SURGRY IN CARDIAC DISEASE
ABDULAMEER M. HUSSEINCONGENITAL HEART DISEASE
Congenital heart problems range from simple to complex.Some types of CHD require surgery as soon as in the first few hours after birth.
A baby may even "grow out" of some of the simpler heart problems, such as patent ductus arteriosus (PDA) or atrial septal defect (ASD), since these defects may simply close up on their own with growth.Other babies will have a combination of defects and require several operations throughout their lives.
What are the different types of congenital heart defects?
We can classify congenital heart defects toA- ACYANOTIC CONGENITAL HEART DISEASE
B- CYANOTC CONGENITAL HEART DISEASE
• A- ACYANOTIC CONGENITAL HEART DISEASE
• Problems that cause too much blood to pass through the lungs these defects allow oxygen-rich blood that should be traveling to the body to re-circulate through the lungs, causing increased pressure and stress in the lungs.B- CYANOTC CONGENITAL HEART DISEASE
Problems that cause too little blood to pass through the lungs.The body does not receive enough oxygen with these heart problems, and the baby will be cyanotic, or have a blue coloring
• Complications of congenital heart disease
Congestive heart failure. ...Slower growth and development.
Repeated chest infections.
Heart rhythm problems. ...
Cyanosis. ...
Endocarditis
• Pulmonary hypertension
• Blood clots and Stroke.• Death
• Emotional issues. ...
• A need for lifelong follow-up.
Treatment of congenital heart disease
Congenital heart disease that affects a child's health and lifestyle will usually require surgery, depending on the exact nature of the disease. Most children make a straight forward recovery.
Advances in the surgical treatment of congenital
heart disease mean that nowadays most children can be cured. At least, treatment can greatly improve quality of life.Palliative and Corrective Cardiac Surgery in Congenital Heart Diseases
The ideal goals of surgery in congenital heart disease are two:1. Restoration of normal physiology of the heart in form of having two separate sequential circulations ( i.e.) not mixing at the cardiac and great vessels.
2. Restoration of normally related 4 cardiac chambers, valves and major vessels (i.e.) AV concordance and ventriculovascular concordance with intact septum and normally functioning competent valves, and the coronaries originating from aorta.
These two goals are not always possible because the correction will depend on the type of structural anomaly and the limitation it imply.
I. Palliative Procedures :
Are divided to two typesA. Early palliative procedures.
B. Definitive palliative procedures.A- Early palliative procedures
They are done in congenital lesions which are usually suitable for future total correction, for certain conditions like
Critically ill patients not tolerating early total correction
In patients with complex cardiac disease.
In these situations the surgeons is forced to do an early palliation as a bridge to future total correction as in RV out flow patch without closing the VSD in some cases of TOF patients.
B- Definitive palliative procedures
Are done in congenital lesions where total correction is structurally impossible in these situations.
The aim is to restore normal or near normal physiology of providing deoxygenated blood to the lungs and providing oxygenated blood to the systemic circulation without restoring normally related 4 cardiac chambers and vessels.
II. Definitive total correction:
The two goals are achieved here where normally related 4 cardiac chambers and great vessels are preserved or restored with intact septum and 2 sequential circulations.
Examples:
Septal defect______ closure
Relieving out flow obstruction as in congenital PS
ligation of PDA.
Restoration of ventriculoarterial concordance and reimplantation of coronaries in arterial switch operation in TGA.
ACQUIRED HEART DISEASE
Valvular Heart DiseaseWhat is valvular heart disease?
There are four major valves in the heart that direct blood flow through the chambers of the heart. Valvular heart disease is when heart valves don’t open and close properly.
Diseased valves have one of two malfunctions:
Regurgitation: A valve doesn’t close completely, causing blood to flow backward instead of forward through the valve.Stenosis: A valve opening doesn’t form properly or becomes narrow, inhibiting the flow of blood out of the chambers of the heart.
