CARDIAC  SURGERY
  - general principles
  - congenital heart disease
  - ischemic heart disease
Petr Fila
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Dear students, welcome to on-line presentation in cardiac surgery practice. My name is Petr Fila
and I´m heart and transplant surgeon in Center of Cardiovascular surgery and tranplantation here in
Brno.
Due to current pandemic situation this type of online webinars was chosen. Today I would like to
introduce you to general principles in cardiac surgery. And I will talk about congenital heart
disease and ischemic heart disease. In second part we will talk abou valve diseases and aortic
dilatation and dissection and Surgical solution in case of Afib. Third part will be about MCS and
heart, liver and kidney.
Commented presentations are uploaded in IS MUNI web. In case any question don‘t hesitate to
interrupt me in case any question during my presentation.

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)
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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)
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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, asc. aorta, …)
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
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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
-
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On this video, you cad see ministernotomy approach for AVR. After skin incision…

Cardiac surgery
-
- without cardiopulmonary bypass - beating heart surgery
- congenital heart diseases (open arterial duct, CoA)
           - CABG
           - pericarditis
           - heart injury
           - mitral comissurotomy (history)
- with cardiopulmonary bypass (ECC)
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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
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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
-
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This is picture of one of the first machine for ECC… big machine.

First ECC in central Europe
-
Brno, 1958
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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
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collaboration between cardiac surgeon, anesthesiologiest and perfusionist

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.
For optimal result is importatnt co-operation betwen cardiac surgeon anesthesiologiest and
perfusionist

Myocardial protection
-
ischemic cardiac arrest = myocyt injury
→ complete electromechanical arrest
→ cell membrane stabilization
→ myocardial cooling – to achieve metabolic
                                           suppression
Cardioplegic solution
crystaloid x blood
                warm x cold

Types of delivery
antegrade
retrograde
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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 diseases
-
Congenital
   - without shunting
   - left to right shunt
   - right to left shunt

Acquired
   - ischemic heart diseases
   - valve diseases
   - aortic diseases
   - tumors
   - others
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Basic division of heart diseases is on congenital or acquired.
And now something about Congenital heart surgery…

Congenital heart diseases
-
0,6-0,8% 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
                   - conection (shunt) between
                     systemic and pulmonary circulation
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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
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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 diseases
-
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


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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
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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
hypertension in upper part of body
ACC l.sin.
AO arch
AO desc.
AS l.sin.
Hudečková-ReCOA oblouk.jpg
CoA
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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
Resection + end to end anastomosis
Reconstruction - Waldhausen
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Types of surgery: excision of narrowing part and: end-to-end anastomosis (mostr often),
The others are dilatation using patch, using flap of subclavian artery,

Coarctation of the aorta - surgery
-
Extraanatomic
bypass
Stent/SG implantation
Excision + vascular prosthesis
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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
- reduction of surgery
- delaying of aortic valve replacement
Therapy:
- catheter treatment,
- aortic valve sparing surgery
- aortic valve replacement
      mechanical (biological)valve
      Ross procedure
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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
-
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On this video you can see pulmonary autograft harvesting for Ross procedure.

Heart diseases
-
Congenital
   - without shunt
   - left-to-right shunt  -       ↑pulmonary blood flow → RV volume overload
                                                  → ↑PVR →RV pressure overload
   - 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)
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CHD with left to right with increasing pulmonary blood flow are:
↑průtok plicním řečištěm - objemové
                                                  přetěžování PK - ↑plicní cévní rezistence -
                                                  tlakové přetížení PK

Ventricular septal defect
-
Soubor:Heart right vsd.jpg
- most often CHD
- isolated  x   with other CHD
- blood circulation pathophysiology
  depends on diameter and PVR
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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
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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
-
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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 between pulmonary and systemic circulation
during fetal circulation
- ↑prostaglandins (E2, E1) → persistent connection
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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.
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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
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Initial persistent OAD therapy starts with PG inhibitors (ibuprofen)
If there is not effect of 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. 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.
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Diferent types of closure devices

AV septal defect
-
-deficiency of the AV septum
-caused by an abnormal fusion of the superior and inferior endocardial cushions with the mid
portion of the atrial septum and the muscular portion of the ventricular
-
partial
complete
Mehta SK, Younoszai A, Pietz J, Achanti BP. Pharmacological closure of the patent ductus
arteriosus.Images Paediatr Cardiol 2003;14:1-15
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Other CHD with L-R shunt is atrioventricular septal defect. Where the deficiency of AV septum is
present. AV septal defects caused by an abnormal fusion of the superior and inferior endocardial
cushions with the mid portion of the atrial septum and the muscular portion of the ventricular
There are two main types .. Partial and complete

AV septal defect
-
-deficiency of the AV septum
-caused by an abnormal fusion of the superior and inferior endocardial cushions with the mid
portion of the atrial septum and the muscular portion of the ventricular
-
partial
defect in the inferior part of the atrial septum
usually associated with a cleft in the mitral valve
    that may cause the valve to leak
Mehta SK, Younoszai A, Pietz J, Achanti BP. Pharmacological closure of the patent ductus
arteriosus.Images Paediatr Cardiol 2003;14:1-15
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Defect: Age and Outcomes - ScienceDirect

In partial type defect in the inferior part of the atrial septum (so called defect septum primum)
is present. And usually is associated with a cleft in the mitral valve leaflet. This claft can
cause mitral regurgitation.
During Surgical correction mitral leaflet cleft is closed with direct suture  and atrial septal
defect is closed with pericardial patch.

