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Figure... 1, , INDICATIONS OF CORONARY ANGIOGRAM, 1.Patients in whom a diagnosis of CAD is suspected., 2.In patients planned for major non cardiac or, valvular cardiac surgery.
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3.All patients with acute STEMI should undergo, coronary angiogram and Percutaneous coronary, intervention witnin 90 min of presentation., 4.NSTEMI, RELATIVE CONTRAINDICATIONS OF CORONARY, ANGIOGRAM, 1.Ongoing infections, 2.AKI, 3.Severe anemia, 4.Previous allergic reactions to contrast, 5.Severe electrolyte imbalance, PRE PROCEDURE PREPARATIONS, 1.History, 2.Clinical Examinations, 3.Routine test.. Hb, wbc, platelet count to ensure, there is no occult blood loss, infections and, thrombocytopenia., 4.KFT
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5.LFT, 6.INR, 7. aPTT, 8.TTE to identify regional wall motion abnormality,, valvular disease or left ventricular thrombus., 9.Patients hydration status.. 1000 ml of 0.9% of, saline infused over 6 hrs., ACCESS, This can be gained through.., 1.Femoral, 2.Radial, 3.Ulnar, 4.Brachial, 5.Axillary, 6.Subclavian, Most popular approach... Transradial., Technique used for access... Seldinger technique.
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Following figure shows vascular access for, Percutaneous insertion of a sheath., , Figure.. 2
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PHARMACOLOGY, Intra arterial administration of verapamil or nitrates, via radial sheath is used to limit occurance of, vascular spasm., Sedation prior to coronary angiogram., Transradial Coronary angiography... An intravenous, bolus of 2500 to 5000 units of Unfractioned heparin, for anticoagulation., Before starting the coronary Angiographic, injections... Administer nitrates(sublingual,, intravenous or intracoronary)., CATHETER SELECTION, Judkins left and right pre shaped catheters... are, most commonly used catheters in world., ANGIOGRAPHIC VIEWS, Angiographic views are labelled according to the, position of the C arm image receptor in relation to, the patients.
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LAO... Left anterior oblique view... X Ray machine is, positioned to the left., RAO... Right anterior oblique view... X Ray machine, is positioned to the right of the patients., CRAN... Cranial view... Machine is positioned, cranially., CAUD... Caudal view... Machine is positioned, caudally., When the receptor is in midline then term... PA, view is used., Following figure shows the common Angiographic, views.
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Figure.. 3, , POST PROCEDURE CARE, Sheath removal and closure device, Standard manual compression after sheath removal, is usually enough to acquire haemostasis after, transfemoral approach diagnostic angiography., Several vascular closure device to prevent bleeding, complications are..
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1.Suture based.. Prostar, 2.Collagen based.. Angioseal, 3.Non collagen based, 4.Clip closure, , The above figure shows angiography view of RCA., CORONARY ANGIOGRAPHIC ANALYSIS, The severity classification ranges from.., Low grade stenosis<49%., Intermediate grade stenosis.. 50 to 74%, High grade.. 75 to 90%.
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Subtotal.. 91 to 99%., Total occlusion.. 100%, Scoring system developed to describe coronary, Anatomy... Leaman score and SYNTAX score., COMPLICATIONS, Serious complications are very low.. 0.1 to 0.2% and, include.., 1.Death, 2.Myocardial infaraction, 3.Cerebrovascular accidents, Other complications are.., 1.Pseudoaneurysm, 2.Haemotoma, 3.allergic reactions, 4.Anaphylactic shock, 5.Pulmonary oedema, INDICATIONS OF RIGHT HEART CATHETERIZATION, 1.Pulmonary artery Hypertension
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2.Congenital heart disease, 3.Left to right shunt, 4.Mitral valve disease, PROCEDURE, Access is obtained by.., 1.Common femoral vein, 2.Basilic vein, 3.Cephalic vein, 4.Median cubital vein, Most commonly catheters used to perform a RHC, are multipurpose and Swan ganz., COMPLICATIONS, 1.RV/RA chamber perforation, 2.Tamponade, 3.Distal pulmonary artery perforations, 4.Haematoma, 5.Arrhythmia, 6.Pulmonary infaraction
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7.Thromboembolism, 8.Stroke, INTERPRETING HAEMODYNAMICS, Right atrium, The normal waveform include.., A wave.. Contraction of the atria. X descent is the, drop in RA pressure following contraction., C wave represents closure of tricuspid valve., CANNON A WAVES...., Can be seen in..., 1.Complete heart block, 2.V paced rhythm, 3.Ventricular tachycardia, 4.AV nodal tachycardia, In atrial fibrillation a waves are absent., NORMAL RA PRESSURE... 0 to 7 mm of Hg., ELEVATED RA PRESSURE..., 1.Pulmonary Hypertension
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2.Pulmonary valve stenosis, 3.Volume or pressure overload due to left to right, shunt., 4.RV dysfunction, 5.Tricuspid valve disease, 6.Tamponade, 7.Constrictive pericarditis, RIGHT VENTRICLE...., Normal RV systolic pressure... 15 to 25 mm of Hg., Normal RV end diastolic pressure.... 3 to 12 mm of, Hg., RV systolic pressure elevated.... When there is, increased afterload..., 1.Pulmonary Hypertension, 2.Massive pulmonary embolism, 3.Pulmonary stenosis, Elevation in RVEDP occur... When RV is failing., 1.longstanding pulmonary hypertension
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2.Cardiomyopathies affecting RV., 3.RV infaraction, 4.Constriction and tamponade, PULMONARY ARTERY, Normal PA systolic pressure... 15 to 25 mm of Hg., Normal PA diastolic pressure... 8 to 15 mm of Hg., PULMONARY HYPERTENSION....Mean PA pressure, more than 25 mm of Hg., Etiology of pulmonary Hypertension..., 1.Pulmonary arterial Hypertension(idiopathic,, connective tissue disease, congenital heart disease), 2.left heart disease(left heart failure, mitral valvular, disease), 3.Chronic lung disease and hypoxemia, 4.Chronic pulmonary thromboembolism, 5.Multifactorial mechanism, PULMONARY CAPILLARY WEDGE PRESSURE, PCWP is an estimate of left atrial pressure.
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Normal PCWP... 6 to 15 mm of Hg., Mean PCWP... 9 mm of Hg., Elevation in pulmonary capillary wedge pressure, occur in any condition that elevates LA and LV, pressure.. Such as.., 1.LV systolic and diastolic failure, 2.Mitral and aortic valve disease, 3.Cardiac tamponade, 4.Constrictive or Restrictive cardiomyopathy, LOW PCWP.., 1.Hypovolemia, 2.Pulmonary veno occlusive disease, 3.Obstructive disease due to large pulmonary, embolism, PCWP has a, c and v waves as well as x descent., Large a waves... Mitral stenosis, LV systolic or, diastolic dysfunction.
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Large v waves... Mitral regurgitation, CARDIAC OUTPUT, Can be measured by.., 1.Thermodilution, 2.Fick method, Cardiac index... CO/BSA, CI normal value... 2.8 to 4.2 L/min/m2, LOW CO..., 1.LV systolic or diastolic failure, 2.RV systolic failure, 3.Severe MR, 4.Pulmonary HTN, 5.Hypovolemia, , END OF MODULE 1........
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FRACTIONAL FLOW RESERVE... MODULE 2, DEFINITIONS, FRACTIONAL FLOW RESERVE (FFR)... Is the ratio of, the maximum achievable blood flow to a, myocardial territory in the presence of stenosis to, the maximum achievable flow to the same territory, in the absence of stenosis., Normal FFR.... 1, Positive test... When FFR<0.80, STUDIES WITH FFR..., DEFER TRIAL.. Deferral of PCI of a functionally non, significant stenosis is associated with the favourable, very long term follow up., FAME TRIAL.., Fractional flow Reserve versus angiography for, guiding Percutaneous coronary intervention., Routine measurement of FFR in patients with, multivessel coronary artery disease who are, undergoing PCI with drug eluting stents significantly
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reduce the rate of composite end point of death,, non fatal MI and repeat revascularization at 1 year., FAME 2 TRIAL.., In patients with stable coronary artery disease and, functionally significant stenosis, FFR guided PCI plus, the best available medical therapy, as compared, with the best medical therapy alone, decreased the, need for urgent revascularization. In patients, without ischemia, the outcome appeared to be, favourable with the best available medical therapy, alone., COMPARE ACUTE TRIAL, The aim of the COMPARE ACUTE Trial is to assess, whether FFR guided complete revascularization in, the acute setting is superior to culprit lesion, treatment only., , END OF MODULE 2......
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ECHOCARDIOGRAPHY.....MODULE 3., ESSENTIAL ULTRASOUND THEORY FOR, ECHOCARDIOGRAPHY.., The ultrasound used in Echocardiography... is, produced by passing electric current through a, piezoelectric crystal, causing it to vibrate at, frequencies of 2-7 MHz., MODALITIES OF ECHOCARDIOGRAPHY, 2D ECHO.., Anatomy and morphology.., Recognizable moving images., Dependent on acoustic Windows and operator.
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Eyeballing function and valve motion., , Above figure shows 2D four chamber view in a, patients with normal heart., MOTION MODE.. M mode., High temporal resolution., Assessment of Hemodynamic significance of a, pericardial effusion, when the presence of early
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diastolic collapse of the free wall of right ventricle is, one of the important echo indicators of incipient, tamponade., PULSED WAVE AND CONTINUOUS WAVE DOPPLER, ECHOCARDIOGRAPHY, Assess flow velocity., COLOR FLOW DOPPLER, In area of image, where blood is flowing towards, the transducer it is coded red and when it is flowing, away from transducer it is coded blue., Allow accurate measurements of velocities., Valve lesion., TISSUE DOPPLER IMAGING, Motion of myocardium., Assess RV free wall., An E at the lateral annulus of >=8 cm/s indicate, constriction., 3D ECHOCARDIOGRAPHY, Assessment of intracardiac masses.
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Assessing complications of infective endocarditis., Planning complex surgical procedures such as mitral, valve and aortic root repair., , Above figure shows colour flow Doppler confirming, large atrial septal defect (arrow) in 6 year old boy., Red colour indicates blood moving towards the, transducer, at the apex of the scan sector., ASSESSMENT OF MYOCARDIAL FUNCTION, LEFT VENTRICULAR SYSTOLIC FUNCTION
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The assessment of myocardial systolic function is, done by assessing following parameters., 1.Change in volume or dimensions from diastole to, systole, 2.Indices of contractility such as rate of rise of, pressure with time., CHANGES IN VOLUME AND DIMENSIONS, LVEF... which is the stroke volume expressed as a, proportion of the end diastolic volume., INDICES OF GLOBAL CONTRACTILITY, Tie index.. is the ratio of the sum of the sum of the, isovolumic contraction time and the isovolumic, relaxation time to the ejection time., Regional or segmental... contractile abnormalities, are most commonly seen in ischemic heart disease, and represent areas of full or partial thickness, myocardial infaraction., RIGHT VENTRICULAR SYSTOLIC FUNCTION
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The right ventricle is structurally more complex than, the left ventricle and is more difficult to assess by, Noninvasive imaging., In any condition affecting the left heart, the, addition of Impaired RV function increases, mortality., ALL PARAMETERS WITH RESPECT TO RV THAT CAN, BE MEASURED BY ECHOCARDIOGRAPHY, FRACTIONAL AREA CHANGE... normal>31%., TAPSE...Tricuspid annular plane systolic excursion, normal>15%., DIASTOLIC ABNORMALITIES MAY PREDOMINATE, IN.., 1.HCM, 2.Aortic stenosis, 3.Infiltrative disorder... Amyloidosis, ASSESSMENT OF VALVE PATHOLOGY, Aortic stenosis..., Morphology and motion of leaflets.
