease or congenital heart failure)
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43. What are some of the types of arrhythmias?
• Ventricular tachycardia and ventricular fibrillation
The heart beats too fast and may not pump enough blood. These
types of arrhythmias are very dangerous and need immediate
treatment.
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44. VALVULAR DISEASES
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45. Mitral Valve Stenosis (MS)
• In mitral valve stenosis,
the mitral valve leaflets
are fused to getter by scar
tissue, gradually
narrowing the valve and
slowing the flow of blood
from the left atrium to the
left ventricle.
• Cause: Rheumatic heart
disease
• Signs and symptom: Atrial
fibullation, orthopnea
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46. Treatment of MS
• MVS’s treatment are
percutaneous balloon mitral
valvolotomy (PBMV), closed
mitral commissurotomy and
mitral commissurotomy.
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47. (De Dang Hanh, MD, A Thomas Pezzella, MD, 2000)
Closed Mitral Commissurotomy
Figure (A) The left atrium enlarges to the right, increasing visualization from the right thoracotomy approach. (B) The interatrial groove is dissected
approximately l-cm deep, down to the left atrial wall. The pursestring suture is placed in the nondissected area. This prevents tearing of the
dissected left atrial wall when the suture is tied down. (C) Sagittal view shows location of mitral valve in relation to the atriotomy. (D) Direction of
the index finger allows easy palpation of the valve. (E) Usually, the first assistant ties the pursestring suture as the operating surgeon removes the
index finger. (F) A second-layer closure acts as a buttress to reinforce the suture line and restore the interatrial groove.
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48. Disadvantage of closed
mitral commissurotomy
1. Risk of embolic events
due to dislodging atrial
thrombi.
2. Incomplete relief of
mitral regurgitation due
to tearing of the leaflets
rather than opening of
the fused commissures.
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49. Open Mitral Commissurotomy
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50. Mitral Valve Regurgitation (MR)
• Mitral valve regurgitation or mitral
regurgitation (MR) is a condition in
which the mitral valve doesn't close
tightly, allowing blood to flow backward
in your heart.
• Cause: infective endocarditis, dilated
cardiomyopathy, rheumatic disease,
collagen vascular disease, rupture of
the chordae tendineae and cardiac
tumor
• Cardiac manifestation:
 Lack of sign warm
 Exertional dyspnea
 Exercise-induced fatigue
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51. Treatment of MR
• Surgical intervention
my be recommended
if the left ventricular
function is impaired.
• Mitral valve repair has
a lower operation
mortality and better
late outcome than
mitral replacement.
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52. Mitral Valve Prolapse (MP)
• Defines as a slight variation in the shape or
structure of the mitral valve.
• Etiology: may be genetic component
• Clinical manifestation: profound fatigue, tremor,
swelling, sleep disturbance, irritable bowel syndrom
• Treatment: β-blocker to control arrhythmia,
prophylaxis, surgyry
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53. Aortic Stenosis (AS)
• Defined as a
narrowing or
obstruction of the
hearts aortic valve,
which prevent from
opening properly and
blocks the flow of
blood from the left
ventricle to aorta
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54. Symptoms
• Fainting or weakness with activity
• Breathlessness with activity
• Sensation of feeling the heart beat
(palpitation)
• Chest pain, angina-type
- under the sternum, may radiate
- crushing, squeezing, pressure,
tightness
- increased with exercise, relieved with
rest
• Treatment
- Medicine
- Surgery: Balloon valvuloplasty, Valve
replace ment
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55. Balloon valvuloplasty
Percutaneous AVR
a) Balloon valvuloplasty; b)
Balloon catheter with valve in
the diseased valve; c) Balloon
inflation to secure the valve; d)
Valve in place
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56. Aortic Valve
Replacement
Aortic valve replacement is an open-heart
surgery that removes a malfunctioning
aortic valve and puts a new one in place.
The replacement valve may be:
* Mechanical–Made entirely out of artificial
materials
* Bioprosthetic–Engineered out of a
combination of artificial materials and
tissues from a pig, cow, or other animal
* Homograft or Allograft–Harvested from
a donated human heart
* Ross Procedure (Self-donated)–In
selected patients less than 50 years of age,
another one of the patient’s own heart
valves, the pulmonic valve, may be
removed from its original location and sewn
in to take the place of the faulty aortic valve.
A homograft is then sewn in to take the
original place of the pulmonic valve.
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57. Aortic Valve Regurgitation (AR)
• If the valve leaflet are damaged or fail
to close properly, blood leaks back
from the aorta into the left ventricle
between heartbeats.
• Symptoms
- Usually none until age 40-50 yrs old
- Shortness of breath on exertion
- Shortness of breath while resting
prone
- Chest pain
- Light headedness
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58. Cause:
• Congenital bicuspid aortic valve (person is born with only two aortic
valve leaflets, instead of the normal three)
• Rheumatic heart disease (caused by untreated – strep throat in children)
• Hypertention
• Infective endocarditis
• Marfan’s syndrome
• Ankylosing spondylytis
• Reiter syndrom
• Aortic dissection
• Syphitis
Treatment:
• Medication
• Surgery
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59. Endocarditis
• Defined as an infection that invades the innermost
lining of the heart, the endothelium
• Cause: Bacteremia
• Symptom: fever, fatigue, weight loss, new rashes,
(either painful or painless), headaches, backaches,
joint pains and confusion.
• A new heart murmur as well as new skin, fingernail
and retinal lesion are typical physical findings in
endocarditis.
• Treatment: medication and surgery
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60. Rheumatic Fever and Heart Disease
• Rheumatic fever is an inflammatory disease. It can
affect many of bodies connective tissues –
especially those of heart joints, brain or skin.
• Cause: Streptococal bacteria
• Incidence: children 5-15 yrs old
• Symptom: Eritherma marginum, Carditis,
Polyarthitis
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61. What are the chest physiotherapy used in
surgical patients?
• Preoperation
• Postoperation
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