CARDIAC SURGERIES

Prepared by: Mrs. Theresa Margarita Marivee L. Saldevar

BRIEF HISTORY
1801 - Francisco Romero is credited with the first attempted cardiac surgery. Romero unsuccessfully attempted to perform an open pericardiostomy 4th of September 1895 - The German doctor Ludwig Wilhelm Carl Rehn (1849 to 1930) is credited with performing the first successful heart surgery that involved sutures. December of 1967 - Dr. Christiaan Barnard, a surgeon from South Africa, completed the first successful heart transplant.

SURGICAL APPROACHES
Open Heart Surgery Modified Partial Sternotomy Surgeries with Smaller Incisions or Minimally Invasive Heart Surgery

TRADITIONAL FULL STERNOTOMY

involves making an incision in the middle of the chest from the top of the sternum to the bottom the entire rib cage is opened and the heart muscle is fully exposed The patient is placed on heartlung bypass which allows oxygenated blood to circulate to the body while it bypasses the heart

TRADITIONAL FULL STERNOTOMY

Advantages: The benefit of a full sternotomy is full exposure. Disadvantages: The disadvantages are a longer recovery period for the patient and significant musculo-skeletal discomfort. There is also higher risk of stroke, kidney damage and bleeding when a patient is placed on a heart-lung bypass machine.

FULL STERNOTOMY BUT WITH AN "OFF BYPASS"

the patient will still experience the same musculo-skeletal insult, he/she will not be placed on the heart lung machine the surgeon performs the bypass on a beating heart utilizing a stabilizing instrument

FULL STERNOTOMY BUT WITH AN "OFF BYPASS"

Indication: The "off bypass" approach is recommended for patients with a highly calcified aorta. Placing a patient with highly calcified lesions onto bypass involves passing cannulae through vessels.

FULL STERNOTOMY BUT WITH AN "OFF BYPASS"

Contraindication: "Off bypass" is not recommended for a patient with a weakened heart muscle. As mentioned above, this approach places stress on the heart and is, therefore, not well tolerated by this group of patients. Since the operation is done on a beating heart, patients requiring valve repair or replacement are not candidates for this procedure.

MODIFIED PARTIAL STERNOTOMY

A partial sternotomy can be performed when limited exposure is adequate. Indications: 1. Used for valve surgery (done with a midline incision of approximately four inches in length with disruption of only about half of the sternum) 2. Can also be done for coronary surgery (the incision begins at the bottom of the chest bone and stops at the third rib)

Surgeries with Smaller Incisions or Minimally Invasive Heart Surgery

This approach offers many benefits over traditional heart surgery. These include: Smaller incisions with little scarring Less pain Minimal blood loss and less need for transfusion Greatly reduced risk for infection Faster return to normal activities Shorter hospital stay

Surgeries with Smaller Incisions or Minimally Invasive Heart Surgery

Heart surgeries that may be done using minimally invasive techniques include: Coronary bypass surgery possible when only one or two bypass grafts is needed ASD/PFO closure a technique to close a hole in the septum (wall) between the atria, the two upper chambers of the heart. The hole an atrial septal defect (ASD) or a patent foramen ovale (PFO) is a congenital defect. Atrial fibrillation (arrhythmia) ablation to correct an abnormal heart rhythm Mitral valve surgery to repair or replace the mitral valve Aortic valve surgery to repair or replace the aortic valve

Types of Minimally Invasive Heart Surgery:

Minimally Invasive Direct Coronary Artery Bypass (MIDCAB)

Portal Access Surgery Robotic-Assisted Heart Surgery

Minimally Invasive Direct Coronary Artery Bypass (MIDCAB)

It involves a small incision usually on the left anterior portion of the chest wall between the third and fourth or fourth and fifth rib This surgery is usually reserved for patients with single or double vessel disease with the blocked vessels being located on the anterior portion of the heart as these vessels are more easily accessed by the surgeon

Portal Access Surgery

is a method of surgery consisting of catheters and cannulae that allows the surgeon to put the patient on bypass. The heart is stopped and your blood is pumped through an oxygenator or "heart-lung" machine to receive oxygen during the surgery. This is called "cardiopulmonary bypass." Then several small holes or "ports" are made in your chest. The surgical team passes instruments through the ports to perform the bypasses, with or without another small chest incision. The cardiac surgeon views these operations on video monitors rather than directly.

Robotic-Assisted Heart Surgery

One type of minimally invasive heart surgery that's still being developed is robotic-assisted surgery. For this surgery, a surgeon uses a computer to control surgical tools on thin robotic arms. The tools are inserted through small incisions in the chest. This allows the surgeon to do complex and highly precise surgery. The surgeon always is in total control of the robotic arms; they don't move on their own.

TYPES OF CARDIAC SURGERY

Coronary artery bypass grafting Valve surgery Vascular surgery Arrhythmia (atrial fibrillation) surgery Heart transplant surgery

CORONARY ARTERY BYPASS GRAFTING

During CABG, a surgeon takes a vein or an artery from your chest, leg or another part of your body and connects, or grafts, it to the blocked artery. The grafted artery bypasses the blockage

Indications: patients with severe angina from atherosclerosis and others with CAD who have a risk of MI

CARDIAC VALVE SURGERY

Heart valve surgery is used to repair or replace diseased heart valves.

Types of Valve Surgery:

Open surgery Minimally invasive valve surgery 1.LaparoscopyLaparoscopy or endoscopyendoscopy 2.Percutaneous surgery (through the skin) 3.Robot-assisted surgery

Types of Valve Surgery:

Ring annuloplasty -- The surgeon repairs the ring-like part around the valve by sewing a ring of metal, cloth, or tissue around the valve. Valve repair -- The surgeon trims, shapes, or rebuilds one or more of the leaflets of the valve. The leaflets are flaps that open and close the valve.

