Dr.Hesham Noor, MBBCH,M.Sc.M.D

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Dr.Hesham Noor, MBBCH,M.Sc.M.D

• Assistant Prof. and Consultant Of General Surgery

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CARDIAC SURGERY
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Valvular heart disease

• Aetiology
• Causes vary between developed and developing
  countries
• Common causes are
• Congenital Valvular abnormalities (e.g.
  bicuspid aortic valve)
• Acquired
• Rheumatic fever
• Infective endocarditis
• Degenerative valve disease
• Ischaemic heart disease IHD/CAD

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Pathophysiology and Heamodyamics

• Rheumatic fever results from immune-mediated
  inflammation of heart valve resulting in either
  stenosis or incompetence or both of them
• Due to cross-reactivity between Group A B-
  haemolytic strep antigens and the cardiac
  proteins
• Stenosis causes pressure overload on proximal
  chamber
• Incompetence causes volume overload proximal
  chamber
• AF and Thrombus may form in dilated left
  atrium resulting in peripheral embolisation
  (Distal Showering)
• MVO
• ACUTE LIMB ISCHAEMIA
• CEREBRAL STROKE

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Clinical Features

• Aortic stenosis (Subvalvulae/valvular/supravalvula
  r)
• Angina pectoris
• Syncopal episodes
• Left ventricular failure
• Ejection systolic murmur in 2nd right intercostal
  space
• Aortic regurgitation Acute /Chronic
• Congestive cardiac failure
• Increased pulse pressure Water-hammer pulse
• Early diastolic murmur at left sternal edge

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• Mitral stenosis
• Pulmonary hypertension
• Paroxysmal nocturnal dyspnoea
• Atrial fibrillation
• Loud first heart sound
• Mid diastolic murmur at apex
• Mitral regurgitation
• Pulmonary oedema
• Apex beat displace laterally
• Apical pansystolic murmur

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• Tricuspid stenosis
• Fatigue and peripheral oedema
• Hepatomegaly and ascites
• Increased JVP with prominent a waves
• Diastolic murmur at left sternal edge
• Tricuspid regurgitation
• Pulsatile hepatomegaly and ascites
• Right ventricular heave
• Prominent JVP with large v waves
• Pansystolic murmur at left sternal edge

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New York Heart Association classification NYHA

• Dyspnoea can be classified by severity of
  symptoms into 4 classes
• NYHA I
• No dyspnea ordinary physical activity
• NYHA II
• Ordinary physical activity induces dyspnoea
• NYHA III
• Limitation of ordinary physical activity
• NYHA IV
• Rest Dyspnea

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Investigations

• Non-invasive
• Electrocardiogram
• Chest x-ray
• Echocardiography Transthoracic ECHO
• Invasive
• Transoesophageal ECHO
• Cardiac catheterisation
• To measure the transvalvular pressure gradient

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Medical Management

• Few patients with symptomatic aortic stenosis
  survive 5 years and about 20 of symptomatic
  patients will suffer sudden death
• Asymptomatic mitral stenosis is well tolerated
  with greater than 50 10-year survival
• Medical management consists of
• Treatment of cardiac failure
• Digitalisation if in AF
• Diuretics
• Prophylactic Oral Anticoagulation if evidence
  of Lt. atrial thrombus or peripheral
  embolisation

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Surgical management

• Approximately 7,000 patients per year undergo
  valve replacement .Aortic valve is commonest to
  be replaced (75 of operations)
• Surgery performed through a median sternotomy
• On cardiopulmonary bypass (CPBP) with systemic
  hypothermia
• Heart is arrested and protected with cardioplegic
  solution
• Valve can be either dilated , repaired or
  replaced
• Valve repair results in better haemodynamics and
  does not require long-term anticoagulation

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Indications for surgery

• Aortic valve replacement
• Symptomatic aortic stenosis
• Asymptomatic aortic stenosis with pressure
  gradient gt 50 mmHg
• Symptomatic aortic regurgitation
• Mitral valve replacement
• Symptomatic mitral stenosis
• MS with peripheral emboli or distal showering
• Mitral valve area less than 1 cm2 
• MS with Pulmonary Hypertension

