CARDIAC SURGERY - general principles - congenital heart disease - ischemic heart disease Petr Fila [USEMAP] Dear students, welcome to commented presentation about cardiac surgery. My name is Petr Fila and I´m heart and transplant surgeon in Center of Cardiovascular surgery and tranplantation here in Brno. Now I would like to introduce you to general principles in cardiac surgery. And I will talk aboit congenital heart disease and ischemic heart disease. Cardiac surgery history 1896 - heart stab wound suture (Rehn) 1923 - „close path“ mitral stenosis operation (Cutler,Levine) 1925 - comisurolysis of mitral valve through LA appendage (Souttar) 1938 - open arterial duct ligation (Gross) 1944 - Blalock-Taussig shunt in tetralogy of Fallot 1944 - surgery for coarctation of the aorta – resection (Crafoord) 1953 - atrial septal defetct closure – hypothemia (Lewis) 1953 - EXTRACORPOREAL CIRCULATION – ASD closure (Gibbon) 1955 - surgery for tetralogy of Fallot (Kirklin) 1960 - aortic valve replacement (Harken) 1960 - mitral valve replacement (Starr) 1962 - heart revascularization with vein grafts 1964 - heart revascularization with LITA 1967 - heart transplantation 1967 - artifitial heart (Cooley) [USEMAP] Something from cardiac surgery history … Important point was developing of machine for extracorporeal circulation. After that the open heart surgery started. In 1960 first aortic valve repacement was performed with mechanical valve. Cardiac surgery in hypothermia - 006 First open heart surgery in hypothermia – ASD closure (Navrátil , Brno 1956) [USEMAP] In our country first open heart sugery was ASD closure by prof. Navratil, here in Brno in 1956. It was without ECC.This was due to hypothermia. The patient was colled down in a bathtub and circulation was stopped, heart was opened, ASD was closed quickly. And then patient was warmed and blood flow restored. Prof. Navratil was the pioneer of cardiac surgery in this count and than also in Austria. Surgical approaches in cardiac surgery - Median sternotomy Ministernotomy (aortic valve, …) Thoracotomy - right side (ASD, Mi, Tri, re-do surgery) - left side (open arterial duct, CoA, decs. aorta) Minithoracotomy - left side – ischemic heart disease, open arterial duct) - right side (IHD) Transverse sternotomy Parasternal incision Incision in the epigastrium Endoscopic approach (robotic) https://www.mayoclinic.org/-/media/kcms/gbs/patient-consumer/images/2013/12/13/16/29/minimally-inva sive-heart-surgery-3coljpg.jpg [USEMAP] Surgical approaches in CS. Median sternotomy – the most often approache in CS. Next… In last years miniinvasive aproaches for endoscopic heart surgery are used for mitral, tricuspid valve surgery, ASD closure, revascularization. Ministernotomy - [USEMAP] On this video, you cad see ministernotomy approach for AVR. After skin incision… Cardiac surgery - - without cardiopulmonary bypass - beating heart - congenital heart diseases (open arterial duct, CoA) - CABG - pericarditis - heart injury - mitral comissurotomy - with cardiopulmonary bypass (ECC) [USEMAP] Two basic types of surgical procedures in cardiac surgery are… Extracorporeal circulation – cardiopulmonary bypass - 1. Pump 2. Oxygenator 3. Heat exchanger Principles - heparinization (2-3 mg/kg) - hemodilution - hypothermia normothermia [USEMAP] As I said, due to establish of ECC open hear surgery was started. ECC is also called CP bypass because function of heart and lung is replaced. Main parts of ECC are pump, oxygenator and heat exchanger. Blood (with heparin) from patienst goes by venous cannula (s) to reservoir and pumps accross membrane oxygenator and heat exchanger, and returns by arterial cannula to aorta or other artery (femoral, axxilary…) Some operation are in normothermia, some in hypothermia. Extracorporeal circulation - [USEMAP] This is picture of one of the first machine for ECC… big machine. First ECC in central Europe - Brno, 1958 [USEMAP] First operation in ECC in central Europe was here in Brno in 1958, due to prof, Navratil Extracorporeal circulation nowadays - D:\USB_backup_021011\Kardio\Medici\Foto medici\ECC1.JPG