nursing students

1. CARDIAC SURGERY

2. TYPES OF CARDIAC SURGERY
1. Reparative surgery
2. Reconstructive procedures
3. Substitutional procedures
REPARATIVE SURGERY:
Procedures are likely to produce a cure or excellent and prolonged improvement
 Patent Ductus Arteriosus
 ASD, VSD
 Repair of mitral Stenosis and Tetralogy of Fallot

3. TYPES OF CARDIAC SURGERY
Reconstructive procedures:
 These are more complex, they are not always curative and
reoperation may be needed
1. CABG
2. Reconstruction of an incompetent mitral, tricuspid or aortic valves

4. TYPES OF CARDIAC SURGERY
SUBSTITUTIONAL PROCEDURES:
 These are not usually curative because of the preoperative
condition of patient
1. Valve replacement
2. Cardiac transplantation

5. OPEN HEART SURGERY
This is a surgery in which the patient's chest is opened and surgery is performed
on the heart.
The term "open" refers to the chest, not to the heart itself
The heart may or may not be opened depending on the particular type of surgery
Open-heart surgery is a procedure in which the heart is cut open to correct a
defect, such as repair of heart valves.
The heartbeat is stopped during the procedure, and the person is placed on a CP
machine to deliver blood to the body.
The CP machine temporarily serves in place of the heart and lungs by removing
carbon dioxide from the blood, and pumping oxygenated blood throughout the
body.

6. OPEN HEART SURGERY
The CP machine does the following functions
 Diverts circulation from the heart and lung, providing the surgeon
with the bloodless operative field
 Performs all gas exchange function
 Filters, rewarms and cools the blood
 Circulates oxygenated, filtered blood back into the arterial system

7. COMPONENTS OF CARDIO PULMONARY BYPASS
The three components of cardio pulmonary bypass are
1. Hemodilution
2. Hypothermia
3. Anticoagulation

8. COMPONENTS OF CARDIO PULMONARY BYPASS
1. Hemodilution occurs as the clients blood become diluted with the isotonic
crystalloid solution used to prime the bypass machine
2. Hypothermia (28-36 degree Celsius) is used to reduce tissue oxygen
requirements by approximately 50% to protect the organ from ischemic injury.
3. Anticoagulation is necessary to prevent coagulation in the bypass machine

9. PRIMING
The deairing of CPB circuit is done by priming
solutions, consisting of a mixture of crystalloids and
colloids.
Priming causes haemodilution which improves flows
during hypothermia.
Heparin 3–4 units/ml is added to the prime.
Lactated Ringer's solution,Ringer's solution, normal
saline, Plasma-Lyte,

10. COMPONENTS OF CARDIOPULMONARY BYPASS CIRCUIT

11.  Cannula is inserted into right atrium to drain venous
return
 Venous blood passes into venous reservoir under
gravity
 Oxygenated (and CO2) removed usually by membrane
oxygenator
 Heat exchanger control blood temperature
 Surgery often performed with 5-10 C of hypothermia
 A 40 mm filter removes air bubbles
 Pump returns blood into aorta distal to a cross clamp
 Suction used to remove blood from operative field
 Returned to patient via cardiotomy reservoir

12. CORONARY ARTERY BYPASS SURGERY
Coronary Artery Bypass Surgery or CABG is a surgical procedure performed to
restore the blood supply to sections of heart that have reduced or no blood supply
Coronary artery bypass surgery OR coronary artery bypass graft (CABG) surgery
Performed to relieve angina and reduce the risk of death from coronary artery
disease.
Arteries or veins from elsewhere in the patient's body are grafted to the coronary
arteries to bypass atherosclerotic narrowing and improve the blood supply to the
coronary circulation supplying the myocardium

13. INDICATIONS OF CABG
1. Left main coronary artery disease
2. Multiple vessel disease
3. Abnormal Left Ventricular function
4. Failed PTCA
5. Immediately after Myocardial Infarction (to help perfusion of the viable
myocardium).
6. Life threatening arrhythmias caused by a previous myocardial infarction
7. Occlusion of grafts from previous CABGs