When this happens, the heart is forced to pump blood with increased force in order to move blood through the stiff (stenotic) valve
Heart valves can have both malfunctions. Valvular heart disease can occur in any or all of the valves.
Without treatment, valvular heart disease can lead to heart failure.
STENOTIC VALVE
Valve
REGURGETANT VALVE
Fibro-calcific degeneration
most commonly affects the aortic valve. It most often occurs in adults over the age of 65.
Normal aortic valve
Bicuspid aortic valve
Endocarditis
Stretching or tearing of chordae tendineae or papillary
muscles
Dilatation of the valve annulus causes the valve to leak
What causes valvular heart disease?Some people are born with valvular heart disease. Others acquire it. Sometimes the cause is unknown
Valvular heart disease can be caused by:
Aortic aneurysmsCardiomyopathy
Connective tissue diseases
Coronary artery disease
High blood pressure
Infections, including endocarditis and rheumatic fever
Radiation
Syphilis
Tumors
How is valvular heart disease diagnosed?
Clinical features
Symptoms do not always relate to how serious valve disease is. Pt. may have no symptoms at all and have severe valve disease, requiring prompt treatment.
Or, as with mitral valve prolapse, may have severe symptoms, yet diagnostic tests may show valve leak is not significant. These symptoms may cause pt. to worry, but they are not dangerous or life-threatening, and may not require treatment at all.
The physical exam: the first step in diagnosing valve disease
We look forDuring a physical exam, we will listen to the heart to hear the sounds the heart makes as the valves open and close.
A murmur is a swishing sound made by blood flowing through a stenotic or leaky valve.
Cardiomegaly.
Heart rhythm
retaining fluid in the lungs
By examining the body, you can find clues about the circulation and the function of other organs.
• Shortness of breath
• Palpitations: This may feel like a rapid heart rhythm orirregular heart beats
• Swelling of ankles, feet or abdomen
• Weakness or dizziness
• Discomfort in the chest This may feel like a pressure orweight in the chest with activity
Symptoms
InvestigationsElectrocardiogram (ECG)
Doppler ultrasoundEchocardiogram (Echo)
Transesophageal echocardiogram
Cardiac catheterization
Electrocardiogram (EKG)
Magnetic resonance imaging
What is the treatment for valvular heart disease?
Treatment for valvular heart disease can include:
Medication
Medications are used to control symptoms and help the heart pump blood more efficiently.B- Valvular surgery
1- Repair.2- Replace the valve
Many factors help determine the appropriate surgery to treat heart valve disease, including a patient's
age
general health.
the extent of damage to the valves.
the type of valve,
the patient's preference.
Many of these procedures can be done using surgery.
1- Heart Valve Repair
Whenever possible a heart valve should be repaired instead of replaced. Valve repair may be performed toSeparate fused valve leaflets.
Sew torn leaflets.
Reshape parts of the valve.
However, repair is not possible for severely damaged valves such as those affected by calcium deposits or rheumatic disease.
Annuloplasty is one type of heart valve surgery
- Repair of structural support
Valvuloplasty is one type of heart valve surgery.
2- Valve Replacement SurgeryIf a diseased heart valve can’t be repaired, it must be replaced. There are three types of replacement valves.
Human Heart Valves
Tissue Valves
Mechanical Valves
Risks of Valve Replacement Surgery
Heart valve surgery, lead to increased risk of developing an infection of the valve. This is known as endocarditis. As a precaution, you will need to take antibiotics before undergoing some dental or surgical procedures. In most cases, we will also prescribe an anticoagulant medication to prevent blood clots.Ischemic heart disease (IHD) or myocardial ischemia
Is a disease characterized by reduced blood supply to the heart muscle, usually due to coronary artery disease (atherosclerosis of the coronary arteries)Coronary Artery Disease (CAD) is the most common form of heart disease.
What Is Coronary Artery Disease?
Coronary artery disease (CAD) is a condition in which plaque builds up inside the coronary arteries. These arteries supply heart muscle with oxygen-rich blood.
