Cardiac surgery

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Cardiac surgery
Coronary artery bypass surgery Image 657B-PH.jpg
Two cardiac surgeons performing coronary artery bypass surgery. Note the use of a steel retractor to forcefully maintain the exposure of the heart.
ICD-9-CM 35-37
MeSH D006348
OPS-301 code 5-35...5-37
Cardiac surgery
Specialty Cardiothoracic surgery

Cardiac surgery, or cardiovascular surgery, is surgery on the heart or great vessels performed by cardiac surgeons. It is often used to treat complications of ischemic heart disease (for example, with coronary artery bypass grafting); to correct congenital heart disease; or to treat valvular heart disease from various causes, including endocarditis, rheumatic heart disease, [1] and atherosclerosis. [2] It also includes heart transplantation. [3]

Contents

History

19th century

The earliest operations on the pericardium (the sac that surrounds the heart) took place in the 19th century and were performed by Francisco Romero (1801) in the city of Almería (Spain), [4] Dominique Jean Larrey (1810), Henry Dalton (1891), and Daniel Hale Williams (1893). [5] The first surgery on the heart itself was performed by Axel Cappelen on 4 September 1895 at Rikshospitalet in Kristiania, now Oslo. Cappelen ligated a bleeding coronary artery in a 24-year-old man who had been stabbed in the left axilla and was in deep shock upon arrival. Access was through a left thoracotomy. The patient awoke and seemed fine for 24 hours but became ill with a fever and died three days after the surgery from mediastinitis. [6] [7]

20th century

Surgery on the great vessels (e.g., aortic coarctation repair, Blalock–Thomas–Taussig shunt creation, closure of patent ductus arteriosus) became common after the turn of the century. However, operations on the heart valves were unknown until, in 1925, Henry Souttar operated successfully on a young woman with mitral valve stenosis. He made an opening in the appendage of the left atrium and inserted a finger in order to palpate and explore the damaged mitral valve. The patient survived for several years, [8] but Souttar's colleagues considered the procedure unjustified, and he could not continue. [9] [10]

Alfred Blalock, Helen Taussig, and Vivien Thomas performed the first successful palliative pediatric cardiac operation at Johns Hopkins Hospital on 29 November 1944, in a one-year-old girl with Tetralogy of Fallot. [11]

Cardiac surgery changed significantly after World War II. In 1947, Thomas Sellors of Middlesex Hospital in London operated on a Tetralogy of Fallot patient with pulmonary stenosis and successfully divided the stenosed pulmonary valve. In 1948, Russell Brock, probably unaware of Sellors's work, [12] used a specially designed dilator in three cases of pulmonary stenosis. Later that year, he designed a punch to resect a stenosed infundibulum, which is often associated with Tetralogy of Fallot. Many thousands of these "blind" operations were performed until the introduction of cardiopulmonary bypass made direct surgery on valves possible. [9]

Also in 1948, four surgeons carried out successful operations for mitral valve stenosis resulting from rheumatic fever. Horace Smithy of Charlotte used a valvulotome to remove a portion of a patient's mitral valve, [13] while three other doctors—Charles Bailey of Hahnemann University Hospital in Philadelphia; Dwight Harken in Boston; and Russell Brock of Guy's Hospital in London—adopted Souttar's method. All four men began their work independently of one another within a period of a few months. This time, Souttar's technique was widely adopted, with some modifications. [9] [10]

The first successful intracardiac correction of a congenital heart defect using hypothermia was performed by lead surgeon Dr. F. John Lewis [14] [15] (Dr. C. Walton Lillehei assisted) at the University of Minnesota on 2 September 1952. In 1953, Alexander Alexandrovich Vishnevsky conducted the first cardiac surgery under local anesthesia. In 1956, Dr. John Carter Callaghan performed the first documented open-heart surgery in Canada. [16]

Types of cardiac surgery

Open-heart surgery

Open-heart surgery is any kind of surgery in which a surgeon makes a large incision (cut) in the chest to open the rib cage and operate on the heart. "Open" refers to the chest, not the heart. Depending on the type of surgery, the surgeon also may open the heart. [17]