14. CONTRAINDICATIONS FOR CABG
1. Absence of viable myocardium
2. The artery that needs grafting is too small

15. TYPES OF CABG SURGICAL PROCEDURE
1. Traditional or on pump open heart surgery
2. Minimally invasive heart surgery

18. ON PUMP OPEN HEART BYPASS SURGERY
In the traditional CABG procedure, the heart is stopped with a potassium
solution
An open heart bypass surgery is performed under general anaesthesia
Patient be on a ventilator during surgery.
The surgeon or an assistant surgeon removes the graft from legs or hands,
ensuring the other ends are ligated properly.

19. ON PUMP OPEN HEART BYPASS SURGERY
He then cleans the unwanted fat and other tissues attached to the graft.
Injects saline to ensure that all branches are properly ligated or clipped. The
saphenous vein in the leg is commonly used because it is long enough to
create multiple grafts.
The left internal mammary artery is used for a single graft and is taken once
the chest is opened for surgery

20. ON PUMP OPEN HEART BYPASS SURGERY
Meanwhile, the chest layers are cut open right in the middle almost on top of the
sternum.
When the sternum is reached, the bone is sawed and the ribcage is retracted to
expose the heart.
The patient is connected to a heart lung machine by diverting blood from the
systemic circulation.

21. ON PUMP OPEN HEART BYPASS SURGERY
The blood is oxygenized and filtered in the machine and sent back to the aorta
thereby maintaining oxygen and nutrient supply to other vital organs.
When the heart stops working, the surgeon identifies the block, makes incision
below the block.
He then sutures the graft to that incision.
The left internal mammary artery that comes as a branch from aorta is left
connected to its origin; however the distal or far end of the artery is divided for
connection to the diseased coronary artery

22. ON PUMP OPEN HEART BYPASS SURGERY
When all the grafts are in place and sutured, the heart is allowed to fill with blood
CP machine is slowly weaned off.
The surgeons make sure that there are no leaks in the connection between the graft
and the aorta.
Once the heart regains its function the pacing wires and drainage tubes are placed in
the chest cavity to drain any fluid that normally collects after the procedure.
The ribs are usually brought together and closed together with sternal wires and the
rest of the muscles are closed in layers.

23. ON PUMP OPEN HEART BYPASS SURGERY
The graft-harvested area is also sutured or closed in layers.
Following the surgery the chest wound is cleaned of the blood marks and
dressed.
The leg wound is dressed and bandaged with pressure to prevent swelling or
limb edema.
Throughout the procedure an anaesthesiologist will monitor the blood
pressure, oxygen saturation and body temperature.
Few blood tests may be repeated in intervals, especially when the patient is
connected to the bypass machine.

25. Pros of On Pump Open Heart
Surgery
 Surgeon can operate quicker because
the heart is still
 Very little blood makes surgery faster
 Appropriate for unstable patients
Cons of On Pump Open Heart Surgery
 Increased inflammation/clotting after
surgery
 Transfusion more likely after surgery
than with off pump
 More fluid retention than off pump
 Higher risk of kidney damage than off
pump
 Longer hospital stay than off pump
 Increased risk of stroke

26. MINIMALLY INVASIVE HEART SURGERY
Minimally invasive heart surgery refers to surgery performed on the beating
heart to provide coronary artery bypass grafting.
This technique is often referred to as MIDCAB, MINIMALLY INVASIVE DIRECT
CORONARY ARTERY BYPASS; or off-pump CABG (OPCAB)
1. Off-pump CABG (OPCAB)
2. Minimally invasive direct coronary artery bypass (MIDCAB).

