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CardiaC OperatiOns
and CardiOpulmOnary
bypass
prOf. ahmed deebis
head Of CardiOthOraCiC surgery
department- ZagaZig university
Cardiac Operations
Types of cardiac operations
1- Extracardiac Operations
2- Closed Cardiac Operations
3-Open Heart Surgery
1- Extracardiac Operations
• Carried out on the main vessels outside the
heart
• Usually performed without cardiopulmonary
bypass
• Examples:
Pericardiectomy,
Ligation of patent ductus arteriosus,
Repair of aortic coarctation
Palliative procedures for congenital heart diseases
2- Closed Cardiac Operations
• Blind procedures performed by the finger of
the surgeon or by an instrument placed inside
the heart
• Examples:
closed mitral commissurotomy (valvotomy )for
mitral stenosis
• These operations are rarely done in current
era, and have replaced with open heart
surgery techniques or endovascular catheter-
based procedures.
3-Open Heart Surgery
• During these operations the heart functionally
disconnected from the circulations,
an artificial heart lung machine (cardiopulmonary
bypass, extracorporeal circulation) do the function of
the heart and the lung temporarily
• The operations performed under direct vision in a
bloodless field within the chambers of the heart or
great vessels
• Classically performed through median sternotomy
excellent exposure
Cardiopulmonary Bypass (CPB)
OR
“heart–lung machine”
Cardiopulmonary Bypass (CPB)
• Definition:
CPB is a technique that temporarily diverting
blood from heart and lungs and provides
oxygenation and pump functions in the
presence of a still bloodless heart.
• Uses:
CPB is used in heart surgery requiring arrested
heart either with or without opening of
cardiac chambers to support the circulation
during that period.
Cardiopulmonary Bypass (CPB), cont.
• Haw?
1) Heparinization, 2) Using priming fluids,
3) Cannulation, and 4) Myocardial protection
• 1) Heparinization:
heparin dose of 300 U/kg (reversed by protamine
sulfate after weaning from CPB and removal of
cannulae)
• 2) Using priming fluids:
to augment peripheral circulation and to decrease
blood viscosity
Cardiopulmonary Bypass (CPB), cont.
3) Cannulation:
1) Arterial Cannulation:
cannula is inserted usually
in Aorta (some cases in
femoral artery)
2) Venous Cannulation:
usually double cannulation
in SVC and IVC
(sometimes single
cannulation in R.A)
Cardiopulmonary Bypass (CPB), cont.
4) Myocardial protection
• After aortic cross–clamping cardioplegic solution
injected either in proximal Aorta (antegrade), Or in
coronary sinus (retrograde).
Cardioplegia
• 1) Cold, Tepid or Iced.
Recently there is also warm blood cardioplegia which
is mainly used in our center.
• 2) High potassium (K) content.
• N.B The time from beginning CPB to its end is called CPB
Time, while time from aortic cross clamping till aortic de-
clamping is called ischemic time.
Cardiopulmonary Bypass (CPB), cont.
Complications of cardiopulmonary bypass:
• Prolonged bypass induces cytokine activation
and inflammatory response results in:
red cell damage and haemoglobinuria,
thrombocytopenia,
clotting abnormalities,
Reduced pulmonary gas exchange, and
Cerebrovascular accidents
Minimal invasive cardiac Surgery
• Median sternotomy is the standard approach for
open heart surgery,
• But ,also other approaches can be used as
i) Right sbumammary thoracotomy for ASD closure
and mitral valve surgery,
ii) Limited left anterior thoracotomy for bypassing a
stenosed left anterior descending coronary artery
with left internal thoracic( mammary) artery.
• The main disadvantage of these incisions is the small
field they yield, that is insufficient in emergency
situations.
Surgery for
ValVular Heart
DiSeaSeS
Prof. aHmeD DeebiS
HeaD of CarDiotHoraCiC
Surgery DePartment.
ZagaZig uniVerSity
Valvular Anatomy
Types of Valve Disease
• Valvular heart diseases includes valvular
stenosis and valvular regurgitation
(incompetence) or both
 Valvular stenosis: When a valve opening is smaller
than normal
 Valvular regurge : occurs when a valve does not
close tightly, thus allowing blood to leak
backwards.