Dr. Wilfred G. Bigelow of the University of Toronto found that procedures involving opening the patient's heart could be performed better in a bloodless and motionless environment. Therefore, during such surgery, the heart is temporarily stopped, and the patient is placed on cardiopulmonary bypass, meaning a machine pumps their blood and oxygen. Because the machine cannot function the same way as the heart, surgeons try to minimize the time a patient spends on it. [18]

Cardiac surgery at Gemelli Hospital in Rome Cardiac surgery operating room.jpg
Cardiac surgery at Gemelli Hospital in Rome

Cardiopulmonary bypass was developed after surgeons realized the limitations of hypothermia in cardiac surgery: Complex intracardiac repairs take time, and the patient needs blood flow to the body (particularly to the brain), as well as heart and lung function. In July 1952, Forest Dodrill was the first to use a mechanical pump in a human to bypass the left side of the heart whilst allowing the patient's lungs to oxygenate the blood, in order to operate on the mitral valve. [19] In 1953, Dr. John Heysham Gibbon of Jefferson Medical School in Philadelphia reported the first successful use of extracorporeal circulation by means of an oxygenator, but he abandoned the method after subsequent failures. [20] In 1954, Dr. Lillehei performed a series of successful operations with the controlled cross-circulation technique, in which the patient's mother or father was used as a "heart-lung machine". [21] Dr. John W. Kirklin at the Mayo Clinic was the first to use a Gibbon-type pump-oxygenator. [20] [22]

Nazih Zuhdi performed the first total intentional hemodilution open-heart surgery on Terry Gene Nix, age 7, on 25 February 1960 at Mercy Hospital in Oklahoma City. The operation was a success; however, Nix died three years later. [23] In March 1961, Zuhdi, Carey, and Greer performed open-heart surgery on a child, aged 3+1⁄2, using the total intentional hemodilution machine.

Modern beating-heart surgery

In the early 1990s, surgeons began to perform off-pump coronary artery bypass, done without cardiopulmonary bypass. In these operations, the heart continues beating during surgery, but is stabilized to provide an almost still work area in which to connect a conduit vessel that bypasses a blockage. The conduit vessel that is often used is the saphenous vein. This vein is harvested using a technique known as endoscopic vein harvesting (EVH).

Heart transplant

In 1945, the Soviet pathologist Nikolai Sinitsyn successfully transplanted a heart from one frog to another frog and from one dog to another dog.

Norman Shumway is widely regarded as the father of human heart transplantation, although the world's first adult heart transplant was performed by a South African cardiac surgeon, Christiaan Barnard, using techniques developed by Shumway and Richard Lower. [24] Barnard performed the first transplant on Louis Washkansky on 3 December 1967 at Groote Schuur Hospital in Cape Town. [24] [25] Adrian Kantrowitz performed the first pediatric heart transplant on 6 December 1967 at Maimonides Hospital (now Maimonides Medical Center) in Brooklyn, New York, barely three days later. [24] Shumway performed the first adult heart transplant in the United States on 6 January 1968 at Stanford University Hospital. [24]

Coronary artery bypass grafting

Coronary artery bypass grafting (CABG), also called revascularization, is a common surgical procedure to create an alternative path to deliver blood supply to the heart and body, with the goal of preventing clot formation. This can be done in many ways, and the arteries used can be taken from several areas of the body. [26] Arteries are typically harvested from the chest, arm, or wrist and then attached to a portion of the coronary artery, relieving pressure and limiting clotting factors in that area of the heart. [27]

The procedure is typically performed because of coronary artery disease (CAD), in which a plaque-like substance builds up in the coronary artery, the main pathway carrying oxygen-rich blood to the heart. This can cause a blockage and/or a rupture, which can lead to a heart attack. [27]

Minimally invasive surgery

As an alternative to open-heart surgery, which involves a five- to eight-inch incision in the chest wall, a surgeon may perform an endoscopic procedure by making very small incisions through which a camera and specialized tools are inserted. [28]

