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Presentation and management of cardiac surgical diseases PowerPoint Presentation

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This medical PowerPoint presentation talks about diseases of heart, where surgery can play a role, surgical indications and the Basic Principles of Cardiac Surgery.

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Published on : Mar 19, 2023 | Views : 2101 | Downloads : 3

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Presentation and management of cardiac surgical diseases Division of Cardiac Surgery Department of Cardiac Sciences King Saud University Medical city King Saud University, Riyadh.
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Objectives of the lecture Overview of diseases of heart, where surgery can play a role Surgical indications Understanding of the Basic Principles of Cardiac Surgery
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Cardiac Diseases Coronary Artery Disease Valvular Heart Diseases Congenital Heart Diseases Miscellaneous : Aortic Diseases Pericardial Disease Cardiac Tumors Trauma Heart failure Arrhythmia surgery
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Approach: 1. History 2. Physical examination 3. Chest x-ray 4. E.C.G. 5. Investigations (non-invasive & invasive). Surgery for Cardio-thoracic Diseases
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Modes of Presentation of Cardiac Diseases Chest pain Shortness of Breath Palpitations Dizziness, Syncope Congestive Cardiac Failure Cyanosis and Clubbing in Congenital Defects Other Symptoms (fever, sweating, G.I. symptoms, embolic symptoms, loss of weight)
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Surgery for Cardio-thoracic Diseases Chest pain Differential diagnosis: 1. Cardiac causes 2. Non-cardiac causes Life threatening causes: Myocardial infarction Aortic dissection Pulmonary embolism.
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Shortness of breath Cardiac causes: Heart failure, myocardial ischemia, congenital heart disease, arrhythmias, pericardial diseases, and valvular heart diseases. Respiratory causes: COPD, pneumothorax, infections, pulmonary embolism, pleural effusion, restrictive ling disease. Surgery for Cardio-thoracic Diseases
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Shortness of breath Others: Anemia, renal failure, obesity, anxiety and hyperthyroidism. Surgery for Cardio-thoracic Diseases
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Ischemic Heart Disease Clinical manifestations: 1. Asymptomatic 2. Symptomatic: -angina pectoris: stable- unstable -myocardial infarction -V.S.D., Ischemic mitral regurge, Ventricular aneurysm, Heart failure, Conduction defects.
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Ischemic Heart Disease Indications of surgery: 1. Failure of medical therapy or percutaneous intervention. 2. Left main disease more than 50%. 3. proximal LAD & proximal Cx more than 70%. 4. 3-vessel disease with left ventricular dysfunction 5. Mechanical complications of myocardial infarction. 6. Associated valve disease
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Surgery for Cardio-thoracic Diseases Coronary conduits: 1. Arterial: Internal thoracic artery 2. Venous : Long saphenous vein. Types of surgery: 1. Conventional: using the heart lung machine, and cardioplegic arrest 2. Off-pump (beating heart surgery)
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Coronary Artery Bypass Grafting
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Coronary Artery Bypass Surgery
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Surgery for Cardio-thoracic Diseases Valvular Heart Diseases 1. Mitral stenosis: Etiology: Rheumatic, Congenital The natural progression of MS causes the mitral valve area to reduce by 0.1-0.3 cm per year. The progression from the onset of rheumatic fever to onset of signs of MS takes 10-20 years. The progression from signs of MS to mild symptoms of MS takes 10-20 years. The progression from mild symptoms to decompensation takes 10-20 years In patients with severe PH the mean survival is 3 years.
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Symptoms of mitral stenosis 1.Asymptomatic for many years. 2. Easy fatiguability. 3. Dyspnea, Orthopnea and PND. 4. Palpitations 5. Dysphagia, compression of left main bronchus Surgery for Cardio-thoracic Diseases
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Signs of mitral stenosis 1. Low volume pulse. 2. Irregular pulse. 3. Tapping non-displaced apex beat. 4. Loud S1 5. Mid-diastolic rumbling murmur. 6. signs of PH: central cyanosis, Loud P2, T.R. P.R. Surgery for Cardio-thoracic Diseases
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Surgery for Cardio-thoracic Diseases Mitral Stenosis Treatment: 1. Medical 2. Balloon valvuloplasty 3. Closed mitral commissurotomy 4. Open mitral commissurotomy 5. Mitral valve replacement / repair
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Mitral Valve
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Surgery for Cardio-thoracic Diseases 2. Mitral Regurgitation: Etiology: Rheumatic, Degenerative, Endocarditis, Ischemic, Traumatic Chronic mitral regurgitation: Rheumatic fever, Myxomatous degeneration, ischemic cardiomyopathy. Acute mitral regurgitation: chordal rupture, infective endocarditis, papillary muscle rupture following MI.