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Any Degenerative changes., Calcification., Color flow Doppler.. Is used to assess turbulence, through the valve., Pulse and continuous wave Doppler... Is used to, measure the velocity of blood flow in the left, ventricular outflow tract and through the valve, respectively., The pressure drop or gradient across... The, narrowed valve is calculated using a simplified, Bernoulli equation., P=4V*2, V is maximum velocity of blood flow through the, valve., P is the gradient., Severe aortic stenosis... Velocity of 4 m/s across, aortic valve., Gradient of 64 mm of Hg.
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EOA... effective orifice area of aortic valve.. Is, calculated using continuity equation., TRICUSPID ANNULOPLASTY.. May be performed if, tricuspid annulus is dilated>40 mm., , The above table shows criteria for assessing severity, of aortic stenosis., AORTIC REGURGITATION, The etiology of aortic Regurgitation.., 1.Valve abnormalities(congenital, infective,, Rheumatic and Degenerative), 2.Root dilatation, Root dilatation is associated with the.., 1.long standing Hypertension, 2.Marfan syndrome
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3.Ehlers danlos syndrome, , The above table shows criteria for assessing severity, of aortic regurgitation.
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The above figure shows, the normal aortic root in a, Tee lower esophageal view, showing aortic, measurements made at various standard level., MITRAL STENOSIS, RHD is the commonest cause of MS., The Hockey stick... appearance of the anterior, mitral leaflets is diagnostic., When considering whether balloon valvuloplasty, may be more appropriate for the patients then, surgery, The Wilkins score may be used to assess, the likely hood of a favourable outcome., Wilkins score is based on echo appearance and, rates the valve for..., 1.leaflet mobility, 2.leaflet thickening, 3.Calcification, 4.Subvalvar involvement, Score range... 4 to 16.
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A score of 8 or below... is predictive of a favourable, outcome with balloon valvuloplasty., , The above figure shows Parasternal long axis(A) and, 4 chamber(B) view showing Rheumatic mitral valvenote the typical hockey stick appearance of the, anterior leaflets., MITRAL REGURGITATION, Echocardiography distinguishes... between primary, Degenerative mitral valve disease and secondary, mitral regurgitation due to abnormality of LV, geometry and function.
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In severe MR, the early filling is(E wave) should, be>1 m/s., The PISA equation can be used to calculate effective, regurgitant orifice area and regurgitant volume., For the same calculated MR regurgitant volume, the, Prognosis for Degenerative MR is better than that, of ischemic functional MR., TRICUSPID VALVE ASSESSMENT, Morphology is assessed., Leaflets, annulus and RV is assessed., TEE is more sensitive... In visvulizing vegetation., ECHOCARDIOGRAPHY.. is technique of choice to, confirm presence of pericardial disease., BECK’S TRIAD... is found in cardiac tamponade. It, include.., 1.Hypotension, 2.Distended neck veins, 3.Muffled heart sound
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The above figure shows loculated pericardial, effusion seen by TEE in transgastric view., The most commonly encountered masses.... in the, heart are thrombi due to low flow or thrombophilia, trait.
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Thrombi are seen in... Left atrial appendage of, patients in atrial fibrillation and lining the wall of, akinetic aneurysmal infaracted area of left ventricle., BUBBLE CONTRAST AGENT, It composed of 8 ml of saline mixed with 1 ml air, and... 1 ml of patients blood, agitated vigorously by, mixing through a 3 way tap to produce, microcavitation,which are then injected as, bolus,which results in rapid fast venous return to, the heart and produce a small R to L shunt in, patients with patent foramen ovale., STRESS ECHO, INDICATIONS...., 1.To look for areas of inducible myocardial ischemia, in patients with known or suspected coronary, artery disease., 2.To assess the severity and impact of both aortic, and mitral valve disease., PREOPERATIVE TEE INDICATIONS, Planning complex procedure such as...
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1.Mitral valve repair, 2.Aortic root repair, 3.Operations for infections., , END OF MODULE 3...
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CARDIAC COMPUTED TOMOGRAPHY.... MODULE 4, COMPUTED TOMOGRAPHY, CT scanner utilises... X Ray tube., A CT scan for the heart... And vessels is typically, performed with intravenous contrast to opacify the, lumen of the cardiac chambers, coronary arteries, and the vessels., Contrast used... Iodinated low osmolar agents, Injected in.. Veins, mostly antecubital fossa., Heart rate<65 beat per min... Beta blocker should, be used., MAGNETIC RESONANCE IMAGING(MRI), Magnetic field and gradient coil are used., Contrast used are gadolinium., Pacemaker implant are contraindicated.
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The above chart shows essential difference, between CT and MRI., APPLICATION OF CT AND MRI
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Used in assessment of..., 1.Ventricular chambers, 2.Function, 3.Myocardium, 4.Valves, 5.Pericardium, 6.Great vessels
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The above chart shows main difference in the, clinical application of cardiac CT angiogram and, MRI., CORONARY ARTERY DISEASE, Best demonstrated non invasively... ECG gated CT, CARDIAC ANGIOGRAPHY., Demonstrate lumina stenosis., Shows calcified and non calcified plaques in the wall, of coronary arteries., Patients with severe stenosis>70% diameter, stenosis in CT A are referred for coronary, angiography to confirm diagnosis and treatment, (PCI or CABG)., CT Angiography demonstrate.., 1.Size of cardiac chambers, 2.Myocardial thickness, 4.Chronic infaraction, 5.Morphology of valves, 6.Pericardium
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7.Surrounding lung parenchyma, MYOCARDIAL ISCHAEMIA, CT A provides best anatomical of coronary lumen, and plaque burden., Cardiac MRI has become one of the most frequently, used techniques for assessment of myocardial, viability prior to revascularization., HEART FAILURE AND CARDIOMYOPATHIES, Cardiac MRI is more accurate for assessment of, ventricular volume and systolic function., CMR is now used routinely to assess heart failure, due to IHD,dilated cardiomyopathy, hypertrophic, cardiomyopathy, Restrictive cardiomyopathy., The role of CTCA in patients with new onset heart, failure is in demonstration or exclusion of CAD., VALVULAR HEART DISEASE, CMR can demonstrate the morphology of all cardiac, valves.
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Help in quantifying the degree of stenosis and, regurgitation., Size and function... Of cardiac chambers., Degree of myocardial fibrosis can also be, associated., The degree of stenosis is quantified by simple, planimetry., Maximum flow velocity and gradient can also be, quantified with CMR., CT is best... for demonstration of calcification in the, valves and surrounding annulus., CTCA is now become the main imaging modality for, TAVI(Transcatheter aortic valve implantation) for, assessment of size of aortic root including the, annulus., CONGENITAL HEART DISEASE, CTCA demonstrate the Anatomy... of cardiac, chambers and great vessels.
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The main limitation of CTCA is inability... to quantify, function and flow and exposure to ionizing, radiation., CTCA is best for demonstrating the...., 1.The anomalies of coronary arteries, 2.Coronary fistula, 3.Kawasaki disease, 4.CoA, 5.Left to right shunt, The strength of CMR is estimating the shunt by, measuring flow through ascending aorta and main, pulmonary artery., PERICARDIAL DISEASE, CT is best for demonstrating... calcification in, pericardium and its extent along with any fibrosis., Pericardial effusion... can also be demonstrated., CMR is helpful in evaluating.., 1.Ventricular function
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2.Demonstrate septal bounce in patients with, constrictive pericarditis., 3.Congenital pericardial cyst and masses., CARDIAC TUMORS, Metastatic masses are commonest tumours, involving the heart and pericardium., The commonest... Tumours in surgical practice are, the myxomas, which are benign and mostly found in, left atrium., Diagnosis.... Echocardiography.., CT and MRI can demonstrate..., 1.Morphology, 2.Location, 3.Extent, 4.Tissue characteristics of tumours., AORTIC DISEASE, CT is best performed with ECG gating... and used for, measurement of..
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1.Size of ascending aorta, 2.aortic root, 3.exclusion of dissection flap., 4.Involvement of branches of arch and abdominal, aorta., CT is superior in demonstrating calcification., POST SURGICAL PATIENTS, CTCA is useful to both identify the number and, location of bypass graft and their patency., CT is useful in demonstrating..., 1.Thrombosis of prosthetic valve, 2.Peri aortic abscess, 3.Haemotoma, 4.Infective collection, 5.Pseudoaneurysm, 6.Perforation, 7.Rupture
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CT is also useful while patients is being planned for, Redo sternotomy to see course of Bypass graft,, position of anterior surface of heart, aortic root and, ascending aorta.
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The above figure shows CT cardiac angiogram, showing left internal mammary graft., , END OF MODULE 4..........
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ASSESSMENT OF MYOCARDIAL VIABILITY..., MODULE 5.., INTRODUCTION, Hibernating myocardium..... is a viable,, dysfunctional state of myocardium with a reduced, contractility due to reduced coronary blood flow at, rest,which may be partially or completely reversible, upon revascularization., Stunned myocardium... dysfunctional state that, may persist for period of time after an episode of, transient ischemia despite restoration of normal, blood flow,with spontaneous recovery, subsequently., Non viable myocardium.. irreversible necrosis of the, myocytes leading to fibrosis and infaraction., ASSESSMENT OF MYOCARDIAL VIABILITY
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The above chart shows comparison of imaging, modality for myocardial viability., ELECTROCARDIOGRAM, Viable myocardium... Absence of pathologic Q, wave., The presence of Q wave... not specific for, myocardial infarction., Differential Diagnosis of pathologic Q wave.., 1.Myocardial Hypertrphy
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2.WPW syndrome, 3.Hybernating myocardium, BASELINE 2D ECHOCARDIOGRAPHY, Myocardial thickness... Clue to viability status., Normal segmental thickness>6 mm implies viable, myocardium.... and severely thinned(4 mm or less), segments may be suggestive of non or terminal, stages of hibernating myocardium., DOBUTAMINE STRESS ECHOCARDIOGRAPHY, Stress Echocardiography using Dobutamine is used., Myocardial contractile reserve is used as an, indicator of viability., Cardiac PET uses Rubidium-82 to access perfusion, and 18F-FDG to assess myocardial glucose, metabolism., CARDIAC MAGNETIC RESONANCE IMAGING, CMR identify.., 1.Scar burden, 2.Myocardial perfusion
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3.Segmental wall motion, 4.Thickness and contractile reserve, 5.Left ventricular ejection fraction, STICH TRIAL.., Surgical treatment of Ischemic heart failure., STICH viability sub study trial showed no difference, in mortality outcomes between the medical versus,, medial and revascularization therapy group in, severe ischemic cardiomyopathy (LVEF<30%)., In the STICH long term follow up, study shows, the, surgical revascularization group showed, improved, 10 year mortality outcomes compared to medical, therapy alone, , END OF MODULE 5.......
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BLOOD CONSERVATION STRATEGIES IN CARDIAC, SURGERY..... MODULE 6, Major transfusion.. >4 units red cells., , Above table shows factors associated with, increased risk of bleeding and need for transfusion., Anemia is defined by WHO as a hemoglobin, concentration <13 gm/dl for men and <12 gm/dl for, non pregnant women., PILLAR ONE, Optimization of Red cell mass and Erythropoiesis, prior to surgery.