Signs and symptoms
Ischaemic heart disease may present with any of the following problems:
Angina pectoris (chest pain on exertion, in cold weather or emotional situations(
Acute chest pain: acute coronary syndrome, unstable angina or myocardial infarction ("heart attack", severe chest pain unrelieved by rest associated with evidence of acute heart damage(Heart failure
Risk factors for Coronary Artery Disease
Risk factors are conditions that increase the probability of developing heart disease. Some
can be changed and some cannot.
Coronary Artery Disease Major Factors –
Uncontrollable1- Gender
2- Heredity
3- Age
Coronary Artery Disease Contributing Factors :
Controllable
1- High blood pressure2- High blood cholesterol and triglycerides
3- Cigarette smoke
4- Obesity
5- Physical inactivity
6- Diet - A diet high in fats and carbohydrates increases the risk of CAD
7- Diabetes
8- Stress
Treatment Options for Coronary Artery Disease
MedicationInterventional Cardiology
Cardiovascular Surgery
Medical Treatment
Aspirin.
Beta-blockers.
Nitroglycerin.
Calcium channel blockers:
ACE inhibitors: Angiotensin-converting enzyme (ACE) inhibitors
Statins. Atorvastatin (Lipitor), pravastatin (Pravachol), simvastatin (Zocor).
• Interventional procedures:
Brachytherapy: Radiation is applied to the blockage to clear it.Minimal Invasive cardiac surgery has been done through a small incision by the side or front of the chest( without cutting the central bone of the chest)
Minimal Invasive cardiac surgery
Advantages
Reduced Post Operative PainReduced length of ICU stay
Minimal Blood loss
Reduced chances of infection
Faster recovery
Surgery
Surgery in coronary heart disease is reserved for people whose disease is either severe or is not improved or stabilized by medication and other less invasive therapies.
Coronary artery bypass grafting (CABG):
This is the standard operation for blockages of coronary arteries.
- If multiple coronary arteries are blocked
- If the left main artery shows significant blockage
Off-pump bypass surgery:
Minimally invasive coronary bypass (MINI-CABS):
Transmyocardial laser revascularization (TMR):
TMR offers an alternative for people who are not good candidates for either angioplasty or bypass surgery.A surgeon uses a laser catheter to create multiple pinholes in the heart muscle.
The holes encourage growth of new vessels into the diseased heart muscle. This procedure can be done by itself or in conjunction with coronary bypass surgery.THE SCOPE OF CARDIAC SURGERY
There are 3 types of cardiac operations:1. Extra-cardiac operations.
2. Closed intra-cardiac operations.
3. Open cardiac operations.Extra-cardiac Operations
These are carried out on the main vessels outside theheart or on the pericardium. The ventricles or atria are not directly interfered with so that cardiac function is not disturbed. Examples include ligation of a patent ductus, excision of coarctation, systemic-pulmonary anastomoses, pericardiectomy and resection of some thoracic aortic aneurysms.
Closed Intra-cardiac Operations
• These are blind intracardiac procedures performed by instrument or finger and controlled by touch. Access is obtained to the interior of the heart through either the ventricular or atrial walls or through the base of one of the great vessels. Cardiac action is interfered with to some extent so that irregularity of heart action is liable to be encountered. Mitral valvotomy is the only closed procedure still used regularly.
Open Cardiac Operations
The desire of every surgeon is to operate with safety under direct vision on the open and motionless heart. Cardiopulmonary bypass (extra-corporeal circulation) allows the surgeon to manage the circulation while operating on a still heart in a bloodless fieldHeart-Lung Machines
Several clinically proven heart- lung machines are now in regular use. Basically each consists of a pump and an oxygenator. Blood is withdrawn from the venae cavae, passed through the oxygenator and returned into the arterial circulation through the femoral artery or ascending aorta. The blood is thus diverted completely from the heart and lungs but a good supply of well oxygenated blood is made available to the vital organs.