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Mitral Regurgitation Asymptomatic patients can have a long latent period before the onset of symptoms as chronic M.R is well tolerated if L.V function is still preserved. Surgery for Cardio-thoracic Diseases
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Mitral Regurgitation Symptoms of mitral regurgitation: 1. fatigue and weakness 2. Dyspnea, Orthopnea, PND 3. Pulmonary hypertension and right heart failure. Surgery for Cardio-thoracic Diseases
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Mitral Regurgitation Signs of mitral regurgitation: 1. displaced apex beat 2. apical thrill 3. apical pan-systolic murmur 4.signs of pulmonary hypertension Surgery for Cardio-thoracic Diseases
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Mitral Valve
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Mitral Valve replacement
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Mitral Valve Repair
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Surgery for Cardio-thoracic Diseases Aortic stenosis Etiology: Rheumatic, Congenital, Degenerative. Symptoms: Asymptomatic Chest pain Syncopal attacks Dyspnea and CHF
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Aortic stenosis Signs of aortic stenosis: 1. slow-rising pulse 2. small amplitude pulse 3. sustained apical pulse 4. harsh ejection systolic murmur. Surgery for Cardio-thoracic Diseases
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Aortic Valve
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Aortic Stenosis
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Surgery for Cardio-thoracic Diseases Aortic regurgitation Etiology: Rheumatic, Endocarditis, Connective tissue disorders, Aortic dissection or aneurysm.
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Aortic Valve
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Aortic Regurgitation
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Valvular Prostheses
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Valvular Prostheses Surgery for Cardio-thoracic Diseases
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Surgery for Cardio-thoracic Diseases Valvular Prostheses Complications of prosthetic valves: 1. Thrombosis 2. Bleeding complications 3. Infective endocarditis 4. Paravalvular leak 5. Degeneration of biological valves
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Endocarditis
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Heart Failure Ventricular Assist Devices:
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Heart Failure Indications for Heart Transplant:
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Heart Failure
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Arrhythmia
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Surgery for Cardio-thoracic Diseases Thoracic Aortic Disease 1. Thoracic aortic aneurysm Symptoms are usually due to pressure on surrounding stuctures. 2. Aortic dissection: Tear in the intima allowing blood to enter and flow in a false channel. There are 2 lumens separated by the dissecting membrane
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Type A dissections Arising in the ascending aorta Are a medical emergency and require immediate surgery. Mortality rate up to 5% per hour. Surgery for Cardio-thoracic Diseases
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Type B dissections Arising in the descending aorta Carry a lower mortality rate and can be managed medically May cause symptoms due to vascular compromise to other areas e.g. acute limb ischemia, renal ischemia, paraplegia, mesenteric ischemia. Surgery for Cardio-thoracic Diseases
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Aortic Dissection DeBakey classification system Type I - Originates in ascending aorta, propagates at least to the aortic arch and often beyond it distally. Type II – Originates in and is confined to the ascending aorta. Type III – Originates in descending aorta, rarely extends proximally but will extend distally. Daily (Stanford) classification system Divided into 2 groups; A and B depending on whether the ascending aorta is involved. A = Type I and II DeBakey B = Type III DeBakey
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Aortic Disease
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Aortic Disease
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Aortic Surgery
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Surgery for Cardio-thoracic Diseases
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Surgery for Cardio-thoracic Diseases
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Surgery for Cardio-thoracic Diseases
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Cardiac Tumors
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Surgery for Cardio-thoracic Diseases Basic Principles of Cardiac Surgery Adequate Exposure Full or Partial Sternotomy / Thoracotomy / Robotic or Endoscopic Bloodless Operative Field Suction and re-transfusion / Snaring or clamping of bleeding vessels Static Operative Target Cardiac Arrest / Ventricular Fibrillation / Mechanical Stabilizers Preservation of body perfusion Use of Heart Lung Machine / Off-pump Techniques Preservation of Myocardium Off-pump Techniques / Hypothermia / Cardiac Arrest with cardioplegia
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Surface Cooling Hypothermia (28c˚) for ASD Closure in Children, 1952
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In 1953, John Gibbon reported the first successful ASD closure using his heart-lung machine. It took him 20 years of work and experiments!