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• Three surgical options For the Mitral Valve
• Valvuloplasty (REPAIR)
• Commissurotomy (VALVOTOMY)
• Mitral valve replacement

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Prosthetic heart valves

• Principal types of valves
• Heterografts (e.g. pig) Stented or Unstented
• Homografts
• MECHANICAL
• Ball and cage (e.g. Starr-Edwards)
• Tilting disc (e.g. Bjork-Shiley)

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Mechanical valves

• Readily available
• Good durability/Life Span
• Require life-long anticoagulation
• Risk of endocarditis
• Prophlactic antibiotics must be given before any
  invasive procedure or surgery for patients with
  prosthetic valves

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• Heterografts
• Readily available
• Limited life span (aortic valves 15 years,
  mitral valve 8 years)
• Limited duration of anticoagulation
• Homografts
• Not readily available
• Long-term outcome uncertain
• Do not require anticoagulation

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Coronary artery surgery

• 3 ARTERIES OF LIFE
• Right coronary artery (RCA)
• Left anterior descending artery (LADA)
• Left Circumflex coronary artery (LCCA)
• Atherosclerosis occurs in the proximal
  portions of these vessels(At the Coronary Ostia
  arising from the ASCENDING Aorta)
• Depending on number of vessels involved
• Single-vessel disease
• Double-vessel disease
• Triple-vessel disease
• Prognosis depends on
• Number of vessels involved
• Left ventricular function (EJECTION FRACTION)

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• The internal mammary artery, a branch of the
  subclavian artery, descends along the pleura
  behind the costal cartilages ending at the 6th
  intercostal space where it divides to become the
  superior epigastric and musculophrenic arteries.

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• Risk factors can usefully be divided into fixed
  (non- modifiable) and modifiable risk factors.
• Fixed risk factors include older age, male
  gender, family history, and a South Asian
  background.
• Modifiable risk factors include hypertension.
  hyperlipidaemia. Diabetes, smoking, alcohol,
  exercise, and stress.

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• Modifiable risk factors
• 6. Hypertension. If hypertensive, ask about
  latest blood pressure measurement, time since
  first diagnosis, and any medication being taken.
• 7. Hyperlipidaemia. If hyperlipidaemic, ask about
  latest serum cholesterol level, time since first
  diagnosis, and any medication being taken.
• 8. Diabetes mellitus. If diabetic, ask about
  medication being taken, level of diabetes control
  being achieved, and time since first diagnosis,
  and presence of complications.
• 9. Cigarette smoking. If a smoker or ex-smoker.
  ask about number of years spent smoking and
  average number of cigarettes smoked per day.

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• 10. Alcohol. Ask about the number of units of
  alcohol drunk in a day.
• 11. Lack of exercise. Ask about amount of
  exercise taken in a day or week. Does the patient
  walk to work or walk to the shops?
• 12. Stress. Ask about occupational history and
  home/social life.

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• Having one or more of these risk factors does not
  mean that a person is going to develop
  cardiovascular disease, but merely that he is at
  increased probability of developing it.
• Conversely, having no risk factors is not a
  guarantee that a person is not going to develop
  cardiovascular disease.
• Coronary heart disease, cerebrovascular disease,
  Mesenteric Vascular disease and peripheral
  vascular disease) often coexist.

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Investigations

• 1-Left ventricular function test assessed by
  assessing ejection fraction on
• Echocardiography
• Angiography
• Multi-gated acquisition (MUGA) scan
• 2-Coronary angiography
• a- Provides accurate anatomical diagnosis
  and may be combined with Coronary
  angioplasty treatment.
• b- Allows Preoperative planning of the
  sites of grafting

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• Stress/Exercise ECG Identifies myocardial
  ischaemia and indicates severity of stenosis 75
  of patients with significant disease will have a
  positive result.
• Stress/Exercise echocardiogram Shows abnormal
  myocardial contraction resulting from ischaemia.
  More sensitive than exercise ECG.

