presentation and management of cardiac surgical diseases division of cardiothoracic surgery...
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Presentation and Presentation and management of cardiac management of cardiac surgical diseasessurgical diseases
Division of Cardiothoracic SurgeryDivision of Cardiothoracic SurgeryDepartment of SurgeryDepartment of SurgeryKing Khalid University Hospital, Riyadh.King Khalid University Hospital, Riyadh.
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Objectives of the Lecture Objectives of the Lecture
Overview of diseases of heart, where surgery Overview of diseases of heart, where surgery can play a rolecan play a role
Understanding of the Basic Principles of Understanding of the Basic Principles of Cardiac SurgeryCardiac Surgery
Information regarding pre-operative, operative Information regarding pre-operative, operative and post-operative care in cardiac surgeryand post-operative care in cardiac surgery
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Cardiac Diseases Cardiac Diseases
Coronary Artery DiseaseCoronary Artery Disease Valvular Heart DiseasesValvular Heart Diseases Congenital Heart DiseasesCongenital Heart Diseases Miscellaneous :Miscellaneous :
– Aortic DiseasesAortic Diseases– Pericardial DiseasePericardial Disease– Cardiac TumourCardiac Tumour– TraumaTrauma
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Modes of Presentation Modes of Presentation of Cardiac Diseasesof Cardiac Diseases
Chest painChest pain Shortness of BreathShortness of Breath PalpitationsPalpitations Peripheral EdemaPeripheral Edema Congestive Cardiac FailureCongestive Cardiac Failure Cyanosis and Clubbing in Congenital DefectsCyanosis and Clubbing in Congenital Defects Uncommon presentationsUncommon presentations
– Pleural EffusionPleural Effusion – HaemoptysisHaemoptysis
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Common Cardiac OperationCommon Cardiac Operation
Coronary Artery Bypass Grafting (CABG)Coronary Artery Bypass Grafting (CABG) Valve Replacement / Repair Valve Replacement / Repair Repair of congenital defects like of VSD or Repair of congenital defects like of VSD or
ASDASD Heart TransplantationHeart Transplantation
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Ischemic Heart DiseaseIschemic Heart Disease
Clinical manifestations:Clinical manifestations: 1. Asymptomatic1. Asymptomatic 2. Symptomatic:2. Symptomatic:
-angina pectoris: stable- unstable-angina pectoris: stable- unstable
-myocardial infarction-myocardial infarction
-V.S.D., Ischemic mitral regurge, -V.S.D., Ischemic mitral regurge, Ventricular aneurysm, Heart failure, Ventricular aneurysm, Heart failure, Conduction defects.Conduction defects.
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Risk factors:Risk factors: Smoking, Diabetes mellitus, Hypertension, Smoking, Diabetes mellitus, Hypertension,
Hyperlipedemia, Hereditary factors.Hyperlipedemia, Hereditary factors.
Laboratory Investigations:Laboratory Investigations: -Routine investigations-Routine investigations -Cardiac enzymes-Cardiac enzymes -E.C.G.-E.C.G. -Echocardiography-Echocardiography -Coronary angiography-Coronary angiography
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Indications of surgery:Indications of surgery: 1. Failure of medical therapy or 1. Failure of medical therapy or
percutaneous intervention.percutaneous intervention. 2. Left main disease2. Left main disease 3. 3-vessel disease with left 3. 3-vessel disease with left
ventricular dysfunction ventricular dysfunction 4. Mechanical complications of 4. Mechanical complications of
myocardial infarction.myocardial infarction. 5. Associated valve disease5. Associated valve disease
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Coronary conduits:Coronary conduits: 1. Arterial: Internal thoracic artery1. Arterial: Internal thoracic artery 2. Venous : Long saphenous vein.2. Venous : Long saphenous vein.
Types of surgery:Types of surgery: 1. Conventional: using the heart lung 1. Conventional: using the heart lung
machine, and cardioplegic arrestmachine, and cardioplegic arrest 2. Off-pump (beating heart surgery)2. Off-pump (beating heart surgery)
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Coronary Artery Bypass Coronary Artery Bypass GraftingGrafting
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Valvular Heart DiseasesValvular Heart Diseases 1. Mitral stenosis:1. Mitral stenosis:- Etiology: Rheumatic, CongenitalEtiology: Rheumatic, Congenital
- Investigations: E.C.G., X-ray chest, - Investigations: E.C.G., X-ray chest, EchocardiographyEchocardiography
-Indications for surgery:-Indications for surgery: Symptoms: exertional dyspnea, pulmonary Symptoms: exertional dyspnea, pulmonary
hypertension, hemoptysishypertension, hemoptysis Severe mitral stenosis: area less than 1 cm.Severe mitral stenosis: area less than 1 cm. Left atrial thrombus.Left atrial thrombus.
