Cardiac Surgery

Cardiac surgery is the surgical management of cardiac abnormalities and of the great vessels of the thorax. In general terms, surgical intervention of the heart is performed to directly restore adequate pump function, correct inherent structural issues, and reestablish proper blood supply via the coronary circulation. Common interventions treat ischemic and valvular heart disease as well as disorders of the great vessels.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Table of Contents

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Anatomy of the Heart

The operator needs to be familiar with the anatomy of the heart Anatomy of the heart The heart is a 4-chambered muscular pump made primarily of cardiac muscle tissue. The heart is divided into 4 chambers: 2 upper chambers for receiving blood from the great vessels, known as the right and left atria, and 2 stronger lower chambers, known as the right and left ventricles, which pump blood throughout the body. Anatomy of the Heart and surrounding structures, as well as vascular territories, to avoid damaging vessels and nerves and to achieve successful reperfusion of the tissues.

General anatomy of the heart Anatomy of the heart The heart is a 4-chambered muscular pump made primarily of cardiac muscle tissue. The heart is divided into 4 chambers: 2 upper chambers for receiving blood from the great vessels, known as the right and left atria, and 2 stronger lower chambers, known as the right and left ventricles, which pump blood throughout the body. Anatomy of the Heart

  • Location: middle mediastinum Mediastinum The mediastinum is the thoracic area between the 2 pleural cavities. The mediastinum contains vital structures of the circulatory, respiratory, digestive, and nervous systems including the heart and esophagus, and major thoracic vessels. Mediastinum and Great Vessels 
  • Enclosed within the pericardium
  • Relations: 
    • Anterior: sternum and rib cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage
    • Posterior: vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column (T5–T8), esophagus Esophagus The esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part. Esophagus, primary bronchi, great vessels
    • Lateral: lungs Lungs Lungs are the main organs of the respiratory system. Lungs are paired viscera located in the thoracic cavity and are composed of spongy tissue. The primary function of the lungs is to oxygenate blood and eliminate CO2. Lungs and pleura Pleura The pleura is a serous membrane that lines the walls of the thoracic cavity and the surface of the lungs. This structure of mesodermal origin covers both lungs, the mediastinum, the thoracic surface of the diaphragm, and the inner part of the thoracic cage. The pleura is divided into a visceral pleura and parietal pleura. Pleura
    • Superior: bifurcation of the main pulmonary trunk
    • Inferior: diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm
  • Cone-shaped, with ⅔ of its mass to the left of the midline
The heart within the pericardial cavity

The heart within the pericardial cavity

Image by Lecturio.

Chambers

  • 4 chambers: 2 upper atria and 2 lower ventricles
  • The interatrial septum separates the atria, and the interventricular septum separates the ventricles (visible as the anterior and posterior longitudinal sulci).
  • Right atrium: vena cava → right atrium → right ventricle
    • Deoxygenated blood is returned to the right atrium from the:
    • Right atrial appendage (auricle): a muscular sac that increases atrial capacity
  • Left atrium: pulmonary veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins → left atrium → left ventricle 
    • Receives oxygenated blood from the pulmonary veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins
    • Left atrial appendage (auricle): A muscular sac that increases atrial capacity, a common location for thrombi to lodge
  • Right ventricle: receives deoxygenated blood from right atrium through the tricuspid valve, then transports it through the pulmonic valve and into the pulmonary artery to the pulmonary circulation for oxygenation
  • Left ventricle: receives oxygenated blood from the left atrium through the mitral valve, then pumps it through the aortic valve and into the aorta and the systemic circulation Systemic circulation Circulation is the movement of blood throughout the body through one continuous circuit of blood vessels. Different organs have unique functions and, therefore, have different requirements, circulatory patterns, and regulatory mechanisms. Systemic and Special Circulations

Valves

Prevent retrograde flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure, their closure produces heart sounds Heart sounds Heart sounds are brief, transient sounds produced by valve opening and closure and by movement of blood in the heart. They are divided into systolic and diastolic sounds. In most cases, only the first (S1) and second (S2) heart sounds are heard. These are high-frequency sounds and arise from aortic and pulmonary valve closure (S1), as well as mitral and tricuspid valve closure (S2). Heart Sounds that can be heard on auscultation:

  • Mitral valve: 
    • 2 cusps (bicuspid)
    • Between left atrium and left ventricle
  • Tricuspid valve: 
    • 3 cusps (tricuspid)
    • Between right atrium and right ventricle
  • Pulmonary valve: 
    • Semilunar
    • Between right ventricle and pulmonary trunk
  • Aortic valve: 
    • Semilunar
    • Between left ventricle and aorta 
  • Subvalvular apparatus found under atrioventricular (AV) valves, consisting of chordae tendineae and papillary muscles, act to prevent cusp prolapse into the atria
View of the valves of the heart from an atrial perspective

View of the valves of the heart from an atrial perspective:
Atria removed

Image by BioDigital, edited by Lecturio

Coronary circulation

Assessment of the coronary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries starts with a review of their origin on an axial cut.

