Congenital coronary anomalies occur in 1-5% of the population. Around 20% of these anomalies have potential to cause coronary ischemia and its sequelae. The development of the coronary vascular system is a complex process whereby cells from outside the heart migrate into and through the myocardium to form blood vessels. Some important congenital coronary anomalies that can cause clinical issues include coronary arteriovenous fistula, ALCAPA, anomalous connection of a main coronary artery to the aorta, and congenital ostial atresia of the left main coronary artery. Surgical correction of these anomalies has generally good outcomes.
- The document discusses the Fontan procedure for univentricular heart defects. It covers the evolution of the Fontan concept from the original atriopulmonary connection to lateral tunnel and extracardiac conduit techniques. It also discusses indications for Fontan, complications such as arrhythmias and ventricular dysfunction, and strategies to optimize outcomes like fenestration.
Cardiopulmonary Bypass overview for beginnersNICS, Bangalore
This document provides an overview of cardiopulmonary bypass (CPB), including its history, components of the modern CPB machine, and the CPB procedure. Some key points:
- John Heysham Gibbon Jr. performed the first successful open heart surgery using total cardiopulmonary bypass in 1953.
- The main components of the modern CPB machine include the systemic pump, oxygenator, venous reservoir, and arterial filter.
- CPB allows for an open, bloodless field during cardiac surgery by taking over the functions of the heart and lungs. Various techniques like hypothermia, cardioplegia, and venting are used to protect the heart during bypass.
Anatomy & physiology for the EP professional part I 8.4.14lpesbens
This document provides an overview of cardiac anatomy and physiology for electrophysiology professionals. It describes the structures of the chest, including the thoracic cage and vasculature. It identifies the cardiac chambers, valves, arteries and veins. It discusses blood flow through the heart and the coronary blood supply. Complications of vascular access sites like the chest, internal jugular vein, and femoral vein are outlined. References are provided for further reading.
The univentricular repair indications, procedures, outcomes and controversiesJoel Regondola
This document discusses surgical options for single ventricle heart defects, including the indications, timing, and outcomes of various palliative surgeries. It describes initial procedures like pulmonary artery banding or shunting to relieve obstruction and provide pulmonary blood flow. It then discusses staged repairs like the bidirectional Glenn procedure or hemi-Fontan that redirect blood flow. Finally, it covers the modified Fontan operation, which separates systemic and pulmonary circulation without a subpulmonary ventricle. Complications, long-term outcomes, and factors affecting success are also addressed.
Open heart surgery involves opening the chest to operate directly on the heart or surrounding structures. Common procedures include heart valve surgery, repair of congenital defects, and coronary artery bypass grafting. Before surgery, patients undergo tests to assess cardiac function and risks. During surgery, general anesthesia is induced carefully to maintain stable hemodynamics while the heart is monitored closely using techniques like pulmonary artery catheters. Premedication aims to minimize stress on the heart during induction and intubation.
The document discusses various techniques for cannulation during cardiopulmonary bypass (CPB). Venous cannulation is typically done via the superior vena cava (SVC) and inferior vena cava (IVC) using either a bicaval, single atrial, or cavoatrial approach. Arterial cannulation is usually via the ascending aorta but can also be done through femoral, axillary, or other arteries if needed. Proper positioning and sizing of cannulas is important to maximize blood flow and minimize complications like air embolism, bleeding, or malposition. Factors such as patient anatomy, surgical plan, and vessel disease must be considered to select the optimal cannulation method.
Valular heart disease is very common in most of Afro Asian counteries mainly due to Rheumatic heart disease..Definitive treatment is surgery.which may be valve replacement or reapir. In this ppp I have discussed this subject in a simple way
Systolic anterior motion of mitral valve - SAMgagsol
This document summarizes the hospital course of an 80-year-old female admitted with weakness and nausea. Key findings include:
- Hypertrophic cardiomyopathy with systolic anterior motion (SAM) of the mitral valve was seen on echocardiogram.
- She developed respiratory acidosis and was intubated. Atrial fibrillation was also found.
- She was treated with antibiotics for possible sepsis, amiodarone for atrial fibrillation, and beta blockers were increased to control heart rate.
- SAM occurs in HCM and involves anterior movement of the mitral valve during systole, which can be exacerbated by factors like decreased preload. It is an
- The document discusses the Fontan procedure for univentricular heart defects. It covers the evolution of the Fontan concept from the original atriopulmonary connection to lateral tunnel and extracardiac conduit techniques. It also discusses indications for Fontan, complications such as arrhythmias and ventricular dysfunction, and strategies to optimize outcomes like fenestration.
Cardiopulmonary Bypass overview for beginnersNICS, Bangalore
This document provides an overview of cardiopulmonary bypass (CPB), including its history, components of the modern CPB machine, and the CPB procedure. Some key points:
- John Heysham Gibbon Jr. performed the first successful open heart surgery using total cardiopulmonary bypass in 1953.
- The main components of the modern CPB machine include the systemic pump, oxygenator, venous reservoir, and arterial filter.
- CPB allows for an open, bloodless field during cardiac surgery by taking over the functions of the heart and lungs. Various techniques like hypothermia, cardioplegia, and venting are used to protect the heart during bypass.
Anatomy & physiology for the EP professional part I 8.4.14lpesbens
This document provides an overview of cardiac anatomy and physiology for electrophysiology professionals. It describes the structures of the chest, including the thoracic cage and vasculature. It identifies the cardiac chambers, valves, arteries and veins. It discusses blood flow through the heart and the coronary blood supply. Complications of vascular access sites like the chest, internal jugular vein, and femoral vein are outlined. References are provided for further reading.
The univentricular repair indications, procedures, outcomes and controversiesJoel Regondola
This document discusses surgical options for single ventricle heart defects, including the indications, timing, and outcomes of various palliative surgeries. It describes initial procedures like pulmonary artery banding or shunting to relieve obstruction and provide pulmonary blood flow. It then discusses staged repairs like the bidirectional Glenn procedure or hemi-Fontan that redirect blood flow. Finally, it covers the modified Fontan operation, which separates systemic and pulmonary circulation without a subpulmonary ventricle. Complications, long-term outcomes, and factors affecting success are also addressed.
Open heart surgery involves opening the chest to operate directly on the heart or surrounding structures. Common procedures include heart valve surgery, repair of congenital defects, and coronary artery bypass grafting. Before surgery, patients undergo tests to assess cardiac function and risks. During surgery, general anesthesia is induced carefully to maintain stable hemodynamics while the heart is monitored closely using techniques like pulmonary artery catheters. Premedication aims to minimize stress on the heart during induction and intubation.
The document discusses various techniques for cannulation during cardiopulmonary bypass (CPB). Venous cannulation is typically done via the superior vena cava (SVC) and inferior vena cava (IVC) using either a bicaval, single atrial, or cavoatrial approach. Arterial cannulation is usually via the ascending aorta but can also be done through femoral, axillary, or other arteries if needed. Proper positioning and sizing of cannulas is important to maximize blood flow and minimize complications like air embolism, bleeding, or malposition. Factors such as patient anatomy, surgical plan, and vessel disease must be considered to select the optimal cannulation method.
