Coronary Artery Bypass Grafting

Coronary Artery Bypass Grafting

VALVULAR CARDIAC SURGERY Outline Heart and Heart Valve A & P Valvular Pathology Valvular Diagnostics Open Heart Patient Preparation Supplies, Instrumentation, and Equipment

Valve Surgery (aortic, mitral, tricuspid) Ventricular Aneurysmectomy A&P Your Hearts Valves Normal Circulation Blood comes back to heart for reoxygenation via the superior and inferior vena cava entering into the right atrium Passes through the tricuspid valve into the right ventricle, then through the pulmonic valve into the pulmonary artery Blood is reoxygenated in the lungs and returns via the

pulmonic veins into the left atrium There it goes through the mitral valve into the left ventricle through the aortic valve pushing oxygenated blood into the coronary ostia as it passes them and throughout the rest of the body where oxygen is needed by all the organs and tissues CARDIAC VALVES Tricuspid valve lies between the right atrium and right ventricle Blood returns to the heart through the superior and inferior vena cavae into the right atrium where it passes through the

tricuspid valve into the right ventricle where it is pumped through the pulmonic valve into the pulmonary artery to be taken to the lungs for re-oxygenation CARDIAC VALVES Mitral Valve lies between the left atrium and the left ventricle Blood returns via the pulmonary veins (after re-oxygenation) into the left atrium, passes through the mitral valve and into the left ventricle, where it is pumped through the aortic valve

CARDIAC VALVES Aortic valve lies between the aorta and the left ventricle Blood is pumped from the left ventricle through the aorta to the coronary ostia, head vessels, upper and lower extremities, and the abdominal organs, via the aorta

Clarification The aortic and pulmonic are often referred to as semi-lunar, meaning they have three half moon shaped cusps The mitral and tricuspid are often referred to as atrioventricular valves, as they separate the atria and ventricles The tricuspid valve is three-cusped The mitral valve is two-cusped or bicuspid

Mitral Valve Has two cusps (a posterior and anterior leaflet) Often referred to as the bicuspid valve Leaflets are attached and anchored to the endocardial papillary muscles by cords called cordae tendineae Cordae tendinae keep the valve from prolapsing Cardiac Conduction

Coordinates cardiac conduction SA Node (sinoatrial) the pacemaker AV Node (atrioventricular) Bundle of HIS or AV Bundle Down R/L insulated branched bundles in ventricular septum Purkinge Fibers non-insulated and feed into R/L ventricles Cardiac Conduction

SA node initiates impulse > atria contract (blood forced into ventricles)> stimulus picked up by AV node > AV Bundle (signal slightly delayed) > brnached bundles > purkinge fibers > ventricles stimulated and contract (blood forces atrioventricular valves to close and semilunar valves to open) These valves should go one-way Pathology of Valves

Obstruction of the valves is usually caused by stenosis or fusion of the leaflets causing diminished blood flow resulting in poor oxygenation or backup of blood into the respective ventricles Backup of blood damages the ventricular endocardium and myocardium over time, which can cause ventricular aneurysm (thinning and enlargement of the ventricle) Can be regurgitant or insufficient due to leaflet damage (may not necessarily be stenosed) In the case of the mitral valve, damage can be to the cordae tendineae, causing elongation, rupture, or shortening

Aortic Stenosis Calcification of the aortic valve cusps LV hypertrophy develops as result of restricted blood flow into the aorta Sx: fatigue, DOE, palpitations, dizziness, fainting, angina (chest pain) Pulmonic Stenosis

Calcification of pulmonic valve cusps Restricts flow into PA RV hypertrophy Mitral Regurgitation Blood flows back (regurgitates) into the LA through the incompetent mitral valve LV hypertrophy Sx: fatigue, palpitations, orthopnea (need to sit up to breath), PND (paroxysmal nocturnal dyspnea, after

sleeping wakes up needing air) Mitral Stenosis Calcified mitral valve Impedes flow of blood into LV LA hypertrophy or enlargement Sx: fatigue, palpitations, DOE, orthopnea, PND, pulmonary edema Tricuspid Regurgitation

Blood flows back (regurgitates) into RA due to incompetent tricuspid valve Sx: engorged pulsating neck veins, liver enlargement, RV hypertrophy, thrill at left sternum Tricuspid Stenosis Calcification of tricuspid valve Impedes blood flow into RV Sx: diminished arterial pulse, jugular venous prominence

Valvular Disease Causes: CAD and MI

Degenerative disease due to age Rheumatic heart disease (a complication of bacterial strep) Congenital disease Obstruction results in left ventricular myocardial overload due to backflow of blood, which stresses the myocardium over time IV Drug Abuse Dental Infections Lupus Marfans Syndrome Scleroderma Symptoms of Valvular Disease