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Treatment:Treatment: 1. Medical1. Medical 2. Balloon valvuloplasty2. Balloon valvuloplasty 3. Closed mitral commissurotomy3. Closed mitral commissurotomy 4. Open mitral commissurotomy4. Open mitral commissurotomy 5. Mitral valve replacement.5. Mitral valve replacement.
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
2. Mitral Regurgitation:2. Mitral Regurgitation: Etiology: Rheumatic, Degenerative, Endocarditis, Etiology: Rheumatic, Degenerative, Endocarditis,
Ischemic, TraumaticIschemic, Traumatic
Indications for surgery:Indications for surgery: Symptomatic, dilated left ventricle, diminished Symptomatic, dilated left ventricle, diminished
ejection fractionejection fraction
Treatment: Treatment: 1.Medical1.Medical 2.Mitral valve repair2.Mitral valve repair 3.Mitral valve replacement3.Mitral valve replacement
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
3. Aortic stenosis:3. Aortic stenosis: Etiology: Rheumatic, Congenital, Degenerative.Etiology: Rheumatic, Congenital, Degenerative.
Indications for surgery:Indications for surgery: Symptoms (angina, shortness of breath, syncopaal Symptoms (angina, shortness of breath, syncopaal
attacks)attacks) Severe aortic stenosisSevere aortic stenosis
Treatment:Treatment: MedicalMedical Aortic valve replacementAortic valve replacement
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
4. Aortic regurgitation:4. Aortic regurgitation: Etiology: Rheumatic, Endocarditis, Etiology: Rheumatic, Endocarditis,
Connective tissue disorders, Aortic Connective tissue disorders, Aortic dissectiondissection
Indications for surgery:Indications for surgery: Symptomatic patients, Progressive Symptomatic patients, Progressive
left ventricular dilatation.left ventricular dilatation.
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Types of Prosthetic Valves Types of Prosthetic Valves and their merits and demerits and their merits and demerits
Tissue Valves (Bio prosthesis)Tissue Valves (Bio prosthesis)– No need to use long term anticoagulation.No need to use long term anticoagulation.– Limited and unpredictable durability.Limited and unpredictable durability.
Mechanical Valves Mechanical Valves – Anticoagulation Anticoagulation – Prolonged durability Prolonged durability
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Complications of prosthetic valves:Complications of prosthetic valves: 1. Thrombosis1. Thrombosis 2. Bleeding complications2. Bleeding complications 3. Infective endocarditis3. Infective endocarditis 4. Paravalvular leak4. Paravalvular leak 5. Degeneration of biological valves5. Degeneration of biological valves
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Types of Prosthetic Valves Types of Prosthetic Valves and their merits and demerits and their merits and demerits
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Thoracic Aortic DiseaseThoracic Aortic Disease 1. Thoracic aortic aneurysm1. Thoracic aortic aneurysm Symptoms are usually due to Symptoms are usually due to
pressure on surrounding stuctures.pressure on surrounding stuctures.
2. Aortic dissection:2. Aortic dissection:Tear in the intima allowing blood to Tear in the intima allowing blood to
enter and flow in a false channel. enter and flow in a false channel. There are 2 lumens separated by the There are 2 lumens separated by the dissecting membranedissecting membrane
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Pericardial effusionPericardial effusion
Progressive accumulation of fluid inside Progressive accumulation of fluid inside the pericardial cavity, may compress the the pericardial cavity, may compress the cardiac chambers.cardiac chambers.
Etiology:Etiology: -Traumatic-Traumatic -pericarditis-pericarditis -malignancy-malignancy -uremia, post irradiation-uremia, post irradiation -postoperative.-postoperative.
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Investigations:Investigations: -Plain x-ray chest-Plain x-ray chest -Echocardiography-Echocardiography -CT scan-CT scan
Management:Management: - treat the cause- treat the cause -Aspiration -Aspiration -Pericardiostomy-Pericardiostomy
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
CardioThoracic EmergencyCardioThoracic Emergency
1. Chest pain:1. Chest pain: -Myocardial ischemia-Myocardial ischemia -Pulmonary embolism-Pulmonary embolism -Aortic dissection-Aortic dissection -Tension pneumothorax-Tension pneumothorax -Rupture esophagus-Rupture esophagus
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
2. Acute dyspnea:2. Acute dyspnea: -myocardial infarction-myocardial infarction -Pulmonary embolism-Pulmonary embolism -- spontaneous pneumothoraxspontaneous pneumothorax - bronchial asthma- bronchial asthma -F.B. aspiration-F.B. aspiration -stuck mechanical valve.-stuck mechanical valve.