  • Roots (located just distal to the aortic valve):
    •  Right coronary artery (RCA): right sinus of Valsalva (the anterior sinus)
    •  Left coronary artery (LCA): left sinus of Valsalva (the posterior sinus)
  • Arteries:
    • RCA:
      • Supplies blood to the right atrium, portion of both ventricles, and the cardiac conduction system
      • Gives rise to the posterior descending artery ( PDA PDA The ductus arteriosus (DA) allows blood to bypass pulmonary circulation. After birth, the DA remains open for up to 72 hours and then constricts and involutes, becoming the ligamentum arteriosum. Failure of this process to occur results in patent ductus arteriosus (PDA), a condition that causes up to 10% of congenital heart defects. Patent Ductus Arteriosus (PDA); most commonly, 70% of cases)
    • LCA:
      • Supplies blood to the left atrium, left ventricle, and interventricular septum
      • Gives rise to the left anterior descending artery and the circumflex artery
  • Patterns of circulation:
    • Right dominant: 
      • PDA PDA The ductus arteriosus (DA) allows blood to bypass pulmonary circulation. After birth, the DA remains open for up to 72 hours and then constricts and involutes, becoming the ligamentum arteriosum. Failure of this process to occur results in patent ductus arteriosus (PDA), a condition that causes up to 10% of congenital heart defects. Patent Ductus Arteriosus (PDA) originates from the RCA
      • Majority (70%–80%) of the population
    • Left dominant:
      • PDA PDA The ductus arteriosus (DA) allows blood to bypass pulmonary circulation. After birth, the DA remains open for up to 72 hours and then constricts and involutes, becoming the ligamentum arteriosum. Failure of this process to occur results in patent ductus arteriosus (PDA), a condition that causes up to 10% of congenital heart defects. Patent Ductus Arteriosus (PDA) originates from the LCA
      • Minority (10%) of the population
    • Codominant (also known as balanced): 
      • PDA PDA The ductus arteriosus (DA) allows blood to bypass pulmonary circulation. After birth, the DA remains open for up to 72 hours and then constricts and involutes, becoming the ligamentum arteriosum. Failure of this process to occur results in patent ductus arteriosus (PDA), a condition that causes up to 10% of congenital heart defects. Patent Ductus Arteriosus (PDA) made up from contributions of the LCA and RCA.
      • Minority (20%) of the population

Pericardium

Layers of loose connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue that envelop the heart, forming a potential space.

  • Fibrous pericardium: 
    • Tough outer layer composed of connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue
    • Continuous with the adventitia of the neighboring great vessels
  • Serous pericardium: 
    • Inner serous membrane 
    • 2 layers:
      • Parietal: inner lining of the outer layer, continuous with and inseparable from the fibrous pericardium
      • Visceral (also known as epicardium): inner layer covering the myocardial surface
  • Pericardial cavity:
    • Potential space between the parietal and visceral layer of the pericardium
    • Contains serous fluid that lubricates the movements of the heart within the pericardium and allows some degree of cushion to the heart

Pericardiocentesis

Definition

Pericardiocentesis is an invasive procedure that consists of inserting a needle into the pericardial space to extract, for diagnostic or therapeutic reasons, fluid from the pericardial space.

Indications

Diagnostic pericardiocentesis (obtaining pericardial fluid for diagnosis): 

  • Suspicion of bacterial, mycobacterial, or fungal effusion
  • Suspicion of malignant effusion

Therapeutic pericardiocentesis:

  • Cardiac tamponade Cardiac tamponade Pericardial effusion is the accumulation of excess fluid in the pericardial space around the heart. The pericardium does not easily expand; thus, rapid fluid accumulation leads to increased pressure around the heart. The increase in pressure restricts cardiac filling, resulting in decreased cardiac output and cardiac tamponade. Pericardial Effusion and Cardiac Tamponade: restriction in cardiac filling due to excessive accumulation of fluid within pericardial cavity; leads to decreased cardiac output and potentially hemodynamic instability ( hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension and shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock)
  • Large pericardial effusions with no known etiology