D:\USB_backup_021011\Kardio\Medici\Foto medici\ECC2.JPG [USEMAP] And maschine for ECC now. Several pumps, one is the main. Blood goes from RA to reservoir and is pumps across the oxygenator (which is situated here bellow t. the reservoir) back to body (aorta) Perfusionist check vital parameters on monitor and cooperates with anesthesiologist Myocardial protection - Ischemic cardiac arrest = myocyt injury Cardioplegic solution crystaloid x blood warm x cold Types of delivery antegrade retrograde [USEMAP] For open heart surgery is need to stop the heart, to stop heart beating. You well know, that ischemic cardiac arrest causes myocyt injury. So to avoid this, we use so called cardiplegic solution to stop the heart. There are diferent types of cardioplegic solutions. Crystaloid, blood, according to the temperature warm or cold. According to path of delivery can be antegrade – to aortic root or to origins of coronary arteries or retrograde to coronary sinus. Heart disease - Congenital - without shunting - left to right shunt - right to left shunt Acquired - ischemic heart diseases - valve diseases - aortic diseases - tumors - others [USEMAP] Basic division of heart diseases is on congenital or acquired. And now something about Congenital heart surgery… Surgery for congenital heart diseases - history - 1938 - arterial duct ligation (Gross) 1944 - B-T shunt 1944 - coarctation of aorta (Crafoord) 1951 - closure of ASD (Dennis) 1953 - extracorporeal circulation (Gibbon) 1947 – arterial duct ligation (Bedrna) 1949 – B-T shunt, coarctation of aorta (Rapant) 1956 – ASD closure (Navrátil) 1958 – first operation with C-P bypass (Navrátil) 1961 – Tetralogy of Fallot (Navrátil) Here some importatn point from world congenital heart surgery. And the same from czech CHD history…..You see (that i said) about prof. Navrátil. He played important role in CS development. Congenital heart disease - 0,6-1% newborns the most often - VSD, ASD, open arterial duct Main principles of treatment - critical defects - early repair - others – at the preschool-age surgery - radical correction - palliative surgery [USEMAP] Less than 1 % newborns have some type of CHD. The most often are… Main principles of treatment are: - Early correction of critical defects and the others at preschool-age And if it´s possible radical correction is prefered. But sometimes in some complex CHD it‘s impossible Advance in congenital heart surgery - - fetal ECHO development, noninvasive diagnosis - reduction of palliative surgery - radical correction during first step of surgery - catether intervention techniques development (BAS, ASD and VSD closure, PDA closure, coils, stents, dilation) - post surgery mortality reduction, intensive care [USEMAP] Main advances in congenital heart surgery are: fetal ECHO development and noninvasive diagnosis, Almost always congenital heart surgeons try to do radical correction during first step of surgery. Other milestone in CHD was developing of cathether intervention techniques. As well progress in intensive care results in post surgery mortality reduction. Congenital heart disease - 85% of CHD live to the age of adult 50% - absolutely healthy 25% - time to time observation (possibility occurrence of residues) 25% - regular observation if need - reintervention [USEMAP] This is very important slide Congenital heart diseases - types - Congenital - without shunt - left to right shunt - right to left shunt Acquired - ischemic heart diseases - valve diseases - aortic diseases - tumors - others coarctation of aorta aortic arch disorders aortic stenosis pulmonary stenosis [USEMAP] CHD without shunt are.. Coarctation of the aorta - 5-8 % of CHD male : female 2-5:1 congenital narrowing of thoracic aorta after the origin of subclavian artery - hypertensin in upper part of body ACC l.sin. AO arch AO desc. AS l.sin. Hudečková-ReCOA oblouk.jpg CoA [USEMAP] Coarctation of aorta is congenital narrowing of thoracic aorta after the origin of subclavian artery. The typical sign is hypertenson in upper part of body and low pressure in lower part. You see CoA on 3D CT images…and on ECHO Coarctation