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
3. Chest trauma:3. Chest trauma: -flail chest-flail chest -traumatic hemo/pneumothorax-traumatic hemo/pneumothorax -hemopericardium-hemopericardium
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Congenital Heart DiseasesCongenital Heart Diseases
1. Acyanotic:1. Acyanotic: -Patent ductus arteriosus-Patent ductus arteriosus -Coarctation of the aorta-Coarctation of the aorta -Pulmonary stenosis-Pulmonary stenosis -Atrial septal defect-Atrial septal defect -Ventricular septal defect-Ventricular septal defect
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
2. Cyanotic:2. Cyanotic: -Tetralogy of Fallot-Tetralogy of Fallot -Transposition of the great vessels-Transposition of the great vessels -Tricuspid atresia -Tricuspid atresia -Total anomalous venous drainage-Total anomalous venous drainage -Truncus arteriosus-Truncus arteriosus
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Basic Principles of Cardiac SurgeryBasic Principles of Cardiac Surgery
Adequate ExposureAdequate Exposure– Full or Partial Sternotomy / Thoracotomy / Robotic or EndoscopicFull or Partial Sternotomy / Thoracotomy / Robotic or Endoscopic
Bloodless Operative Field Bloodless Operative Field – Suction and re-transfusion / Snaring or clamping of bleeding vesselsSuction and re-transfusion / Snaring or clamping of bleeding vessels
Static Operative TargetStatic Operative Target– Cardiac Arrest / Ventricular Fibrillation / Mechanical StabilizersCardiac Arrest / Ventricular Fibrillation / Mechanical Stabilizers
Preservation of body perfusionPreservation of body perfusion– Use of Heart Lung Machine / Off-pump TechniquesUse of Heart Lung Machine / Off-pump Techniques
Preservation of MyocardiumPreservation of Myocardium– Off-pump Techniques / Hypothermia / Cardiac Arrest with Off-pump Techniques / Hypothermia / Cardiac Arrest with
cardioplegiacardioplegia
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Heart Lung MachineHeart Lung Machine
Components :Components :– Roller pumpsRoller pumps– Blood Reservoir (cardiotomy reservoir)Blood Reservoir (cardiotomy reservoir)– OxygenatorOxygenator– Heater-cooler unit Heater-cooler unit – Tubing and Monitoring console etcTubing and Monitoring console etc
Limitation/Problems : Limitation/Problems : – Requires full anticoagulationRequires full anticoagulation– Can cause micro embolismCan cause micro embolism– Initiates Systemic Inflammatory Response Initiates Systemic Inflammatory Response
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Heart Lung Machine Heart Lung Machine
Preoperative assessment of Preoperative assessment of cardiac surgical patientscardiac surgical patients
Evaluation of patients referred for Evaluation of patients referred for cardiac surgery aims to answer the cardiac surgery aims to answer the following questions:following questions:
Is surgery appropriate for the Is surgery appropriate for the conditioncondition
Is the patient fit to undergo the Is the patient fit to undergo the planned operationplanned operation
Is there any comorbidities that may Is there any comorbidities that may affect the operative managementaffect the operative management
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Preoperative assessment of Preoperative assessment of cardiac surgical patientscardiac surgical patients
Approach:Approach: 1. History1. History 2. Physical examination2. Physical examination 3. Chest x-ray3. Chest x-ray 4. E.C.G.4. E.C.G. 5. Laboratory investigations5. Laboratory investigations
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Pre-Operative Investigations for Pre-Operative Investigations for Cardiac SurgeryCardiac Surgery
Full Blood CountFull Blood CountBlood BiochemistryBlood BiochemistryECGECGChest X-rayChest X-rayPulmonary Function Tests.Pulmonary Function Tests.Other test according to systemic review of patientOther test according to systemic review of patient
EchocardiographyEchocardiographyAngiographyAngiographyCarotid Duplex Scan Carotid Duplex Scan Peripheral Duplex ScanPeripheral Duplex Scan
Surgery for Cardio-thoracic Surgery for Cardio-thoracic DiseasesDiseases
Usual Duration of Stay in HospitalUsual Duration of Stay in Hospital
One day before surgeryOne day before surgery 3-6 hours OR time3-6 hours OR time One day in ICUOne day in ICU 4-5 Days in Ward 4-5 Days in Ward Total 5-7 daysTotal 5-7 days