Valular heart disease is very common in most of Afro Asian counteries mainly due to Rheumatic heart disease..Definitive treatment is surgery.which may be valve replacement or reapir. In this ppp I have discussed this subject in a simple way
Systolic anterior motion of mitral valve - SAMgagsol
This document summarizes the hospital course of an 80-year-old female admitted with weakness and nausea. Key findings include:
- Hypertrophic cardiomyopathy with systolic anterior motion (SAM) of the mitral valve was seen on echocardiogram.
- She developed respiratory acidosis and was intubated. Atrial fibrillation was also found.
- She was treated with antibiotics for possible sepsis, amiodarone for atrial fibrillation, and beta blockers were increased to control heart rate.
- SAM occurs in HCM and involves anterior movement of the mitral valve during systole, which can be exacerbated by factors like decreased preload. It is an
The cardiac conduction system receives its blood supply from branches of the left anterior descending coronary artery and right coronary artery. A critical portion of the interventricular conduction system is supplied by the first septal branch of the left anterior descending artery. The bundle of His receives blood supply from both the left anterior descending artery and right coronary artery, with approximately 50% of the blood coming from the septal branch of the left anterior descending artery and atrioventricular nodal branch of the right coronary artery.
Surgical management of d-tga Dr. ankit jain AIIMSAnkit Jain
This document provides information on the surgical management of transposition of the great arteries (TGA). It discusses the history, embryology, associated lesions, and surgical techniques for TGA. Some key points include:
- TGA accounts for 5-7% of congenital heart defects and was first described in 1797.
- The most accepted embryological theory is abnormal development of the bilateral subarterial conus.
- Associated lesions include VSD, LVOT obstruction, and aortic arch anomalies.
- Surgical techniques have evolved from atrial septectomy in the 1950s to the arterial switch operation (ASO) developed in 1975, which has high survival rates of over 98% today.
This document provides information about coronary flow imaging techniques. It discusses visualization of the coronary arteries, heart segmentation, and scan views used. Details are given on quantifying coronary flow reserve using Doppler, including measuring flow velocities in the left anterior descending coronary artery at rest, during stress, and recovery. Examples of normal and pathological coronary flow patterns are shown. The roles of various ultrasound settings and protocols for coronary flow reserve assessment are outlined.
Anesthesia for off Pump Coronary artery bypass graftingDr. Harshil Joshi
This document provides an overview of off-pump coronary artery bypass grafting (OPCAB). It discusses the epidemiology and anatomy of coronary artery disease. It then covers the pathophysiology of atherosclerosis, determinants of coronary blood flow, and tools for assessing patient risk. Details are provided on preoperative evaluation and intraoperative considerations like anesthesia techniques, monitoring, myocardial protection strategies, and treatments for ischemia. Challenges of OPCAB and indications for conversion to cardiopulmonary bypass are also summarized.
The document provides information on aortic valve disease including anatomy, etiology, and pathophysiology. It describes the key components of the aortic root including the aortic annulus, cusps, sinuses, and sinotubular junction. The three main causes of aortic stenosis are discussed as congenital bicuspid valve with calcification, calcification of a normal trileaflet valve, and rheumatic disease. The pathophysiology of aortic stenosis involves left ventricular pressure overload leading to hypertrophy and eventually decreased ejection fraction if severe stenosis is not corrected.
The treatment of patients with advanced acute heart failure is still challenging.
Intra-aortic balloon pump (IABP) has widely been used in the management of
patients with cardiogenic shock. However, according to international guidelines, its
routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated
that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian
Association of Hospital Cardiologists, reviews the available data derived from clinical
studies. It also provides practical recommendations for the optimal use of IABP in
the treatment of cardiogenic shock and advanced acute heart failure.
The document summarizes Fontan circulation, which is a surgical procedure that redirects blood flow from the inferior vena cava and superior vena cava directly to the pulmonary arteries, bypassing the right ventricle. It allows for systemic and pulmonary blood to circulate in parallel, driven by a single ventricle. The document discusses the history and evolution of the Fontan procedure, patient selection criteria, surgical techniques, postoperative physiology, and challenges.
The document summarizes the anatomy and physiology of the coronary circulation. It describes:
1) The coronary arteries originate from the aorta and branch to form the right and left coronary arteries which further divide to supply the myocardium.
2) The left main coronary artery divides into the left anterior descending artery and left circumflex artery. The right coronary artery supplies the right side of the heart.
3) Coronary blood flow is highest in diastole when the heart muscle is relaxed to perfuse the subendocardial layers of the left ventricle. Various neural and chemical factors regulate blood flow to meet myocardial demand.
1) Pulmonary regurgitation is a common consequence of tetralogy of Fallot repair and can lead to right ventricular dilation and dysfunction over time.
2) Echocardiography and cardiac MRI are useful for evaluating the severity of pulmonary regurgitation and assessing the degree of right ventricular dilation and dysfunction.
3) Indications for pulmonary valve replacement include moderate or severe pulmonary regurgitation with signs of right heart failure or dilation out of proportion to age. It aims to prevent irreversible right ventricular damage.
Anatomy and imaging of coronary artery disease withSarbesh Tiwari
1) Coronary CT angiography (CCTA) uses computed tomography to non-invasively image the coronary arteries. It provides high quality images of the coronary arteries and their branches.
2) CCTA is performed using either electron-beam CT or multi-detector row CT (MDCT). MDCT is now more commonly used due to its wider availability and lower cost. The latest generation 64-detector MDCT allows for very high resolution imaging.
3) CCTA requires careful preparation of the patient including medication to control heart rate and dilation of the coronary arteries. The scan itself involves ECG gating to image the heart during diastasis and injection of iodinated contrast to outline the coronary
Major aortopulmonary collateral arteries (MAPCAs) are abnormal blood vessels that provide blood flow to the lungs in some patients with congenital heart defects. MAPCAs originate from the aorta or its branches and connect abnormally to the pulmonary arteries. They develop when normal pulmonary blood flow is obstructed in utero. MAPCAs vary in number, origin and path to the lungs. They may cause uneven blood flow within the lungs and become narrowed over time. The clinical presentation of patients with MAPCAs depends on the pattern of blood flow they provide.
1. The document discusses the management of single ventricle physiology, which involves connecting the systemic and pulmonary circulations in parallel rather than series due to the inability to establish two independent functioning ventricles.
2. The management involves initial palliation through procedures such as the bidirectional Glenn shunt or pulmonary artery banding, followed by definitive palliation with a Fontan operation around 3 years of age to connect the systemic venous return directly to the pulmonary arteries without an interposing ventricle.
3. The Fontan operation has evolved over time from atrio-pulmonary connections to total cavopulmonary connections using intra-atrial tunnels or extracardiac conduits to more efficiently direct superior vena c
This document provides an overview of cardiac catheterization procedures. It discusses indications, contraindications, techniques, views obtained, and interpretation of pressure waveforms. Key points include that cardiac catheterization guides treatment decisions by measuring pressures, outputs, and obtaining images. It is now often used therapeutically for procedures like angioplasty and device closures. The document outlines patient preparation, access methods, catheters used, views obtained, and complications that can occur.