27. MINIMALLY INVASIVE HEART SURGERY
The MIDCAB procedure includes procedures done both with and without
cardiopulmonary bypass, the later being referred to as OFF-PUMP MIDCAB.
Unless otherwise specified, MIDCAB refers to both types of procedures.
Minimally invasive valve surgery has been an outgrowth of the success

28. PURPOSE
Minimally invasive heart surgery is performed on the diseased heart to
reroute blood around clogged arteries and improve the blood and oxygen
supply to the heart.
This approach provides patients some benefit which includes
 Cardiopulmonary bypass machine may be avoided
 Smaller incisions can be used instead of the standard sternotomy (incision
through the sternum)
 Faster recovery time
 Decreased procedure costs
 Reduced morbidity and mortality

29. Candidates for Minimally invasive heart surgery
 Patients with advanced age
 Patients at risk for stroke or suffering peripheral vascular disease,
 Patients with renal disease
 Patients with poor lung function

30. OFF-PUMP CORONARY ARTERY BYPASS (OPCAB) SURGERY
 The same procedure as in on pump open heart surgery can be performed without the
use of the heart lung machine.
It is often called as OPCAB or Off-Pump coronary artery bypass. This procedure can be
performed when the heart is still beating.
 The OPCAB procedure does not use cardiopulmonary bypass. The incision of choice can
be a midline sternotomy or a left anterior thoracotomy
The midline sternotomy allows access to both the right and left internal mammary
arteries.
Additional vascular bypass conduits may be acquired by harvesting the saphenous vein
(in the leg), gastroepiploic artery (near the stomach), or radial artery (in the arm).

31. OFF-PUMP CORONARY ARTERY BYPASS (OPCAB) SURGERY
A stabilizing device is used to secure the coronary artery of
choice. This device applies gentle pressure or suction, mildly
limiting cardiac function, but providing better access to
posterior and inferior vessels of the heart.
The surgeon makes the necessary anastomosis to the
targeted coronary arteries.
If conduits other then the mammary arteries are used they
are connected to the ascending aorta to provide systemic
blood flow.

32. Pros of Off Pump Open Heart
Surgery
 Less blood loss and fewer
transfusions
 Decreased risk of stroke
 Decreased length of hospital stay
 Less expensive
Cons of Off Pump Open Heart Surgery
 The heart is moving, slowing surgery
 Up to 70% of patients not eligible due
to anatomy or medical condition
 Rarely performed on an unstable
patients

33. MIDCAB
The surgeon performs an alternative incision (rather
than a midline sternotomy), typically a left anterior
THORACOTOMY
The left internal mammary artery is dissected from the
left chest wall.
A stabilizer device is placed on the heart to provide
support of the left anterior descending artery as the
heart continues to beat.

34. MIDCAB
This device applies gentle pressure or suction,
mildly limiting cardiac function
The left internal mammary artery is sutured to
the left anterior descending artery to bypass
the blockage (anastomosis)

35. MIDCAB
If cardiopulmonary bypass is indicated, the surgeon inserts cannulae (small,
flexible tubes) into the femoral vessels.
Aortic occlusion and cardioplegia are administered through a catheter advanced
through the contra lateral femoral artery into the aortic root (ascending aorta).
This catheter has a balloon tip that stops blood flow to the coronary arteries
when inflated, but allows selective administration of cardioplegia (a solution that
stops the heart) to the coronary arteries.

36. MIDCAB
The use of cardioplegic arrest makes this a non-beating heart procedure,
Angiography is performed to provide visualization of catheter placement
The left internal mammary artery is sutured to the left anterior descending
artery to bypass the blockage (anastomosis).
Once the anastomosis is complete the balloon is deflated, allowing the
heart to begin to beat.
Cardiopulmonary bypass is discontinued once cardiac function is stabilized.
The cannulae and catheter are removed, and the groin wounds are closed
with sutures.

37. PREOPERATIVE MANAGEMENT
Many cardiac surgeons order extensive testing before proceeding with a CABG
to determine which arteries are obstructed and the severity of the blockage.
PRE-OPERATIVE TESTS
 An angiogram
 A stress test
 Electrocardiogram (EKG)

38. PREOPERATIVE MANAGEMENT
 Blood tests are usually done in advance of the surgery
 Blood tests may be repeated immediately prior to surgery to
determine if the patient is likely to bleed during surgery, along
with their general
 Chest X-Ray, Echocardiogram , Breathing test (spirometry)