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The above table shows factors in pillar 1 of patient, blood management., PILLAR TWO, Minimize blood loss
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The above table shows factors in pillar two of, patients blood management., PREOPERATIVE, Assessment include..., 1.Personal history of bleeding associated with, trauma or surgery, Guideline suggests that surgery should be, postponed for 3 days if the patients is taking
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ticagrelor, 5 days with Clopidogrel and 7 days for, prasugrel., INTRAOPERATIVE, Prevent haemodilution and the reinfusion of, processed shed or sequestered blood., Haemodilution prevention is achieved by..., 1.low prime volume, 2.Retrograde autologous prime, Cell salvage technique have been shown to be, excellent for red cell conservation., Haemostasis is optimal if the skin temperature is, maintained and acidosis is prevented., Benefit to reduce transfusion burden is related to, serine protease inhibitor aprotinin and lysine, analogue antifibrinolytics of which Tranexamic acid, is the most popular., Aprotinin lead to transient rise in creatinine., POSTOPERATIVE
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Phlebotomy has been identified as one of the main, factors in blood losses in ICU., , Above table shows, factors in pillar three of patient, blood management., Postoperative pulmonary complications increases, the use of medical resources., A six factor model(age >70 years, productive cough,, smoking, DM, inspiratory vital capacity, and, maximum expiratory mouth pressure lower than, 75% of predicted value) has been used to predict, the risk of developing pulmonary complications in, patients undergoing elective cardiac surgery.
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END OF MODULE 6........
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At higher doses, a rise in SVR predominate with, consequent decrease in cardiac output and rise in, systolic and diastolic BP., It may also cause... Hyperglycemia and lactic, acidosis., Principal use in supporting... Right and left, ventricular function in heart transplantation,right, ventricular function during left ventricular assist, device(LVAD) implantation and in general Inotropic, support in acute heart failure, Cardiogenic shock, and cardiopulmonary resuscitation., SIDE EFFECTS...., 1.Dysrhythmias, 2.Spasm of coronary artery and angina, 3.Worsen LVOTO in HOCM or systolic anterior, motion of mitral valve., 4.LV hypertrophy, NOREPINEPHRINE (NORADRENALINE)
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Weaker Inotropic effects... But powerful, inoconstrictor., Used in cardiac surgery... To treat mild Hypotension, and to counteract SIRS response., First line treatment in refractory Hypotension..., It result in slight decrease in cardiac output and, oxygen delivery due to increased afterload., Also useful in Cardiogenic shock... Due to increase, in coronary perfusion pressure and improvement of, myocardial performance., DOPAMINE, Inodilator at low doses., Dopamine becomes... an inoconstrictor at doses>5, micro/kg/min., Increase cardiac output in patients with septic, shock., Increases stroke volume., Increases urine output.
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The use of dopamine as a first line vasopressor, increased mortality in patients with Cardiogenic, shock., DOBUTAMINE, Positive inotropy with mild chronotropy and overall, peripheral effects of an increase in blood flow to, skeletal muscle and splanchnic circulation., Pulmonary vasodilators., High doses can cause tachycardia and pulmonary, vasoconstriction., PHOSPHODIESTERASE TYPE III INHIBITORS, Enoximone., Milrinone., Positive Inotropic effects on heart... and also, vasodilation with net result of increased cardiac, contractility and output decreased preload and, afterload with mild or moderate chronotropic, effects., Useful for short term treatment of...
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PULMONARY CIRCULATION, Administration of pulmonary vasodilators remains, one of the mainstay in the management of RV, dysfunction., The intravenous application of pulmonary, vasodilators (prostacycline) is effective in reducing, PVR but due to non selectivity, they also result in, systemic Hypotension and may worsen RV function,, ventilation perfusion matching and increase in, pulmonary right to left shunting., Inhaled nitric oxide(iNO) and prostacycline(PGI2), are metabolised within Lungs before reaching the, systemic circulation and thus systemic arterial, Hypotension is prevented., Inhaled nitric oxide is a powerful vasodilators and, reduces elevated PVR and improvement in RV, performance and increases oxygenation in lung, injury., iNO has been used for management of, perioperative pulmonary hypertension.. Such as..
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1.Heart transplantation, 2.Lung transplantation, 3.LVAD, 4.Congenital cardiac surgery, PHOSPHODIESTERASE TYPE V INHIBITOR, Sildenafil, Tadalafil, After oral application, sildenafil causes... Pulmonary, vasodilation with a maximum effect after 60, minutes., The effect of intravenous sildenafil starts 10 to 15, minutes after infusion and last 4 to 6 hrs., PROSTACYCLIN PATHWAY, Endogenous PGI2 results in vasodilation and has, antithrombotic, anti Inflammatory and anti, proliferative effects., Inhaled epoprostenol and iloprost are the most, commonly used modalities in the perioperative
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management of pulmonary hypertension /RV, dysfunction., INHALED EPOPROSTENOL, Selective pulmonary vasodilation can be achieved, via inhalation of PGI2 and has been shown to be as, efficious as iNO., INHALED ILOPROST, The use of inhaled iloprost has been used in heart, and lung transplantation., , END OF MODULE 7.....
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CARDIAC PACING IN ADULTS..... MODULE 8, CONDUCTION SYSTEM, The sino atrial node located in the right atrium, initiates cardiac contraction., Each wave front spreads out to activate the atria., The atrio ventricular (AV) ring electrically isolate the, atria from ventricles., The AV node though allows conduction to the, ventricles passing through the bundle of His which, progress into bundle branches., These Furthur split into the purkinje fibres which, allow rapid propagation to the ventricle.
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The above figure shows location of sino atrial node, is seen close to location of superior vena cava(SVC), within right atrium(RA)., INDICATIONS OF PACING DEFIBRILLATORS
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The above figure shows indication of pacing.
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The below figure shows indication of pacing.
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The above chart shows guideline recommendations, for pacing., Causes of cardiac conduction disease include, intrinsic and extrinsic causes., Intrinsic causes are mostly idiopathic and, Degenerative but also include ischemic heart, disease or infiltrative conditions.
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Extrinsic causes include rate limiting drugs,, increased vagal tone, infections and Metabolic, derangement., Bradycardia can lead to presyncope, syncope and, injury., Sinus node disease is considered benign and pacing, is indicated to improve symptoms and not, Prognosis., High grade AV block(complete heart block or, Mobitz type II block) can be fatal, irrespective of, symptoms pacing is indicated., Defibrillators are implanted to reduce the risk of, sudden cardiac death in those with prior history of, ventricular Arrhythmia associated with, hemodynamic compromise., BASIC PRINCIPLES OF PACING, Type of pacemaker..., 1.Single chamber, 2.Dual chamber
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3.Biventricular pacemaker, A single chamber permanent pacemaker will usually, only pace the ventricle and is often used in patients, with permanent AF., A dual chamber PPM will pace right atrium and, ventricle., A biventricular pacemaker will pace the right atrium, and right ventricle and left ventricle via coronary, sinus., , The above figure shows types of pacemaker.
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The above figure shows dual chamber pacemaker., IMPLANTATION TECHNIQUE, Pacemaker and ICD are usually implanted under, local anaesthesia., Implantation takes 45 to 120 minutes.
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Pacemakers are usually implanted on the left side of, chest wall through a 4 to 5 cm incision made, horizontally approx 2 cm infraclavicularly., Dissection down to the prepectrol plane is, performed and within this plane a pocket fashioned, for device., Venous access is obtained via a cephalic vein, following cut down and venotomy or puncture of, the axillary vein or subclavian vein., Seldinger technique are used to deliver to their, appropriate position., Leads are fixed to myocardium using an active fix, screw that grip the lead to heart muscle., Once the leads are in situ the electrical parameters, are checked., The leads are screwed in place to muscle with, suture prior to connecting to generator and closing, the wound., COMPLICATIONS AND PROBLEMS WITH DEVICE, 1.Venous thrombosis..
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Occurs peri procedurally., Cause swelling in the arm., Usually settles in few days., 2.Pacemaker infection.., 1% of patients will develop an infection post, transplant., Require removal of whole system to reduce risk of, endocarditis., 3.Pneumothorax, 1% of patients during pacemaker implantation will, suffer a pneumothorax., More common with subclavian access., 4.Pericardial effusion/tamponade, Positioning pacing leads can lead to development of, pericardial effusion., Can be asymptomatic., No intervention is required as the perforation, spontaneously repair itself.
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5.Lead displacement.., Occur in 1% of patients., Lead displacement in a pacing dependant patients, may lead to development of presyncope or, syncope., LEADLESS PACING, The Micra(medtronic) is an example of a,, transcatheter single chamber ventricular, pacemaker.
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The above figure shows deployment of LEADLESS, pacemaker., SUBCUTANEOUS ICD, The defibrillator lead is tunneled subcutaneously, lateral to the sternum and then across to the left, axillary region where it is connected to generator.
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Above figure shows subcutaneous ICD., MRI is a contraindicated in case of PPM, implantation., PERIOPERATIVE AND POSTOPERATIVE PACING IN, CARDIAC SURGERY
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Epicardial pacing wires are placed during surgery to, provide pacing for transient Brady arrhythmia Post, cardiac surgery., These are.. usually placed on ventricles and the, atria., , The above chart shows causes of postoperative, Bradycardia., The most common approach for lead placement is, transvenous., Device infections and in many cases lead failure, necessitate lead extraction.
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The above chart shows risk associated with, Percutaneous lead extraction., , END OF MODULE 8........
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ADULT CARDIOPULMONARY BYPASS.... MODULE, 9..., The application of cardiopulmonary bypass first, introduced in 1953,in order to provide an arrested, heart and bloodless field., CANNULATION STRATEGIES, Preoperative planning involves selection of, appropriate cannulae to connect the arterial and, venous limb of the CPB circuit to the patients., Arterial inflow options include..., 1.The ascending aorta, 2.The arch vessels including innominate and carotid, arteries directly or via synthetic graft., 3.The axillary artery directly or via synthetic graft., 4.The femoral artery directly or via synthetic graft., 5.The ventricular apex, in emergent condition., The ascending aorta remains the most common site, of arterial cannulation.
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In Redo surgery and aortic dissection other sites, may be selected., Innominate, carotid or axillary cannulation may also, be used for antegrade cerebral perfusion, during, period of circulatory arrest., During deep Hypothermia and arrest, Retrograde, cerebral perfusion can be achieved via an arterial, inflow side arm, connected to the superior vena, cava or internal jugular vein at 300 to 500 ml/min, and pressure 15 to 25 mmHg., VENOUS DRAINAGE IS VIA..., The right atrium and superior vena cava., The cannulae most commonly used are... Two stage, allowing for cavo atrial drainage., In case where the inferior vena cava is not, amenable to cannulation a single Ross basket, device... May be used., Three stage cannulae also exist that permits, drainage even when the right is collapsed.
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Both vena cavae(Bicaval cannulation).... For, intracardiac surgery or transplantation, utilising two, venous straight or right angled single stage, cannulae., Femoral vein., Internal jugular vein., In minimally invasive/port access surgery... Jugular, and femoral vein cannulation are both employed., Venting contributes towards a bloodless field.. And, avoids deleterious myocardial distention. It also, helps in removing air from cardiac chambers,, especially during weaning from CPB., It can be achieved most commonly via.., The ascending aorta, coupled with a delivery system, for antegrade blood cardioplegia., The right superior pulmonary vein, towards left, ventricle., Pulmonary artery.