Mitral regurgitation occurs when blood flows backward from the left ventricle to the left atrium due to problems with the mitral valve. It can be caused by conditions like endocarditis or myocardial infarction. Hemodynamically, it decreases cardiac output and overloads the left atrium and lungs. Clinically, patients experience dyspnea, fatigue, edema and signs of pulmonary congestion. The severity is classified by the regurgitant volume and fraction. Treatment involves diuretics, vasodilators, and sometimes surgery. The anesthetic goals are to maintain forward flow by keeping heart rate and contractility normal while decreasing afterload and preload to limit regurgitant fraction. Induction and maintenance of
This document discusses coronary artery bypass graft (CABG) surgery. It aims to completely revascularize the heart muscle to relieve symptoms, improve quality of life, and increase life expectancy. CABG surgery is indicated for significant stenosis of the left main coronary artery or other multi-vessel disease. The standard approach is on-pump CABG using cardiopulmonary bypass, though off-pump CABG is also performed. The left internal thoracic artery is the preferred graft for the left anterior descending artery due to its excellent long-term patency rates. Reversed saphenous veins are commonly used for other grafts but have lower patency rates over time. Patient and vessel characteristics help determine surgical candidacy and technique.
Types of heart surgeries include open heart surgery, where the heart is stopped and surgery is performed on internal structures. Modern beating-heart surgery is done without bypass and stabilizes the heart during surgery. Minimally invasive surgery uses small incisions and a robot to perform surgery. Other types are pediatric cardiovascular surgery, heart transplantation, coronary artery bypass grafting to create new blood flow paths, heart valve repair or replacement, and stent placement via angioplasty to open blocked arteries.
This document provides information on various bedside invasive procedures performed in critical care units, including arterial line placement, central venous catheter insertion, Swan-Ganz catheterization, pericardiocentesis, intra-aortic balloon counterpulsation, and temporary pacemaker insertion. Details are given on the indications, techniques, complications, and interpretations of findings for each procedure. Arterial and central lines are discussed in terms of cannulation sites, waveforms, and potential issues. Swan-Ganz catheters are described for measuring pressures in the right atrium, ventricle, and pulmonary artery to evaluate hemodynamics.
There are many interventional cardiac procedure those need a trans septal puncture of the interatrial septum. This presentation clearly elaborates everything you need to know about the TSP.
This document summarizes heart embryology and radiological anatomy. It describes how the heart develops from mesenchymal cell clusters that form the primitive heart tube. This tube undergoes looping and partitioning to form the four chambers. Endocardial cushions develop and divide the atrioventricular canal and outflow tract. The document then describes heart anatomy and landmarks seen on imaging modalities like ultrasound, CT and MRI. It details the structures of the atria, ventricles, valves and coronary arteries. Standard views used in echocardiography are also mentioned.
The cardiac conduction system receives its blood supply from branches of the left anterior descending coronary artery and right coronary artery. A critical portion of the interventricular conduction system is supplied by the first septal branch of the left anterior descending artery. The bundle of His receives blood supply from both the left anterior descending artery and right coronary artery, with approximately 50% of the blood coming from the septal branch of the left anterior descending artery and atrioventricular nodal branch of the right coronary artery.
Surgical management of d-tga Dr. ankit jain AIIMSAnkit Jain
This document provides information on the surgical management of transposition of the great arteries (TGA). It discusses the history, embryology, associated lesions, and surgical techniques for TGA. Some key points include:
- TGA accounts for 5-7% of congenital heart defects and was first described in 1797.
- The most accepted embryological theory is abnormal development of the bilateral subarterial conus.
- Associated lesions include VSD, LVOT obstruction, and aortic arch anomalies.
- Surgical techniques have evolved from atrial septectomy in the 1950s to the arterial switch operation (ASO) developed in 1975, which has high survival rates of over 98% today.
This document provides information about coronary flow imaging techniques. It discusses visualization of the coronary arteries, heart segmentation, and scan views used. Details are given on quantifying coronary flow reserve using Doppler, including measuring flow velocities in the left anterior descending coronary artery at rest, during stress, and recovery. Examples of normal and pathological coronary flow patterns are shown. The roles of various ultrasound settings and protocols for coronary flow reserve assessment are outlined.
Anesthesia for off Pump Coronary artery bypass graftingDr. Harshil Joshi
This document provides an overview of off-pump coronary artery bypass grafting (OPCAB). It discusses the epidemiology and anatomy of coronary artery disease. It then covers the pathophysiology of atherosclerosis, determinants of coronary blood flow, and tools for assessing patient risk. Details are provided on preoperative evaluation and intraoperative considerations like anesthesia techniques, monitoring, myocardial protection strategies, and treatments for ischemia. Challenges of OPCAB and indications for conversion to cardiopulmonary bypass are also summarized.
The document provides information on aortic valve disease including anatomy, etiology, and pathophysiology. It describes the key components of the aortic root including the aortic annulus, cusps, sinuses, and sinotubular junction. The three main causes of aortic stenosis are discussed as congenital bicuspid valve with calcification, calcification of a normal trileaflet valve, and rheumatic disease. The pathophysiology of aortic stenosis involves left ventricular pressure overload leading to hypertrophy and eventually decreased ejection fraction if severe stenosis is not corrected.
The treatment of patients with advanced acute heart failure is still challenging.
Intra-aortic balloon pump (IABP) has widely been used in the management of
patients with cardiogenic shock. However, according to international guidelines, its
routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated
that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian
Association of Hospital Cardiologists, reviews the available data derived from clinical
studies. It also provides practical recommendations for the optimal use of IABP in
the treatment of cardiogenic shock and advanced acute heart failure.
The document summarizes Fontan circulation, which is a surgical procedure that redirects blood flow from the inferior vena cava and superior vena cava directly to the pulmonary arteries, bypassing the right ventricle. It allows for systemic and pulmonary blood to circulate in parallel, driven by a single ventricle. The document discusses the history and evolution of the Fontan procedure, patient selection criteria, surgical techniques, postoperative physiology, and challenges.
The document summarizes the anatomy and physiology of the coronary circulation. It describes:
1) The coronary arteries originate from the aorta and branch to form the right and left coronary arteries which further divide to supply the myocardium.
2) The left main coronary artery divides into the left anterior descending artery and left circumflex artery. The right coronary artery supplies the right side of the heart.
3) Coronary blood flow is highest in diastole when the heart muscle is relaxed to perfuse the subendocardial layers of the left ventricle. Various neural and chemical factors regulate blood flow to meet myocardial demand.
1) Pulmonary regurgitation is a common consequence of tetralogy of Fallot repair and can lead to right ventricular dilation and dysfunction over time.
2) Echocardiography and cardiac MRI are useful for evaluating the severity of pulmonary regurgitation and assessing the degree of right ventricular dilation and dysfunction.
3) Indications for pulmonary valve replacement include moderate or severe pulmonary regurgitation with signs of right heart failure or dilation out of proportion to age. It aims to prevent irreversible right ventricular damage.
Anatomy and imaging of coronary artery disease withSarbesh Tiwari
1) Coronary CT angiography (CCTA) uses computed tomography to non-invasively image the coronary arteries. It provides high quality images of the coronary arteries and their branches.
2) CCTA is performed using either electron-beam CT or multi-detector row CT (MDCT). MDCT is now more commonly used due to its wider availability and lower cost. The latest generation 64-detector MDCT allows for very high resolution imaging.