Contraindications

  • Aortic dissection Aortic dissection Aortic dissection occurs due to shearing stress from pulsatile pressure causing a tear in the tunica intima of the aortic wall. This tear allows blood to flow into the media, creating a "false lumen." Aortic dissection is most commonly caused by uncontrolled hypertension. Aortic Dissection
  • Coagulopathy (PTT > 2x normal) or thrombopenia (platelet count < 50,000)
  • Small or loculated pericardial effusion Pericardial effusion Pericardial effusion is the accumulation of excess fluid in the pericardial space around the heart. The pericardium does not easily expand; thus, rapid fluid accumulation leads to increased pressure around the heart. The increase in pressure restricts cardiac filling, resulting in decreased cardiac output and cardiac tamponade. Pericardial Effusion and Cardiac Tamponade
  • Traumatic hemopericardium (free ventricular wall rupture)
  • Nonviral infectious pericarditis Pericarditis Pericarditis is an inflammation of the pericardium, often with fluid accumulation. It can be caused by infection (often viral), myocardial infarction, drugs, malignancies, metabolic disorders, autoimmune disorders, or trauma. Acute, subacute, and chronic forms exist. Pericarditis

Procedure

Unless the individual is in cardiac arrest Cardiac arrest Cardiac arrest is the sudden, complete cessation of cardiac output with hemodynamic collapse. Patients present as pulseless, unresponsive, and apneic. Rhythms associated with cardiac arrest are ventricular fibrillation/tachycardia, asystole, or pulseless electrical activity. Cardiac Arrest or has an imminently life-threatening condition, a pericardiocentesis should be performed under ultrasound guidance. 

  1. Echocardiography is performed (in emergency situations, this step is skipped).  
  2. The left xiphochondral junction is located and marked with a pen.
  3. The skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin is washed and draped, leaving a window for the left xiphochondral junction.
  4. 1 mL of lidocaine is infiltrated into the puncture site, creating a skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin wheal, and into the deeper tissues. 
  5. The skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin is punctured with a scalpel 1–2 cm inferior to the left xiphochondral junction.
  6. The needle is introduced and advanced at a 45-degree angle through the small incision toward the left midscapula while maintaining negative pressure (pulling back on the plunger) on the syringe. 
  7. The needle is advanced until it reaches the pericardial space, confirmed by:
    1. Aspiration of pericardial fluid or blood
    2. Sensation of entrance to the cavity
    3. Sensation of cardiac pulsations
    4. Elevation of ST segment on ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG) (withdraw needle until normalized)
  8. The pericardial content is aspirated.
  9. The collected pericardial content is sent to the laboratory for:
    1. Gram stain
    2. Culture (bacterial, fungal, and mycobacterial)
    3. Hematologic cell count
    4. Cytology
    5. Protein
    6. Glucose
    7. Biochemical examination (i.e., pH, LDH)
  10. The needle is removed once no more fluid can be aspirated.
Needle pericardiocentesis

Needle pericardiocentesis:
To successfully reach the pericardial cavity, the needle has to be pointed at a 45-degree angle toward the left midscapula while maintaining negative pressure on the syringe.

Image by Lecturio.

Complications

  • Lack of clinical resolution: Improvement should be immediate after extraction of the pericardial fluid. 
  • Penetration of the myocardial wall (right ventricle)
  • Coronary artery puncture
  • Left internal mammary artery puncture
  • Hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax: accumulation of blood within the pleural space due to profuse bleeding, usually seen in the context of trauma to the chest
  • Pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax: accumulation of air within the pleural space (between the parietal and visceral pleura Pleura The pleura is a serous membrane that lines the walls of the thoracic cavity and the surface of the lungs. This structure of mesodermal origin covers both lungs, the mediastinum, the thoracic surface of the diaphragm, and the inner part of the thoracic cage. The pleura is divided into a visceral pleura and parietal pleura. Pleura), which can be open (communication with the atmosphere) or under tension (without an opening in the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall)
  • MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction
  • Pneumopericardium
  • Hepatic injury
  • Bowel perforation
  • Pleuropericardial fistula

Pericardial Window

Definition

A pericardial window is a surgical procedure done on the parietal pericardium to provide access to the pericardial space and to evacuate occupying fluid and break loculations. The main goal of this procedure is to restore effective ventricular filling and cardiac output.