Fatigue Weakness Dyspnea with or without exertion, stress, or pregnancy Pulmonary edema 1 cause rheumatic fever May go from mild to total disability in 5- 10 years May be asymptomatic 10-20 years after initial damage to valve Diagnosis

NONINVASIVE H&P ECG/EKG Exercise EKG (stress test) Echocardiogram (echocardiography is the Gold Standard for diagnosing valvular disease) Chest x-ray Diagnosis

INVASIVE Cardiac catheterization ( may be in conjunction with echocardiogram) Trans-esophageal echocardiogram (usually done preoperatively in the OR suite in conjunction with valve surgery) Anesthesia General

Medications Warm saline with antibiotic solution Topical hemostatic agents of choice: surgicel, gelfoam and thrombin, gelfoam/thrombin/antibiotic rolled into balls for sternal bone application, bone wax for sternum with raytex underneath to prevent surgeon from ripping gloves on rough edges Extra NS for valve rinsing if is a xenograft Will rinse x 3 in 250cc NS each rinse for 2 minutes each or per manufacturers recommendations

Some surgeons may want antibiotic added to 2nd or 3rd rinse Patient Positioning Supine position Arms padded and tucked May want a shoulder roll to elevate the sternum (optional) Headrest

Pillow under knees (preferable) Heel pads (preferable) Prep Begin at anterior thorax prepping outward in a circular motion to the bedline, prep to top of thighs/ bilateral groins, then pubis With a separate sponge prep both legs to knees to the bedline

Use betadine soap, then paint May use gel or spray Should do minimum of two coats of paint PREP For a CABG and valve replacement, will prep sternum to neck, bedline to bedline, groins, pubis, then each leg circumferentially to ankles or feet (institutional policy) Equipment

Two large tables (back table and Mayfield) Mayo stand (for saw) Double ring Prep tables x 2 Slush machine/warmer ECU x 2 Cell saver CPB machine Off-table suction

External Pacing box Instumentation Open heart Trays Valve Tray Suture Guide Holder Sternal retractor (Ankinney for aortic valve) and

(Cosgrove or Korous for mitral or tricuspid) Finochetti Sternal saw Internal defibrillator paddles Doctors specials Micro instruments needed if CABG done with valve surgery Supplies

Valve Custom Pack (Coronary pack for CABG/Valve) CV Drape Pack Gloves Chest tubes Suture guide inserts Valve Sizers for appropriate valve Appropriate valves of surgeon request in the room Misc. suture: pericardial suture, cannulation suture, aortic retraction suture (for aortic valve only), valve repair or replacement suture, suture to close aorta or atrium, pacing wires, suture to sew in pacing wires, cutting needles to sew in chest tubes and pacing wires, sternal wires, fascia suture, subcutaneous, subcuticular Coronary ostia perfusion catheters (auto-inflating, gummy tip, or spencers (for aortic only)

Supplies continued Aortic cannula Venous cannula (need two for bicaval cannulation-need for mitral valve surgery) Antegrade cannula (may just use retrograde and place this

after aorta closed for aortic valve surgery/is placed for mitral valve surgery) Retrograde cannula Medusa Cardiac insulation pad Myocardial temperature probe Extra saline Three cytals for washing valve if using a xenograft (porcine or bovine) Valve Replacement Options Mechanical Biological

Diseased valve excised and replaced Valve Replacement Options (Aortic and Mitral) 1. Mechanical: St. Jude or Starr-Edwards

valve only conduit/valve available for aortic Durable Used primarily in young patients Patient requires long-term anticoagulant therapy (not for elderly) Complications: emboli and bleeding from other injury due to anticoagulant therapy Valve Replacement Options (Aortic or Mitral)

2. Heterograft/Xenograft Biologic May be bovine or porcine Bovine pericardium is the new rage Old porcine has a duration of 15 years Bovine pericardial are thought to last longer/ research inconclusive due to recent development No anticoagulant therapy needed Valve Replacement Option (Aortic)

3. Aortic Stentless Biologic Porcine Durability good over age of 60 No anticoagulant therapy needed Valve Replacement Options (Aortic, Mitral, Pulmonic)

4. Allograft/Homograft Biologic Cadaver from organ donor Will measure annulus size with TEE Will choose graft before incision made or as opening chest Time will be required for proper thawing procedure to be implemented to prevent damage to the graft Long term Limited availability Valve Replacement Option (Aortic)

5. Autograft (ROSS Procedure) Requires expert valve surgeon Excision of patients pulmonic valve to be used as the patients new aortic valve A pulmonic allograft will be used to replace excised pulmonic valve Long term Limited availability of pulmonic allograft