3) CCTA requires careful preparation of the patient including medication to control heart rate and dilation of the coronary arteries. The scan itself involves ECG gating to image the heart during diastasis and injection of iodinated contrast to outline the coronary
Major aortopulmonary collateral arteries (MAPCAs) are abnormal blood vessels that provide blood flow to the lungs in some patients with congenital heart defects. MAPCAs originate from the aorta or its branches and connect abnormally to the pulmonary arteries. They develop when normal pulmonary blood flow is obstructed in utero. MAPCAs vary in number, origin and path to the lungs. They may cause uneven blood flow within the lungs and become narrowed over time. The clinical presentation of patients with MAPCAs depends on the pattern of blood flow they provide.
1. The document discusses the management of single ventricle physiology, which involves connecting the systemic and pulmonary circulations in parallel rather than series due to the inability to establish two independent functioning ventricles.
2. The management involves initial palliation through procedures such as the bidirectional Glenn shunt or pulmonary artery banding, followed by definitive palliation with a Fontan operation around 3 years of age to connect the systemic venous return directly to the pulmonary arteries without an interposing ventricle.
3. The Fontan operation has evolved over time from atrio-pulmonary connections to total cavopulmonary connections using intra-atrial tunnels or extracardiac conduits to more efficiently direct superior vena c
This document provides an overview of cardiac catheterization procedures. It discusses indications, contraindications, techniques, views obtained, and interpretation of pressure waveforms. Key points include that cardiac catheterization guides treatment decisions by measuring pressures, outputs, and obtaining images. It is now often used therapeutically for procedures like angioplasty and device closures. The document outlines patient preparation, access methods, catheters used, views obtained, and complications that can occur.
Mitral regurgitation occurs when blood flows backward from the left ventricle to the left atrium due to problems with the mitral valve. It can be caused by conditions like endocarditis or myocardial infarction. Hemodynamically, it decreases cardiac output and overloads the left atrium and lungs. Clinically, patients experience dyspnea, fatigue, edema and signs of pulmonary congestion. The severity is classified by the regurgitant volume and fraction. Treatment involves diuretics, vasodilators, and sometimes surgery. The anesthetic goals are to maintain forward flow by keeping heart rate and contractility normal while decreasing afterload and preload to limit regurgitant fraction. Induction and maintenance of
This document discusses coronary artery bypass graft (CABG) surgery. It aims to completely revascularize the heart muscle to relieve symptoms, improve quality of life, and increase life expectancy. CABG surgery is indicated for significant stenosis of the left main coronary artery or other multi-vessel disease. The standard approach is on-pump CABG using cardiopulmonary bypass, though off-pump CABG is also performed. The left internal thoracic artery is the preferred graft for the left anterior descending artery due to its excellent long-term patency rates. Reversed saphenous veins are commonly used for other grafts but have lower patency rates over time. Patient and vessel characteristics help determine surgical candidacy and technique.
Types of heart surgeries include open heart surgery, where the heart is stopped and surgery is performed on internal structures. Modern beating-heart surgery is done without bypass and stabilizes the heart during surgery. Minimally invasive surgery uses small incisions and a robot to perform surgery. Other types are pediatric cardiovascular surgery, heart transplantation, coronary artery bypass grafting to create new blood flow paths, heart valve repair or replacement, and stent placement via angioplasty to open blocked arteries.
This document provides information on various bedside invasive procedures performed in critical care units, including arterial line placement, central venous catheter insertion, Swan-Ganz catheterization, pericardiocentesis, intra-aortic balloon counterpulsation, and temporary pacemaker insertion. Details are given on the indications, techniques, complications, and interpretations of findings for each procedure. Arterial and central lines are discussed in terms of cannulation sites, waveforms, and potential issues. Swan-Ganz catheters are described for measuring pressures in the right atrium, ventricle, and pulmonary artery to evaluate hemodynamics.
There are many interventional cardiac procedure those need a trans septal puncture of the interatrial septum. This presentation clearly elaborates everything you need to know about the TSP.
This document summarizes heart embryology and radiological anatomy. It describes how the heart develops from mesenchymal cell clusters that form the primitive heart tube. This tube undergoes looping and partitioning to form the four chambers. Endocardial cushions develop and divide the atrioventricular canal and outflow tract. The document then describes heart anatomy and landmarks seen on imaging modalities like ultrasound, CT and MRI. It details the structures of the atria, ventricles, valves and coronary arteries. Standard views used in echocardiography are also mentioned.
Aortic arch and venous system developmentTapish Sahu
The document summarizes the development of the aortic arch, thoracic and abdominal aorta, and venous system during embryogenesis. It describes how the paired dorsal aortas fuse to form the descending aorta and how the aortic arches give rise to major arteries like the carotid and subclavian arteries. Common aortic arch anomalies are discussed along with the regression of embryonic veins and formation of major veins like the inferior vena cava from segments including the vitelline, umbilical, and cardinal veins. Rare anomalies of the venous system and arterial variations are also mentioned.
Cardiovascular physiology for university studentsItsOnyii
A detailed pdf document on cardiovascular physiology for university students including structure and functions of heart, Electrocardiogram, echocardiography, chest and limb leads, Diseases and disorders of the heart.
1) Mammals require transport systems like the circulatory system to efficiently deliver oxygen and nutrients to cells throughout the body since diffusion is only effective over short distances. The circulatory system can be open, closed, or a double circulatory system.
2) In a closed circulatory system, blood remains within blood vessels and nutrients/gases are exchanged through vessel walls. A double circulatory system has two circuits - pulmonary and systemic - allowing blood to pass through the heart twice.
3) Diseases can occur if cholesterol builds up in artery walls, restricting blood flow and oxygen delivery. This can cause heart attacks, strokes, aneurysms, and high blood pressure. Proper diet, exercise, and managing
CARDIO VASCULAR SYSTEM.pdf for bsc nursing studentsshanmukhadevi
The cardiovascular system refers to the heart, blood vessels and the blood.
Blood contains oxygen and other nutrients, which your body needs to survive. The body takes these essential nutrients from the blood.
At the same time, the body dumps waste products like carbon dioxide, back into the blood, so they can be removed.
The main function of the cardiovascular system is therefore to maintain blood flow to all parts of the body, to allow it to survive.
Veins deliver used blood from the body back to the heart. Blood in the veins is low in oxygen (as it has been taken out by the body) and high in carbon dioxide (as the body has unloaded it back into the blood).
All the veins drain into the superior and inferior vena cava, which then drain into the right atrium.
The right atrium pumps blood into the right ventricle. Then the right ventricle pumps blood to the pulmonary trunk, through the pulmonary arteries and into the lungs.
In the lungs the blood picks up oxygen that we breathe in and gets rid of carbon dioxide, which we breathe out. The blood is becomes rich in oxygen, which the body can use.
From the lungs, blood drains into the left atrium and is then pumped into the left ventricle. The left ventricle then pumps this oxygen-rich blood out into the aorta, which then distributes it to the rest of the body through other arteries.
This blood will again return back to the heart through the veins and the cycle continues.
The cardiovascular system can be thought of as the transport system of the body.
This system has three main components: the heart, the blood vessel and the blood itself.
The heart is the system's pump and the blood vessels are like the delivery routes.
Blood can be thought of as a fluid, which contains the oxygen and nutrients the body needs and carries the wastes, which need to be removed.
