Adult Cardiac Surgery

1. Mahmoud ABU-ABEELEHAssociate ProfessorDepartment of SurgeryDivision of Cardiothoracic Surgery School of MedicineUniversity Of Jordan Adult Cardiac Surgery

2. 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

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

5. Adult Cardiac Surgery: Ischemic Heart Disease (History) • KOLOSOV in Russia LIMA→LAD • 1962- David C. Sabiston, Jr.- • Aortocoronary saphenous vein bypass • Rene Favaloro • Cleveland Clinic • Frank Spencer/George Green • Internal mammary artery

6. 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

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

9. Pathogenesis of ACS

10. ATHEROSCLEROSIS

11. Risk Factors Controllable Uncontrollable • Sex • Hereditary • Race • Age • High blood pressure • High blood cholesterol • Smoking • 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

13. 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”

15. Adult Cardiac Surgery: CABG Techniques

17. Heart Lung Machine

22. Anatomy of heart valves

23. Anatomy • MV: • 2Cusps, Anterior and posterior • The Ant is the larger • Intervenes bet. A-V and aortic orifice • AV: • 3 semilunar cusps, ant (RT), post. Wall (LT and post) • TV; • 3cusps, ant, septal ,post. • PV; • 3 semilunar cusps one post. (lt) two ant( ant and rt)

24. AVS tricuspid and bicuspid calcifications

25. Adult Cardiac Surgery: Valvular Heart Disease • Aortic stenosis- • Age-related degenerative • Mild AS: AVA > 1.5cm2 ; Moderate 1-1.5cm2 ; Severe <1cm2 • 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 >75mm, LVESD >55mm

26. 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

27. Symptoms of AS • Exertional dyspnea • Angina • Pulmonary edema • Exertional syncope • Sudden death

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

29. Investigations • ECG • CXR • ECHO • CATH

30. ECHO criteria for assessment of aortic stenosis

31. Recommendations for Aortic Valve Replacement in Aortic Stenosis

32. Asymptomatic patients with severe AS and the following

33. 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)

34. Mechanical valvesball and cage bileaflet

35. Mechanical valvestilting-disc valve

36. Bioprosthetic ValvesAortic homograft • Human tissue valves • autograft • homograft • Animal tissue valves • Heterograft or xenograft

37. Adult Cardiac Surgery

38. How to choose a valve • Mechanical valve in patients < 65years. • 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.

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

41. 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 80-100mg/d. (AF, ↓EF, prior TE, hypercoagulable state) • Mitral position • All- INR 2.5-3.5

42. 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

43. THANK YOU