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• Coronary angioplasty Widens or recanalises
  occluded vessels with intracoronary stents or
  balloons.
• Provides good symptom relief but there is still
  debate about any prognostic advantage over
  medical therapy.
• Recent trials
• Drug-eluting stents (e.g. sirolimus, paclitaxel)
  reduce restenosis rates.
• Surgical CABG is indicated for symptomatic
  angina not relieved by medical therapy and in
  patients with severe three-vessel coronary artery
  disease, left main stem coronary artery disease
  or coronary artery disease with impaired left
  ventricular function.

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Indications for surgery

• 1- Severe stenosis (gt70) of the left main stem
  or triple vessel disease
• 2- Patients with poor left ventricular function
• 3- Patients with multi-vessel disease

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What are the indications for CABG?

• 1- Chronic angina, unstable angina.
• 2- Post-infarction angina
• 3- Asymptomatic patients or patients with single
  or double-vessel disease showing reversible
  ischemia on stress test

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What are the functional studies used to assess
myocardial viability after myocardial infarction
(MI)?

• 1- PET Scan POSITRON EMISSION TOMOGRAPHY
• 2- Thallium scan.
• 3- Magnetic resonance imaging (MRI) viability
  scan

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Assessment of risk

• Patients at greatest risk have the greatest
  benefit to gain from surgical intervention
• Mortality risk can be estimated using various
  scoring tools in which the risk is calculated by
  summating individual risk factors

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Euroscore1-Age for each 5 years over 60 years
1 2-Female sex 1 3-Chronic respiratory
disease 1 4-Extracardiac arteriopathy 2
5-Neurological dysfunction 2 6-Creatinine
above 200 µmol/l 2 7-Previous cardiac surgery
3 8-Unstable angina 2 9-Recent Myocardial
infarction 210-Ejection fraction Good Nil
Moderate 1 Poor 3

• Parsonnet score
• 1-Age greater than 70 years 7
• Age greater than 75 years 12
• Age greater than 80 years 20
• 2-Female sex 1
• 3-Hypertension 3
• 4-Diabetes 3
• 5-Obesity 3
• 6-Ejection Fraction
• Good Nil
• Moderate 2
• Poor 4

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Choice of conduit

• Vascular Conduits for CAD can be either venous
  or arterial
• 1- Long Saphenous Vein is easy to harvest by
  a second surgeon and allows multiple grafts to
  be fashioned
• Patency rate 50 at 10 years
• 2- Left internal mammary artery (LIMA) as
  been used to graft the left anterior descending
• Patency rate 90 at 10 years

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What are the other conduit options?

• 1- Radial artery. RA
• 2- Gastroepiploic artery. GEA
• 3- Inferior epigastric artery. IEA
• What is the risk of using both internal mammary
  arteries as conduits?
• Sternal necrosis

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• Obtaining vein graft
• The left internal mammary artery is dissected
  free from the anterior chest wall proximally up
  to the level of the subclavian vein and distally
  to its bifurcation.
• If a leg vein graft is required, an incision is
  made from the groin to the midcalf to carefully
  excise and dissect free the long saphenous vein
  with ligation and division of any branches.

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Surgery

• Chest is entered via a median sternotomy
• Left internal mammary artery is dissected
• Long saphenous vein can be harvested and prepared
  by second surgeon
• Rt.Atrium is cannulated and patient is placed on
  cardiopulmonary bypass (CPB)
• Aorta is cross clamped
• MYOCARDIAL PROTECTION by cardioplegic solutions
• Cardioplegia can be either warm (37 degrees) or
  cold (15-20 degrees) to induce a hypothermic,
  cardioplegic arrest.