of the aorta - surgery - Reconstruction with patch - Vossschulte ( 1957) Resection + end to end anastomosis ( 1945 C.Crafoord ) Reconstruction - Waldhausen ( 1966) [USEMAP] Types of surgery: excision of narrowing part and: end-to-end anastomosis (mostr often), The others are dilatation using patch (in history, because the patiets after this type of procedure were suffered from pseudoaneurysm quite often), using flap of subclavian artery, Coarctation of the aorta - surgery - Extraanatomic bypass Stent/SG implantation Excision + vascular prosthesis [USEMAP] or in adult by interpositum of vascular graft prothesis. If there is any contraindication for prosthesis we can bypass CoA with extraanatomic bypass from AA to DA. Catheter interventin stent or stentgraft implantation is also possible. Congenital aortic valve stenosis - - subvalvular, valvular, supravalvular - palliative treatment - reduction of surgery - delaying of aortic valve replacement Therapy: - catheter treatment, - aortic valve sparing surgery - aortic valve replacement mechanical (biological)valve Ross procedure [USEMAP] Other CHD without shunt is congenital aortic valve stenosis. According to localization types of congenital aortic stenosis are subvalvular, valvula and supravalvular. Target of treatment is reduction of surgery in young age. Due to catheter treatment (baloon dilatation) and AVS surgery is possible to delay AVR to adult. AVR is made with mechanical prosthesis (rarely with biological in young age) prothesis. In childhood and in young people we kan use so called Ross procedure - replacement aortic valve by autograft of pulmonary valve. During this procedure we remove stenotic aortic valve, after that a pulmonary autograft is harvested and implated in aortic position, we have to reimplant coronary artery ostia. After that pulmonary valve is replaced with homograft from tissue bank. Ross operation – autograft harvesting - Autograft harvesting.mp4 [USEMAP] On this video you can see pulmonary autograft harvesting for Ross procedure. Heart disease - Congenital - without shunt - left-to-right shunt - increased pulmonary blood flow - right-to-left shunt Acquired - ischemic heart diseases - valve diseases - aortic diseases - tumors - others -VSD -ASD -patent ductus arteriosus -aortopulmonary window -anomalous origin of the LCA from the pulmonary artery -AV septal defect (incomplete x complete) [USEMAP] CHD with left to right with increasing pulmonary blood flow are: Ventricular septal defect - Soubor:Heart right vsd.jpg - most often CHD - solated x with other CHD - blood circulation pathophysiology depends on diameter and PVR [USEMAP] Most often CHD is VSD It can be isolated or VSD with other CHD Here you can see are many types of VSD according to localization (membranous, muscular, subvalvular, apical..) Small VSD often will close spontaneously. Non critic defects are closed by surcical corection by patch at preschool age. Usually autologous pericardium patch is used. Atrial septal defect - no symptoms x large defect - weariness symptoms in adult – enlarging RA, RV, RV failure, arythmia ↑ CVP - paradoxical embolism surgery x catheterization Soubor:Heart right asd.jpg [USEMAP] ASD is the second most often CHD. Sometimes ASD is diagnose in adult. The symptoms are murmur. We can close with catheterization technique or surgicaly. Atrial septal defect - closure - [USEMAP] You see catheter closing with so called Amplatzer occluder. From groin catheter with ocluder, across the defect. After checking correct position , occluder is released and ASD closed. During surgery after RA opening we can close with direct suture or large ASD is closed with pericardial patch. Persistent open arterial duct - before birth.jpg Extracardial connection – pulmonary and systemic circulation During fetal circulation - ↑prostaglandins (E2, E1) → persistent connection [USEMAP] Arterial duct is embryonal extracardiac connection between pulmonary and systemic circulation. Open arterial duct is localized between pulmonary artery and initial parto of descending aorta. During fatal circulation increasing level of prostaglandins causes opening and persistent connection Persistent open arterial duct - after birth.jpg After birth ↑pO2 a ↓PG (placental removal) 5-10% all congenital heart diseases In prematurely born 20-30% 1.jpg LITWIN, S. Bert. Color atlas of congenital heart surgery. 