Indications

  • Cardiac tamponade Cardiac tamponade Pericardial effusion is the accumulation of excess fluid in the pericardial space around the heart. The pericardium does not easily expand; thus, rapid fluid accumulation leads to increased pressure around the heart. The increase in pressure restricts cardiac filling, resulting in decreased cardiac output and cardiac tamponade. Pericardial Effusion and Cardiac Tamponade
  • Symptomatic pericardial effusion Pericardial effusion Pericardial effusion is the accumulation of excess fluid in the pericardial space around the heart. The pericardium does not easily expand; thus, rapid fluid accumulation leads to increased pressure around the heart. The increase in pressure restricts cardiac filling, resulting in decreased cardiac output and cardiac tamponade. Pericardial Effusion and Cardiac Tamponade that persists despite 7–10 days of intensive medical treatment

Contraindications

There are no absolute contraindications. Relative contraindications include coagulopathy, thrombocytopenia Thrombocytopenia Thrombocytopenia occurs when the platelet count is < 150,000 per microliter. The normal range for platelets is usually 150,000-450,000/µL of whole blood. Thrombocytopenia can be a result of decreased production, increased destruction, or splenic sequestration of platelets. Patients are often asymptomatic until platelet counts are < 50,000/µL. Thrombocytopenia, and lack of operator experience.

Procedure

Subxiphoid approach (preferred because of its greater simplicity):

  1. A  4-cm vertical midline incision is made over the xiphoid process and upper abdomen.
  2. The linea alba is separated and the xiphoid process is retracted upward.
  3. The diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm is dissected away from the sternum and xiphoid to access the thoracic cavity.
  4. When the surgeon has direct visualization, the pericardium is opened.
  5. Fluid is aspirated and loculations are gently broken.
  6. Pericardial tissue and fluid are sent for bacteriologic and histologic study.
  7. A drain is placed for continuous evacuation.

Anterolateral approach:

  • Thoracotomy
  • A pericardial window is made anterior to the phrenic nerve.
  • The skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin is loosely closed off using nonabsorbable sutures and cleansed of any residue (e.g., blood, adipose tissue Adipose tissue Adipose tissue is a specialized type of connective tissue that has both structural and highly complex metabolic functions, including energy storage, glucose homeostasis, and a multitude of endocrine capabilities. There are three types of adipose tissue, white adipose tissue, brown adipose tissue, and beige or "brite" adipose tissue, which is a transitional form. Adipose Tissue)
  • Sterile gauze and a dressing are placed over the surgical wound(s). 
Pericardial window procedure

Example of a pericardial window

Image: “The place of pericardial window” by Toth et al. License: CC BY 2.0

Complications

  • Bleeding
  • Surgical site infection ( SSI SSI Surgical site infection (SSI) is a type of surgical infection that occurs at or near a surgical incision within 30 days of the procedure or within 90 days if prosthetic material is implanted. Surgical site infections are classified according to the depth of involvement as superficial, deep, or organ/space. Surgical Site Infections)
  • Arrhythmia
  • MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction
  • Hemodynamic collapse

Coronary Artery Bypass Graft (CABG)

Definition

Coronary artery bypass graft (CABG) surgery is an invasive revascularization procedure that consists of placing grafts between the arterial and coronary circulations in order to bypass obstructed segments of the coronary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries and supply the myocardium with oxygenated blood.

Indications

  • Individuals with activity-limiting angina despite maximum medical therapy
  • Significant left main coronary artery disease (narrowing > 70%)
  • Coronary artery disease (CAD) affecting multiple vessels, with a reduction of left ventricular ejection fraction (LVEF)
  • 3-vessel disease

Contraindications

  • Coronary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries incompatible with grafting
  • Absence of viable myocardium to graft

Procedure

  1. A median sternotomy is performed.
  2. The saphenous vein is simultaneously removed from 1 or both legs using an open or video-assisted approach. The vein is used to make the grafts or conduits.
  3.  The heart is arrested using high-potassium cardioplegic solution.
  4. The surgeon anastomoses the conduits to the coronary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries
  5. The conduits are later attached to new openings created in the proximal aorta and/or other major vessels.
  6. After the cardioplegic solution is washed out, the surgeon checks for conduit competence and bleeding from anastomosis sites. 
  7. If the procedure is considered satisfactory, the chest is closed using sternal wires.
A median sternotomy is performed during many cardiac operations to include a coronary artery bypass graft.