Both valvular diseases can involve all four valves
What Are The Causes Valvular
Disease?
• Congenital : Mostly affect the aortic or
pulmonary valve
• Acquired : Due to a variety of diseases or
infections leading to changes in the structure
of the valve as:
Rheumatic fever , Endocarditis, Coronary
artery disease, Myxomatous degeneration
Cardiomyopathy (heart muscle disease), or
Connective tissue diseases
Rheumatic heart diseases are the commonest cardiac
lesions in Egypt.
• Chronic stage of rheumatic heart disease
produce permanent dysfunction, in the form
of valvular stenosis, valvular incompetence or
both.
• The most affected valve is the mitral valve
followed by the aortic valve.
• Rheumatic tricuspid valve lesions are rare and
rheumatic pulmonary valve lesions are
extremely rare.
Diagnosis
Clinically : Symptoms & Signs.
Chest X-ray & ECG
Trans-thoracic Echocardiography (TTE): routinely for
diagnosis of valvular heart lesions & to assess the
severity of the lesions.
Trans-esophageal Echocardiography (TEE): detection of
thrombotic or vegetative deposits, and malfunctioning
prosthetic valve.
Coronary angiography:
indicated to detect associated coronary artery lesions in
patients over 40 years of age.
Mitral Stenosis
• Almost caused by rheumatic heart disease.
• Progressive obstruction of the mitral valve causes
increased L A pressure reflected to the
pulmonary circulation ---- pulmonary
Hypertension.
• Common symptoms : Congestive symptoms
(dyspnea on exertion, orthopnea and paroxysmal
nocturnal dyspnea), Palpitation, hemoptysis.
• May be complicated with AF , may lead to LA
thrombus formation & thromboembolism
Indications for Surgery in MS
• Sever mitral stenosis with mitral valve area
less than 1.2 cm2 (normally 4-6 cm2).
• Moderate mitral stenosis with paroxysmal
nocturnal dyspnea, or orthopnea despite
adequate medical therapy.
• History of A F and/or systemic emboli (from
LA thrombus)
• Worsening pulmonary hypertension
Surgical Options for M S
Percutaneous balloon mitral valvuloplasty:
• Needs good leaflet pliability, minimal chordal
thickening and intact subvalvular mechanism.
• Contraindicated if left atrial thrombus present.
Open mitral commissurotomy
• For patients with mild calcification and mild
leaflet/chordal thickening.
Mitral valve replacement
• For moderate to severe calcification with severely
scarred valve leaflets or subvalvular apparatus
Mitral Regurgitation
• Primarily caused by rheumatic heart disease, but
may be congenital, infective endocarditis , ischemic
heart disease, or myxomatous degeneration
• Blood flows back into the left atrium during systole
• During diastole the regurge output flows into the LV
and increases the volume into the LV
• Progression is slowly – fatigue, chronic weakness,
dyspnea, anxiety, palpitations
• May develop AF and LV failure
• May develop right sided failure as well
The New York Heart Association (NYHA) Functional
Classification
N.B.: Heart disease must be present
Symptoms (undue fatigue, palpitations, dyspnea and/or anginal pain)
Indications for surgery in MR
• Patients in NYHA class III-IV
• Patients in NYHA class I-II symptoms with
onset of AF or evidence of deteriorating LV
function.
• Acute MR associated with CHF, cardiogenic
shock, or papillary muscle rupture
Surgical Options for MR
Mitral Valve Repair:
• Myxomatous degeneration of the MV is ideal for
repair.
• Ischemic mitral regurge
• Selected cases of rheumatic etiology.
Mitral valve replacement
• If satisfactory repair can not be accomblished
(heavily calcified annulus, or valve)
• Patients with MR due to rheumatic heart disease are
more likely to need MV replacement
Advantages of valve repair versus
replacement
• Lack of need for chronic anticoagulation.
• Elimination of prosthesis-related complications.
• Low rate of endocarditis.