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• Recent advances include
• 1- Off-pump coronary artery surgery (BEATING
  HEART SURGERY)
• 2- Minimally invasive direct coronary artery
  surgery
• Both can avoid either CPB or median sternotomy

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Right atrial cannulation to drain venous blood
into venous reservoir by gravity .Oxygenation
and CO2 removal usually by membrane oxygenator
Air bubbles removal by A 40 mm filter. Heat
exchanger Lowers blood temperature at 5-10 C of
hypothermia Pump returns blood into aorta
distal to the cross clamp Suction used to remove
blood from operative field and returned to
patient via cardiotomy reservoir
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Cardiac Transplantation

• CARDIAC PACING

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Congenital heart disease

• Tetralogy of Fallot
• The most common cyanotic heart defect and the
  commonost cause of blue baby syndrome.
• It occurs in approximately 3 to 6 per 10,000
  births and account for 5-7 of congenital heart
  defects
• Environmental or Genetic factors or a
  combination
• Chromosome 22 deletions and diGeorge syndrome

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• TOF has 4 components
• 1- Right ventricular outflow tract obstruction
  (infundibular stenosis)
• 2- Ventricular septal defect
• 3 Overiding of the Aorta (Aortic dextroposition
  to overrides VSD)
• 4- Right ventricular hypertrophy
• The VSD and Infundibular stenosis determine the
  pathophysiological features

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Pathology

• Underdevelopment of the right ventricular
  infundibulum leading to displacement of the
  infundibular septum .This determines the degree
  of right ventricular outflow tract obstruction.
• A large subaortic ventricular septal defect
  results in aortic overriding of the VSD into the
  right ventricle.

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TOF with pulmonary Atresia (TOFPA) Variable
pulmonary blood flow is present via a patent
ductus arteriosus or aortopulmonary collaterals
Hyoplastic remnants Of the Pulmonary artery
branches

• TOF with pulmonary Stenosis (TOFPS)
• Hypoplastic RVOT is associated with pulmonary
  valve stenosis
• The branches of pulmonary arteries are
  usually normal

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• In TOFPA, the source of pulmonary blood flow
  heavily influences the clinical presentation
• The VSD is usually large and non restrictive
• The severity of the RVOT and systemic
  vascular bed determines the pathophysiology and
  the natural history is determined by the
  severity of the RVOT obstruction
• Prognosis
• 25 of untreated infants die in 1st year of
  life
• Risk of death is greatest in 1st year

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Clinical features

• Cyanosis
• Usually constant But may be intermittent with
  hypoxic spells
• Infants with severe infundibular stenosis and
  valvular stenosis are deeply cyanotic since
  birth
• Cyanosis occurs later in infants with dominant
  infundibular stenosis
• Systolic ejection murmur
• The murmur disappears during a spell
• Continuous murmurs may be found in patients with
  aortopulmonary collaterals
• 2ry Polycythaemia
• Clubbing
• Develops in older infants , usually after 6
  months of age

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Investigation

• CXR shows a "boot-shaped" heart and is most
  common in older infants and children
• ECG shows right ventricular hypertrophy and right
  axis deviation
• Echocardiography shows the VSD and RVOT
  obstruction
• Cardiac Catheterization Can delineate AV valve
  morphology, and central pulmonary arteries

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Management

• Progressive hypoxemia (saturation 75-80) is
  an indication for operation
• Occurrence of spells is a second indication
  for operation
• Asymptomatic children with TOFPS and
  uncomplicated morphology should have elective
  repair between 3 and 24 months of age
• Very young infants with complicated morphology
  can be managed with a staged shunt (usually
  modified Blalock-Taussig)

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• Many centres now perform single-stage complete
  repair regardless of age.
• Advantages single-stage complete repair
• 1- Avoid Prolonged RVOT obstruction and
  subsequent right ventricular hypertrophy
• 2- Avoid Prolonged cyanosis

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• TOFPA treatment strategy depends on the pulmonary
  artery anatomy
• The goal is to repair the defect and provide
  blood flow from the RV to as many pulmonary
  segments as possible
• There are many surgical options
• Shunting and second-stage repair
• Relieve RVOT obstruction and leave VSD open,
  adding a shunt as necessary to maintain
  saturation
• The residual VSD can be closed after further
  development of the pulmonary vasculature
• Ligation of aortopulmonary collaterals may be
  necessary

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Transposition of the great vessels

• Present in the immediate neonatal period,
  particularly if no ventricular septal defect
  (VSD) is present
• Infants can present in shock and severe
  acidosis
• The infant is invariably cyanosed
• No murmur is present, unless there is a VSD or
  some other structural cardiac lesion.