In robot-assisted heart surgery, a machine controlled by a cardiac surgeon is used to perform a procedure. The main advantage to this is the size of the incision required: three small port holes instead of an incision big enough for the surgeon's hands. [29] The use of robotics in heart surgery continues to be evaluated, but early research has shown it to be a safe alternative to traditional techniques. [30]

Post-surgical procedures

As with any surgical procedure, cardiac surgery requires postoperative precautions to avoid complications. Incision care is needed to avoid infection and minimize scarring. Swelling and loss of appetite are common. [31] [32]

Recovery from open-heart surgery begins with about 48 hours in an intensive care unit, where heart rate, blood pressure, and oxygen levels are closely monitored. Chest tubes are inserted to drain blood around the heart and lungs. After discharge from the hospital, compression socks may be recommended in order to regulate blood flow. [33]

Risks

The advancement of cardiac surgery and cardiopulmonary bypass techniques has greatly reduced the mortality rates of these procedures. For instance, repairs of congenital heart defects are currently estimated to have 4–6% mortality rates. [34] [35]

A major concern with cardiac surgery is neurological damage. Stroke occurs in 2–3% of all people undergoing cardiac surgery, and the rate is higher in patients with other risk factors for stroke. [36] A more subtle complication attributed to cardiopulmonary bypass is postperfusion syndrome, sometimes called "pumphead". The neurocognitive symptoms of postperfusion syndrome were initially thought to be permanent, [37] but turned out to be transient, with no permanent neurological impairment. [38]

In order to assess the performance of surgical units and individual surgeons, a popular risk model has been created called the EuroSCORE. It takes a number of health factors from a patient and, using precalculated logistic regression coefficients, attempts to quantify the probability that they will survive to discharge. Within the United Kingdom, the EuroSCORE was used to give a breakdown of all cardiothoracic surgery centres and to indicate whether the units and their individuals surgeons performed within an acceptable range. The results are available on the Care Quality Commission website. [39] [40]

Another important source of complications are the neuropsychological and psychopathologic changes following open-heart surgery. One example is Skumin syndrome  [ fr ], described by Victor Skumin in 1978, which is a "cardioprosthetic psychopathological syndrome" [41] associated with mechanical heart valve implants and characterized by irrational fear, anxiety, depression, sleep disorder, and weakness. [42] [43]

Risk reduction

Pharmacological and non-pharmacological prevention approaches may reduce the risk of atrial fibrillation after an operation and reduce the length of hospital stays, however there is no evidence that this improves mortality. [44]

Non-pharmacologic approaches

Preoperative physical therapy may reduce postoperative pulmonary complications, such as pneumonia and atelectasis, in patients undergoing elective cardiac surgery and may decrease the length of hospital stay by more than three days on average. [45] There is evidence that quitting smoking at least four weeks before surgery may reduce the risk of postoperative complications. [46]

Pharmacological approaches

Beta-blocking medication is sometimes prescribed during cardiac surgery. There is some low certainty evidence that this perioperative blockade of beta-adrenergic receptors may reduce the incidence of atrial fibrillation and ventricular arrhythmias in patients undergoing cardiac surgery. [47]

See also

Related Research Articles

<span class="mw-page-title-main">Cardiology</span> Branch of medicine dealing with the heart

Cardiology is the study of the heart. Cardiology is a branch of medicine that deals with disorders of the heart and the cardiovascular system. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease, and electrophysiology. Physicians who specialize in this field of medicine are called cardiologists, a sub-specialty of internal medicine. Pediatric cardiologists are pediatricians who specialize in cardiology. Physicians who specialize in cardiac surgery are called cardiothoracic surgeons or cardiac surgeons, a specialty of general surgery.