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UNFRACTIONATED HEPARIN... 3 to 5 mg/kg is, administered to maintain a activated clotting, time(ACT) >400s., The ACT is monitored through out CPB and also, during reversal of Heparin with its antidote, protamine., Protamine is usually given at a dose of 1 to 1.3 mg, per 100 units of Heparin used., Lysine analogues(Tranexamic acid, E-amino caproic, acid) are commonly used to reduce fibrinolytic, haemorrhage.
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The above figure shows cardiopulmonary bypass, circuit., TEMPERATURE AND pH MANAGEMENT, Hypothermia reduces Metabolic demand in tissues, thus aiding primarily... in myocardial and, neurological protection.
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Cerebral metabolism decrease by 6-7% for every.. 1, degree centigrade decrease in temperature from 37, degree centigrade., Deep Hypothermia arrest takes place at 18 to 20, degree... Centigrade and is considered safe, between 30 to 60 minutes duration., Deep hypothermic circulatory arrest(DHCA)..., Congenital and aortic arch surgery., Retrograde and antegrade cerebral perfusion.. To, minimize neurological complication during period of, circulatory arrest., During CPB there are two strategies employed in, managing pH., Alpha stat.., Samples are not corrected for temperature., Alkalosis occur during cooling., Enjyme system function., Cerebral auto regulation adapt to level adjusted to, existing temperature.
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pH stat.., Samples are corrected with the addition of CO2, leading to pH values similar to normal temperature., Cerebral vasodilation improves blood flow., Risk of debris and gas embolization., CARDIOPLEGIA, Cardioplegia solutions can be utilized to arrest the, heart, in any of the following combination., 1.Continuous or intermittant, 2.Blood or crystalloid, 3.Cold(4 degree C) or warm(37 degree C), 4.Antegrade via the aortic root or direct cannulation, of the coronary ostia or retrograde via cannulation, of coronary sinus., CRYSTALLOID CARDIOPLEGIC SOLUTION, 1.Procaine, 2.Magnesium, 3.THAM
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4.CPD, 5.Potassium, BLOOD CARDIOPLEGIA, Mixture of blood and crystalloid cardioplegic, solutions of 4:1 ratio., It helps to preserve oncotic pressure and reduces, hemodilution and contains natural buffers and free, radical scavengers., Aspartate and glutamate are also added., , END OF MODULE 9......
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MYOCARDIAL PROTECTION IN ADULTS... MODULE, 10., Systemic Inflammatory response syndrome(SIRS), remains the most important factor responsible for, heart damage after CPB., MYOCARDIAL PROTECTION, Two pillars of myocardial protection during CPB, are.., 1.Hypothermia, 2.Electromechanical cardiac arrest, Cardioplegic solution.., 1.Arrest heart during diastole, 2.Minimize myocardial energy requirements, 3.Preserve myocardial function, 4.Provide bloodless, motionless operating field, Electromechanical arrest.., 1.Reduce myocardial metabolism, 2.Protect from ischemia
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The above chart shows principal aim of, cardioplegia., ANTEGRADE CARDIOPLEGIA, Cannula is usually placed in ascending aorta below, the site chosen for the aortic Cross clamp., This site can subsequently used to anostomose the, proximal end of a graft during coronary artery, bypass grafting(CABG) operation., A 4-0 purse string polypropylene suture is used to, secure cannula., Antegrade cardioplegia is delivered at a rate of 200, ml/min for 2 min.
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The above chart shows composition of the St., Thomas Hospital Cardioplegic solution., , The above chart shows composition of custodial, cardioplegia solution.
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The above chart shows composition of cold, cardioplegia solution., Cold blood cardioplegia is a method which combine, advantage of hypothermia and blood solution., HOT SHOT, At the end of surgical procedure, patients receive a, terminal warm perfusion., This solution is usually blood based and substrate, enhanced with no potassium and is recommended, in patients with poor ventricular function or after, long cross clamp time in complex surgical, procedures.
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The above chart shows Adjuncts in cardioplegia, solution., , END OF MODULE 10......
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HEPARIN INDUCED THROMBOCYTOPENIA...., MODULE 11......., INTRODUCTION, The anticoagulant effect of Heparin, especially, Unfractionated Heparin (UFH) is mainstay in.., 1.Extracorporeal membrane oxygenation, 2.Left heart bypass, 3.Hemofiltration, 4.Hemoperfusion, 5.Cardiopulmonary bypass, 6.Cardiovascular surgical procedures, Heparin anticoagulant effect can be rapidly and, safely reversed by protamine., Heparin use can be associated with lethal and rare, complications called.... Heparin induced, thrombocytopenia (HIT)., HIT is adverse drug reaction., It occur due to binding of Heparin to endogenous, platelet factor 4....PF4
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It can elicit immune response with the development, of IgG antibodies against... The complex of PF4 and, heparin., IgG antibodies bound to PF4-heparin complex,can, cross link platelet surface., Platelets are activated... with intravascular, aggregation, consumption and thrombocytopenia,, which is associated with paradoxical prothrombotic, state but not bleeding., Venous and arterial thrombosis occur., HIT was first described in 1958., For a given degree of PF4 availability, complex, formation occurs with decreasing frequency with.., Prophylactic dose of UFH > therapeutic dose of UFH, > Prophylactic dose of LMWH > therapeutic dose of, LMWH > fondaparinux., Below diagram shows pathophysiology of Heparin, induced thrombocytopenia.
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CLASSIFICATION OF HIT, , The above chart shows classification of HIT., CLINICAL PICTURE, In cardiac and vascular surgery patients
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1.Arterial and venous thrombosis, 2.Limb ischemia may result in amputation in 5 to, 10% of patients., 3.Mortality rate is high (8 to 20%) of patients., Rare complications include.., 1.Skin necrosis, 2.Thrombosis at unusual site, such as Adrenal veins, with Adrenal hemorrhagic necrosis, 3.DIC, 4.Anaphylactoid reaction, In case of reexposure of Heparin within 1 month,, HIT can occur by day 1(rapid onset HIT), , The below chart shows timing of serial platelet, counts to screen for HIT.
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The above chart shows 4T score clinical prediction, rule for HIT., The most widely evaluated clinical prediction rule, for HIT is 4T score.., 1.Thrombocytopenia
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2.Timing, 3.Thrombosis, 4.Other causes for thrombocytopenia, LABORATORY IMMUNOLOGICAL ASSAYS FOR HIT, , The above chart shows laboratory immunological, assays for HIT., TREATMENT, Stopping Heparin or substitution with vit k, antagonists is insufficient to inhibit thrombin, generated by HIT.
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The above chart shows alternative non Heparin, anticoagulants in HIT., BIVALIRUDIN IN CARDIAC SURGERY
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Guidelines favour the use of BIVALIRUDIN for HIT, where cardiac surgery is urgent and cannot be, postponed., , The above chart shows protocol for BIVALIRUDIN, use in cardiopulmonary bypass.
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The above chart shows other intervention in HIT, patients., , END OF MODULE 11........
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TISSUE SEALANTS IN CARDIAC SURGERY...., MODULE 12....., BULLET POINTS, Tissue sealants, adhesive and hemostatic agents..., are second defence line against surgical bleeding., Topical hemostatic agents are divided into four, classes... mechanical, flow able, fibrin and active, sealants., Mechanical hemostatic agents are physical barriers, such as... collagen, gelatin and cellulose that are, applied over bleeding site., Flowable products are made of microfibrillar, collagen and... they are used to block blood flow at, wound site by turning fibrinogen into fibrin., Active products contain concentrated amount of, thrombin.. in order to cleve fibrinogen and form, blood clots., Fibrin based sealant(Tisseel) have great, biocompatibility.... biodegradability, elasticity, drug, delivery and low toxicity.
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Fibrin based sealant.... carry risk of viral, transmission., Polyethylene glycol polymer... (Coseal) are, bioabsorbable and take 3 month to degrade., Bovine serum albumin and glutaraldehyde(Bioglue), ....products are affordable, easy to prepare and, have 3 year shelf life 25%., Thrombin gelatin matrix(Floseal)... have the ability, to conform to wound contours and to fill deep, lesion., INTRODUCTION, The use of anticoagulants and antiplatelets..., Increases risk of anastomotic bleeding during, cardiovascular surgery., This causes..., 1.Blood loss, 2.Perianastomotic hemorrhage, 3.Pseudoaneurysm formation, 4.Reoperation
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5.Graft thrombosis, The first line of defence against bleeding during, surgery involves..., 1.Suture ligation, 2.Staples, 3.Cauterization, 4.Manual compression over bleeding, The second line of defence against bleeding during, surgery..., 1.Tissue sealants, 2.Adhesive, 3.Hemostatic agent
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The above chart shows classification of FDA, approved Topical hemostatic agents., , The above chart shows classification of FDA, approved tissue sealants.
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The above chart shows classification of FDA, approved tissue adhesive., CLINICAL USE IN CARDIOVASCULAR SURGERY, Tissue sealants, adhesive and hemostats are useful, in cardiovascular surgery such as.., 1.CABG, 2.Heart valves, 3.Aorta repair and replacement, 4.Heart transplantation, 5.Aneurysm repair, 6.LVAD
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FIBRIN SEALANTS, They are hemostats, adhesive and sealants., Biological source., Made of fibrinogen and thrombin., Used in cardiovascular surgery., Can be applied in patients with coagulopathy or, under effect of anticoagulant., RISK... acute thrombus formation leading to acute, thrombosis at operative site and distal, embolization., PEG, Polyethylene Glycol polymers., Act as sealants and hemostatic agents., COSEAL and DURASEAL., COSEAL is mainly used for vascular surgery., Bioabsorbable and take 3 months to degrade., ALBUMIN AND GLUTRALDEHYDE, Bioglue is the only FDA approved product.
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Useful in cardiovascular surgery., Used in procedures such as aortic valve, replacement, coronary artery bypass., Aneurysm repair of abdominal aorta., CYANOACRYLATES, Synthetic adhesive and sealants., Histoacryl has hemostatic properties., Glubran 2 is latest product., They are bacteriostatic., OMNEX is FDA approved brand in cardiovascular, surgery., THROMBIN GELATIN MATRIX, Topical hemostatic agent., Surgiflo gelatin., Floseal is composed of bovine gelatin., Cause rapid haemostasis., Floseal has better results.
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Swelling is main Disadvantages that might obstruct, surrounding tissue., , END OF MODULE 12..........
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CONDUITS FOR CORONARY ARTERY BYPASS, SURGERY....... MODULE 13, BULLET POINTS, CABG... mainstays in the treatment of ischemic, heart disease., Arterial and venous... conduits can be used in CABG., Arterial conduits are..., 1.Left internal thoracic artery (LITA), 2.Right internal thoracic artery(RITA), 3.Radial Artery(RA), 4.Right gastroepiploic artery, Pedicled and skeletonized harvesting technique, have been described for arterial conduits., Skeletonization of ITA... reduces the risk of sternal, wound complications., Minimally invasive endoscopic harvesting... can be, applied to RA and long saphenous vein., LITA to LAD is well established... in terms of, Prognosis.