A median sternotomy is performed during many cardiac operations to include a coronary artery bypass graft.

Image by Lecturio.

Complications

  • Graft failure: The inability of the graft to adequately supply the myocardium with oxygenated blood. 
  • Stroke: A serious complication of CABG in which injury to the brain is caused by an interruption of blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure ( ischemic stroke Ischemic Stroke An ischemic stroke (also known as cerebrovascular accident) is an acute neurologic injury that occurs as a result of brain ischemia; this condition may be due to cerebral blood vessel occlusion by thrombosis or embolism, or rarely due to systemic hypoperfusion. Ischemic Stroke) or active hemorrhage (hemorrhagic stroke), which has characteristic neurologic clinical features.
  • SSI SSI Surgical site infection (SSI) is a type of surgical infection that occurs at or near a surgical incision within 30 days of the procedure or within 90 days if prosthetic material is implanted. Surgical site infections are classified according to the depth of involvement as superficial, deep, or organ/space. Surgical Site Infections: A type of surgical infection Surgical infection An infection is the proliferation of microorganisms within tissues, body cavities, or spaces, which induces an immune response and overwhelms the body's natural defenses. In surgical patients, these infections are frequently caused by the translocation of commensal organisms into deeper tissues, combined with the impairment of host defenses due to surgical injury or stress. Surgical Infections that occurs at or near a surgical incision within 30 days after the procedure or within 90 days if prosthetic material is implanted. An SSI SSI Surgical site infection (SSI) is a type of surgical infection that occurs at or near a surgical incision within 30 days of the procedure or within 90 days if prosthetic material is implanted. Surgical site infections are classified according to the depth of involvement as superficial, deep, or organ/space. Surgical Site Infections is classified according to the depth of compromise as superficial, deep, or organ/space.
  • Atrial fibrillation Atrial fibrillation Atrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia and the most common kind of arrhythmia. It is caused by rapid, uncontrolled atrial contractions and uncoordinated ventricular responses. Atrial Fibrillation: A supraventricular tachyarrhythmia Tachyarrhythmia A tachyarrhythmia is a rapid heart rhythm, regular or irregular, with a rate > 100 beats/min. Tachyarrhythmia may or may not be accompanied by symptoms of hemodynamic change. Tachyarrhythmias that is the most common kind of arrhythmia. Atrial fibrillation Atrial fibrillation Atrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia and the most common kind of arrhythmia. It is caused by rapid, uncontrolled atrial contractions and uncoordinated ventricular responses. Atrial Fibrillation is caused by rapid, uncontrolled atrial contractions and uncoordinated ventricular responses.

Cardiac Catheterization

Definition

Cardiac catheterization is an invasive procedure that consists of inserting a catheter into the systemic arterial circulation and advancing it toward the heart to inject contrast dye. This procedure allows for diagnostic vascular imaging and potential therapeutic intervention.

Indications

This procedure may be interventional or diagnostic. 

  • Coronary artery disease: Referred to as ischemic heart disease Ischemic heart disease Coronary heart disease (CHD), or ischemic heart disease, describes a situation in which an inadequate supply of blood to the myocardium exists due to a stenosis of the coronary arteries, typically from atherosclerosis. Coronary Heart Disease, this condition is caused by an inadequate supply of blood to the myocardium due to a stenosis of the coronary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries, typically from atherosclerosis Atherosclerosis Atherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis.
  • Heart failure: This condition refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. 
  • Measuring the hemodynamics in the right and left sides of the heart
  • Arrhythmias
  • Valvular heart disease
  • Assessment of pericardial and myocardial diseases
  • Assessment of the congenital cardiopathies

Contraindications

There are no absolute contraindications for cardiac catheterization. However, if the likelihood of complications is reasonably high, the surgeon may consider other methods. Individuals with renal impairment should be treated cautiously, as contrast media may be nephrotoxic.

Procedure

In the OR:

  1. The individual is placed in the supine position.
  2. A fluoroscope is placed over the individual.
  3. IV access is obtained.
  4. A Foley catheter is placed for quantification of urine output. 
  5. Continuous monitoring:
    • HR
    • Blood pressure
    • O2 saturation (pulse oximetry)
    • ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG) rhythm monitor
  6. Moderate sedation and mild analgesia coupled with local anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts are used.

Operative care:

Cardiac catheterization can be done through an arterial or venous access. A modified version of the Seldinger technique is used for percutaneous catheter insertion.