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Heart Lung Machine Aim of cardiopulmonary bypass: The principal aim of CPB is to facilitate cardiac and thoracic aortic procedures by excluding the heart and lungs from the circulation whilst providing: 1. adequate gas exchange 2. systemic organ perfusion 3. controlling body temp. Surgery for Cardio-thoracic Diseases
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Surgery for Cardio-thoracic Diseases Heart Lung Machine Components : Roller pumps Blood Reservoir (cardiotomy reservoir) Oxygenator Heater-cooler unit Tubing and Monitoring console etc Limitation/Problems : Requires full anticoagulation Can cause micro embolism Initiates Systemic Inflammatory Response
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Complications of CPB 1. systemic inflammatory response due to contact of blood with the foreign surface of CPB circuit resulting in increased capillary permeability, interstitial edema, and subsequent organ dysfunction. 2. coagulopathy caused by platelet dysfunction as well as dilution and consumption of coagulation factors. Surgery for Cardio-thoracic Diseases
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Complications of CPB 3. hemolysis. 4. renal and splanchnic hypoperfusion 5. cerebrovascular accident Surgery for Cardio-thoracic Diseases
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Coronary Artery Bypass Surgery
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Surgery for Cardio-thoracic Diseases Heart Lung Machine
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Surgery for Cardio-thoracic Diseases Pericardial effusion Progressive accumulation of fluid inside the pericardial cavity, may compress the cardiac chambers. Etiology: -Traumatic -pericarditis -malignancy -uremia, post irradiation -postoperative.
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Surgery for Cardio-thoracic Diseases Pericardial effusion Investigations: -Plain x-ray chest -Echocardiography -CT scan Management: - treat the cause -Aspiration -Pericardiostomy
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Surgery for Cardio-thoracic Diseases
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Surgery for Cardio-thoracic Diseases Congenital Heart Diseases 1. Acyanotic: -Patent ductus arteriosus -Coarctation of the aorta -Pulmonary stenosis -Atrial septal defect -Ventricular septal defect
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Surgery for Cardio-thoracic Diseases Congenital Heart Diseases 2. Cyanotic: -Tetralogy of Fallot -Transposition of the great vessels -Tricuspid atresia -Total anomalous venous drainage -Truncus arteriosus
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Surgery for Cardio-thoracic Diseases Pre-Operative Investigations for Cardiac Surgery Full Blood Count Blood Biochemistry ECG Chest X-ray Pulmonary Function Tests. Other test according to systemic review of patient Echocardiography Angiography Carotid Duplex Scan Peripheral Duplex Scan
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Surgery for Cardio-thoracic Diseases Usual Duration of Stay in Hospital One day before surgery 3-6 hours OR time One day in ICU 4-5 Days in Ward Total 5-7 days
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Cardiac Trauma Blunt Penetrating In blunt cardiac trauma, the major challenge is diagnosis, while in penetrating cardiac trauma, the major challenges are rapid resuscitation followed by emergent definitive surgery Surgery for Cardio-thoracic Diseases
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Blunt Cardiac Trauma Myocardial contusion Pericardial tamponade Arrhythmia with cardiac arrest Disruption of valves and septum Coronary artery injuries Cardiac rupture Surgery for Cardio-thoracic Diseases
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Blunt Cardiac Trauma All patients with blunt chest trauma should undergo physical examination, CXR, ECG, and baseline cardiac enzymes. ECHO, C.T. may be needed Treatment depends on the nature of the injury. Surgery for Cardio-thoracic Diseases
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Penetrating Cardiac Trauma All patients with penetrating wounds between the right mid-clavicular and left mid-axillary lines from the epigastrium to the clavicles should be assumed to have injuries involving the heart until proven otherwise. Surgery for Cardio-thoracic Diseases
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Penetrating Cardiac Trauma The most commonly injured chamber is the right ventricle. The typical patient presents with signs of tamponade or hemorrhage. Emergent surgical exploration may be needed. Surgery for Cardio-thoracic Diseases
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