Su
—V
as
c
l
i
u
l
N
a
r
o
&C
a
t
r
d
e
i
a
s
c
—
s
ur
ge
ry
, Cardiac Operations
Extracardiac Operations. Closed Cardiac Operations Open Heart Surgery
Done on pericardium & main vessels Blind procedures performed by the finger of the During these operations the heart functionally
outside the heart without (CPB) surgeon or by an instrument placed inside the heart disconnected from the circulation → an artificial
Aortic coarctation repair MS : Closed mitral commissurotomy (Valvotomy) heart lung machine do their function temporarily
Examples [AP3C]
Pericardiectomy & Pericardio-pleural window (CPB, extracorporeal circulation)
PDA Ligation RARELY DONE in current era, performed under direct vision in a bloodless field
CHD : Palliative procedures replaced with open heart surgery techniques within the heart chambers or great vessels
or endovascular catheter-based procedures. Classically performed through : (approach)
median sternotomy → Dt` excellent exposure
Cardiopulmonary Bypass (CPB) —“heart–lung machine”
a technique that is temporarily divert blood from heart & lungs and supports the circulation .. when ?
Uses
Def
provide O2 & pump functions in the presence of a still bloodless heart In a heart surgery requiring arrested heart ± opening cardiac chambers
How to perform CPB ? [4 steps]
1. Heparinization: 2. Priming fluids ? why 3. Cannulation 4. Myocardial protection
Dose → 300 U/kg 1. ↑ peripheral circulation 1. Venous Cannulation: After aortic cross–clamping
reversed by → protamine sulfate 2. ↓ Blood viscosity. - Usually double cannulation: SVC + IVC CARDIOPLEGIC solution is injected either in/or :
after weaning from CPB and - (sometimes single cannulation in RA) Proximal Aorta (antegrade)
removal of cannula 2. Arterial Cannulation: Coronary sinus (retrograde)
- usually in Aorta
Cardioplagia
- (some cases in femoral artery)
1) High K+ content.
2) Cold crystalloid cardioplegia or warm bl. cardioplega
Complications of CPB Miscellaneous
Prolonged bypass induces cytokine activation → inflamm. Response results in : (CPB Time) : time from beginning CPB to → end
1. RBCs damage → haemoglobinuria Ischemic time: The time from aortic cross clamping till → aortic de clamping
2. Thrombocytopenia → Clotting abnormalities CPB فيعرفوا يشتغلوا و كدا كدا هما مركبينK بيعملوا شلل للقلب عن طريق انهم بيحقنواCardioplagia ال
3. ↓ pulmonary gas exchange فبيحمي القلب من إنMyocardium بتاع الO2 demand في نفس الوقت بيقلل ال، في أمانcirculation فال
4. Cerebrovascular accidents take it note .. Protection وهما في العملية عشان كدا بيقولواIschemia يحصله
Minimally invasive cardiac surgery
1) Median sternotomy
2) Right sub-mammary thoracotomy 3) Mini-sternotomy 4) Limited left Ant. thoracotomy (MIDCAB)
ASD closure the most common J-shaped sternotomy for bypassing a stenosed left ant. Desc.coronary a
THE STANDARD APPROACH
Mitral valve surgery - Aortic valve surgery with left internal thoracic (mammary) a
disadvantages They yield small field that is insufficient in emergency situations
, Surgery for Valvular Heart Diseases
MS MR AS AR
Symptomatic patients with Symptomatic with chronic severe MR. Symptomatic with Symptomatic with
1. severe mitral stenosis 1. severe AS 1. severe AR
→ Mitral valve area ≤ 1.5 cm2 Asymptomatic patients with either; → Aortic valve area < 1 cm2 regardless LV sys. function
(↓ ex. Tolerance - exertional dyspnea) 1. chronic severe MR → mean valve gradient > 40 mmHg
Indications of surgery
2. AF (Exertional dyspnea& angina, syncope)
Asymptomatic patients with either; 3. ↑ P.HTN (PASP > 50 mmHg)
1. severe MS 4. LV dysfunction Asymptomatic with either; Asymptomatic with
(mitral valve area ≤1.5 cm2) (LVEF 30-60% and/or LVESD ≥40 mm) 1. severe AS 1. severe AR
2. severe LAE 2. LV dysfunction (LVEF <50 %) 2. LV dysfunction (LVEF <50 %)