The heart develops from cardiogenic mesoderm and forms endothelial heart tubes that fuse to create a single heart tube located within the pericardial cavity. The heart tube undergoes looping to form the basic chambers and portions. Septae then develop to divide the heart into four chambers - the interatrial septum divides the atria while the interventricular and aorticopulmonary septa divide the ventricles. Various congenital malformations can occur if septation is incomplete or unequal. The great arteries also septate during development.
This document provides an overview of the embryological development and anatomy of arteries and veins in the head and neck region. It discusses the formation of blood and aortic arches in early embryonic development. It then describes the course, branches, and clinical relevance of major arteries like the common carotid artery, external carotid artery, internal carotid artery, and branches including the lingual, facial, and superior thyroid arteries. It also briefly outlines the structure and differences between arteries, veins, and capillaries.
✓Heart
✓Anatomy of heart
✓Blood circulation
✓Blood Vessels
✓Structure and function of artery, vein and capillaries
✓Elements of conduction system of heart and heart beat
✓Its regulation by nervous system
✓Cardiac output
✓Cardiac cycle
✓Regulation of bood pressure
✓Pulse
✓Electrocardiogram
✓Disorder of heart
The document discusses renal vascular anatomy and its implications for surgery. It notes that the renal arteries typically enter the kidney through the hilum and branch into segmental arteries that do not anastomose. It also describes variations such as accessory renal arteries. The segmental arteries further branch within the kidney and an avascular plane exists between anterior and posterior branches. Venous drainage parallels the arterial supply. Imaging like CTA can accurately map the vasculature preoperatively to aid surgery. Understanding variations and collateral circulation is important for procedures like donor nephrectomy.
The cardiovascular system develops from progenitor heart cells that migrate to form the primary heart field (PHF). The PHF forms the atria, left ventricle and most of the right ventricle. The secondary heart field (SHF) forms the remainder of the right ventricle and outflow tract. These cells cluster to form the cardiogenic region and blood islands, which unite to form the heart tube. As the heart tube elongates due to SHF cell addition, it bends to form the cardiac loop. Septa then form to divide the heart into chambers, while cushions form valves and vessels. At birth, circulatory changes occur as the ductus arteriosus and foramen ovale close due
The cardiovascular system develops through several key steps:
1. The heart tube forms from cardiac progenitor cells and fuses to form a single tube.
2. The heart tube undergoes looping to form the chambers and major vessels.
3. Septa form to divide the heart into left and right sides and separate the atria from the ventricles.
4. Valves form in the atrioventricular canal and outflow tract to regulate blood flow through the heart.
The document summarizes the major arteries of the head and neck, including their origins, courses, and branches. It begins with an overview of the aorta and its branches that supply the head and neck (brachiocephalic artery, common carotid artery, subclavian artery). It then describes the external and internal carotid arteries in detail, outlining their branches which include the facial, lingual, occipital, and maxillary arteries. Throughout, clinical correlations and examples of surgical/traumatic implications are provided.
The heart has four chambers. The two superior receiving chambers are the atria (= entry halls or chambers), and the two inferior pumping chambers are the ventricles (= little bellies).
On the anterior surface of each atrium is a wrinkled pouchlike structure called an auricle
The document discusses the embryology of the heart and lungs. It describes how the heart develops from a primitive heart tube into its four-chambered structure through processes of looping, wedging, and septation of the atria and ventricles. The lungs develop as the lung buds derive blood from the splanchnic plexus and pulmonary veins grow towards them. Abnormalities during these developmental stages can result in various congenital heart defects.
The document discusses cerebral venous thrombosis (CVT), including its etiology, pathogenesis, clinical features, investigations, and treatment. Some key points:
- CVT most commonly affects young and middle-aged adults, especially women who are pregnant or postpartum. Common causes include hypercoagulable states, infections, and anatomical factors.
- Thrombosis impairs venous drainage and can cause hemorrhagic infarction, increased intracranial pressure, and seizures. Common symptoms are headache, seizures, hemiparesis, and altered mental status.
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2. • Congenital Coronary Anomalies are seen in 1 to 5% of population.
• 20% of these have the potential to cause coronary ischemia and its
sequalae.
• Any congenital abnormalities in the coronary system can have major
deleterious effects on heart function.
• It is also possible that even subtle variation in the patterning of
coronary vessels has significant but uncharacterized effects on
myocardial structure and function.
3. • Let us define normal features of coronary anatomy to differentiate
from anomalies.
5. • The mammalian heart is one of the most vascularized organs of the
body.
• Still, not a single cell that makes up the coronary system of the heart
arises from the heart. All the cells that make up the coronary system
come from outside the heart, are brought to the heart and
differentiate into blood vessels only when they are in the heart.
• And all of this happens without ever tapping into the blood that
courses through the heart lumen.
6. Not Everybody Has a Coronary System!
• It should be noted that not all organisms with heart have coronary systems. Some
of the species get blood supply to their heart directly from the circulating luminal
blood in the heart.
• Among the vertebrates, mammals, reptiles and avians have coronary system,
complete with arterial output and venous return. What these species have in
common is that they depend on pulmonic respiration and lack cutaneous
respiration. The hearts of these organisms have complete anatomical and / or
physiological separation of oxygenated and deoxygenated blood.
• So in these species, getting fresh oxygenated blood to the right side of the
myocardium from the circulating luminal blood is not an option. Also these
species have developed very thick walled ventricles.
• Thus an alternative method of delivery – The Coronary System was necessary.
7. Structure of the Coronary Vascular System
• The blood supply to the heart of higher vertebrates actually originates
outside the heart from the ascending aorta.
• These arteries travel well-defined routes along the surface of the heart in
the epicardium and give rise to branches that penetrate the substance of
the myocardium.
• Small muscular arteries are found throughout the myocardium that further
branch into an extensive capillary bed that embraces nearly all of the
cardiac myocytes. The venous return to the coronary sinus courses over the
surface of the heart with accompanying arteries.
• Although the major arteries and veins travel together over the surface of
the heart, the origin of the coronary arteries and termination of the
coronary sinus are different & Epicardial lymphatics do not appear to travel
with arteries and veins.
8. Circle and Loop Model
• Major epicardial arteries
traverse the AV groove and
interventricular groove to form a
circle and loop model.
• They give branches which
descend down from this circle.
• Till this branching stage, some
amount of consistency is seen in
the anatomy.
9. • These epicardial branches then give small penetrating intramural
arteries. This branching system is highly variable except for 2
important things,
1. There is a fairly consistent spacing between these penetrating
muscular arteries.
2. The branching of these arteries leaves no myocytes untouched.
• This variation in the origin, number, and patterning of the coronary
system is far greater than variation seen in valves, myocardium,
and/or great vessels.
10. Origin of cells that make the Coronaries
• Coronaries develop from mesenchymal cells coming from epicardium
which comes from ‘Septum Transversum’. Lets see how.
• The tubular heart is formed as an endothelial tube within a muscular tube.
Both these layers come from lateral plate mesoderm. (and the only cell
types in heart that come from lateral plate mesoderm)
• Till 24th day of development, heart has only endothelium and myocardium
and lacks epicardium.
• Epicardium arises from an epithelium associated with ‘Septum
Transversum’ which also gives origin to the pleura, parietal pericardium,
diaphragm and peritoneum. This epithelium is named as PEO –
Proepicardial Organ.