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INTRODUCTION, Rene Favaloro did.... the first CABG in 1967., Different conduits for CABG are..., 1.Left internal thoracic artery, 2.Right internal thoracic artery, 3.Radial artery, 4.Right gastroepiploic artery, 5.Saphenous vein graft, INTERNAL THORACIC ARTERY, Left internal thoracic artery originates from, subclavian artery... and supplies sternum and, breast., Bifurcates into superior epigastric artery... and, musculophrenic artery., Multiple elastic laminae in the absence of..., significant muscular component., LITA can be harvested in a skeletonized... or, pedicled fashion with the first technique carry the, advantage of increasing the effective length of
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conduit and avoiding extreme devascularization of, the sternum., Skeletonization of ITA has been reported to reduce, the risk of deep sternal wound infection.... also in, diabetes patients, normally more prone to this type, of complications., The prognostic benefits of LITA grafting of the LAD, artery and its superiority in comparison to other, conduits... is well established., THE RADIAL ARTERY, The Radial artery arises from the bifurcation of the, brachial artery in... the antecubital fossa., It joins deep branch of... ulnar artery., The anastomosis among the radial and ulnar system, is best... Assessed by the Allen test., Allen’s test proves.. collateralization of the two, system., RA has well developed muscular profile... It is, associated with vasospasm, when used as conduit in, CABG.
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RA might be harvested in skeletonized or pedicled, fashion.. with an open or pedicled technique., THE RIGHT GASTROEPIPLOIC ARTERY, The right gastroepiploic artery is one of two, terminal branches of gastro duodenal artery..., running along the greater curvature of stomach., Most favourable target for the in situ RGEA graft is, the distal right coronary artery., THE SAPHENOUS VEIN, The great SAPHENOUS vein is a large,, subcutaneous, Superficial vein of the leg., Presence of valve necessitates its use in a reversed, fashion... When used as coronary bypass graft., The SAPHENOUS vein can also be harvested, endoscopically, ROOBY trial shows... Lower SVG patency rate in the, off pump CABG., GRAFTING STRATEGY AND CONDUITS CHOICE, LITA is always anastomosed to LAD.
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The above chart shows decisional algorithm for, CABG., , END OF MODULE 13....
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ENDOSCOPIC SAPHENOUS VEIN AND RADIAL, ARTERY HARVESTING...... MODULE 14, BULLET POINTS, Minimally invasive endoscopic SAPHENOUS vein, and radial artery harvesting technique lead to, significant reduction in postoperative pain... Wound, and neurological complication., Endoscopic vessels harvesting is not associated with, a higher incidence of... Graft failure., INTRODUCTION, Open techniques of are associated with the, excellent outcomes... in terms of graft quality and, patency... But also lead to complications such as, wound healing, pain and discomfort., Minimally invasive endoscopic conduits harvesting, can be performed using.., 1.Sealed, 2.Non sealed system
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The use of sealed system for endoscopic SV, harvesting is associated with a significant incidence, of graft thrombosis., In the... PREVENT IV trial, a higher incidence of vein, graft failure was demonstrated in patients, undergoing endoscopic SV harvesting., In ROOBY trial.. Showed a reduced SV patency at 12, month, when a Minimally invasive approach was, used., WOUND AND NEUROLOGICAL COMPLICATION, In open technique during SV harvesting wound, complications such as..., 1.Infection, 2.Cellulitis, 3.Dehiscence, 4.Delayed healing, 5.Drainage, 6.Lymphangitis, 7.Sepsis
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Above complications can occur in 2 to 25% of, patients., When the overall incidence of complication is taken, into account after endoscopic RA harvesting, the, Minimally invasive technique is superior to open, approach., , END OF MODULE 14.....
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CONVENTIONAL CORONARY ARTERY BYPASS, GRAFTING.... MODULE 15, BULLET POINTS, CABG on cardiopulmonary bypass is the gold, standard... For treatment of coronary artery, disease., Single clamp is preferred to side clamp technique, during proximal anastomosis to reduce, atheroemboli., The observed mortality risk in CABG is... 1 to 3 %., Major complications include..., 1.stroke, 2.renal dysfunction, 3.deep sternal wound infection, 4.atrial fibrillation, Patients undergoing CABG must receive 81 to 325, mg of... Aspirin indefinitely., HISTORY OF CORONARY ARTERY BYPASS, GRAFTING
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The below chart shows history of CABG, , INDICATIONS OF CABG, The below diagram shows indication of CABG.
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KEY TECHNICAL STEPS IN CONVENTIONAL CABG, The below chart shows key technical steps in, , conventional CABG., CONDUCT OF OPERATION, INCISION
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Sternotomy is the standard incision for CABG., The median vertical incision from sternal notch to, the tip of xiphoid is made., The bleeding is controlled by sealing the bone, marrow with towels, antibiotic paste or bone wax., The sternum is retracted slowly and progressively, with retractor., The pericardium is opened and a cradle is created, using retraction sutures to enhance exposure., AORTIC CANNULATION, Two purse string running through aortic media are, placed on the aorta at opposite ends., The incision is made in the disease free segment of, ascending aorta,slightly smaller than the diameter, of aortic cannula., The cannula is advanced atraumatically and, secured., In patients with severe atherosclerotic disease in, aorta, an epiaortic ultrasound is necessary to
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identify safe site for cannulation and aortic Cross, clamp., The below diagram shows cannulation site., , VENOUS CANNULATION, The cannulation can be done in dual stage, with, purse string placed in right atrium., A 2 cm vertical incision is made in the right atrium, and is dilated before inserting the cannula., Some dual stage cannula may need to be, supplemented with an SVC cannula, if venous, drainage needs to be improved.
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INITIATION OF CARDIOPULMONARY BYPASS, Once Retrograde and antegrade cannulae for, cardioplegia have been placed the CPB is initiated., Aorta is cross clamped., Induction dose of antegrade and Retrograde, cardioplegia(700 to 1000 ml) is administered to, achieve diastolic myocardial arrest., Normothermia is preferred., TARGET IDENTIFICATION, The conduits are chosen at the beginning of, surgery, harvested before giving Heparin and are, prepared for anastomosis., The target are identified by placing wet sponge, behind the heart and by lifting heart atraumatically.
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For tissue around the coronaries can be trimmed or, held away with a retractor or 5/0 suture to expose, the location for distal anastomosis., The lumen of coronary artery is entered by gently, stroking on the surface with the belly of no 15, blade., The ARTERIOTOMY is enlarged with fine coronary, artery scissors approx to match the size of conduits., GRAFT CONFIGURATION, Composite graft such as sequential or Y graft can be, performed using end to side or side to side, anostomosis., LITA to LAD anastomosis is most common.
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The below diagram shows different grafts, , configuration., PROXIMAL ANASTOMOSIS, The coronary grafts are placed anteriorly or on the, lateral sides of aorta., The proximal anastomosis can be constructed as T, or Y graft to the in situ LITA., DE AIRING AND CROSS CLAMP REMOVAL
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Routine de airing, before and after cross clamp, removal, is performed to avoid air Embolism., This is achieved by needle de airing of individual, grafts and the venting of aortic root with passive, ventricular filling by partially clamping venous line., DECANNULATION, Resume ventilation and wean from CPB after...., 1.Resumption of sinus rhythm with adequate heart, rate and place temporary pacing wires., 2.Rewarming to physiologic core body temperature., 3.Correction of hematocrit, potassium, glucose and, arterial blood gas., 4.Assessing systolic function and ruling out new wall, motion abnormality using TEE., STERNAL CLOSURE, Coagulopathy should be promptly corrected during, rewarming and chest tubes are placed.
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Four to eight stainless steel wires are used in figure, of 8 fashion passing perpendicularly through, intercostal space., The retrosternal side of the wire is examined for, bleeding and haemostasis is achieved., Wires are twisted and cut after tightly, approximating the sternal halves., Subcutaneous tissue and skin is closed., OUTCOMES, The observed mortality risk in CABG is 1 to 3%.
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The below chart shows morbidity associated with, , CABG., , END OF MODULE 15........
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OFF PUMP CORONARY ARTERY BYPASS, GRAFTING..... MODULE 16, BULLET POINTS, Off pump coronary artery bypass grafting was, developed to minimize deleterious effect of CPB., CABG remains the standard of care for patients, with... Three vessel or left main coronary artery, disease., INTRODUCTION, On pump CABG is associated with..., 1.Thrombocytopenia, 2.Activation of Compliments factors, 3.Immune suppresion, 4.Organ dysfunction, 5.Manipulating ascending aorta can predispose to, embolization and stroke risk.
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TECHNIQUE, A standard median Sternotomy is required., Cardiac displacement allows the exposure of, posterior, lateral and inferior targets,and can be, achieved by placement of deep pericardial, retraction sutures., Exposure of LAD artery, its diagonal branches or, proximal RCA can be achieved with minimal, displacement by placing laparotomy sponge in the, pericardial sac., Stabilisers placed on the epicardium over the, planned site of ARTERIOTOMY reduces cardiac, motion either by pressure or suction device., A bloodless field for safe coronary anastomosis can, be achieved by snares, sutures, clamps or coronary, occluders., In off pump surgery, activated coagulation, time>300 seconds is adequate and this should be, fully reversed at the end of surgery with an, appropriate dose of protamine.
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Strategies to prevent hemodynamic instability., , The below algorithm shows, decision making for, choice of surgical strategies.
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CONTRAINDICATION, , Above chart shows Contraindications to off pump, CABG., , END OF MODULE 16...
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MINIMALLY INVASIVE CORONARY ARTERY BYPASS, GRAFTING..... MODULE 17, BULLET POINTS, It was developed to allow adequate exposure and, complete revascularization through a small, thoracotomy incision without CPB., Shorter hospital stay and earlier postoperative, physical recovery., The below chart shows Contraindications of, , Minimally invasive CABG.
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The octopus Epicardial stabalizers helps to maintain, the target ARTERIOTOMY for revascularization in a, stable position on a beating heart., The distal anastomosis are performed with 7-0 or 80 polypropylene., , END OF MODULE 17......
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TOTALLY ENDOSCOPIC CORONARY ARTERY BYPASS, GRAFTING.... MODULE 18, BULLET POINTS, Robotic totally endoscopic coronary artery bypass, grafting (TECAB)., TECAB can be part of a hybrid revascularization, concept to treat multivessel coronary artery, disease., INTRODUCTION, TECAB can be performed on arrested and beating, heart., TECAB was first performed using CPB and, Cardioplegic arrest., With the arrested heart anastomosis was, constructed on a still heart., Working space is increased with the heart empty, and the lungs deflated., Technical challenges including bleeding,, intramyocardial vessel, myocardial perforation,
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myocardial ischaemia and Hemodynamic instability, are easier to manage with CPB support., , Above chart shows preoperative evaluation of, TECAB surgery., ANESTHETIC CONSIDERATION, Patients are positioned supine with the left, hemithorax elevated 30 degree., A double lumen endotracheal tube will achieve, single lung ventilation., CARDIOPULMONARY BYPASS AND MYOCARDIAL, PROTECTION, CPB is achieved through peripheral cannulation,, most commonly via left common femoral artery.
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Preoperative CTA of chest, abdomen and pelvis is, highly advised for safe peripheral cannulation.