  1. The selected vessel is identified (e.g., femoral artery).
  2. The vessel is punctured with a needle under ultrasound guidance.
  3. A guidewire is advanced through the needle. 
  4. The needle is withdrawn and a dilator is inserted over the guidewire.
  5. The guidewire is advanced through the systemic circulation Systemic circulation Circulation is the movement of blood throughout the body through one continuous circuit of blood vessels. Different organs have unique functions and, therefore, have different requirements, circulatory patterns, and regulatory mechanisms. Systemic and Special Circulations to the heart.
  6. The operator inserts the catheter over the guidewire toward the heart.
  7. Once the catheter reaches the heart, the surgeon performs the necessary assessments, according to the indications for the procedure.
  8. The catheter and dilator are extracted while applying pressure to the puncture site to prevent bleeding. 

Complications

  • Hematoma
  • Retroperitoneal bleeding
  • Pseudoaneurysm
  • AV fistula
  • Embolism (e.g., thrombus, atherosclerotic plaque, air)
  • Ventricular fibrillation Ventricular fibrillation Ventricular fibrillation (VF or V-fib) is a type of ventricular tachyarrhythmia (> 300/min) often preceded by ventricular tachycardia. In this arrhythmia, the ventricle beats rapidly and sporadically. The ventricular contraction is uncoordinated, leading to a decrease in cardiac output and immediate hemodynamic collapse. Ventricular Fibrillation: a type of ventricular tachyarrhythmia Tachyarrhythmia A tachyarrhythmia is a rapid heart rhythm, regular or irregular, with a rate > 100 beats/min. Tachyarrhythmia may or may not be accompanied by symptoms of hemodynamic change. Tachyarrhythmias characterized by uncoordinated ventricular contraction, which leads to a decrease in cardiac output and immediate hemodynamic collapse
  • MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction: an injury to the myocardium due to ischemia, characterized by an increase in cardiac enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body's constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes (especially troponin T), ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG) changes suggestive of ischemia in 2 continuous leads, and chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain
  • Stroke
  • Aortic dissection Aortic dissection Aortic dissection occurs due to shearing stress from pulsatile pressure causing a tear in the tunica intima of the aortic wall. This tear allows blood to flow into the media, creating a "false lumen." Aortic dissection is most commonly caused by uncontrolled hypertension. Aortic Dissection: separation of the tunica intima from the aortic wall due to shearing stress from pulsatile pressure that allows blood to flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure into the tunica media, creating a “false lumen”
  • Hypersensitivity reaction: There is growing evidence that some hypersensitivity reactions to contrast media, particularly those that are severe, may be IgE-mediated.
  • AKI AKI Acute kidney injury refers to sudden and often reversible loss of renal function, which develops over days or weeks. Azotemia refers to elevated levels of nitrogen-containing substances in the blood that accompany AKI, which include BUN and creatinine. Acute Kidney Injury: due to contrast required for the procedure

Percutaneous Coronary Intervention (PCI)

Definition

Formerly known as coronary angioplasty and stenting, PCI is an invasive, nonsurgical procedure that consists of introducing a catheter into the coronary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries and using a balloon and stent to relieve an occlusion within the vessel.

Indications

  • Critical coronary heart disease Coronary heart disease Coronary heart disease (CHD), or ischemic heart disease, describes a situation in which an inadequate supply of blood to the myocardium exists due to a stenosis of the coronary arteries, typically from atherosclerosis. Coronary Heart Disease (CHD): 
    • The descriptive term denoting a situation in which an inadequate supply of blood to the myocardium exists because of stenosis of the coronary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries
    • Typically from atherosclerosis Atherosclerosis Atherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis
    • PCI is indicated in individuals with CHD who do not qualify for CABG.
  • Acute ST-elevation MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction (STEMI): 
    • Ischemic symptoms < 12 hours 
    • Contraindicated in combination with fibrinolytic therapy
  • Non–ST-elevation acute coronary syndrome 
    • Refractory angina
    • Recurrent angina
    • Symptoms of heart failure
    • New or worsening mitral regurgitation Mitral regurgitation Mitral regurgitation (MR) is the backflow of blood from the left ventricle (LV) to the left atrium (LA) during systole. Mitral regurgitation may be acute (myocardial infarction) or chronic (myxomatous degeneration). Acute and decompensated chronic MR can lead to pulmonary venous congestion, resulting in symptoms of dyspnea, orthopnea, and fatigue. Mitral Regurgitation
    • Hemodynamic instability
    • Sustained ventricular tachycardia Ventricular tachycardia Ventricular tachycardia is any heart rhythm faster than 100 beats/min, with 3 or more irregular beats in a row, arising distal to the bundle of His. Ventricular tachycardia is the most common form of wide-complex tachycardia, and it is associated with a high mortality rate. Ventricular Tachycardia/fibrillation
  • Angina (stable and unstable): substernal, pressure-like chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain or discomfort, radiating to the neck, jaw Jaw The jaw is made up of the mandible, which comprises the lower jaw, and the maxilla, which comprises the upper jaw. The mandible articulates with the temporal bone via the temporomandibular joint (TMJ). The 4 muscles of mastication produce the movements of the TMJ to ensure the efficient chewing of food. Jaw and Temporomandibular Joint, and/or left-upper limb that is associated with dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea, palpitations, anxiety, nausea, vomiting, abdominal or epigastric pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, and/or diaphoresis
    • Stable angina Stable angina Persistent and reproducible chest discomfort usually precipitated by a physical exertion that dissipates upon cessation of such an activity. The symptoms are manifestations of myocardial ischemia. Stable and Unstable Angina (< 20 minutes) 
    • Unstable angina Unstable angina Precordial pain at rest, which may precede a myocardial infarction. Stable and Unstable Angina (≥ 20 minutes)
  • High-risk stress test findings