Aortic Valve Disease
• Most patients with aortic valve disease
indicated for surgery require aortic valve
replacement.
• Aortic valve repair had a limited role in aortic
valve surgery ( only in selected cases).
Indications for surgery for Aortic
Stenosis(AS)
• Symptomatic patients with mean valve gradient
of over 50 mmHg or valve area less than 0.8
cm2 (normal 3-4 cm2).
• Asymptomatic patients with significant stenosis
and Left Ventricular Hypertrophy(LVH).
Indications for surgery for Aortic
Regurgitation (AR)
• Patients in NYHA class III-IV symptoms,
• Evidence of Left Ventricular decompensation
in asymptomatic patient (Echo Data)
Ejection Fraction (EF) less than 55%,
End-diastolic dimension of the left ventricle more
than 70 mm,
End-systolic dimension of the left ventricle
more than 55 mm
Choice of Valve Prosthesis
2types of prosthetic valves, mechanical Valves
and bioprosthetic valves
Mechanical Valves
These have many designs, e.g.,
•Caged ball (Starr-Edwards),
•Tilting monoleaflet, and
•Tilting bileaflet valves.
•The commonly used now are the tilting bileaflet valves.
•The patients should be anticoagulated usually with
warfarine with a target INR between 2.5 to 3.5.
Bioprosthetic valves
•Valve leaflets are either
porcine, bovine, or human
from fresh cadavers.
•The valve is suspended on a
prosthetic ring to allow it to be
sewn in place.
•The patient does not need
long-term anticoagulation,
but the durability of the valve
is shorter than prosthetic
valves.
Common types of heart valve prostheses:
Bileaflet (top left); Starr-Edwards ball and cage (top right);
tilting monoleaflet disc (bottom right); stented porcine prosthesis (bottom left).
Mechanical Valve vs. Bioprosthetic
Valve
Mechanical Valve
 Long durability
 Long-term anticoagulation
with warfarine. Target INR:
2.5-3.5
 Increased risk of
thromboembolism (1-
3%/year).
 Increased risk of
hemorrhage: 1-2% /year
Bioprosthetic Valve
 Short durability
 Usually long-term
anticoagulation not needed.
 Low risk of
thromboembolism
 Low risk of hemorrhage
Thank You

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Cardiopulmonary Bypass and Valvular Surgery

  • 1. CardiaC OperatiOns and CardiOpulmOnary bypass prOf. ahmed deebis head Of CardiOthOraCiC surgery department- ZagaZig university
  • 2. Cardiac Operations Types of cardiac operations 1- Extracardiac Operations 2- Closed Cardiac Operations 3-Open Heart Surgery
  • 3. 1- Extracardiac Operations • Carried out on the main vessels outside the heart • Usually performed without cardiopulmonary bypass • Examples: Pericardiectomy, Ligation of patent ductus arteriosus, Repair of aortic coarctation Palliative procedures for congenital heart diseases
  • 4. 2- Closed Cardiac Operations • Blind procedures performed by the finger of the surgeon or by an instrument placed inside the heart • Examples: closed mitral commissurotomy (valvotomy )for mitral stenosis • These operations are rarely done in current era, and have replaced with open heart surgery techniques or endovascular catheter- based procedures.
  • 5. 3-Open Heart Surgery • During these operations the heart functionally disconnected from the circulations, an artificial heart lung machine (cardiopulmonary bypass, extracorporeal circulation) do the function of the heart and the lung temporarily • The operations performed under direct vision in a bloodless field within the chambers of the heart or great vessels • Classically performed through median sternotomy excellent exposure
  • 7. Cardiopulmonary Bypass (CPB) • Definition: CPB is a technique that temporarily diverting blood from heart and lungs and provides oxygenation and pump functions in the presence of a still bloodless heart. • Uses: CPB is used in heart surgery requiring arrested heart either with or without opening of cardiac chambers to support the circulation during that period.