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The above diagram shows steps for surgical, procedure in TECAB., HYBRID REVASCULARIZATION, It combines benefit of IMA grafts and Percutaneous, coronary intervention., Approaches are..., 1.simultaneous TECAB and PCI, 2.TECAB first then PCI, 3.PCI first, Surgery prior to PCI is often preferred., Exclusion criteria for TECAB.., 1.Low EF(<30%), 2.Small distal coronary vessels, 3.Previous left lung trauma, 4.Prior sternotomy, 5.Lung disease, OUTCOME
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Postoperative MI, stroke and mortality are similar, to standard CABG., GRAFT patency after TECAB exceed 95% at 3 year, follow up., , END OF MODULE... 18
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REDO CORONARY ARTERY BYPASS GRAFTING....., MODULE 19...., BULLET POINTS, The number of Redo coronary artery bypass grafting, procedure is on the decline., Early surgical outcome of Redo CABG, although, improving, are worse than that of primary CABG., INTRODUCTION, Redo coronary artery bypass grafting(CABG) is more, demanding procedure than primary CABG, because..., 1.Increasing age, 2.lncreasing comobidities, 3.Atheromatous disease in the native coronary, arteries
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4.Decreased ventricular function, , The above chart shows challenges in Redo CABG., RECENT TRENDS, Redo CABG now constitute less than 2% total, isolated CABG., Reason for decline in Redo CABG are.., 1.Aggresive PCI especially for patients with previous, CABG., 2.Patient has arterial graft at primary operation, INDICATIONS, In case of early post operative graft failure,, emergency PCI may limit the extent of infaraction., The target for PCI is the native vessel or the ITA, grafts.
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Acutely occluded SVG and any anastomotic site, should be avoided if possible due to concern, regarding embolization or perforation., Redo surgery should be favoured if the Anatomy is, unsuitable for PCI,if several important grafts are, occluded or in case of clear anastomotic errors., , The above chart shows indication for Redo CABG, and PCI when SAPHENOUS vein graft is stenotic., TECHNICAL CONSIDERATION, STERNAL REENTRY, Most Redo CABGs are performed through median, Sternotomy., The wires are cut anteriorly but not removed., The sternum is cut with an oscillating saw, while the, wires are pulled up.
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It is better to use micro oscillator saw, because it, conveys the sensation of cutting inner layer of, sternum., , The above figure shows micro oscillator saw., If the patient ITA graft or the ascending aorta is, adherant to the back of sternum, an anterior, thoracotomy near adhesion is made, and dissection, of adhesion is performed and repeat median, Sternotomy is performed., If dissection of adhesion is difficult, peripheral, cannulation is performed in groin.
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DISSECTION OF THE HEART, ASCENDING AORTA, AND GRAFTS, Once the sternum is safely re entered, dissection of, heart is started adjacent to diaphragm., Dissecting the aortic and venous cannulation sites in, early stage of operation to initiate CPB., Dissection is preceeded from the right ventricle to, left ventricle., A harmonic scalpel is useful and safe to dissect the, heart., Dissection of the diseased vein graft should be, minimised., The patent ITA should be dissected free for almost, its whole length., When the circumflex artery is to be grafted, the, lateral wall of the left ventricle should be dissected, upto left pulmonary vein., CARDIOPROTECTION
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Cardioprotection is extremely important especially, in Redo CABG., Coronary arteries of patients undergoing Redo, CABG are often severely atherosclerotic and totally, occluded., Care should be taken to protect myocardium., GRAFTING PATTERN, The basic concept of how to select bypass graft in, Redo CABG is the same as the primary CABG., If only the SAPHENOUS vein was used in primary, CABG, the left and right ITA are available for Redo, CABG., If the LAD needs to be grafted, ITA should be used., If the left ITA to LAD graft is patent and the left, circumflex artery needs to be grafted, the right ITA, is the choice., SURGICAL OUTCOME
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Surgical outcome of Redo CABG in terms of hospital, mortality has been improving, however it remains, three times higher than that of primary CABG., , END OF MODULE 19....
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HYBRID CORONARY REVASCULARIZATION......, MODULE 20...., BULLET POINTS, Hybrid coronary revascularization consists of, combination of coronary artery bypass grafting and, PCI to achieve full revascularization., Involves Minimally invasive approach to graft the, left internal thoracic artery to the left anterior, descending artery., Hybrid revascularization often utilizes robotic, techniques without manipulation of ascending, aorta to prevent major comobidities such as stroke., Candidates for hybrid coronary revascularization, must have coronary artery disease in the proximal, or mid left anterior descending as well as at least, One other non left anterior descending artery with, a moderate syntax score., INTRODUCTION, LITA grafting was associated with improved survival,, reduced risk of myocardial infarction and reduced
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need for repeat revascularization at 10 year follow, up., As demonstrated in multiple trial(SYNTAX,, FREEDOM, ASCERT) in patients with multivessel, CAD, CABG is associated with superior long term, survival,more complete revascularization, improved, long term relief from Angina and lower need for, repeat revascularization when compared with PCI., PCI has lower rates of periprocedural stroke, blood, transfusion, atrial fibrillation and morbidity., The superiority of the LITA over the SAPHENOUS, vein graft or intracoronary Stent is due to the an, intrinsic resistance to the development of, atherosclerosis and the native production of nitrous, oxide, promoting vasodilation of the entire down, stream coronary circulation., HYBRID CORONARY REVASCULARIZATION, CABG+PCI technique to address multiple coronary, lesion in concurrent or staged setting., RATIONALE FOR HCR
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HCR combines the minimal invasiveness and safety, of PCI with the most beneficial aspect of CABG, the, LITA to LAD anastomosis., CPB is avoided., RISK of stroke is sharply reduced given that aortic, manipulation is completely avoided., PATIENT SELECTION, For patients to be eligible for HCR, the patients, need to have CAD of his proximal or mid LAD as well, as one other coronary lesion requiring, revascularization., The lesion for PCI need to be non complex and of a, lower SYNTAX score., Patients must be eligible for the minimal invasive, CABG., Any prior chest surgeries or Intra thoracic infections, that may result in dense pleural adhesions as these, may preclude a robotic or mini thoracotomy, approach., Morbid obesity is contraindicated to HCR.
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MIDCAB, Minimally invasive direct coronary artery bypass, grafting (MIDCAB) was first developed in 1990s., The technique utilizes an anterolateral thoracotomy, in combination with a specialised retractor that, allows for the same incision to be used for both, LITA harvest and LITA to LAD anastomosis., TECHNIQUE, Placement of arterial line and central line., Dual lumen endotracheal tube must be placed., Robotic harvest of LITA require single lung, ventilation., External defibrillator pads must be placed., A bump is placed under the left chest in cranial, caudal orientation., Before any incision are made, the left lung should, be deflated using bronchial blocker or dual lumen, endotracheal tube., CO2 is used in insufflation of the left chest.
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Monitor BP as it may cause tension pneumothorax., The first step is to open the pericardium to, visualized the LAD., An initial pericardial incision is made posterior to, left phrenic nerve., LITA harvest begin., LITA is taken down in a skeletonized fashion., LITA is inspected and a combination of milrinone,, Heparin and blood is injected into LITA to promote, vasodilation., LAD arteriotomy is made., An intracoronary shunt is inserted., The anastomosis is completed in usual fashion., Aspirin and Clopidogrel is given within 6 hours of, surgery., TIMING OF INTERVENTION, HCR can be sequenced in one of three ways., 1.Concommitantly in hybrid OR
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2.Staged with CABG before PCI, 3.Staged with PCI than CABG, Typically the CABG is performed first with PCI to, follow immediately after. But there does exist a, concern for postoperative bleeding due to need for, immediate dual antiplatelets therapy., Staged CABG followed by PCI allow for angiography, evaluation of the LITA to LAD anastomosis as well as, PCI in the setting of the protected anterior wall., This provide some degree of protection for PCI of, the non LAD vessel., The risk of bleeding is lower and allows for full dual, antiplatelets therapy with minimal perioperative, bleeding risk., RESULT, CABG first HCR was the most popular followed by, PCI first HCR., END OF MODULE... 20..
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BILATERAL INTERNAL MAMMARY ARTERY, GRAFTING.... MODULE 21, BULLET POINTS, Left internal mammary artery grafting of left, anterior descending artery is the gold standard of, revascularization., Bilateral IMA grafting is associated with better long, term outcomes including improved survival,, enhanced freedom from re intervention and better, symptom relief., Bilateral IMAs can be used in various configuration., Diabetics are less frequently offered BIMA grafting, due to concern about sternal wound complications., Skeletonization techniques for IMA harvesting, lowers the risk of sternal wound complications in, patients with diabetes., Arterial revascularization trial(ART) is the only, randomised trial of bilateral IMA versus single IMA, with a primary outcome of survival 10 years.
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INTRODUCTION, Conventionally most patients undergoing CABG, receive the standard operation comprising of single, IMA with additional vein graft performed using CPB., The use of bilateral IMA during CABG, has improved, long term survival and event free cardiac survival., HISTORICAL ASPECTS, Utilization of left IMA as a bypass graft was due to, encouraging results of the work by Arthur Vineberg, in 1946., Vasilii kolesov, performed the first sutured, anastomosis of left IMA to LAD artery in 1964., Rene Favaloro is considered as father of coronary, surgery, described the technique and outcomes of, bilateral IMA implants into the myocardium., Saphenous vein graft is the most commonly used, graft., Suzuki was the first to report the use of bilateral, IMA for coronary revascularization to revascularize, coronary arteries.
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RATIONALE, Benefits of bilateral IMAs..., 1.Excellent patency rates, 2.Relief of symptoms, 3.Low reoperation rate, 4.Superior Long term survival, compared with SVG., IMA are resistant to atherosclerosis., The radial artery and SVG are more commonly used, as second choice conduits after left IMA.
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The above chart shows characteristics of internal, mammary artery., TECHNICAL ASPECTS, , The above chart shows pros and cons of various, surgical strategies for BIMA grafting., , The above figure shows various configuration of, bilateral IMAs.... (a) In situ Rima to the PDA and in, situ Lima to LAD.
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(B)LIMA-RIMA Y graft with in situ LIMA to LAD and, RIMA to Cx branches., (C) in situ RIMA through the transverse sinus to Cx, branches and in situ LIMA to LAD., (D) retrosternal in situ RIMA to LAD and in situ, LIMA to Cx branches., CONCLUSION, Increased risk of deep sternal wound infection,, particularly in patients with diabetes, obesity, COPD, is a key concern for bilateral IMA use., In addition, the technical complexity of the, harvesting technique, the longer operative time and, potential increase in short term morbidities are also, seen as obstacle that prevent widespread use of, bilateral IMA grafting., , END OF MODULE 21......
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TOTAL AND MULTIPLE ARTERIAL, REVASCULARIZATION..... MODULE 22, BULLET POINTS, Arterial graft patency rates are always better than, those of saphenous vein graft(90 to 95 % versus 50, to 60 %) at 10 years., Perioperative results for both total arterial, revascularization(TAR) and multiple arterial bypass, grafting(MABG) and single arterial coronary artery, bypass grafting are excellent and identical (1%, perioperative and 30 day mortality)., In total arterial revascularization and multiple, arterial bypass grafting, multiple graft strategies, and combination can be used and are equally, effective as well as on or off pump., The second arterial graft should be to the next most, important vessel., Arterial graft patency rates are similar, irrespective, of which arterial conduit, if it is anostomose to the
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same target vessel, with the same degree of native, CAD., Patency rates to the left anterior descending (LAD), at 10 years are 90 to 95%,circumflex artery 90% and, posterior descending artery 80 to 90 %., TAR/MABG enhance Prognosis in older patients,, women, Diabetics and those with preoperative, renal dysfunction., Spasm prophylaxis and avoidance of competitive, flow are essential for all arterial grafts especially, radial artery and right gastroepiploic artery., INTRODUCTION, In 1967 aortocoronary saphenous vein graft was, used to bypass stenotic coronary lesion., Symptomatic relief and enhanced Prognosis in...., 1.Triple vessel disease, 2.Left main, 3.Proximal severe LAD stenosis... remain goal of, CABG.
