CARDIAC SURGERY Petr Fila Cardiac surgery history 1896 - heart stab wound suture (Rehn) 1908 - pulmonary embolectomy – unsuccessful (Trendelenburg) 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) Cardiac surgery in hypothermia First open heart surgery in hypothermia – ASD closure (Navrátil , Brno 1956) 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, ao arch., 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) Ministernotomy Cardiac surgery - without cardiopulmonary bypass - beating heart - congenital heart diseases (open arterial duct, CoA) - CABG - pericarditis - heart injury - mitral comissurotomy - with cardiopulmonary bypass (ECC) Extracorporeal circulation 1. Pump 2. Oxygenator 3. Heat exchanger Principles - heparinization (2-3 mg/kg) - hemodilution - hypothermia normothermia Extracorporeal circulation First ECC in central Europe Brno, 1958 Extracorporeal circulation nowadays Myocardial protection Ischemic cardiac arrest = myocyt injury Cardioplegic solution crystaloid x blood warm x cold Types of delivery antegrade retrograde Heart diseases Congenital - without shunting - left to right shunt - right to left shunt - others Acquired - ischemic heart diseases - valve diseases - aortic diseases - tumors - others 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) Congenital heart diseases 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 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 Congenital heart diseases 85% of CHD live to the age of adult 50% - absolutely healthy 25% - time to time obsarvation (possibility occurrence of residues) 25% - regular observation if need - reintervention Congenital heart diseases - types Congenital - without shunt - left to right shunt - right to left shunt - others Acquired - ischemic heart diseases - valve diseases - aortic diseases - tumors - others coarctation of aorta aortic arch disorders aortic stenosis pulmonary stenosis 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. CoA Coarctation of the aorta - surgery Reconstruction with patch - Vossschulte ( 1957) Resection + end to end anastomosis ( 1945 C.Crafoord ) Reconstruction Waldhausen ( 1966) Coarctation of the aorta - surgery Extraanatomic bypass Stent/SG implantationExcision + vascular prosthesis 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 Ross operation – autograft harvesting Congenital heart dieases Congenital - without shunt - left to right shunt - increased pulmonary blood flow - right to left shunt - others Acquired - ischemic heart diseases - valve diseases - aortic diseases - tumors - others - patent ductus arteriosus - aortopulmonary window - anomalous origin of the LCA from the pulmonary artery - ASD - VSD - AV septal defect - incomplete x complete Ventricular septal defect most often CHD Isolated x with other CHD Blood circulation pathophysiology depends on diameter and PVR Atrial septal defect no symptoms x large defect - weariness symptoms in adult – enlarging RA, RV, RV failure, arythmia ↑ CVP - paradoxical embolism surgery x cathetrization Atrial septal defect - closure Persistent open arterial duct Extracardial connection – pulmonary and systemic circulation During fetal circulation - ↑prostaglandins (E2, E1) → persistent connection Persistent open arterial duct After birth ↑pO2 a ↓PG (placental removal) 5-10% all congenital heart diseases In prematurely born 20-30% 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) Persistent open arterial duct (persistent ductus arteriosus) 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 Congenital heart diseases Congenital - without shun - left to right shunt - right to left shunt - cyanotic - others Acquired - ischemic heart diseases - valve diseases - aortic diseases - tumors - others - tetralogy of Fallotova - TGA - VSD with pulmonary atresia - total anomalous pulmonary venous return - truncus arteriosus Tetralogy of Fallot - surgery during first year - observation - 20% redo surgery in adult 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, 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! Transposition of great arteries Follow-up…., redo surgery - Senning, Mustard after 30 years - RV dysfunction, TriR, arrythmia → heart transplantation - switch Jatene supravalvular AoS, PS; neo-aortic root dilatation; coronary artery stenosis Aquired heart diseases Congenital - without shunting - left to right shunt - right to left shunt - others Acquired - ischemic heart diseases - valve diseases - aortic diseases - tumors - others Ischemic heart disease - cause of death 6% 5% 8% 6% 29% 46% men respiratory s. digestive s. external others neoplasms circulatory s. 5% 4% 4% 7% 23%57% women IHD – risk factors, signs, symptoms - hypertension - diabetes - obezity - smoking - hyperlipoproteinemia - … - no symptoms - angina pectoris - myocardial infarction - heart failure, sudden death IHD - treatment PREVENTION!!! - drugs - percutaneous coronary intervention - surgical revascularization - combination - heart transplantation Coronary arteries Coronarogram – ischemic heart disease 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) IHD – surgical treatment options without C-P bypass – „off- pump“ with C-P bypass sternotomy minithoracotomy endoscopic robotic Choice of conduits for coronary artery bypass Arterial - LITA (a. thoracica int. l. sin) – 10 years patency 90-95% - RITA LIMA harvesting Choice of conduits for coronary artery bypass Arterial - LITA (a. thoracica int. l. sin) – 10 years patency 90-95% - RITA - radial artery Radial artery – Allen´s test 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. 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 Endoscopic vein harvesting Choice of conduits for coronary artery bypass Choice of conduits for coronary artery bypass Mechanical complications of acute MI free wall rupture VSD mitral regurgitation Mechanical complications of acute MI free wall rupture VSD mitral regurgitation Mechanical complications of acute MI free wall rupture VSD mitral regurgitation – papillary muscle rupture Mechanical complications of acute MI LV aneurysm LV pseudoaneurysm Valve diseases - history 1950 - Bailey – closed aortic valvulotomy 1952 - Hufnagel – descending thoratic aortic valve 1956 - Murray – descending thoratic aortic homograft end of 50th – Hurley, Kirklin – open valvulotomy 1960 - Harken, Starr – AVR with aortic ball valve 1962 - Barratt-Boyes – AVR with homograft 1965 - Binet – AVR with bioprothesis 1967 – Ross procedure 1991 - David, Yacoub – aortic valve sparing surgery Anatomy of heart valves Atrio-ventricular valves (Mi,Tri) - annulus - leaflets - papillary muscles - chords - left /right ventricle Ventriculo-arterial valves - anulus - leaflets - root Anatomy of heart valves - localization Aortic valve disease - stenosis most often AS risk factors bicuspid - 2% turbulent flow aortic root dilatation! + Mi valve Etiology - degenerative - congenital - post-rheumatic Aortic valve disease – stenosis - pathophysiology LV concentric hypertrophy coronary flow reduction ↓ aortic pressure (= coronary artery perfusion pressure) ↓ diastolic time (= coronary artery perfusion time) LV hypertrophy, ↑ APS , increase time of ejection → ↑ O2 consumption systolic/diastolic dysfunction myocyt hypetrophy fibrosis (collagen +15%) Aortic valve disease – stenosis – indication for surgery (AVR) aortic valve stenosis (on ECHO) symptoms (AP, dyspnea, syncope) surgery symptoms …. LV function? (↓EF, LV dilatation) surgery Aortic valve disease - regurgitation acute x chronic Etiology - post-rheumatic - endocarditis - congenital - degenerative - annulus/root dilatation Mitral valve diseases Stenosis Etiology - post-rheumatic Indication for surgery - symptoms (dyspnoa) - MV ≤ 1,5cm2 - atrial fibrilation - PH Regurgitation (acute, chronic) Etiology - myxomatous degeneration - post-rheumatic - endocarditis - ischemic Indication for surgery - symptoms - RV > 40ml, RF > 40%, Tricuspid valve diseases Stenosis Etiology - post-rheumatic Indication for surgery - gradient > 2-3mmHg Regurgitation Etiology- relative…annulus dilatation - endocarditis Indication for surgery - TriR grade III-IV Heart valve surgery 1. Valve sparing – if it possible X risk of failure valve sparing surgery → redo surgery 2. Valve replacement X risk of valve prosthesis Anatomy of heart valves Ventriculo-arterial valves - leaflets - anulus - root Aortic valve sparing surgery Leaflets Aortic valve sparing surgery Annulus Aortic valve sparing surgery Root Anatomy of herat valves - localization Atrio-ventricular valves (Mi,Tri) - leaflets - anulus - papillary muscles - chords - left/right ventricle Mitral valve reconstruction surgery Leaflets Mitral valve reconstruction surgery Papillary muscles Chords Mitral valve reconstruction surgery Annulus Tricuspid valve reconstruction surgery Annulus Leaflets (chords) Valve replacement - mechanical Valve replacement - biological Aortic valve replacement - video Aortic valve replacement – sutureless bioprosthesis Mechanical vs. biological valves Mechanical - advantages - long-term durability - disadvantages - need of anticoagulation Biological - advantages - no anticoagulation - disadvantages - limited durability Complications after valve replacement - thrombembolism - bleeding - valve dysfunction (pannus, thrombus) - prosthetic endocarditis 2 - 4% per year Mortality 1% per year TAVI – transcatheter aortic valve implantation TAVI - transfemoral TAVI - transapical TAVI Aortic dissection tear in the inner wall of the aorta causes blood to flow between the layers of the wall of the aorta and force the layers apart → true and false lumen - acute (< 2 weeks) - chronic Aortic dissection