Mahmoud ABU-ABEELEH Associate Professor Department of Surgery Division of Cardiothoracic Surgery School of Medicine University Of Jordan Adult Cardiac Surgery

Adult Cardiac Surgery: Ischemic Heart Disease (History)  William Heberden described angina pectoris.  Claude Beck  1930’s- sought to increase myocardial blood flow indirectly with pericardial fat and omentum.  Arthur Vineberg  1940’s- Mobilization of left internal mammary artery with implantation of bleeding end into the left ventricle.  follow-up study on 140 patients 33% mortality 85% relief from angina

Adult Cardiac Surgery: Ischemic Heart Disease (History)  John H. Gibbon, Jr. Heart-lung machine  May ASD closure

Adult Cardiac Surgery: Ischemic Heart Disease (History)  KOLOSOV in Russia LIMA→LAD  David C. Sabiston, Jr.-  Aortocoronary saphenous vein bypass  Rene Favaloro  Cleveland Clinic  Frank Spencer/George Green  Internal mammary artery

Adult Cardiac Surgery: Ischemic Heart Disease (CABG)  Early and widespread acceptance of coronary bypass was delayed.  Best known cooperative studies ( ’s) were the; VA CASS Coronary Artery Surgery Study European Coronary Surgery Study

Intima Adventitia Media The Normal Heart - Coronary Artery Anatomy Left Main CA Circumflex Left Anterior Descending CA Right CA Marginal Branch Layers of the Arterial Wall Intima composed of endothelial cells

Pathogenesis of ACS

ATHEROSCLEROSIS

Risk Factors UncontrollableUncontrollable 11 Sex Hereditary Race Age ControllableControllable High blood pressure High blood cholesterol Smoking Physical activity Obesity Diabetes Stress and anger

Indications for open-heart surgery  Coronary heart disease: (CABG)  Triple vessel disease  Lf main coronary artery disease  Unstable angina,failed Mx therapy  Complications of PTCA  Life threatening complications of MI

Adult Cardiac Surgery: CABG Techniques  Median sternotomy  Cardiopulmonary bypass  Cardioplegic arrest  Mammary artery, reversed saphenous vein, radial artery  Minimally access incisions (Port Access)  “Off-pump”

Adult Cardiac Surgery: CABG Techniques

Heart Lung Machine

Anatomy of heart valves

Anatomy  MV:  2Cusps, Anterior and posterior  The Ant is the larger  Intervenes bet. A-V and aortic orifice  AV:  3 semilunar cusps, ant (RT), post. Wall (LT and post)  TV;  3cusps, ant, septal,post.  PV;  3 semilunar cusps one post. (lt) two ant( ant and rt)

AVS tricuspid and bicuspid calcifications

Adult Cardiac Surgery: Valvular Heart Disease  Aortic stenosis-  Age-related degenerative  Mild AS: AVA > 1.5cm 2 ; Moderate 1-1.5cm 2 ; Severe <1cm 2  Indications for surgery largely based on symptoms Syncope, angina, dyspnea and CHF  Aortic regurgitation-  Calcific aortic disease, idiopathic degenerative disease, endocarditis, rheumatic disease, bicuspid valve, aortic dissection, Marfan, etc.  Indications for surgery Acute AR- inadequate time for ventricular compensation Chronic AR- symptoms, decreasing EF, LVEDD >75mm, LVESD >55mm

Pathophysiolgy of AS  Except in the congenital forms, AS develops slowly  The LV becomes increasingly hypertrophied, and coronary blood flow may become inadequate  The fixed outflow obstruction limits the increase in C.O required on exercise.  The progressive LV outflow obstruction results in increased LV mass. This increase in wall thickness is a compensatory mechanism to normalize LV wall stress

Symptoms of AS  Exertional dyspnea  Angina  Pulmonary edema  Exertional syncope  Sudden death

Signs of AS  Ejection systolic murmur  Slow rising carotid pulse  Reduce pulse pressure  LV hypertrophy  Signs of LV failure (crepitations, pulmonary edema )

Investigations  ECG  CXR  ECHO  CATH

ECHO criteria for assessment of aortic stenosis Aortic valve area (cm2) Mean gradient(mmhg)severity >1.5<25mild moderate <1>50severe <0.7>80critical

Recommendations for Aortic Valve Replacement in Aortic Stenosis Symptomatic patients with severe AS Patients with severe AS undergoing coronary artery bypass surgery Patients with severe AS undergoing surgery on the aorta or other heart valves Patients with moderate AS undergoing coronary artery bypass surgery or surgery on the aorta or other heart valves Asymptomatic patients with severe AS and the following;

Asymptomatic patients with severe AS and the following LV systolic dysfunction Abnormal response to exercise (e.g. hypotension) Ventricular tachycardia Marked or excessive LVH (>15 mm) Valve area <0.6 cm2 Prevention of sudden death in asymptomatic patients with none of the findings listed under asymptomatic patients with severe AS

Adult Cardiac Surgery: Valve Prostheses  Mechanical Valves  Caged-ball valves  Tilting disc valves single leaflet bileaflet  Tissue Valves  Animal tissue (porcine aortic valves, bovine pericardium)  Human tissue (Homografts, Autografts)

Mechanical valves ball and cage bileaflet

Mechanical valves tilting-disc valve

Bioprosthetic Valves Aortic homograft  Human tissue valves  autograft  homograft  Animal tissue valves  Heterograft or xenograft

Adult Cardiac Surgery

How to choose a valve  Mechanical valve in patients < 65years.  Tissue valves in patients > 65 years  Tissue valves in patients whose life expectancy is < 10 year  Tissue valve in patients who have problems which are likely to cause life threatening bleeding.

Adult Cardiac Surgery: Aortic Valve Replacement  Median sternotomy, hemi-sternotomy  Cardiopulmonary bypass  Cardioplegic arrest  Excision of the valve  Debridement  Implantation

Adult Cardiac Surgery: ACC/AHA  Aortic position  Bileaflet- INR of 2-3  Other disk valves and Starr-Edwards- INR  In patients with higher risk of TE, INR with addition of aspirin mg/d. (AF, ↓EF, prior TE, hypercoagulable state)  Mitral position  All- INR

Adult Cardiac Surgery: ACC/AHA  Tissue prosthesis-  Anticoagulation recommended in first 3 months, although aspirin alone in aortic position in some centers. INR  After 3 months, discontinue unless other circumstances

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