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• Radiologically
• The lungs appear to have increased blood flow
  and increased pulmonary vascular markings.
• The mediastinum is narrow, as the great
  arteries are running parallel.
• Diagnosis is made by echocardiography that can
  shoe important important informations as
• The size of the ductus arteriosus
• Presence or Absence of VSD.
• Degree of atrial mixing of blood

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• Infants with a large VSD or large atrial
  communication may present later, within the first
  2 weeks, with cyanosis. Cardiac failure may be
  present in the presence of a large VSD
• In the short-term, a prostaglandin infusion
  therapy should be commenced to ensure ductal
  patency
• A balloon atrial septostomy is usually
  performed within the first day or two of life to
  assist with mixing at an atrial level.
• An arterial switch procedure is usually
  performed within the first week

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Cardiac Tumours

• LT ATRIAL MYXOMA
• Benign tumour gelatinous firm mass can turn
  malignant
• PUO PYREXIA OF UNKNOWN ORIGN
• DISTAL EMBOLIZATION MAY BE THE FIRST PRESENTATION.

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Aortic Coarctation

• Coarctation of the aorta is narrowing
• or constriction of the aorta and can occur along
  any of its portion.
• It most commonly occurs distal to the origin of
  the left subclavian artery.
• It is the most common congenital cardiovascular
  cause of hypertension, affecting more males than
  females in a ratio of 21. It occurs in 1 of
  every 2000 live term births

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• The clinical diagnosis of coarctation is made by
  comparison of the pulses and blood pressures of
  the extremities.
• Obstruction proximal to the ligamentum
  arteriosum or is at the left subclavian artery
  a stronger pulse is felt in the right arm as
  compared to the left arm.
• Obstruction is distal to the subclavian no
  difference between the upper extremities
• Lower extremity pulses are weaker than upper
  extremity pulses.

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• Chest X-ray may show
• Cardiomegaly with a dilated ascending
• aorta or subclavian artery and poststenotic
  dilation of the descending aorta.
• Rib notching is due to erosions and indentation
• by tortuous collateral vessels.

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• Initial management
• Decrease blood pressure with beta-blockers,
  ACE inhibitors, and Diuretics.
• Definitive management
• 1- Surgical repair Aortoplasty
• Resection of the narrowed segment with Graft
  interposition
• 2- Axillary to femoral bypass grafting may be
  used in high-risk patients.

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ASD

• May be INCIDENTAL FINDING
• Should be closed optimal time is debated many
  are closed percutaneously (if child weight 10
  kg)

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VSD

• Symptoms and signs if defect is small, no
  symptoms if large, defect causes heart failure
  with dyspnea, frequent respiratory infections,
  poor growth (FAILURE TO THRIVE )
• Echocardiography is diagnostic
• Small defects, which often close spontaneously by
  age 8 years large defects should be repaired.
• Postinfarct VSD infarction of interventricular
  septum with subsequent VSD formation interval
  between MI and septal rupture is 112 days
  classically, sudden shock or congestive heart
  failure develops in a patient after MI.

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PDA

• Left-to-right shunt, pulmonary vascular
  congestion, PA hypertension, lung infection,
  right heart failure
• Symptoms and signs infants have poor feeding,
  respiratory distress, frequent respiratory
  infection, heart failure older patients are
  often asymptomatic or have continuous murmur over
  pulmonary area
• Treatment
• Premature infants medical therapy with
  indomethacin (50success)
• Full-term infants or children surgical
  obliteration by ligation, clipping, or division
• Larger infants and children Video assisted
  thoracoscopy

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