2nd ed. New York, N.Y: Springer, 2007. ISBN 03-873-5415-8. [USEMAP] After birth increasing level of pO2 and decreasing level of PG (due to placental removing) causes spontaneous closing Closing of OAD come normaly after birth. But epecially in prematurely born stay open in 20-30% of newborns. On picture you see distal part of aortic arch, descending aorta and wide OAD Persistent open arterial duct (persistent ductus arteriosus) - farmacotherapy - ibuprofen - PG inhibitors cathetrization surgery - VATS - „open surgery“ - thoracotomy Closing is making except for disorders, when PDA is important for survival. - PG E1 - (pulmonary stenosis, HLHS, TGA) Výřez obrazovky Mehta SK, Younoszai A, Pietz J, Achanti BP. Pharmacological closure of the patent ductus arteriosus.Images Paediatr Cardiol 2003;14:1-15 Výřez obrazovky [USEMAP] Initial persistent OAD therapy starts wit PG inhibitors (ibuprofen) If not it´s possible with drugs we can continue by cathetr closing or by surgical ligation. In case of for example pulmonary stenosis, hypoplastic left heart syndrom, TGA prostaglandins are indicated for duct patency. Types of closure devices - Mehta SK, Younoszai A, Pietz J, Achanti BP. Pharmacological closure of the patent ductus arteriosus.Images Paediatr Cardiol 2003;14:1-15 Rashkind, Amplazer, coil Full-size image (64 K) SCHNEIDER, Douglas J. The Patent Ductus Arteriosus in Term Infants, Children, and Adults. In: Seminars in Perinatology. WB Saunders, 2012. p. 146-153. SCHNEIDER, Douglas J.; MOORE, John W. Patent ductus arteriosus. Circulation, 2006, 114.17: 1873-1882. [USEMAP] Diferent types of closure devices Congenital heart diseases - Congenital - without shunt - left-to-right shunt - right-to-left shunt - cyanotic Acquired - ischemic heart diseases - valve diseases - aortic diseases - tumors - others - tetralogy of Fallot - TGA - VSD with pulmonary atresia - total anomalous pulmonary venous return - truncus arteriosus [USEMAP] CHD with R-to-L shunt –called cyanotic disorders are .. Tetralogy of Fallot - http://pediatricheartspecialists.com/images/uploads/content/Tetralogy-of-Fallot---Shunt-web.jpg http://pediatricheartspecialists.com/images/uploads/content/Tetralogy-of-Fallot---Surgical-Repair-w eb.jpg -surgery during first year -observation -20% redo surgery in adult [USEMAP] Four signs of TofF are: pulmonary artery stenosis, RV hypertrophy, VSD+ aorta over the VSD. Surgical therapy is made during firts year. Surgery is discision of stenotic pulmonyay valve and closing of VSD. Observation is important becacuse developing of pulmonary regurgitation in about 25%. And that regurgitatio causes RV , arrhytmhmias, RV dilatation, and then RV failure in future. So the rest of pulmonary valve (after discision) has to be replaced by (biological) valve. Transposition of great arteries - dTGA - 1.dextro-transposition of the great arteries (d-TGA) - also complete transposition of the great arteries. The primary arteries (the aorta and the pulmonary artery) are transposed. - cyanotic congenital heart defect - this condition is described as ventriculoarterial discordance with atrioventricular concordance, - http://www.medmovie.com/MediaService/medium.aspx?code=TWVkaXVtSUQ9ODY3-ZH97eJYf%2B0c%3D [USEMAP] TGA is group of congenital heart defects. In transposition of the great arteries, the aorta is connected to the right ventricle, and the pulmonary artery is connected to the left ventricle - the exact opposite of a normal heart's anatomy. There are 2 types of TGA: Type 1… ..possibility of surviving is only due to shunts: ASD, patent arterial duct. Or artefitial shunt is made (ASD) by cathether after birth ( so called Rashkind procedure- atrial septostomy) Transposition of great arteries - ccTGA - 2. levo-transposition of the great arteries (l-TGA) also congenitally corrected transposition of the great arteries (cc-TGA), - non-cyanotic congenital heart defect (CHD) - the aorta and the pulmonary artery are transposed - morphological left and right ventricles are also transposed. This condition is described as atrioventricular discordance (ventricular inversion) with ventriculoarterial discordance. Problem? The systemic ventricle is the RV! - [USEMAP] Second type of TGA so called congenitaly corrected transposition of GA. But this is noncyanotic CHD. Probles is that RV is not adapted as systemic ventricle. So without surgery RV failure can occur Transposition of great arteries - Follow-up…., redo surgery - Senning, Mustard after 30 years - RV dysfunction, TriR, arrhythmia → heart transplantation - switch Jatene supravalvular AoS, pulmonary stenosi; neo-aortic root dilatation; coronary artery stenosis tga_senningX tga_mustardX tga_jateneX [USEMAP] According the complexity of transposition there are three basic types of operations. Sennig and Mustard – redirection on the level of right and left atrium. TGA is disorder which requires follow up observation after surgery. After Sennig and Mustard procedures RV dysfunction can occur. Today’s children born with TGA usually have an operation called an arterial switch. This operation was first developed in the late 1980s. In the arterial switch, the surgeon disconnects and reattaches the heart’s arteries to create more normal blood flow. After years supravalvular AoS, pulmonary stenosis, neo aortic root dilatation or coronary artery stenosis can occur Aquired heart diseases - Congenital - without shunting - left to right shunt - right to left shunt Acquired - ischemic heart diseases - valve diseases - aortic diseases - tumors - others [USEMAP] Second type of heart diseases are acquired heart diseases. Main of them is ischemic heart disease. Why IHD? Because is main cause of death in population. IHD – risk factors, signs, symptoms, therapy - - hypertension - diabetes - obezity - smoking - hyperlipoproteinemia - … - - - no symptoms - angina pectoris - myocardial infarction - heart failure, sudden death PREVENTION!!! - drugs - percutaneous coronary intervention - surgical revascularization - combination - heart transplantation [USEMAP] You well known this.. Risk factors of IHD… Patients with IHD can have no symtoms, or other as AP,… Important is prevention, but if the IHD occurs, possibility of treatment… In case of heart failure..HTx Coronary arteries - 1.jpg 1.jpg [USEMAP] You see anatomy of coronary arteries with normal patency of coronaries. Coronarogram – ischemic heart disease - 1.jpg 1.jpg [USEMAP] Stenosis on LAD Stenosis on main RCA before branching on posterior interventricular artery and right postero-lateral branch. IHD – indication for surgical treatment - Clinical - stable angina pectoris - instable angina - MI without possibility of intervention - postinfarction angina Anatomical - number of arteries with stenosis (left main coronary artery, one, two, three arteries…) - grade and localization of coronary artery stenosis - possibility of surgical treatment (diffuse coronary artery disease, artery diameter, myocardial viability) [USEMAP] IHD – surgical treatment options - without C-P bypass – „off-pump“ with C-P bypass sternotomy minithoracotomy endoscopic robotic [USEMAP] The surgical treatment options are with CP bypass, or without Choice of conduits for coronary artery bypass - Arterial - LITA (a. thoracica int. l. sin) – 10 years patency 90-95% - RITA [USEMAP] What is crucial for surgery …choice of conduits (grafts) We can use arterail garfts LIT and RIA. Advantage of use arterial graft is10 years patency around 95% LIMA harvesting - Lima HARVESTING skeletonised HD(1).mp4 [USEMAP] You can see LIMA harvesting Choice of conduits for coronary artery bypass - Arterial - LITA (a. thoracica int. l. sin) – 10 years patency 90-95% - RITA - radial artery [USEMAP] Other arterial graft is Radial artery. But We can harvested radial artery only if we check ulnar artery and palm arch patency Radial artery – Allen´s test - Allens Test.mp4 [USEMAP] For checking we use so called allens test Allens test is used in examination of arterial blood flow to the hand. 1.the patient is asked to clench their fist for about 30 seconds. 