• PEO balloons out from the septum transversum and approaches the
surface of the heart towards sinoatrial pole.
11. • Epicardial migration (aka ‘The First Directed Migration’) proceeds over the
atria first and somewhat later over the ventricles. The advancing
epithelium (continuous simple squamous) spreads out over the heart,
eventually covering the entire myocardium and pericardial cavity.
• Failure of this First Directed Migration due to disruption of cellular
adhesion system results in embryonic death suggesting critical function of
epicardium in cardiac development.
• During the next stage of development, some cells lose contact with the
epicardial epithelium. These cells become freely migratory mesenchyme
and move into the subepicardial connective tissue space (EMT – epithelia
to mesenchymal transition).
• EMT is dependent on a Friend Of GATA 2 (FOG-2) regulated signalling
pathway from myocardium (FOG-2 is specific to myocardium).
• In FOG-2 null embryos, pericardium is present but no mesenchym is
generated and thus no coronaries are formed. These embryos die with
multiple cardiac anomalies.
12. • The spreading epicardium fills up the space in the AV groove and has
abundant mesenchymal cells.
• In this region, some of the mesenchymal cells coalesce to form
channels within the connective tissue space and become the
endothelium of the coronary vessels. Other mesenchymal cells take
up positions adjacent to this endothelium and differentiate into
arterial smooth muscle. (So, the first coronary vessel is formed in the
AV groove).
• These channels then fuse to form blood vessels. Note that there is no
blood flow and hence no blood pressure at this time in the
coronaries.
• So it is interesting that the initial size of the proximal and distal
coronary arteries is set in the absence of blood flow. (Mechanisms
governing this are still unknown).
13. • Then there is ‘The Second Directed
Migration’ of the EMT cells into the
developing myocardium. These
cells traverse the entire thickness
of the myocardium till they reach
the endothelium of the heart. (But
they don’t penetrate the
endothelium. If they do – Coronary
cameral fistula).
• Subsequently they transform into
vascular endothelium and vascular
smooth mucles cells to form plexi.
• These plexi are then remodeled
into definitive arteries, capillaries
and veins. (Dysregulation of this
remodeling can result into
Coronary AV fistula)
14. • The proximal end of the coronary arteries actually grows into the
aorta, penetrating the tunica media and finally the intima. Final
connection to the aorta involves local apoptotic events that
eventually lead to the melding of coronary endothelia with that of the
aorta. (Failure of this apoptotic event results into congenital coronary
osteal atresia.)
• Considering the very complex nature of this developmental system,
errors are bound to happen.
• Errors of misconnection – (these are always radial and not
longitudinal i.e. malpositioned coronary vessels are not observed up
the ascending aorta, but they are observed at the correct level and
are radially misplaced on the aorta or pulmonary artery.)
1. ALCAPA
2. Anomalous Connection of MCA to Aorta
3. Anomalous Coronary Artery Course between Aorta and PA
15. To summarize this complex part, just understand that,
1. Coronaries originate from epicardium.
2. Coronaries don’t shoot out from aorta as aortic branches but are
developed on and in the myocardium to be fused with the aorta
later.
3. Circuitry of the coronary vascular system is well established and
even completed before the system ‘taps into’ the systemic
circulation.
16. Classification of Coronary Artery Anomalies
• But the surgically important
ones are,
1) Coronary Aretriovenous Fistula
2) ALCAPA
3) Anomalous Connection of a
Main Coronary Artery to Aorta
4) Congenital Ostial Atresia of the
Left Main Coronary Artery
18. • Direct communication between a coronary artery and the lumen
of any one of the four cardiac chambers, the coronary sinus or
its tributary veins, or the superior vena cava, pulmonary artery,
or pulmonary veins close to the heart.
• First described by Krause in 1865.
• First reported in literature by Trevor in 1912
• First repair using CPB was by Swan and colleagues in 1959.
19. Morphology
• RCA 50 to 55%
• LCA 35%
• Both 5%
• Almost invariably part of a normally distributed coronary artery with a normal
branching pattern. Rarely, the involved artery is anomalous.
• The fistula occurs either in the main vessel that continues beyond the fistula (a
side-to-side pattern) or at the termination of the main vessel itself, or at a branch
(an end artery).
• Proximal to the fistula, the artery is always dilated, elongated and may be
serpiginous and/or aneurysmal, and these changes are roughly proportional to
the size of shunt.
• Giant aneurysms are seen exclusively with RCA entering RV or LV.
• Beyond fistula, if the artery continues, it has a very very small calibre.
20. • More than 90% of fistulae open into right heart chambers or their
connecting vessels producing L-R shunts. These have rapid systolic and
diastolic runoffs. Of these,
o40% to RV
o25% to RA
o15 – 20% to PA
o7% to CS
o1% to SVC
• About 8% of fistulae drain into left heart chambers or their tributaries,
usually the left atrium, less often the left ventricle (about 3%), and rarely
the proximal pulmonary veins.
• Left heart fistulae are not, of course, AV fistulae but arterioarterial and
therefore do not produce a left-to-right shunt.
• Shunt occurs only during diastole when they enter the left ventricle,
because fistulae usually close off during systole, and also because there is
no pressure gradient.
21. • The fistulous opening when single, is about 2 to 5mm, and usually has
fibrous margin. Most fistulae to the LV are single.
• Occasionally there may be several openings (16%) or a localized
angiomatous network of vessels (10%).
• The cardiac chambers associated with the fistula show dilatation
except LV.
• Fistulous connection to CS causes its aneurysm and it’s the only site
reported of having aneurysmal rupture in case of a coronary fistula.
• Fistulous opening is a site of turbulence and 5% cases present with
infective endocarditis.
• Coincidental congenital (ASD, VSD) and acquired (valvular, coronary)
lesions are seen with 25 to 30% cases.
22. Clinical Features
• Most are asymptomatic and present either because of a continuous
murmur, or mild cardiomegaly and plethora on chest radiograph or
because of coronary angiography done for other reasons.
• Dyspnea and Fatigue (from L-R shunt)
• Angina (7%) and MI (3%) – more common in older patients.
• Heart Failure (12 to 15%)
o Associated with large shunts in pediatric patients
o In older patients it is due to long standing shunt.
o More common in CS connection
• AF – seen in fistulous connection with RA
• Chills and fever – in IE
23. Diagnosis
• Examination
Continuous murmur (except in LV connection)
Systolic thrill
Wide pulse pressure
• ECG – normal, may show signs of chamber overload.
• CXR – mild cardiomegaly with plethora or can be normal
• 2D ECHO & Doppler – shows enlarged coronary and dilated chambers.
• Cardiac Catheterisation – Gold Standard.
24.
25. Natural History
• Small fistulae remain small, moderate ones slowly increase in size.
• Spontaneous closure is very rare.
• Large fistulae cause early symptoms and early heart failure (but rarely
before 20 years of age)
• Heart Failure is most common in 5th and 6th decade.
• 5% develop IE
• Aneurysm formation is seen in 9% of paediatric and 14 to 29% of
adult population.
26. Technique of Operation
• Standard median sternotomy with preparation made for use of CPB.