Valve Repair Options Annuloplasty rings Mitral annuloplasty rings Tricuspid annuloplasty rings Replacement verses Repair

Aortic and Mitral are replaced Tricuspid in extreme situations can be replaced with a mitral valve Mitral and tricuspid usually repaired with annuloplasty rings Mitral may have to be replaced if attempted repair is unsuccessful Annuloplasty Rings

Used for repairing of the mitral or tricuspid valves Mitral rings are a near to complete circle Tricuspid rings are an incomplete circle or half-circle Sizers are half moon shaped and have T or M on them (will come with a malleable handle-bend it slightly for ease of sizing) Are differentiated between by T or M on the tag (remove the Minnie-Pearl tag before passing it to the surgeon) Provide reduction of the dilated annulus Often the tricuspid function will return to normal with the repair of the mitral

Valve Repair/Replacement Procedure Incision with #10 blade Cautery May use curved mayo scissors to ream under the xiphoid to loosen the fascia from the sternum Sternal saw

Bone wax or gelfoam powder mixed with saline or thrombin to make soft balls to spread on sternum Wet laps folded in half (should have been soaked in antibiotic NS and wrung out) Sternal retractor Cautery and debakeys to open/dissect the pericardium Pericardial sutures (may use pop-off silk or neurolon) Valve Repair/Replacement Procedure

Dissect aorta from pulmonary artery to provide room to place aortic cross-clamp Purse-string cannulation stitches for aortic cannula (x2), venous cannula, and retrograde cannula, each is rommeled Heparin is administered by anesthesia at surgeon prompt Cannulas are placed, aortic first, stab blade (#11), aortic cannula, heavy tie or umbilical tape, tube clamp, bowl and scissors to cut aortic pump line, hook to CPB tubing, make sew cannula to patient/drape or clamp with non-penetrating towel clip Venous cannula placed, metz, cannula (some surgeons may use a satinsky to clamp the atrial appendage before incising it), heavy tie or umbilical tape, tube clamp or not and hook to venous line from CPB machine Surgeon will say to perfusion, Go on bypass

Valve Repair/Replacement Procedure Hypothermia will begin by perfusion who can cool the blood he is circulating Cross Clamp will be placed across the aorta Cardiac insulation pad may be placed Myocardial temp probe may be placed near the apex of the left ventricle

Ice may be applied to the heart as well Aortic Valve Replacement AORTIC Once temperature is where surgeon wants it, he will take a metz and cut the aorta open above the aortic valve and below the aortic cross clamp He may want stay sutures or retraction sutures He may continue to perfuse the heart with

cardioplegia fluid directly into the coronary ostia via the medusa and coronary perfusion cannula that is attached (his/her preference) Aortic Valve Replacement He/She will begin to excise the valve using metz, a pituitary ronguer, knife (#15c or #11) Be prepared to wipe ronguer , metz, and forceps frequently with a moist lap Retraction may be provided by the assistant with a

hand-held aortic retractor Off-table suction will be used to vacuum (tonsil suction without tip) as plaque is removed Care is taken NOT to get debris into the ventricle as it could cause stroke later Cold NS Irrigation provides thorough cleaning using an asepto Mitral Valve Repair/Replacement

Caval tapes will be used with a ligature passer or right angle and long dacron or polyester tapes and rommeled to provide a tight seal around the cavae and their cannuli to prevent blood from coming into the field around the cannuli Heart is turned over and left atrium is exposed Surgeon will take an #11 or #15 blade to open the atrium, long metz to widen the incision Mitral retraction will be achieved with a hand-held mitral/atrial retractor or placement of the arm attachments for the cosgrove or korous retractor Two long, blunt nerve hooks will be passed to the surgeon for him to manipulate the valve leaflets and determine location/extent of damage Will repair by removing a leaflet, repairing the cordae tendineae with gortex (PTFE) or prolene suture (have knife, metz, and nerve hooks available) One of the leaflets may be left to maintain ventricular configuration (if one passed to you, ask if it is the anterior or posterior for proper specimen labeling)

Mitral Valve Repair/Replacement Once the annulus is cleaned or the cordae are repaired, the annulus will be sized using mitral sizers for the appropriate valve being used Clarify the valve before obtaining it from the circulator Valve sutures will be placed (double load pledgeted

valve sutures) Once valve sutures are in hand up three NH as you will assist with loading the valve sutures in order to place through the annuloplasty ring or valve Be sure you keep up with how many sutures are used Valve Repair/Replacement Procedure