Two main types of new valves:

Mechanical -- made of man-made materials, such as cloth, metal (stainless steel or titanium), or ceramic.

Biological -- made of human or animal tissue. These valves last 12 - 15 years

Heart valve problems treated with surgery:

Aortic insufficiency Aortic stenosis Mitral regurgitation Mitral stenosis Mitral valve prolapse Pulmonary valve stenosis Tricuspid regurgitation

VASCULAR SURGERY
is a specialty of surgery in which diseases of the vascular system, or arteries and veins, are managed by medical therapy, minimally-invasive catheter procedures, and surgical reconstruction

VASCULAR SURGERY
Indications: Arterial diseases: Aneurysms, Ischemia, peripheral artery occlusive disease, Diabetic foot ulcers Venous diseases: Deep Vein Thrombosis, Thrombophlebitis, Varicose Veins and Varicosities, Venous malformations Medical disorders with a significant vascular components, for example: Raynaud's syndrome, Scleroderma, Hyperhidrosis

VASCULAR SURGERY
Types: Aneurysm resection - aneurysm will be removed and the damaged portion of your blood vessel will be replaced with a man-made graft Grafting of aneurysm - Some aortic aneurysms can be repaired without traditional surgery, using endovascular aortic repair. A tube called a stent graft is inserted through an artery in the groin. The stent graft makes a bridge between the healthy parts of the aorta (above and below the aneurysm).

VASCULAR SURGERY
Types: Embolectomy - is the emergency surgical removal of emboli which are blocking blood circulation Endarterectomy - is a surgical procedure to remove the atheromatous plaque material, or blockage, in the lining of an artery constricted by the buildup of soft/hardening deposits. It is carried out by separating the plaque from the arterial wall

ARRHYTHMIA SURGERY
An arrhythmia is a problem with the rate or rhythm of the heartbeat. Types of Surgery: 1.Pacemaker 2.Implantable Cardioverter Defibrillator 3.Maze Surgery

PACEMAKER

A pacemaker is a small device that's placed under the skin of your chest or abdomen. Wires connect the pacemaker to your heart chambers. The pacemaker sends electrical signals through the wires to control your heart rhythm.

Implantable Cardioverter Defibrillator

An Implantable Cardioverter Defibrillator is another small device that's placed in your chest or abdomen. This device also is connected to your heart with wires. An ICD checks your heartbeat for dangerous arrhythmias. If it senses one, it sends an electric shock to your heart to restore a normal heart rhythm.

MAZE SURGERY

During the surgery, the surgeon makes a number of small incisions in both of the heart's upper chambers. To make the incisions, surgeons can use a sharp surgical knife called a scalpel, a cryoablation device that destroys tissue by freezing it, or a radiofrequency device that destroys tissue using radiofrequency energy (like microwave heat). Some surgeons use a combination of techniques to make the incisions. The incisions are made in a certain pattern, like a maze, that will direct the heart's electrical impulses straight to the heart's lower chambers.

CARDIAC TRANSPLANT
Hearts transplants, or cardiac transplantation, is a surgical transplant procedure performed on patients with end-stage heart failure or severe coronary artery disease. The most common procedure is to take a working heart from a recently deceased organ donor (allograft) and implant it into the patient. The patient's own heart may either be removed (orthotopic procedure) or, less commonly, left in to support the donor heart (heterotopic procedure)

Contraindications of Heart Transplant:

Kidney, lung, or liver disease Insulin-dependent diabetes with other organ dysfunction Life-threatening diseases unrelated to heart failure Vascular disease of the neck and leg arteries. High pulmonary vascular resistance Recent thromboembolism Age over 60 years Alcohol, tobacco or drug abuse

PROCEDURE - Preoperative
Typical heart transplantation begins with a suitable donor heart being located from a recently deceased or brain dead donor, also called a beating heart cadaver. The heart is removed from the donor and inspected by a team of surgeons to see if it is in a suitable condition to be transplanted. The patient must also undergo many emotional, psychological, and physical tests to make sure that they are in good mental health and will make good use of their new heart.

PROCEDURE - Operative
the patient is taken into the operating room and given a general anesthetic

Either an orthotopic or a heterotopic procedure is followed

PROCEDURE - Post-operative
The patient is taken into ICU to recover When they wake up, they will be transferred to a special recovery unit in order to be rehabilitated Once the patient is released, they will have to return to the hospital for regular check-ups and rehabilitation sessions The patient will have to remain on lifetime immunosuppressant medication to avoid the possibility of rejection

NURSING CARE FOR CARDIAC SURGERIES

Patient Preparation Monitoring and Aftercare Home Care Instructions

Patient Preparation
Perform and document extensive assessment Reinforce the doctors explanation of the surgery for the patient Restrict food and fluids after midnight Provide pre-operative medications

Monitoring and Aftercare

The top priority is to keep him hemodynamically stable so his vital organs are adequately perfused Assess cardiopulmonary function Provide analgesia and non-pharmacologic methods of relieving pain. Administer I.V. push opioids in the immediate postoperative period, then switch to oral forms by the second or third postoperative day Monitor post-operative complications, such as stroke, pulmonary embolism, pneumonia and impaired renal function. Gradually allow the patient to increase activities, as ordered Monitor the incision site for signs of infection or drainage Provide emotional support

Home Care Instructions

Watch for and immediately notify the doctor for any signs of infection or possible arterial reocclusion Call the doctor in case of weight gain greater than 3 lb in 1 week Follow the prescribed diet low sodium and cholesterol Maintain a balance between activity and rest Follow exercise program Follow lifestyle modification Perform coughing and deep breathing exercises Make sure the patient understands the prescribed medications Avoid certain things for eight to 12 weeks to reduce the risk of opening the incision