<span class="mw-page-title-main">Coronary artery bypass surgery</span> Surgical procedure to restore normal blood flow to an obstructed coronary artery

Coronary artery bypass surgery, also known as coronary artery bypass graft, is a surgical procedure to treat coronary artery disease (CAD), the buildup of plaques in the arteries of the heart. It can relieve chest pain caused by CAD, slow the progression of CAD, and increase life expectancy. It aims to bypass narrowings in heart arteries by using arteries or veins harvested from other parts of the body, thus restoring adequate blood supply to the previously ischemic heart.

<span class="mw-page-title-main">Cardiopulmonary bypass</span> Technique that temporarily takes over the function of the heart and lungs during surgery

Cardiopulmonary bypass (CPB) or heart-lung machine also called the pump or CPB pump is a machine that temporarily takes over the function of the heart and lungs during open-heart surgery by maintaining the circulation of blood and oxygen throughout the body. As such it is an extracorporeal device.

<span class="mw-page-title-main">Cardiothoracic surgery</span> Medical specialty involved in surgical treatment of organs inside the thorax

Cardiothoracic surgery is the field of medicine involved in surgical treatment of organs inside the thoracic cavity — generally treatment of conditions of the heart, lungs, and other pleural or mediastinal structures.

Aortic valve replacement is a cardiac surgery procedure whereby a failing aortic valve is replaced with an artificial heart valve. The aortic valve may need to be replaced because of aortic regurgitation, or if the valve is narrowed by stenosis.

<span class="mw-page-title-main">Median sternotomy</span> Surgical access through vertical sternum incision

Median sternotomy is a type of surgical procedure in which a vertical inline incision is made along the sternum, after which the sternum itself is divided using a sternal saw. This procedure provides access to the heart and lungs for surgical procedures such as heart transplant, lung transplant, corrective surgery for congenital heart defects, or coronary artery bypass surgery.

Hybrid coronary revascularization (HCR) or hybrid coronary bypass is a relatively new type of heart surgery that provides an alternative to traditional coronary artery bypass surgery (CABG) or percutaneous coronary intervention by combining the two into one operation. It is this combining aspect that "hybrid" refers to. HCR is one of several types of hybrid cardiac surgery; it is not to be confused with a MIDCAB procedure, which uses the smaller thoracotomy incision but does not involve coronary stenting.

A vascular bypass is a surgical procedure performed to redirect blood flow from one area to another by reconnecting blood vessels. Often, this is done to bypass around a diseased artery, from an area of normal blood flow to another relatively normal area. It is commonly performed due to inadequate blood flow (ischemia) caused by atherosclerosis, as a part of organ transplantation, or for vascular access in hemodialysis. In general, someone's own vein (autograft) is the preferred graft material for a vascular bypass, but other types of grafts such as polytetrafluoroethylene (Teflon), polyethylene terephthalate (Dacron), or a different person's vein (allograft) are also commonly used. Arteries can also serve as vascular grafts. A surgeon sews the graft to the source and target vessels by hand using surgical suture, creating a surgical anastomosis.

<span class="mw-page-title-main">Arterial switch operation</span> Open heart surgical procedure

Arterial switch operation (ASO) or arterial switch, is an open heart surgical procedure used to correct dextro-transposition of the great arteries (d-TGA).

Transmyocardial laser revascularization (TMR) is a procedure used to treat inoperable heart disease in people with persistent angina that is not relieved by any other revascularization method.

Minimally invasive direct coronary artery bypass (MIDCAB) is a surgical treatment for coronary heart disease that is a less invasive method of coronary artery bypass surgery (CABG). MIDCAB gains surgical access to the heart with a smaller incision than other types of CABG. MIDCAB is sometimes referred to as "keyhole" heart surgery because the operation is analogous to operating through a keyhole.

<span class="mw-page-title-main">Ross procedure</span> Type of cardiac surgical operation

The Ross procedure, also known as pulmonary autograft, is a heart valve replacement operation to treat severe aortic valve disease, such as in children and young adults with a bicuspid aortic valve. It involves removing the diseased aortic valve, situated at the exit of the left side of the heart, and replacing it with the person's own healthy pulmonary valve (autograft), removed from the exit of the heart's right side. To reconstruct the right sided exit, a pulmonary valve from a cadaver (homograft), or a stentless xenograft, is used to replace the removed pulmonary valve. Compared to a mechanical valve replacement, it avoids the requirement for thinning the blood, has favourable blood flow dynamics, allows growth of the valve with growth of the child and has less risk of endocarditis.