Once valve annulus is clean, annulus is sized with appropriate sizer Valve is passed to field after being verified by the circulator, scrub, and surgeon Bovine and porcine valves require a rinsing process (2 minutes in a minimum of 250ml NS times three) Baxter-Edwards only require one minute x 3 Sutures for valve are placed (pledgeted 2-0 RB-1 ethibond or CV-316 Ticron Pledgeted sutures are used for valve replacement/Non-pledgeted for Repair Sutures will be passed double loaded as all pledgeted sutures should Once sutures are in, if valve is ready, three short NH will be passed up and the assistant, scrub, PA, and surgeon will work their way around the suture guide loading each needle in sequence for the surgeon to pass through the valve

The sutures should have been counted before valve is up so the surgeon knows how far apart to place the sutures in the cuff of the valve Valve Repair/Replacement Procedure After sutures are in surgeon will ask for 2 kellys and you or he will cut the needles

He will pass them to you attached to the other kelly He will work the valve into the annulus of the excised valve (you should moisten the strings with NS as he seats the valve) He may take a knife at that point to release the insert holding the valve to the handle He will work his way around, tying in the interrupted sutures When done, he will take long tenotomy scissors and cut the strands just above the knots He will test the valve leaflets with NS on an asepto (may use several) May want a short piece of a red-rubber catheter attached to asepto for visibility as he is squirting the NS to test the leaflets If mechanical may use rubber shodded debakey forceps or long cotton-tip applicator to test leaflets Valve Repair/Replacement Procedure

Will close aorta with 2 prolene sutures usually pledgeted with a corresponding on a 3-0 or 4-0 tapered RB-1 or SH needle Will close atrium with a 4-0 or 3-0 prolene on a tapered SH or MH needle (usually non-pledgeted) Air is vented via antegrade placement (if was not inaortic) May need a 14 jelco on a 60 cc syringe to stab the apex/ventricle of the heart to remove air within before discontinuing bypass Valve Repair/Replacement Procedure

Topical hemostatic may be used (gelfoam pad strips with NS or thrombin) Patient may need to be defibrillated (have ready when closing aorta or atrium) CPB will be discontinued when patient is re-warmed (metz, tube clamps, metz) Pacing wires will be placed (atrial and ventricular)

Chest tubes will be placed (1 mediastinal and 1 substernal) Sternal wires placed twisted and cut with wire cutter, irrigation of NS with Antibx, fascial layer, subcutaneous, hook up pleurevac after suctioning out the chest tubes, subcuticular Dressing, steri-strips, telfa, 4x4s, primapore Fluffs or 4x4s to chest tubes and tape Ventricular Aneurysm Repair or Ventricular Aneurysmectomy Result of myocardial damage after an MI

causing myocardial replacement with scar tissue Scar stretches with pressure resulting in aneurysm formation Is the excision of the portion of the ventricle that has become aneurysmic and reenforcing it with a patch of synthetic graft material (may be PTFE or hemashield) Often a tube graft is used and a circular patch is cut with it Ventricular Aneurysm Repair or Ventricular Aneurysmectomy

May require CPB Prep/Set up is as described for any Open Heart surgery with exception of if being done alone, you would not need a lot of the previously described items Most frequently done in conjuction with CABG or Valve surgery May hear referred to as the DOR Procedure Ventricular Aneurysm Repair or Ventricular Aneurysmectomy

Procedure: Incision made into the ventricle with a #15 or #11 blade extended with a metz Will require retraction by the assistant with two allises or babcocks (are usually part of a valve tray of instruments) Surgeon may remove or excise a part of the scar tissue A neck will be created in the rim of the scarring with a prolene suture (2-0 or 3-0 on an SH, to pull the tissue back together) Ventricular Aneurysm Repair or Ventricular Aneurysmectomy

Interrupted pledgeted ticron or ethibond sutures will be placed (2-0 RB-1 or CV-316, SH or CV-305) Patch will be passed up with 2 NH to place sutures through the patch Patch will be eased down to cover the created neck Myocardium will be closed with another 3-0 prolene SH Epicardium will be closed with two thinly cut strips of teflon felt and two running 3-0 or 2-0 Prolene sutures on an SH or MH tapered needle

Ventricular Aneurysm Repair or Ventricular Aneurysmectomy Surgery proceeds with patient rewarming if was cooled and discontinuation of CPB Routine open heart surgery closure Complications

Hypothermia Infection Myocardial contusion Bleeding Cardiac tamponade Embolus Valve malfunction Summary

Heart and Heart Valve A & P Valvular Pathology Valvular Diagnostics Open Heart Patient Preparation Supplies, Instrumentation, and Equipment Valve Surgery (aortic, mitral, tricuspid) Ventricular Aneurysmectomy

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