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LITA to LAD anastomosis in 1986., Currently over 70% of all graft are SVG., SVGs fail 10% at one week, 25% at one year and, 50% at 10 year from technical problems, intima and, media hyperplasia and atheroma., Arterial coronary grafts remain free of atheroma, and have better patency rates 90 to 95% at 10, years,resulting in less recurrent Angina, fewer, myocardial infarction and reoperation and better, survival than with SVGs., , The above diagram shows diseased saphenous, vein graft (9 years postoperative) left panel.......
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Sequential Left internal thoracic artery graft to the, diagonal artery and to left anterior descending, artery (15 years postoperative) right panel............., Currently <5% of patients receive MABG in USA., 1 to 10% in Europe and 20 to 60% in Australia and, Asia., ARTERIAL CORONARY GRAFTS, LEFT INTERNAL THORACIC ARTERY (LITA), Elastomuscular artery., 3 to 3.5 mm diameter proximally and 2 to 2.5 mm, distally., Best coronary grafts., Resistance to atherosclerosis., 95% patency at 10 years and 90% patency at 20, years., Used in 95% of CABG exclusively to LAD., The LITA may also be used preferentially to the, circumflex system with right ITA to LAD.
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It is susceptible to spasm but responsible to potent, vasodilators., ITA may be harvested either a pedicled or, skeletonized conduit., The skeletonized technique result in better sternal, vascularity, less dehiscence and infection., , The above diagram shows in situ right internal, thoracic artery graft to right coronary artery (11, years postoperatively), RIGHT INTERNAL THORACIC ARTERY (RITA), RITA is biologically identical to LITA.
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Harvest is identical to LITA and usually easier as it is, larger and more separated from the IT vein., It will only reach mid LAD, intermediate or proximal, circumflex, the right coronary artery near the acute, margin and occasionally proximal PDA., Its use may be extended by construction of LITARITA Y graft, RITA-RA extension graft., Its use is minimal because..., 1.Non familarity, 2.Extra time required, 3.Sternal infection, 4.Hypoperfusion, 5.Evidance from randomizer control trial, RADIAL ARTERY, The RA is the second most commonly, used arterial, graft., 10 to 20% of cases.
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Though first used in early 70s,it was reintroduced, after 1992 when early RA grafts were shown to be, patent 20 years later., The RA is long 20 to 22 cm, versatile and easy to, handle., Assessment of ulnar collateral supply to the, hand(adequate in 90 to 95% of cases) by modified, Allen’s test is mandatory., Harvest by open or endo harvest technique, produces equally good patency results., The RA has a thicker, more muscular wall than the, ITA and is more sensitive to spasm., Contraindications to RA use include...., 1.Inadequate ulnar hand collaterals, 2.Severe calcification, 3.Small size<2 mm, 4.Prior forearm trauma, 5.AV fistula for dialysis
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The above diagram shows radial artery grafts in, posterior descending artery (left panel) and, circumflex marginal artery(right panel) in same, patients., RIGHT GASTROEPIPLOIC ARTERY (RGEA), Muscular wall and sensitive to spasm., Spasm prophylaxis and avoidance of competitive, flow is mandatory as in RA., Used as source of inflow to PDA or RCA., 10 year patency rate 60%.
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OTHER ARTERIAL GRAFT, Inferior epigastric, Ulnar artery, DEPLOYMENT STRATEGIES, LITA is placed to LAD., The diagonal, if stenosed and medially placed may, be grafted sequentially enpassant via a side to side,, parallel anastomosis., RITA can be used in situ, anterior to the aorta or, through the transverse sinus to an intermediate or, proximal circumflex marginal or to the RCA., If RCA stenosis is proximal and distal RCA free of, disease, alternatively as an aortocoronary free graft, to the circumflex or PDA and most commonly as a, LITA/RITA... BITA Y graft., BILATERAL INTERNAL THORACIC ARTERY GRAFT, The commonest format is for a LITA/RITA Y graft, with the LITA to LAD and RITA revascularizing the
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circumflex system through multiple sequential, anastomosis., , The above chart shows conduit patency rates., LONG TERM RESULTS, Survival and postoperative results (recurrent, Angina, MI, reintervention and death) correlate, with graft patency., TAR/MABG confers long term survival advantage, in..., 1.Elderly, 2.Gender....men derieve prognostic benefits, 3.diabetes, 4.Chronic renal disease, 5.Left ventricular dysfunction, 5.Reoperation, END OF MODULE 22.......
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POST INFARCTION VENTRICULAR SEPTAL, DEFECTS... MODULE 23..., BULLET POINTS, Post infaraction ventricular septal defect(VSD) is an, early mechanical complications of acute myocardial, infarction., It occurs in the myocardial territory of an occluded, coronary artery., It can be isolated or associated with other, complications such as free wall aneurysm or acute, mitral regurgitation due to papillary muscle rupture., Cardiogenic shock, right ventricular dysfunction and, emergent surgery are risk factors for higher, operative mortality., Surgical treatment is the is the first line approach to, post infaraction VSD., EPIDEMIOLOGY, NATURAL AND CLINICAL HISTORY, VSD following Acute myocardial infarction has 30, days mortality rate approaching 100% with medical, management alone.
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Incidance rate.... 0.5% of patients presenting with, AMI., GUSTO-I trial... Almost all VSDs occur during first, day following AMI., Death is highest in early days following ventricular, rupture., The risk of early mortality is ranged between 19%, and 54% and may be directly influenced by some, risk factors as.., 1.cardiogenic shock, 2.hemodynamic instability, 3.early repair, 4.right ventricular dysfunction, 5.organ failure, 6.complex VSD, VSD is mainly anterior or apical in case of anterior, MI with acute occlusion of LAD artery.
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VSD is posterior in 50% of cases as a result of, inferior MI due to occlusion dominant RCA or in few, cases occluded dominant circumflex artery., In the later cases acute mitral regurgitation may, occur if the papillary muscle is located in ischemic, zone., The result of sudden septal rupture is blood shunt, from left to right ventricle with increased, pulmonary pressure that may lead to acute right, ventricular dysfunction., A VSD should be suspected if a patient initially, admitted for AMI presents with..., 1.Sudden Cardiogenic shock, 2.Persistant or recurrent chest pain, 3.new onset cardiac murmur, 4.Pulmonary Congestion, TTE and Doppler evaluation is recommended.
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TTE confirms the presence, location and size of, defect and allows assessment of complication such, as..., 1.valvular dysfunction, 2.left ventricular wall motion abnormality, 3.right ventricular dysfunction, , (a. b) transthoracic Echocardiography showing, septal defect and communication between right, and left ventricle. (c) transesophageal
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Echocardiography showing Doppler colour flow, between both ventricle. (d) perioperative picture, of same VSD, THERAPEUTIC STRATEGIES, Medical treatment with Inotropic support can only, temporarily alleviate symptoms and helps to, hemodynamically alleviate symptoms., Surgical treatment is the main approach to treat, post infaraction VSD., 1.Emergent surgical closure of defect, 2.Delayed VSD repair, In case of delayed VSD repair, an Intra aortic, balloon pump(IABP) can be used to decrease left, ventricular afterload and reduce right to left shunt, or more invasive therapy with ECMO or temporary, Percutaneous inserted mechanical assist, device(Impella, tandem heart) is often required., These strategies allow for adequate delivery of, oxygenated blood to peripheral organs and
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prevents multi organ failure despite Cardiogenic, shock., , Above chart shows Indications of heart, transplantation in post infaraction VSD., POSTOPERATIVE RESULTS AND PROGNOSIS, Fatal complications 30 to 40% of cases., Mortality is 100% with medical management alone., Risk factors associated with higher mortality, following post infaraction VSD are..., 1.cardiogenic shock, 2.inability to delay surgery, 3.VSD location
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4.Right ventricular dysfunction, , The above chart shows algorithm for therapeutic, decision making in acute Post infaraction VSD., , END OF MODULE 23.....
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ISCHEMIC MITRAL REGURGITATION....., MODULE 24....., BULLET POINTS, Ischemic mitral valve regurgitation is a valvular, consequence of ventricular pathology arising from, chronic coronary artery disease., Surgical intervention is indicated in patients with, severe IMR who remain symptomatic despite, guideline directed medical therapy., EPIDEMIOLOGY, Mitral valve regurgitation is the most common, valvular heart disorder., Ischemic MR is caused by pathologic left ventricular, remodeling due to chronic coronary artery disease., PATHOPHYSIOLOGY, As the ischemic left ventricle dilate, the mitral, annulus dilates and papillary muscles are apically, Displaced,resulting in leaflet tethering and, suboptimal coaptation.
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Chronic regurgitation exacerbate this ventricular, dilatation furthur worsening MR and leading to, volume overload., , Above diagram shows pathophysiology of ischemic, mitral regurgitation....., DIAGNOSIS AND ASSESSMENT OF ISCHEMIC, MITRAL REGURGITATION, Clinical examination unreliable., Classic systolic regurgitation murmur on, auscultation may be absent due to a lower, regurgitant volume from reduced LV contractility, and high left atrial pressure., TTE is diagnostic.
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Below diagram shows grading of chronic ischemic, , mitral regurgitation., MEDICAL THERAPY, Failure management and it include angiotensin, converting enzyme(ACE) inhibitors and beta blocker, both independent predictors of improved survival in, patients with LV dysfunction., Cardiac resynchronization therapy(CRT) with, biventricular pacemaker is another well established, therapy for NYHA III-IV patients with reduced LV, ejection fraction. QRS>120 Ms and chronic severe, secondary MR., INDICATIONS FOR SURGICAL INTERVENTION, Severe ischemic MR who remain symptomatic, despite guideline directed medical and cardiac, device therapy.
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MITRAL VALVE REPLACEMENT, Several principle and suggestion to consider are..., 1.preservation of the subvalvular apparatus..., excision will distort ventricular geometry and impair, LV function., 2.avoidance of left ventricular outflow tract, obstruction., 3.suture placement... Pay particular attention to the, anterolateral commissure and posterior annulus, where non coronary cusps of aortic valve and, circumflex artery at risk respectively., 4.Mechanical prosthesis have a long term mortality, benefits compared with biologic prosthesis until age, 70 in mitral position., MITRAL VALVE REPAIR, As LV dilatation is one of the most common, etiologies of IMR, most cases involve annular, dilatation and therefore benefits from Restrictive, ring annuloplasty.
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Posterior annulus is most commonly dilated, segments., CONCOMITANT CORONARY BYPASS GRAFTING, As the primary cause of IMR is ischemia induced LV, dilatation, surgical revascularization of ischemic, territories may improve LV function and reduce LV, dilation thereby restoring mitral annular geometry, and function of subvalvular apparatus., MITRAL CLIP(LEAFLET APPOSITION THERAPY), The mitra clip device is the most widely used, transcatheter MVrpr technique., The device deploy a clip which clinches the anterior, and posterior leaflet together at the location of, regurgitant jet creating double orifice MV., The ongoing randomized trial of mitra clip are..., 1.COAPT, 2.MITRA-FR, EVEREST II.... completed trial, END OF MODULE... 24
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POST INFARCTION VENTRICULAR ANEURYSM....., MODULE 25...., BULLET POINTS, True aneurysm are sequelae of transmural, myocardial infarction., True aneurysm has all the three layers of cardiac, tissue., False aneurysm or Pseudo aneurysm are rare, complications of myocardial infarction and, represent contained myocardial rupture., In pseudoaneurysm, wall devoid of endocardial and, myocardial element., In 90% of cases, left ventricular aneurysm is located, at the apex of heart or in the anterior wall and in, 10%,it is in the posterior inferior wall., Majority of pseudoaneurysm are located on the, posterior, lateral, apical or inferior surface of the, left ventricle.