2.Pressure is applied over the ulnar and the radial arteries so as to occlude both of them. 3.the hand is then opened. It should appear blanched 4.Ulnar pressure is released while radial pressure is maintained, and the colour should return within 10 seconds. 5.If color returns as described, Allen's test is considered to be normal. If color fails to return, the test is considered abnormal and it suggests that the ulnar artery supply to the hand is not sufficient. This indicates that it may not be safe to use radial artery as graft Choice of conduits for coronary artery bypass - Arterial - LITA (a. thoracica int. l. sin) – 10 years patency 90-95% - RITA - radial artery - a. gastroepiploica dx., a. epigastrica inf. [USEMAP] Gastroepiploic artery and epigsatric artery are very rarely used Choice of conduits for coronary artery bypass - Arterial - LITA (a. thoracica int. l. sin) – 10 years patency 90-95% - RITA - radial artery - a. gastroepiploica dx., a. epigastrica inf. Venous - great saphenous vein – 10 years patency 50-60% - short saphenous vein - brachial or cephalic veins from upper arms [USEMAP] On the other side we can use venous conduits.. Usually a great saphenous vein is used. Rarely short saphenous vein. Brachila or cephalic veins from upper arms are used very very rarely. Problem of great saphenous vein graft is 10 years patency which is between 50-60% Usually one or two ITA are used a rest vein grafts- Endoscopic vein harvesting - Endoskopický odběr žilního štěpu.mp4 [USEMAP] EVH is minimally invasive technique. This procedure that requires a single 3 cm incision plus one or two smaller incisions of 5 mm. Surgeon start with incision on the level of knee, use endoscope for disection. carefully cutting and sealing off smaller branches prior to removal from the body Choice of conduits for coronary artery bypass - BIMA.JPG [USEMAP] LITA on-site conduit (origin from left subclavian artery) RITA –free condutit Anastomosis end to side RITA-LITA….so called Y ot T graft Choice of conduits for coronary artery bypass - ACB 5x.JPG disekce koronárky2.JPG [USEMAP] Vein grafts Mechanical complications of acute MI - free wall rupture VSD mitral regurgitation F:\Kardio\Prezentace\ruptura volne steny LK\obr final\obr_02.jpg F:\Kardio\Prezentace\ruptura volne steny LK\obr final\obr_05.jpg [USEMAP] Last part o IHD are mechanical complication of MI After transmurral MI myocardila necrosis can occur. First acute mechanical complication of acute MI free wall rupture – according to size often with tamponade and death. Mechanical complications of acute MI - free wall rupture VSD mitral regurgitation obr_07 [USEMAP] The second complication is necrosis of IVS .After that VSD –with L-R shut can occur. Crucial is the timing of surgery of better tissue (scar formation) for patch implantation. Patients are in cardiogenic shock and somentimes short term MCS has to be used before VSD surgical closing. Mechanical complications of acute MI - free wall rupture VSD mitral regurgitation – papillary muscle rupture [USEMAP] Third mechanical complications of acute MI is MR after pappilary muscle rupture. Patient is suffered from severe mitral regurgitation – cardiogenic shock with pulmonyry oedema Acute mitral valve replacement is performer. Mechanical complications of acute MI - LV aneurysm LV pseudoaneurysm [USEMAP] Other complications of acute MI are: LV pseudoaneurysm is false aneurysms that is formed if cardiac rupture is contained by pericardium, organizing thrombus, and hematoma. This condition calls for urgent surgical repair. Left ventricular aneurysms is late complication of acute MI. Left ventricular aneurysm is true aneurysms containing all the layers (endocardium, myocardium, and epicardium). Treatment is limited to surgery with scar resection and using pericardial patch for LV cavity volume reduction. Petr Fila petr.fila@cktch.cz [USEMAP] That is all from first part. The second part is about valve surgery, aortic disection a surgical correction of atrial fibrilation.