3. ↑ P.HTN (PASP) >50 mmHg Acute MR with either; 3. ↓ exercise tolerance
1. CHF 4. ↓ in systemic Bl.P with exercise.
(normal M valve area = 4-6 cm2) 2. Cardiogenic shock
3. Papillary muscle rupture normal A valve area = (3-4 cm2)
Percutaneous balloon M valvuloplasty Mitral Valve Repair Aortic Valve Replacement
Mitral valve score (Wilkins Score) ≤ 8 1. Myxomatous degeneration of MV - Most patients with AR
Surgical procedures & it’s criteria
- Good leaflet pliability 2. Ischemic MR Aortic Valve Repair
- Minimal chordal thickening 3. Some cases of rheumatic etiology - has a limited role in aortic valve surgery (in selected cases).
- Intact subvalvular mechanism Mitral valve replacement Transcatheter aortic valve implantation (TAVI):
without concomitant MR overmild 1. If repair can not be accomblished - for high surgical risk patients
Don’t → in Lt atrial thrombus in heavily calcified annulus/valve Ozaki Procedure
Open mitral commissurotomy 2. Patients with MR due to RHD - Recently introduced,
1. mild calcification - Replace the 3 aortic leaflets with glutaraldehyde-treated pericardium.
2. mild leaflet/chordal thickening. Advantages of repair VS replacement
Mitral valve replacement 1. ↓ need for chronic anticoagulation.
1. moderate /severe calcification 2. ↓ prosthesis-related complications.
2. severely scarred leaflets or 3. ↓ rate of endocarditis.
subvalvular apparatus
Choice of Valve Prosthesis
Mechanical Valves Bioprosthetic valves
Designs : [Pics in the last page] Valve leaflets → [ porcine or bovine or human from fresh cadavers]
- Caged ball (Starr-Edwards)
- Tilting monoleaflet The valve is suspended on a prosthetic ring → allows it to be sewn in place
- Tilting bileaflet valves. (The commonly used)
↑ durability ↓ durability
↑ risk of thromboembolism (1-3%/year). ↓ risk of thromboembolism
↑term anticoagulation with warfarine is needed. Target INR: 2.5-3.5 ↓ or no need for long-termanticoagulation not needed.
↑ risk of hemorrhage: 1-2% /y ↓ risk of hemorrhage
—V
as
c
l
i
u
l
N
a
r
o
&C
a
t
r
d
e
i
a
s
c
—
s
ur
ge
ry
, Cardiac Operations
Extracardiac Operations. Closed Cardiac Operations Open Heart Surgery
Done on pericardium & main vessels Blind procedures performed by the finger of the During these operations the heart functionally
outside the heart without (CPB) surgeon or by an instrument placed inside the heart disconnected from the circulation → an artificial
Aortic coarctation repair MS : Closed mitral commissurotomy (Valvotomy) heart lung machine do their function temporarily
Examples [AP3C]
Pericardiectomy & Pericardio-pleural window (CPB, extracorporeal circulation)
PDA Ligation RARELY DONE in current era, performed under direct vision in a bloodless field
CHD : Palliative procedures replaced with open heart surgery techniques within the heart chambers or great vessels
or endovascular catheter-based procedures. Classically performed through : (approach)
median sternotomy → Dt` excellent exposure
Cardiopulmonary Bypass (CPB) —“heart–lung machine”
a technique that is temporarily divert blood from heart & lungs and supports the circulation .. when ?
Uses
Def
provide O2 & pump functions in the presence of a still bloodless heart In a heart surgery requiring arrested heart ± opening cardiac chambers
How to perform CPB ? [4 steps]
1. Heparinization: 2. Priming fluids ? why 3. Cannulation 4. Myocardial protection
Dose → 300 U/kg 1. ↑ peripheral circulation 1. Venous Cannulation: After aortic cross–clamping
reversed by → protamine sulfate 2. ↓ Blood viscosity. - Usually double cannulation: SVC + IVC CARDIOPLEGIC solution is injected either in/or :
after weaning from CPB and - (sometimes single cannulation in RA) Proximal Aorta (antegrade)
removal of cannula 2. Arterial Cannulation: Coronary sinus (retrograde)
- usually in Aorta
Cardioplagia
- (some cases in femoral artery)
1) High K+ content.