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Generally patients with true or false aneurysm may, present with Nonspecific complaints of chest pain,, Dyspnea or even be asymptomatic., Left ventriculography has been the gold standard, modality to distinguish pseudoaneurysm from true, left ventricular aneurysm with diagnosis accuracy of, >85%., Once the diagnosis of pseudoaneurysm is, established, surgical correction is mandatory., The presence of true left ventricular aneurysm, alone is not surgical indication., Surgery in case of true aneurysm is indicated when, concomitant, persistent Angina, refractory heart, failure, thromboembolism or life threatening, tachyarrhythmia occur., Endoventricular circular patch plasty is the, preferred surgical option for treating true left, ventricular aneurysm.
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Above diagram shows(a) left ventricular, pseudoaneurysm.... (b) left ventricular aneurysm...
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INTRODUCTION, Aneurysm of the left ventricle are of two types..., True and false(Pseudo)., True aneurysm are sequelae of transmural, myocardial infarction., False aneurysm or pseudoaneurysm are rare, complications of myocardial infarction and, represent a contained myocardial rupture., It does not contain all the three layers of, myocardium and is frequently lined by pericardium, and mural thrombus., False aneurysm have tendency to rupture.
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Above chart shows causes of left ventricular, pseudoaneurysm...
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The below chart shows comparison of true and, , false left ventricular aneurysm., INCIDENCE, True left ventricular aneurysm occur in, approximately 7.6% of patients with CAD., Rupture of free wall of left ventricle is a, catastrophic complication occurring in 4% of, patients after myocardial infarction and in 23% of, those who die of myocardial infarction., PATHOPHYSIOLOGY
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Inferior myocardial infarction account for, approximately twice as many cases of, pseudoaneurysm as anterior myocardial infarction., In case of inferior myocardial infarction to result in, left ventricular pseudoaneurysm, the location of, pseudoaneurysm is on posterior, lateral, apical or, inferior surface of the left ventricle., In contrast to left ventricular pseudoaneurysm, only, about 4% of true left ventricular aneurysm are, located at the posterolateral or diaphragmatic, surface., The diameter of a left ventricular aneurysm is from, 1 to 8 cm. In 90% of cases, the left ventricular, aneurysm is located at the apex of heart or in the, anterior wall and in 10%,it is in posterior inferior, wall., CLINICAL FEATURES, Patients present with Nonspecific complaints of, chest pain, Dyspnea or even be asymptomatic.
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Angina, the most prevalent symptoms of left, ventricular aneurysm, has been attributed to, volume overload to the left ventricle and a resultant, increase in oxygen consumption., Dyspnea, the second most frequent symptoms, occurs because of a combination systolic and, diastolic dysfunction., Atrial and ventricular Arrhythmia cause Palpitations,, syncope or sudden death., INVESTIGATIONS, ELECTROCARDIOGRAM, Persistent ST segment elevation, Q waves, These abnormality are present and are neither, specific nor sensitive., CHEST X RAY, Enlarged cardiac silhouette., A discrete bulge on the cardiac border has been, described in patients with pseudoaneurysm.
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The above chest x Ray showing bulge(white arrow), along the left cardiac border in patients with, pseudoaneurysm..., ECHOCARDIOGRAPHY, Transthoracic Echocardiography is the most, common modality to diagnose left ventricular, aneurysm., The distinction between pseudoaneurysm and true, aneurysm proves challenging with TTE.
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LEFT VENTRICULOGRAPHY, Left ventriculography has been the gold standard, modality to distinguish pseudoaneurysm from true, left ventricular aneurysm., The most useful combination of finding to confirm, pseudoaneurysm include a narrow orifice leading, into a saccular aneurysm.
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The above diagram shows A left ventriculogram in, the right anterior oblique view shows a large left, ventricular pseudoaneurysm arising from the, lateral wall of left ventricle (LV) and grade 2 mitral, regurgitation (MR). The white arrow points to the, narrow orifice leading into a saccular aneurysm., COMPUTED TOMOGRAPHY, Computed tomography scanning is a reliable and, non invasive modality for identifying left ventricular, aneurysm and for assessing resectability., MAGNETIC RESONANCE IMAGING, MRI is a reliable Noninvasive modality for, identifying left ventricular aneurysm and for, assessing resectability., MANAGEMENT, PSEUDOANEURYSM, SURGERY
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Once the diagnosis of pseudoaneurysm is, established surgical correction is mandatory., If there is preoperative hemodynamic instability,, Intra aortic balloon pump should be inserted as, early as possible to achieve hemodynamic stability., TRANSCATHETER DEVICE CLOSURE, Case reports have described the successful use of, septal occluders, ventricular septal defect occluders, and coils., TRUE ANEURYSM, SURGICAL INDICATIONS, The presence of left ventricular aneurysm alone is, not a surgical indication., Surgery is indicated when concomitant, persistent, Angina, refractory heart failure, thromboembolism, or life threatening tachyarrhythmia occur., SURGICAL TECHNIQUE, Plication, Cooley technique
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Stoney technique, Jatene technique, Dor technique, MaCarthy technique, CONCLUSION, The goal of surgical intervention is to correct the, size and geometry of the left ventricle, reduce wall, tension and paradoxical movement and improve, systolic function., , END OF MODULE 25.......
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CORONARY ENDARTERECTOMY..... MODULE 26, BULLET POINTS, Coronary endarterectomy firstly described by Bailey, et al in 1957,is not an alternative but an adjunct to, coronary artery bypass grafting., Coronary endarterectomy is the removal of, coronary atherosclerotic core through an, arteriotomy, either by traction(closed technique) or, under direct vision(open technique) to achieve, complete myocardial revascularization., Due to coronary endothelium removal, a, coagulation cascade is triggered, so, thromboprophylaxis by single or double, antiplatelets regimen with or without, anticoagulation treatment is required., Diffuse coronary artery disease affecting side, branches, severe calcification and in Stent, restenosis following full metal jacket procedure are, its indication.
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Coronary endarterectomy can be safely performed, either on pump or off pump., Multi vessel coronary endarterectomy significantly, worsen patients Prognosis., HISTORY, Charles Bailey introduced coronary endarterectomy, in 1956., Antegrade endarterectomy was first performed in, 1958 by Longmire., LAD is currently the target coronary vessel of choice, for endarterectomy., INDICATIONS, Patients having Diffuse CAD and severe calcification, of coronary arteries may benefit from CE., Diffuse CAD affecting side branches with no option, for conventional distal grafting and severe, calcification of the LAD preventing construction of, simple anastomosis of the left ITA graft to the LAD, are main indication.
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The above chart shows coronary endarterectomy, indications., ANTICOAGULATION PROTOCOL, Heparin infusion followed by warfarin for 3 month, aiming at international normaliazed ratio(INR), between 2 to 2.5 or double antiplatelets therapy, immediately after the operation are reasonable., Heparin is withheld when the INR between 2 and 3, is achieved., Subsequently discontinuation of warfarin 3 month, postoperatively with permanent aspirin alone, intake is reasonable.
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The above chart shows recommended, anticoagulation profile., UNRESOLVED ISSUES, Single endarterectomy is associated with better, results than multi vessel endarterectomy., RCA endarterectomy as an adjunct to LAD or, diagonal branch endarterectomy leads to increased, early mortality.
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CONCLUSION, When complete revascularization is threatened due, to Diffuse calcification or Diffuse atheromatous, plaque affecting coronary side branches, CE, constitute valuable surgical option., , END OF MODULE 26.....
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TRANSMYOCARDIAL LASER, REVASCULARIZATION..... MODULE 27..., BULLET POINTS, TRANSMYOCARDIAL laser revascularization (TMR), has emerged as a treatment modality for patients, with refractory Angina who have exhausted option, for CABG and PCI., TMR has been performed in over 100000 patients, worldwide., TMR can be performed through a thoracotomy, incision without the need for cardiopulmonary, bypass or anticoagulation., The likely mechanism is the stimulation, angiogenesis as a result of the TMR channels., Long term survival for TMR patients is higher than, medical management alone., INTRODUCTION, TMR is used to treat moderate to severe Angina, resulting from CAD not amenable to medical, therapy,PCI or CABG.
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The most likely mechanism for the clinical efficacy, of TMR is the stimulation of angiogenesis as a result, of TMR channels., A left anterior thoracotomy in the fifth intercostal, space is the preferred incision site., Channels are created starting near the base of the, heart and then serially in a line approx, 1 cm apart, towards the apex., The number of channels created depends on the, size of the heart and on the size of ischemic area., CONCLUSION, Safety, effectiveness and improved health, outcomes have been demonstrated through, application of TMR for the treatment of selected, patients with severe Angina due to Diffuse disease., , END OF MODULE... 27....
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COMBINED CAROTID AND CORONARY ARTERY, DISEASE.... MODULE 28...., BULLET POINTS, An association between coronary and carotid artery, disease is well known., About 7% of patients referred for coronary artery, bypass grafting have severe asymptomatic carotid, artery stenosis., With severe stenosis, almost half also have bilateral, involvement., Duplex carotid ultrasound is an excellent screening, tool to assess the status of the carotid arteries., Symptomatic carotid stenosis or severe bilateral, stenosis warrent carotid endarterectomy either as a, staged procedure or concomitantly with coronary, artery bypass surgery., In the presence of stable coronary artery disease, and critical symptomatic carotid stenosis, the, traditional option remains carotid endarterectomy, followed by CABG.
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Isolated CABG is recommended for patients with, asymptomatic carotid artery stenosis., INTRODUCTION, Stroke after cardiac surgery is devastating., Many cardiac centre preoperatively screen patients, for concomitant carotid lesion,prior to coronary, artery bypass grafting., Carotid ultrasound is the accepted modality for, initial non invasive testing for carotid artery, stenosis., Coexistent carotid artery stenosis was reported in, 14% patients scheduled for CABG., Among these half have severe stenosis. Selective, screening of patients with following is, recommended..., History of diabetes., Hypertension, Peripheral arterial disease, History of transient ischemic stroke
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Carotid bruit on exam, Amaurosis fugax, New onset extremity weakness, Left main coronary artery disease, MANAGEMENT OF CONCOMITANT CAROTID AND, CORONARY ARTERY DISEASE, Combined CABG+carotid endarterectomy., Staged approach:either CABG followed by CEA or, CEA followed by CABG., Carotid artery Stenting followed by CABG., Off pump CABG with/without CEA., COMBINED CAROTID ENDARTERECTOMY AND, CORONARY ARTERY BYPASS GRAFTING, The combined approach consists of CEA followed by, CABG in the same anesthesia setting., STAGED CAROTID ENDARTERECTOMY AND, CORONARY ARTERY BYPASS GRAFTING, Traditional staged approach of prior carotid, endarterectomy followed by CABG is reserved for
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patients who present with stable coronary artery, disease., The main concern of this approach remains inter, stage myocardial infarction., ROLE OF CAROTID ARTERY STENTING, Results of ACT I trial(asymptomatic carotid trial I), and CREST trial(Carotid revascularization, endarterectomy versus Stenting trial) report, compareble event rates of death,stroke,myocardial, infarction between carotid endarterectomy and, carotid artery Stenting.
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The above chart shows, a practical approach to, patients with combined coronary and carotid, artery disease., , END OF MODULE...... 28....., , THANKS....
