Mahmoud ABU-ABEELEHMahmoud ABU-ABEELEHAssociate ProfessorAssociate Professor

Department of SurgeryDepartment of SurgeryDivision of Cardiothoracic SurgeryDivision of Cardiothoracic Surgery

School of Medicine School of MedicineUniversity Of JordanUniversity Of Jordan

Adult Cardiac SurgeryAdult Cardiac Surgery

Adult Cardiac Surgery: Ischemic Heart Disease (History)Adult Cardiac Surgery: Ischemic Heart Disease (History)

William Heberden- 1768- described angina pectoris.

Claude BeckClaude Beck

1930’s- sought to increase myocardial blood flow indirectly with pericardial fat and omentum.

Arthur VinebergArthur 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)Adult Cardiac Surgery: Ischemic Heart Disease (History)

John H. Gibbon, Jr.John H. Gibbon, Jr.

Heart-lung machine May 1953- ASD closure

Adult Cardiac Surgery: Ischemic Heart Disease (History)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

Adult Cardiac Surgery: Ischemic Heart Disease (CABG)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

CCoronary AArtery SSurgery SStudy

European Coronary Surgery Study

Intima

Adventitia

Media

The Normal Heart - Coronary Artery Anatomy

Left Main CA

Circumflex

Left Anterior Descending CA

Right CA

Marginal Branch

Layers of the Arterial Wall

Intima composed of endothelial cells

Pathogenesis of ACS

ATHEROSCLEROSIS

Risk Factors

UncontrollableUncontrollableUncontrollableUncontrollable

11

•Sex

•Hereditary

•Race

•Age

ControllableControllableControllableControllable

•High blood pressure

•High blood cholesterol

•Smoking

•Physical activity

•Obesity

•Diabetes

•Stress and anger

Indications for open-heart surgery

Coronary heart disease: (CABG)Triple vessel diseaseLf main coronary artery diseaseUnstable angina ,failed Mx therapyComplications of PTCALife threatening complications of MI

Adult Cardiac Surgery: CABG TechniquesAdult Cardiac Surgery: CABG Techniques

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

Adult Cardiac Surgery: CABG TechniquesAdult Cardiac Surgery: CABG Techniques

Heart Lung Machine

Anatomy of heart valves

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)

AVS tricuspid and bicuspid calcifications

Adult Cardiac Surgery: Valvular Heart DiseaseAdult Cardiac Surgery: Valvular Heart Disease

Aortic stenosis-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-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

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

(cm2)

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 cm2

Prevention of sudden death in asymptomatic patients with none of the findings listed under asymptomatic patients with severe AS

Adult Cardiac Surgery: Valve ProsthesesAdult 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 SurgeryAdult Cardiac Surgery

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.

Adult Cardiac Surgery: Aortic Valve ReplacementAdult Cardiac Surgery: Aortic Valve Replacement

Median sternotomy, hemi-sternotomy Cardiopulmonary bypass Cardioplegic arrest Excision of the valve Debridement Implantation

Adult Cardiac Surgery: ACC/AHAAdult 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

Adult Cardiac Surgery: ACC/AHAAdult 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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