  • 8. Cardiopulmonary Bypass (CPB), cont. • Haw? 1) Heparinization, 2) Using priming fluids, 3) Cannulation, and 4) Myocardial protection • 1) Heparinization: heparin dose of 300 U/kg (reversed by protamine sulfate after weaning from CPB and removal of cannulae) • 2) Using priming fluids: to augment peripheral circulation and to decrease blood viscosity
  • 9. Cardiopulmonary Bypass (CPB), cont. 3) Cannulation: 1) Arterial Cannulation: cannula is inserted usually in Aorta (some cases in femoral artery) 2) Venous Cannulation: usually double cannulation in SVC and IVC (sometimes single cannulation in R.A)
  • 10. Cardiopulmonary Bypass (CPB), cont. 4) Myocardial protection • After aortic cross–clamping cardioplegic solution injected either in proximal Aorta (antegrade), Or in coronary sinus (retrograde). Cardioplegia • 1) Cold, Tepid or Iced. Recently there is also warm blood cardioplegia which is mainly used in our center. • 2) High potassium (K) content. • N.B The time from beginning CPB to its end is called CPB Time, while time from aortic cross clamping till aortic de- clamping is called ischemic time.
  • 11. Cardiopulmonary Bypass (CPB), cont. Complications of cardiopulmonary bypass: • Prolonged bypass induces cytokine activation and inflammatory response results in: red cell damage and haemoglobinuria, thrombocytopenia, clotting abnormalities, Reduced pulmonary gas exchange, and Cerebrovascular accidents
  • 12. Minimal invasive cardiac Surgery • Median sternotomy is the standard approach for open heart surgery, • But ,also other approaches can be used as i) Right sbumammary thoracotomy for ASD closure and mitral valve surgery, ii) Limited left anterior thoracotomy for bypassing a stenosed left anterior descending coronary artery with left internal thoracic( mammary) artery. • The main disadvantage of these incisions is the small field they yield, that is insufficient in emergency situations.
  • 13. Surgery for ValVular Heart DiSeaSeS Prof. aHmeD DeebiS HeaD of CarDiotHoraCiC Surgery DePartment. ZagaZig uniVerSity
  • 15. Types of Valve Disease • Valvular heart diseases includes valvular stenosis and valvular regurgitation (incompetence) or both  Valvular stenosis: When a valve opening is smaller than normal  Valvular regurge : occurs when a valve does not close tightly, thus allowing blood to leak backwards. Both valvular diseases can involve all four valves
  • 16. What Are The Causes Valvular Disease? • Congenital : Mostly affect the aortic or pulmonary valve • Acquired : Due to a variety of diseases or infections leading to changes in the structure of the valve as: Rheumatic fever , Endocarditis, Coronary artery disease, Myxomatous degeneration Cardiomyopathy (heart muscle disease), or Connective tissue diseases
  • 17. Rheumatic heart diseases are the commonest cardiac lesions in Egypt. • Chronic stage of rheumatic heart disease produce permanent dysfunction, in the form of valvular stenosis, valvular incompetence or both. • The most affected valve is the mitral valve followed by the aortic valve. • Rheumatic tricuspid valve lesions are rare and rheumatic pulmonary valve lesions are extremely rare.
  • 18. Diagnosis Clinically : Symptoms & Signs. Chest X-ray & ECG Trans-thoracic Echocardiography (TTE): routinely for diagnosis of valvular heart lesions & to assess the severity of the lesions. Trans-esophageal Echocardiography (TEE): detection of thrombotic or vegetative deposits, and malfunctioning prosthetic valve. Coronary angiography: indicated to detect associated coronary artery lesions in patients over 40 years of age.
