Adult Cardiac Surgery Mahmoud ABUABEELEH Associate Professor Department

Adult Cardiac Surgery Mahmoud ABU-ABEELEH Associate Professor Department of Surgery Division of Cardiothoracic Surgery School of Medicine University Of Jordan

INTRODUCTION INDICATIONS FOR CARDIAC SURGERY HISTORY OF CARDIAC SURGERY CORONARY ARTERY ANATOMY ATHEROSCLEROSIS CAD DIAGNOSIS MANAGEMENT SURGICAL INDICATIONS /TECHNIQUES VALVULAR HEART DISEASES

Adult Cardiac Surgery: Ischemic Heart Disease (History) William Heberden- 1768 - described angina pectoris. Claude Beck 1930’s- sought to increase myocardial blood flow indirectly with pericardial fat and omentum. Arthur Vineberg 1940’s- Mobilization of left internal mammary artery with implantation of bleeding end into the left ventricle. 1964 - follow-up study on 140 patients 33% mortality 85% relief from angina

Adult Cardiac Surgery: Ischemic Heart Disease (History) John H. Gibbon, Jr. Heart-lung machine May 1953 - ASD closure

Adult Cardiac Surgery: Ischemic Heart Disease (History) KOLOSOV in Russia LIMA→LAD 1962 - David C. Sabiston, Jr. Aortocoronary saphenous vein bypass

Adult Cardiac Surgery: Ischemic Heart Disease (CABG) Early and widespread acceptance of coronary bypass was delayed. Best known cooperative studies (1970 -80’s) were the; VA Coronary Artery Surgery Study European Coronary Surgery Study

The Normal Heart - Coronary Artery Anatomy Left Main CA Layers of the Arterial Wall Circumflex Adventitia Media Intima Right CA Left Anterior Descending CA Marginal Branch Intima composed of endothelial cells

Pathogenesis of ACS

ATHEROSCLEROSIS

Risk Factors Uncontrollable Controllable • Sex • High blood pressure • Hereditary • High blood cholesterol • Race • Smoking • Age • Physical activity • Obesity • Diabetes • Stress and anger 12

Indications for open-heart surgery Coronary heart disease: (CABG) Triple vessel disease Lf main coronary artery disease Unstable angina , failed Mx therapy Complications of PTCA Life threatening complications of MI

Adult Cardiac Surgery: CABG Techniques Median sternotomy Cardiopulmonary bypass Cardioplegic arrest Mammary artery, reversed saphenous vein, radial artery Minimally access incisions (Port Access) “Off-pump”

Heart Lung Machine

Arterial vs Venous conduits

Anatomy of heart valves

Anatomy MV: 2 Cusps, Anterior and posterior The Ant is the larger AV: 3 semilunar cusps, ant (RT), post. Wall (LT and post) TV; 3 cusps, ant, septal , post. PV; 3 semilunar cusps one post. (lt) two ant( ant and

AVS tricuspid and bicuspid calcifications

Adult Cardiac Surgery: Valvular Heart Disease Aortic stenosis Age-related degenerative Mild AS: AVA > 1. 5 cm 2 ; Moderate 1 -1. 5 cm 2 ; Severe <1 cm 2 Indications for surgery largely based on symptoms Syncope, angina, dyspnea and CHF Aortic regurgitation Calcific aortic disease, idiopathic degenerative disease, endocarditis, rheumatic disease, bicuspid valve, aortic dissection, Marfan, etc. Indications for surgery Acute AR- inadequate time for ventricular compensation Chronic AR- symptoms, decreasing EF, LVEDD >75 mm, LVESD >55 mm

Pathophysiolgy of AS Except in the congenital forms, AS develops slowly The LV becomes increasingly hypertrophied, and coronary blood flow may become inadequate The fixed outflow obstruction limits the increase in C. O required on exercise. The progressive LV outflow obstruction results in increased LV mass. This increase in wall thickness is a compensatory mechanism to normalize LV wall stress

Symptoms of AS Exertional dyspnea Angina Pulmonary edema Exertional syncope Sudden death

Signs of AS Ejection systolic murmur Slow rising carotid pulse Reduce pulse pressure LV hypertrophy Signs of LV failure (crepitations, pulmonary edema)

Investigations ECG CXR ECHO CATH

ECHO criteria for assessment of aortic stenosis severity Mean gradient(mmhg) Aortic valve area (cm 2) mild <25 >1. 5 moderate 25 -50 1 -1. 5 severe >50 <1 critical >80 <0. 7

Recommendations for Aortic Valve Replacement in Aortic Stenosis Symptomatic patients with severe AS Patients with severe AS undergoing coronary artery bypass surgery Patients with severe AS undergoing surgery on the aorta or other heart valves Patients with moderate AS undergoing coronary artery bypass surgery or surgery on the aorta or other heart valves Asymptomatic patients with severe AS and the following;

Asymptomatic patients with severe AS and the following LV systolic dysfunction Abnormal response to exercise (e. g. hypotension) Ventricular tachycardia Marked or excessive LVH (>15 mm) Valve area <0. 6 cm 2 Prevention of sudden death in asymptomatic patients with none of the findings listed under asymptomatic patients with severe AS

Adult Cardiac Surgery: Valve Prostheses Mechanical Valves Caged-ball valves Tilting disc valves single leaflet bileaflet Tissue Valves Animal tissue (porcine aortic valves, bovine pericardium) Human tissue (Homografts, Autografts)

Mechanical valves ball and cage bileaflet

Mechanical valves tilting-disc valve

Bioprosthetic Valves Aortic homograft Human tissue valves autograft homograft Animal tissue valves Heterograft or xenograft

Adult Cardiac Surgery

How to choose a valve Mechanical valve in patients < 65 years. Tissue valves in patients > 65 years Tissue valves in patients whose life expectancy is < 10 year Tissue valve in patients who have problems which are likely to cause life threatening bleeding.

Adult Cardiac Surgery: Aortic Valve Replacement Median sternotomy, hemi-sternotomy Cardiopulmonary bypass Cardioplegic arrest Excision of the valve Debridement Implantation

Adult Cardiac Surgery: ACC/AHA Aortic position Bileaflet- INR of 2 -3 Other disk valves and Starr-Edwards- INR 2. 5 -3. 5 In patients with higher risk of TE, INR 2. 5 -3. 5 with addition of aspirin 80 -100 mg/d. (AF, ↓EF, prior TE, hypercoagulable state) Mitral position All- INR 2. 5 -3. 5

Adult Cardiac Surgery: ACC/AHA Tissue prosthesis Anticoagulation recommended in first 3 months, although aspirin alone in aortic position in some centers. INR 2. 5 -3. 5 After 3 months, discontinue unless other circumstances

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