Splitting tunica media Weakening of the walls of the false lumen Impaired flow of aortic branches Tamponade Malperfusion – brain, myocardial, visceral, extremity Risk of rupture Aortic dissection - hypertension - connective tissue disorders (Marfan, Ehlers-Danlos, Turner) - degenerative or inflamatory disease of aortic wall - iatrogenic injury - atherosclerosis - bicuspid aortic valve - aortic dilatation - trauma - polycystic kidney disease - coarctation of the aorta - … Aortic dissection - classification Survival of untreated pts with type A aortic dissection survival% days post dissection event - 50 % (36–72 %) of untreated pts with acute type A dissection die within 48 hours - mortality rate 1 % / hour - the survival rate without treatment at 1 month is approximately 5% - after 3 weeks approx. 90 % † Aortic dissection - symptoms PAIN!!! - pre-shock symptoms (sweating, hypotension, tachycardia) - malperfusion (peripheral or splanchnic ischemia) CAVE: ALWAYS CONSIDER AORTIC DISSECTION IN CASE OF ISCHEMIC EXTREMITY ! - neurological signs (stroke) - no another symptoms (some patients are only complaining chest pain) Aortic dissection - diagnosis WITHOUT DELAY !!! ECHO CT-angio (MR) Aortic dissection - therapy Initial analgetics ANTIHYPERTENSIVE THERAPY (vasodilatation, betablockers) Definitive Type A - surgery Type B - no surgery - intervention (stentgraft) : rupture malperfusion pain progresive dilatation >10mm/30 days failure of hypertension treatment management Aortic dissection - surgery Aortic dissection - surgery Aortic dissection - surgery Aortic dissection type B - surgery Endovascular therapy of aortic type B dissection Aortic dissection therapeutic results Prognosis without treatment type A - within 48 hours of the event - 50% mortality - survival rate at 1 month is approximately 5% Surgery survival early mortality 1 year 5 years Type A 10-25% 91% 75% Type B 20-50% 93% 82% stentgrafts 5-10% Conservative (no surgery) therapy Type B 10-20% Atrial fibrilation - the most often SV dysrythmias - the most serious consequences - no mapping during surgery Atrial fibrilation – MAZE procedure Lesions - transmural - continual Technique - surgical incision - kryo - radiofrekvency ablace Atrial fibrilation – cryo MAZE Atrial fibrilation – radiofrequency MAZE Thoracoscopic MAZE procedure Heart transplantation Indications terminal heart failure (coronary artery disease, valve disease, cardiomyopathy) Contraindications fixed pulmonary hypertension neoplasms HIV active alcohol or drug abuse age over 60 years (60-65 years – individual assessment), Potential relative contraindications active infection, pulmonary embolism, active peptic ulcer disease liver, kidney failure – 2 or 3 organs transplantation Heart failure - etiology 46% 45% 3% 2% 2% 2% Heart failure cardiomyopathy coronary artery disease valve disease re-Hx congenital heart disease others Heart transplantation - surgical technique biatrial (Lower-Shumway) bicaval Mechanical circulatory support § short-term reversible damage § long-term „brigde-to-transplantation“ § permanent contraindications for heart transplantation § left-side § right-side § biventricular § Pulsatile • pneumatic • electromechanic § Non-pulsatile • axial • centrifugal Duration of support Type of support needed FlowLocalization § paracorporeal § implantable Mechanical circulatory support - indication Postcardiotomy cardiogenic shock unsuccessful weaning from extracorporeal circulation malignant ventricular arrythmias low cardiac output syndrom Other etiology of cardiogenic shock after acute myocardial infarction, after PCI, myocarditis… Chronic heart failure pts on waiting list for heart transplantation Acute rejection after HTx Heart failure (primary graft non-function) after HTx Patients with contraindications for heart transplantation Intraaortic baloon counterpulsation Short-term MCS - Centrimag Short-term MCS - Centrimag Short-term MCS - Centrimag Short-term MCS - ECMO extracorporeal membrane oxygenation Long-term MCS – Heartmate II MCS - HeartWare MCS – LVAD as BiVAD MCS – HEARTMATE 3 Total artificial heart - Syncardia - pneumatic pump – pulsatile flow - bridge-to-transplant - noise Total artificial heart - Carmat - electrohydraulic pump, biological valves, membranes - bovine pericardium - pulsatile flow, autoregulation MCS - future - miniaturization??? – external components - wireless - telemonitoring - no anticoagulation MCS – future - miniaturization MCS – future - wireless MCS – future - telemonitoring MCS – future – no anticoagulation Netuka, I, et al. JHLT, 2018, 37.5: 579-586 Netuka I., et al. JHLT, 2019, 38.4: S113 from MAGENTUM 1 study – n = 5 MAGENTUM 2 – after 6 months – complete withdrawal anticoagulation therapy after 6 weeks - ↓ INR 1,5-1,9 n = 15 after 6 months - no stroke, no pump thrombosis - 1x GI bleeding