  • 19. Mitral Stenosis • Almost caused by rheumatic heart disease. • Progressive obstruction of the mitral valve causes increased L A pressure reflected to the pulmonary circulation ---- pulmonary Hypertension. • Common symptoms : Congestive symptoms (dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea), Palpitation, hemoptysis. • May be complicated with AF , may lead to LA thrombus formation & thromboembolism
  • 20. Indications for Surgery in MS • Sever mitral stenosis with mitral valve area less than 1.2 cm2 (normally 4-6 cm2). • Moderate mitral stenosis with paroxysmal nocturnal dyspnea, or orthopnea despite adequate medical therapy. • History of A F and/or systemic emboli (from LA thrombus) • Worsening pulmonary hypertension
  • 21. Surgical Options for M S Percutaneous balloon mitral valvuloplasty: • Needs good leaflet pliability, minimal chordal thickening and intact subvalvular mechanism. • Contraindicated if left atrial thrombus present. Open mitral commissurotomy • For patients with mild calcification and mild leaflet/chordal thickening. Mitral valve replacement • For moderate to severe calcification with severely scarred valve leaflets or subvalvular apparatus
  • 22. Mitral Regurgitation • Primarily caused by rheumatic heart disease, but may be congenital, infective endocarditis , ischemic heart disease, or myxomatous degeneration • Blood flows back into the left atrium during systole • During diastole the regurge output flows into the LV and increases the volume into the LV • Progression is slowly – fatigue, chronic weakness, dyspnea, anxiety, palpitations • May develop AF and LV failure • May develop right sided failure as well
  • 23. The New York Heart Association (NYHA) Functional Classification N.B.: Heart disease must be present Symptoms (undue fatigue, palpitations, dyspnea and/or anginal pain)
  • 24. Indications for surgery in MR • Patients in NYHA class III-IV • Patients in NYHA class I-II symptoms with onset of AF or evidence of deteriorating LV function. • Acute MR associated with CHF, cardiogenic shock, or papillary muscle rupture
  • 25. Surgical Options for MR Mitral Valve Repair: • Myxomatous degeneration of the MV is ideal for repair. • Ischemic mitral regurge • Selected cases of rheumatic etiology. Mitral valve replacement • If satisfactory repair can not be accomblished (heavily calcified annulus, or valve) • Patients with MR due to rheumatic heart disease are more likely to need MV replacement
  • 26. Advantages of valve repair versus replacement • Lack of need for chronic anticoagulation. • Elimination of prosthesis-related complications. • Low rate of endocarditis.
  • 27. Aortic Valve Disease • Most patients with aortic valve disease indicated for surgery require aortic valve replacement. • Aortic valve repair had a limited role in aortic valve surgery ( only in selected cases).
  • 28. Indications for surgery for Aortic Stenosis(AS) • Symptomatic patients with mean valve gradient of over 50 mmHg or valve area less than 0.8 cm2 (normal 3-4 cm2). • Asymptomatic patients with significant stenosis and Left Ventricular Hypertrophy(LVH).
  • 29. Indications for surgery for Aortic Regurgitation (AR) • Patients in NYHA class III-IV symptoms, • Evidence of Left Ventricular decompensation in asymptomatic patient (Echo Data) Ejection Fraction (EF) less than 55%, End-diastolic dimension of the left ventricle more than 70 mm, End-systolic dimension of the left ventricle more than 55 mm
  • 30. Choice of Valve Prosthesis 2types of prosthetic valves, mechanical Valves and bioprosthetic valves Mechanical Valves These have many designs, e.g., •Caged ball (Starr-Edwards), •Tilting monoleaflet, and •Tilting bileaflet valves. •The commonly used now are the tilting bileaflet valves. •The patients should be anticoagulated usually with warfarine with a target INR between 2.5 to 3.5.
  • 31. Bioprosthetic valves •Valve leaflets are either porcine, bovine, or human from fresh cadavers. •The valve is suspended on a prosthetic ring to allow it to be sewn in place. •The patient does not need long-term anticoagulation, but the durability of the valve is shorter than prosthetic valves.
  • 32. Common types of heart valve prostheses: Bileaflet (top left); Starr-Edwards ball and cage (top right); tilting monoleaflet disc (bottom right); stented porcine prosthesis (bottom left).
  • 33. Mechanical Valve vs. Bioprosthetic Valve Mechanical Valve  Long durability  Long-term anticoagulation with warfarine. Target INR: 2.5-3.5  Increased risk of thromboembolism (1- 3%/year).  Increased risk of hemorrhage: 1-2% /year Bioprosthetic Valve  Short durability  Usually long-term anticoagulation not needed.  Low risk of thromboembolism  Low risk of hemorrhage