2) Cold crystalloid cardioplegia or warm bl. cardioplega
Complications of CPB Miscellaneous
Prolonged bypass induces cytokine activation → inflamm. Response results in : (CPB Time) : time from beginning CPB to → end
1. RBCs damage → haemoglobinuria Ischemic time: The time from aortic cross clamping till → aortic de clamping
2. Thrombocytopenia → Clotting abnormalities CPB فيعرفوا يشتغلوا و كدا كدا هما مركبينK بيعملوا شلل للقلب عن طريق انهم بيحقنواCardioplagia ال
3. ↓ pulmonary gas exchange فبيحمي القلب من إنMyocardium بتاع الO2 demand في نفس الوقت بيقلل ال، في أمانcirculation فال
4. Cerebrovascular accidents take it note .. Protection وهما في العملية عشان كدا بيقولواIschemia يحصله
Minimally invasive cardiac surgery
1) Median sternotomy
2) Right sub-mammary thoracotomy 3) Mini-sternotomy 4) Limited left Ant. thoracotomy (MIDCAB)
ASD closure the most common J-shaped sternotomy for bypassing a stenosed left ant. Desc.coronary a
THE STANDARD APPROACH
Mitral valve surgery - Aortic valve surgery with left internal thoracic (mammary) a
disadvantages They yield small field that is insufficient in emergency situations
, Surgery for Valvular Heart Diseases
MS MR AS AR
Symptomatic patients with Symptomatic with chronic severe MR. Symptomatic with Symptomatic with
1. severe mitral stenosis 1. severe AS 1. severe AR
→ Mitral valve area ≤ 1.5 cm2 Asymptomatic patients with either; → Aortic valve area < 1 cm2 regardless LV sys. function
(↓ ex. Tolerance - exertional dyspnea) 1. chronic severe MR → mean valve gradient > 40 mmHg
Indications of surgery
2. AF (Exertional dyspnea& angina, syncope)
Asymptomatic patients with either; 3. ↑ P.HTN (PASP > 50 mmHg)
1. severe MS 4. LV dysfunction Asymptomatic with either; Asymptomatic with
(mitral valve area ≤1.5 cm2) (LVEF 30-60% and/or LVESD ≥40 mm) 1. severe AS 1. severe AR
2. severe LAE 2. LV dysfunction (LVEF <50 %) 2. LV dysfunction (LVEF <50 %)
3. ↑ P.HTN (PASP) >50 mmHg Acute MR with either; 3. ↓ exercise tolerance
1. CHF 4. ↓ in systemic Bl.P with exercise.
(normal M valve area = 4-6 cm2) 2. Cardiogenic shock
3. Papillary muscle rupture normal A valve area = (3-4 cm2)
Percutaneous balloon M valvuloplasty Mitral Valve Repair Aortic Valve Replacement
Mitral valve score (Wilkins Score) ≤ 8 1. Myxomatous degeneration of MV - Most patients with AR
Surgical procedures & it’s criteria
- Good leaflet pliability 2. Ischemic MR Aortic Valve Repair
- Minimal chordal thickening 3. Some cases of rheumatic etiology - has a limited role in aortic valve surgery (in selected cases).
- Intact subvalvular mechanism Mitral valve replacement Transcatheter aortic valve implantation (TAVI):
without concomitant MR overmild 1. If repair can not be accomblished - for high surgical risk patients
Don’t → in Lt atrial thrombus in heavily calcified annulus/valve Ozaki Procedure
Open mitral commissurotomy 2. Patients with MR due to RHD - Recently introduced,
1. mild calcification - Replace the 3 aortic leaflets with glutaraldehyde-treated pericardium.
2. mild leaflet/chordal thickening. Advantages of repair VS replacement
Mitral valve replacement 1. ↓ need for chronic anticoagulation.
1. moderate /severe calcification 2. ↓ prosthesis-related complications.
2. severely scarred leaflets or 3. ↓ rate of endocarditis.
subvalvular apparatus
Choice of Valve Prosthesis
Mechanical Valves Bioprosthetic valves
Designs : [Pics in the last page] Valve leaflets → [ porcine or bovine or human from fresh cadavers]
- Caged ball (Starr-Edwards)
- Tilting monoleaflet The valve is suspended on a prosthetic ring → allows it to be sewn in place
- Tilting bileaflet valves. (The commonly used)
↑ durability ↓ durability
↑ risk of thromboembolism (1-3%/year). ↓ risk of thromboembolism
↑term anticoagulation with warfarine is needed. Target INR: 2.5-3.5 ↓ or no need for long-termanticoagulation not needed.
↑ risk of hemorrhage: 1-2% /y ↓ risk of hemorrhage