Contraindications

Absolute:

  • Rejection of the procedure
  • Inability to take dual antiplatelet therapy.
  • Increased bleeding risk (i.e., thrombocytopenia Thrombocytopenia Thrombocytopenia occurs when the platelet count is < 150,000 per microliter. The normal range for platelets is usually 150,000-450,000/µL of whole blood. Thrombocytopenia can be a result of decreased production, increased destruction, or splenic sequestration of platelets. Patients are often asymptomatic until platelet counts are < 50,000/µL. Thrombocytopenia)
  • Restenosis due to multiple previous PCIs

Relative:

  • Long-term intolerance to antiplatelet therapy
  • Hypercoagulable Hypercoagulable Hypercoagulable states (also referred to as thrombophilias) are a group of hematologic diseases defined by an increased risk of clot formation (i.e., thrombosis) due to either an increase in procoagulants, a decrease in anticoagulants, or a decrease in fibrinolysis. Hypercoagulable States state
  • Severe CKD CKD Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Chronic Kidney Disease
  • Artery diameter < 1.5 mm
  • Critical left main stenosis with no collateral flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure or patent bypass graft

Preoperative care Preoperative Care Thorough preoperative care is important for patients scheduled to undergo surgery so that they can have the best possible outcomes after their surgical procedure. The preoperative process begins once the decision has been made to proceed with a surgical procedure. Preoperative Care

Preparation for PCI is substantially similar to that for cardiac catheterization, however door-to-balloon time (D2B time) is an important factor to consider.

  • Percutaneous coronary intervention is often performed in the context of an emergency. 
  • The D2B time is the time taken from arrival at the ED to balloon inflation of the culprit artery.
  • Reduction in D2B time is critical to increase the likelihood of in-hospital survival. 

Antiplatelet therapy:

  • Aspirin 162–325 mg on the day of the procedure.
  • GPIIb/IIIa inhibitors (i.e., abciximab)
  • Dual antiplatelet therapy (DAPT): aspirin and a P2Y12 inhibitor (e.g., clopidogrel, prasugrel, ticagrelor)

For anticoagulation, unfractionated heparin may be used at the time of PCI.

Antibiotic prophylaxis is not indicated.

Operative care

The coronary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries are reached via radial, axillary, or femoral approach. The radial artery is preferred because of the decreased risk of bleeding. Stents are preferred over balloon angioplasty alone because of the decreased risk of restenosis. 

Angiography:

  1. Cardiac catheterization is performed to reach the coronary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries.
  2. Contrast medium is introduced into the coronary artery of interest and images are obtained with fluoroscopy. 
  3. Once stenosis and occlusions are identified in the images, the operator places the guidewire through the catheter distal to the stenosis in the artery. 