AV septal defect
-
-deficiency of the AV septum
-caused by an abnormal fusion of the superior and inferior endocardial cushions with the mid
portion of the atrial septum and the muscular portion of the ventricular
-
partial
complete
   defects in the atrial and ventricular septum
   and the AV valve remains undivided or "common"
Mehta SK, Younoszai A, Pietz J, Achanti BP. Pharmacological closure of the patent ductus
arteriosus.Images Paediatr Cardiol 2003;14:1-15
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The second type is complete AV septal defect of the atrial and ventricular septum and the AV valve
remains common (undivided).
Treatment is surgical and involves closure of the atrial and ventricular septal defects (with one
patch or two patches) and the common valve is separated into two distinct valves – mitral and
tricusid valve.

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
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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
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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.
        - ventriculoarterial discordance with atrioventricular concordance
        - RA-Tri-RV-aorta
        - LA-Mi-LV-pulmonary artery
       - possibility of surviving is only due to shunts
-

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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 artifitial  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
       - RA-Mi-LV-pulmonary artery
       - LA-Tri-RV-aorta
Problem?  The RV is the systemic ventricle!
-

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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 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 stenosis;
    neo-aortic root dilatation;  coronary artery stenosis
tga_senningX tga_mustardX tga_jateneX
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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
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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
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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
-
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You see anatomy of coronary arteries- LCA – LAD-cirkumflex artery with several obtuse marginal
arteries
Right coronary artery which divided into right marginal aretery and right posterior descending
artery
And coronarography with normal patency of coronaries.

Coronarogram – ischemic heart disease
-
1.jpg 1.jpg
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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)
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Indication for Surgical treatment (for coronary artery bypass graft) are stable or instable angina
and myocardial infarction without possibility of intervention.
Anatomical criteria depend on number of arteries with stenosis. If stenosis is on left main CA, LAD
or so calle three vessel diseases we prefer Surgical revascularisation.
Indicated is stenosis more than 50 %. Also depends on localization of coronary artery stenosis and
on possibility of sugical treatment.

IHD – surgical treatment options
-
without C-P bypass – „off-pump“ X with C-P bypass
sternotomy
minithoracotomy
endoscopic
robotic
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The surgical treatment options are with CP bypass, or without. So called off-pump procedures on
beating heart due to several types os stabilization. Stabilizator with vakuum can help us stabilize
diferent part of heart. We can open coronary artery , insert intracoronary shut (which help us make
operative field clean) and make peripheral anastomosis.

Choice  of conduits for coronary artery bypass
-
Arterial
  -  LITA (a. thoracica int. l. sin) – 10 years patency 90-95%
  -  RITA

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What is crucial for surgery …choice of conduits (grafts)
We can use arterial grafts LITA (which ois branch from left subclavian artery) and RITA. Advantage
of use arterial graft is10 years patency around 95%

LIMA harvesting
-
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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

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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
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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.
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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
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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
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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
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BIMA.JPG
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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
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ACB 5x.JPG disekce koronárky2.JPG
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Vein grafts on coronary artery usually in fatty tissue on heart sufrace.
The second picture is the typical picture of revascularizarion – LITA on LAD a three veins grafts
central anastomosis on ascending aorta.

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
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Last part o IHD are mechanical complication of MI
After transmurral MI myocardila necrosis can occur.
First acute mechanical complication of acute MI is free wall rupture – according to size often with
tamponade and death.

Mechanical complications of acute MI
-
free wall rupture
VSD
mitral regurgitation
obr_07
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The second complication is MI and 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 for circulatory stabilization and better outcomes. Nevertheless morbidity and mortality
rates are high.

Mechanical complications of acute MI
-
free wall rupture
VSD
mitral regurgitation – papillary muscle rupture
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Third mechanical complications of acute MI is MR after pappilary muscle rupture. Patient is
suffered from severe mitral regurgitation – cardiogenic shock with pulmonary oedema
Emergent mitral valve replacement is necessary.

Mechanical complications of acute MI
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LV aneurysm
LV pseudoaneurysm
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Other complications of acute MI are LV:
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 originally all the layers (endocardium, myocardium, and epicardium). And after
transmural MI scar formation occured. Treatment is limited to surgery with scar resection and using
pericardial patch for LV cavity volume reduction.

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That is all from first part.
The second part is about valve surgery, aortic disection a surgical correction of atrial
fibrilation.