CPB is indicated when
1. Artery is dilated and tortuous
2. Inaccessible site off pump e.g. AV groove
3. Fistula is in course of artery rather than at termination, so as to
avoid ligation of the distal coronary.
4. Aneurysm requiring excision
• Fistula location to be marked with a stitch before going on CPB
(standard bicaval and aortic cannulation with left side vent in LA)
• Cardioplegia given while clamping the fistula site with a finger.
27. 1. RA, LA, PA – open the chamber and close the fistula from within
with over and over suture with pledgeted mattress suture.
2. Ventricle or Large fistula and artery continuing beyond the fistula-
open the coronary artery and close the fistula with a running
suture, f/b closure of the arteriotomy with 6-0 or 7-0 prolene. If
closing from within the chamber, fistula can be identified using
cardioplegia (useful in trabeculated part).
3. Aneurysm – To be excised always. If very large, unroofing to be
done with ligation of coronary proximal and distal to the sac f/b
CABG.
4. CABG – When there is no other option but to ligate the feeding
coronary (provided the artery distal to fistula is adequate sized).
28. • Post op mortality in absence of giant aneurysm and need for CABG is
almost zero. (4% in case of the later).
• No recurrent fistulae, no symptom recurrence and no late mortality is
observed.
• Even if asymptomatic, i/v/o the probability that at least some of the
fistulae will increase in size and therefore eventually produce
symptoms and heart failure, the tendency for development of IE, the
low probability of spontaneous closure, and the safety and efficacy of
operation, it is recommended that diagnosis of a coronary AV fistula
is an indication for operation unless the shunt is small (Qp/Qs < 1.3).
30. • The whole of the LMCA or only the LAD or LCX branch connects
anomalously to the proximal MPA or very rarely to the proximal right
PA.
• Branching pattern of the anomalously connecting left coronary artery
remains normal. The RCA arises normally from the aorta and has a
normal branching pattern.
• Collaterals from RCA feed the left coronary artery, in which flow is
reversed, so that the left coronary artery drains into the PA.
31. • 1886 – Brooks described the condition and explained the pathophysiology (retrograde
flow theory) for the first time.
• 1933 – Bland, White and Garland described the syndrome a/w the anomaly.
• 1953 – Mustard used turned down left Common Carotid Artery for anastomosing on left
coronary
• 1957 – Apley used left Subclavian in the same manner.
• 1959 – Sabiston & collegues performed first surgical correction and verified the
retrograde flow theory of Brooks.
• 1966 – Cooley used RSVG from aorta to LAD and tied the proximal end of the anomalous
connection near PA.
• 1972 – Tingelstad performed first translocation procedure (but it was for anomalous
connection of RCA)
• 1974 – Neches did similar procedure for anomalous connection of LMCA. Also suggested
interposition of left Subclavian free graft to increase the length if inadequate.
• 1979 – First Tunnel Operation
Using Pericardium by Hamilton
Using PA wall by Takeuchi
• Initially all these procedures carried very high postop mortality (as high as 75%) but it
came down drastically with advent of temporary ventricular assistance in the 90s.
32. Morphology
• The anomalous LMCA connects most often to the sinus of Valsalva
immediately above the left or posterior cusp of the pulmonary trunk and
rarely from that above the right cusp.
• Collateral communications between right and left coronary arteries are
always present.
• LV is always hypertrophied and greatly dilated, with dilatation often
involving primarily the LV apex. Diffuse LV fibrosis is virtually always
present with or without evidence of recent and old anterolateral MI.
• Fibrosis is most marked in the subendocardial layer. Focal calcification may
be present in fibrotic areas. Secondary subendocardial fibroelastosis of
variable degree is usually present.
• Chronic ischemic process causes devitalization of myocardium at cellular
and biochemical level (Hibernating Myocardium).
33. • Mitral Valve Regurgitation may be seen resulting from any of the
following-
o extensive fibrosis and calcification of papillary muscles
o endocardial fibroelastosis involving mitral apparatus
o abnormally placed papillary muscle
o LV dilatation resulting in annular dilatation
34. Clinical Features and Diagnosis
• Symptoms appear usually after 2 months when postnatal high PAP regresses
allowing runoff into PA through the anomalous connection and hence coronary
steal.
• Infants present with poor feeding, poor weight gain
• Angina in infants presenting as – feeding interruption with breathlessness,
sweating, baby drawing up knees and arching the back with cry and/or scream.
• Cases with anomalous connection of only LAD or only LCX present during
adulthood.
• Adults present with similar c/o dyspnoea, angina and sometimes palpitations.
• Examination-
o non specific systolic murmur or more specific diastolic murmur of MR
o Precordial lift
o crepitations throughout the lung fields
o hepatomegaly
35. • ECG – ischemic changes in lateral leads with signs of old ALWMI (Q
waves)
• CXR – Cardiomegaly, interstitial pulmonary oedema
• Cardiac Enzymes - elevated
• ECHO and Doppler – low LVEF (<20%), large RCA, anomalous LMCA
connection to PA showing retrograde flow.
• Cardiac Cath – gold standard, shows single RCA with opacification of
pulmonary trunk due to retrograde flow.
36.
37.
38. Natural History
• 65% die during first year of life (but rarely before 2 months)
• If death does not occur during the first year, the hazard lessens
considerably and the chronic phase of natural history is reached. Survival
to this stage may be related to presence of rich inter arterial collaterals.
• Survival beyond the first year may also be related to marked right
dominance, with RCA supplying not only the diaphragmatic portion of the
LV but also much of the septum and lateral wall.
• Still these patients continue to be at risk of death from chronic heart failure
secondary to ischemic LV cardiomyopathy.
• After 4th decade, sudden cardiac death as seen with IHD is more than due
to chronic heart failure.
39. Indications for surgery and choice of
operation
• Diagnosis is an indication for urgent surgery at any age regardless of the
clinical status.
• Creating a two-artery coronary system is indicated in all situations
including critically ill infants. (Preferably at a higher centre with availability
of ventricular assist device)
Procedure of choice is Translocation
If not possible then,
Takeuchi Procedure is the second choice in children
LIMA to LAD is the second choice in adults.
• MV repair or replacement in adults if needed (in younger patients only if
very severe MR)
40. Two Artery Coronary System
• Anomalous coronary connection
is corrected so that both RCA
and LMCA are connected to
aorta with separate openings.
• Both arteries carry blood supply
independently.
Single Artery Coronary System
• Anomalous coronary connection
is tied off from PA so that only
RCA is connected to aorta and
through collaterals its supplies
left coronary system.
• Tying off of LMCA from PA
prevents retrograde runoff and
hence coronary steal.
41. Technique of Operation
• After sternotomy, the pericardium is opened without touching the heart, because
even the slightest trauma can induce ventricular fibrillation.
• Preferably, arterial cannulation of both the aorta and PA is used with a bifurcated
system to maximize myocardial perfusion with single venous cannulation.
• Snuggers are placed around the left and right pulmonary arteries and are
tightened as CPB is initiated to prevent perfusion steal into the pulmonary bed
from the pulmonary trunk arterial cannula. A left-sided vent is placed in the RSPV.
• Cardioplegia is delivered simultaneously into the aortic root and pulmonary trunk
using a bifurcated cardioplegia delivery system. If delivering cardioplegia only into
the aortic root, we have to occlude the branch PAs.