Angioplasty and stent placement:

  1. The guidewire is used to advance the deflated balloon and stent catheter to the stenotic segment. 
  2. Once it reaches the correct location, the balloon is expanded, stretching the stent over it, and opening the lumen of the vessel.
  3. The balloon is deflated, the catheter is withdrawn, and adequate placement of the stent and resolution of stenosis is confirmed via imaging.
  4. The catheter and dilator are extracted while applying pressure in the puncture site to prevent bleeding. 
Example of a coronary stent, an expandable tubular metallic device

Example of a coronary stent, an expandable tubular metallic device

Image: “Lekton Magic coronary stent” by Maryam Moravej and Diego Mantovani. License: CC BY 3.0

Postoperative care Postoperative care After any procedure performed in the operating room, all patients must undergo close observation at least in the recovery room. After larger procedures and for patients who require hospitalization, observation must continue on the surgical ward. The primary intent of this practice is the early detection of postoperative complications. Postoperative Care

  • After the procedure, the individual is taken to the recovery room for 6 hours, to be later transferred to the wards, if indicated.
  • Individuals who have undergone elective procedures and have low risk and no complications may be discharged 6–8 hours after the procedure.

Complications

  • Rupture or dissection of the coronary artery or aorta
  • Bleeding from the puncture site
  • SSI SSI Surgical site infection (SSI) is a type of surgical infection that occurs at or near a surgical incision within 30 days of the procedure or within 90 days if prosthetic material is implanted. Surgical site infections are classified according to the depth of involvement as superficial, deep, or organ/space. Surgical Site Infections
  • Sepsis Sepsis Organ dysfunction resulting from a dysregulated systemic host response to infection separates sepsis from uncomplicated infection. The etiology is mainly bacterial and pneumonia is the most common known source. Patients commonly present with fever, tachycardia, tachypnea, hypotension, and/or altered mentation. Sepsis and Septic Shock
  • AKI AKI Acute kidney injury refers to sudden and often reversible loss of renal function, which develops over days or weeks. Azotemia refers to elevated levels of nitrogen-containing substances in the blood that accompany AKI, which include BUN and creatinine. Acute Kidney Injury: due to contrast from procedure
  • Stroke: due to thrombi generated during the procedure
  • MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction: due to dissection or thrombus within the stent
Coronary angiography showing a severe proximal lad stenosis

Coronary angiography showing severe stenosis of the left anterior descending (LAD) artery

Image: “Coronary angiography showing a severe proximal LAD stenosis” by V. Parisi et al. License: CC BY 2.0

References

  1. Senst, B., Kumar, A., Diaz, R.R. (2021). Cardiac surgery. StatPearls. Retrieved April 8, 2021, from http://www.ncbi.nlm.nih.gov/books/NBK532935/
  2. Doty, D., Doty, J. (2012). Cardiac Surgery: Operative Technique. Elsevier/Saunders.
  3. Kouchoukos, N., Kirklin, J. (2013). Kirklin/Barratt-Boyes Cardiac Surgery: Morphology, Diagnostic Criteria, Natural History, Techniques, Results, and Indications. Elsevier/Saunders.
  4. Manda, Y.R., Baradhi, K.M. (2021). Cardiac catheterization risks and complications. StatPearls. Retrieved April 8, 2021, from http://www.ncbi.nlm.nih.gov/books/NBK531461/
  5. Bachar, B.J., Manna, B. (2021). Coronary artery bypass graft. StatPearls. Retrieved April 8, 2021, from http://www.ncbi.nlm.nih.gov/books/NBK507836/
  6. Zipes, D., Libby, P., Bonow, R., Mann, D., Tomaselli, G., Braunwald, E. (2019). Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. Elsevier/Saunders.
  7. Toth, I., Szucs, G., Molnar, T. F. (2012). Mediastinoscope-controlled parasternal fenestration of the pericardium: definitive surgical palliation of malignant pericardial effusion. Journal of Cardiothoracic Surgery 7:56. https://doi.org/10.1186/1749-8090-7-56
  8. De Carlini, C.C., Maggiolini, S. (2017). Pericardiocentesis in cardiac tamponade: indications and practical aspects. E-Journal of Cardiology Practice 15(19). Retrieved April 8, 2021, from https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-15/Pericardiocentesis-in-cardiac-tamponade-indications-and-practical-aspects
  9. Mueller, X. M., Tevaearai, H. T., Hurni, M., Ruchat, P., Fischer, A. P., Stumpe, F., von Segesser, L. K. (1997). Long-term results of surgical subxiphoid pericardial drainage. Thoracic and Cardiovascular Surgeon 45:65–69. https://doi.org/10.1055/s-2007-1013689
  10. Ahmad, M., Mehta, P., Reddivari, A. K. R., Mungee, S. (2021). StatPearls. Percutaneous coronary intervention. http://www.ncbi.nlm.nih.gov/books/NBK556123/

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