<span class="mw-page-title-main">Oxygenator</span> Medical equipment

An oxygenator is a medical device that is capable of exchanging oxygen and carbon dioxide in the blood of human patients during surgical procedures that may necessitate the interruption or cessation of blood flow in the body, a critical organ or great blood vessel. These organs can be the heart, lungs or liver, while the great vessels can be the aorta, pulmonary artery, pulmonary veins or vena cava.

<span class="mw-page-title-main">Off-pump coronary artery bypass</span>

Off-pump coronary artery bypass (OPCAB), or beating-heart surgery, is a form of coronary artery bypass graft (CABG) surgery performed without cardiopulmonary bypass as a treatment for coronary heart disease. It was primarily developed in the early 1990s by Dr. Amano Atsushi. Historically, during bypass surgeries, the heart is stopped and a heart-lung machine takes over the work of the heart and lungs. When a cardiac surgeon chooses to perform the CABG procedure off-pump (OPCAB) the heart is still beating while the graft attachments are made to bypass a blockage.

<span class="mw-page-title-main">Coronary stent</span> Medical stent implanted into coronary arteries

A coronary stent is a tube-shaped device placed in the coronary arteries that supply blood to the heart, to keep the arteries open in patients suffering from coronary heart disease. The vast majority of stents used in modern interventional cardiology are drug-eluting stents (DES). They are used in a medical procedure called percutaneous coronary intervention (PCI). Coronary stents are divided into two broad types: drug-eluting and bare metal stents. As of 2023, drug-eluting stents were used in more than 90% of all PCI procedures. Stents reduce angina and have been shown to improve survival and decrease adverse events after a patient has suffered a heart attack—medically termed an acute myocardial infarction.

Cardiothoracic anesthesiology is a subspeciality of the medical practice of anesthesiology, devoted to the preoperative, intraoperative, and postoperative care of adult and pediatric patients undergoing cardiothoracic surgery and related invasive procedures.

Minimally invasive cardiac surgery, encompasses various aspects of cardiac surgical procedures that can be performed with minimally invasive approach either via mini-thoracotomy or mini-sternotomy. MICS CABG or the McGinn technique is heart surgery performed through several small incisions instead of the traditional open-heart surgery that requires a median sternotomy approach. MICS CABG is a beating-heart multi-vessel procedure performed under direct vision through an anterolateral mini-thoracotomy.

Vessel harvesting is a surgical technique that may be used in conjunction with a coronary artery bypass graft (CABG). For patients with coronary artery disease, a vascular bypass may be recommended to reroute blood around blocked arteries to restore and improve blood flow and oxygen to the heart. To create the bypass graft, a surgeon will remove or "harvest" healthy blood vessels from another part of the body, either arteries from an arm or the chest, or veins from a leg. This vessel becomes a graft, with one end attaching to a blood source above and the other end below the blocked area, creating a "conduit" channel or new blood flow connection across the heart.

<span class="mw-page-title-main">Hybrid cardiac surgery</span>

A hybrid cardiac surgical procedure in a narrow sense is defined as a procedure that combines a conventional, more invasive surgical part with an interventional part, using some sort of catheter-based procedure guided by fluoroscopy imaging in a hybrid operating room (OR) without interruption. The hybrid technique has a reduced risk of surgical complications and has shown decreased recovery time. It can be used to treat numerous heart diseases and conditions and with the increasing complexity of each case, the hybrid surgical technique is becoming more common.

Transcatheter pulmonary valve replacement (TPVR), also known as percutaneous pulmonary valve implantation (PPVI), is the replacement of the pulmonary valve via catheterization through a vein. It is a significantly less invasive procedure in comparison to open heart surgery and is commonly used to treat conditions such as pulmonary atresia.

References

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Further reading

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