• Myocardial protection during aortic clamping is particularly important for two
reasons: 1) the existing compromised state of the myocardium 2) potential for
inadequate delivery of cardioplegia to LV because of the anomalous coronary
system.
• When the opening of the anomalously connecting LMCA is posterior or right-
sided, the coronary artery translocation technique is used while if it is on the left-
sided aspect of the pulmonary trunk, the tunnel operation should be considered.
42. 1) LMCA Translocation
• A sizable button of pulmonary
artery wall around the coronary
ostium is excised.
• The left coronary artery is carefully
mobilized for a short distance.
• The button around the coronary
ostium is anastomosed to the aorta
with 7-0 monofilament absorbable
sutures.
• Pulmonary trunk is reconstructed
by end-to-end anastomosis, and
the coronary artery explant site is
patched with pericardium or PTFE.
45. 2) Tunnel Operation (Takeuchi Repair)
• A hole (4-5mm) is made in aortic wall at a point at which the left wall of the aorta
is in contact with the right side of the pulmonary trunk.
• Directly opposite to this a similar hole is made on the left side of the pulmonary
trunk.
• These openings are sewn together with continuous 7-0 polypropylene to create
an aortopulmonary window.
• Using a flap of anterior pulmonary trunk wall hinged on the right, the anterior
wall of the tunnel is created, completing the tunnel directing blood from the
aortopulmonary window across the back of the pulmonary trunk to the
anomalously connecting left coronary artery.
• Defect in the anterior wall of the pulmonary trunk is reconstructed with a patch
of pericardium or PTFE.
• If RVOT narrowing happens due to the tunnel, then it is augmented with TAP
using pericardium.
46.
47. Modified Takeuchi
• Here, tunnel is created using a PTFE patch or pericardial patch instead
of using a flap from pulmonary trunk wall.
49. 3) Subclavian to Left Coronary Anastomosis
• Indicated when the anomalous coronary
ostium within the pulmonary trunk is
remote from adjacent aorta, making
direct coronary translocation impossible
and Takeuchi repair difficult.
• Aortic clamping and cardioplegia isn’t
needed.
• The left subclavian artery is dissected as
far distally as possible and then ligated
and divided.
• Coronary is mobilized on a generous
button of pulmonary sinus tissue.
• End to end anastomosis is done using 7-0
monofilament absorbable suture.
51. 5) Ligation of Left Coronary Artery
• In the current era, this procedure may be applicable as an interim
measure to stabilize critically ill patients before more formal
revascularization.
• Carried out in the simplest manner through a limited left
anterolateral fourth ICS thoracotomy.
• Anomalous connection is ligated close to the pulmonary trunk wall
with a single transfixing suture or metal clips.
52. • These patients have poor LV prior to the surgery so coming off needs
lot of patience and GTN along with LA pressure monitoring.
• Low cardiac output can be anticipated during the first few
postoperative days and might require temporary left ventricular
assistance.
• Two coronary artery systems survive better as compared to Coronary
Ligation Method.
• Early post op mortality is nearly 14%, most of the deaths occur from
acute cardiac failure.
• Significant MR is associated with early mortality.
• Long term survival is excellent after any of the described procedure.
• Antiplatelet therapy is required post operatively.
• Functional status remains good postop (NYHA I & II)
54. 1) Either the left main coronary artery connects to the aorta in a site other
than the left coronary sinus or sinotubular junction
2) Or the right coronary artery connects to a site other than the right
coronary sinus or sinotubular junction.
• Have interatrial (between aorta and PA) course or uncommonly
retroaortic/prepulmonic or trans-septal course.
• Commonly has intramural course within the aortic wall
• Occasionally has osteal stenosis
• Rarely the anomalous artery does not arise from the opposite coronary
sinus, but rather from the posterior (noncoronary) sinus.
• It was first described in 1974 by Cheitlin
• Anomalous connection of RCA is more common than LMCA.
55. Clinical Features and Diagnosis
• True prevalence is unknown
• 99% are asymptomatic
• Symptomatic patients present in 2nd or 3rd decade with angina or syncope
or sudden cardiac arrest.
• ECHO is used to define the ostial position and interarterial course of the
vessel and can reveal whether there are one or two ostia and whether
there is an intramural course. But ECHO has limitations if the two ostia are
closely placed.
• MRA, CT and Angiography can be used for determining morphology
further. CT has limitation in younger patients due to faster heart rate.
• Most clinical events, including sudden death, occur in the second and third
decades of life, and more commonly in males
56.
57.
58. Indications & Technique of Operation
• Ischemia, whether reversible or not, is an indication for operation.
• Syncopal event, angina, or an episode of sudden death with
resuscitation is an indication for operation.
• Presence of the anomalous connection without ischemia, symptoms,
or concerning morphologic characteristics is probably not an
indication for operation in the first decade of life.
• The goal of surgery is to eliminate the risk of the interarterial
component of the vessel.
64. • Very rare, with fewer than 50 reported cases in the literature.
• In this coronary anomaly, there is no LMCA ostium; rather, the
correctly positioned LAD and circumflex coronary arteries have a blind
ending and they receive blood flow retrogradely through the RCA via
at least one collateral vessel.
• Usually occurs in the absence of other structural heart disease.
• The main pathophysiology from congenital left main ostial atresia is
inadequate collateral vessel flow from the RCA causing myocardial
ischemia and has a high potential for sudden cardiac death.
65. Clinical Features and Diagnosis
• Age at presentation is variable.
• Despite age at presentation, almost every patient reported in the
literature was symptomatic at diagnosis.
• Infants generally present with heart failure symptoms, including
feeding difficulty, failure to thrive (D/D includes ALCAPA and
Cardiomyopathy)
• Older patients may be diagnosed after experiencing syncope,
dyspnea, angina, and ventricular tachyarrhythmias.
• For any age, sudden death may be the first presentation.
66. • CXR – in infants may show signs of heart failure (pulmonary
congestion), adults usually have normal cxr findings.
• ECG – may be normal or may show ischemic changes in lateral leads,
signs of old ALWMI.
• ECHO & Doppler – Dilated LV with low EF and MR (D/D ALCAPA),
doppler shows retrograde floe from right coronary system to left.
• Cardiac Catheterisation – Gold Standard, direction of flow from the
RCA to the left coronary system and whether the PA is filled
retrogradly should be identified.
67. Technique of Operation
• Goal is to create Two Coronary Artery System.
• An incision is made vertically in the aorta to the desired location of
the ostium and then extended down towards LMCA. The incision
should end prior to the LAD and circumflex coronary artery
bifurcation. PA to be transected if required for adequate exposure.
• An atretic membrane, if present, should be removed.
• An autologous pericardial patch is then used to reconstruct the LMCA
ostium.
• Alternatively, Saphenous vein or a PTFE patch can be used.
• In elderly patients with associated atherosclerotic coronary disease, a
straightforward CABG is done. CABG is avoided in younger patients as
graft patency is limited with any conduit.
68.
69. Thank You!
Reference
Kirklin
Sabiston
Development of Coronary System – Reese, Mikawa, Bader AHA 2002
Coronary Anomalies – Paolo Angelini AHA 2007
Coronary Anomalies – Hauser HEART 2005
MMCTS – YouTube
Dr Prashant Shah - YouTube