Procedures

Coronary artery bypass surgery

1. Coronary artery bypass surgery, also known as coronary artery bypass graft (CABG, pronounced "cabbage"), is a surgical procedure for coronary artery disease (CAD), i.e., blockages in the vessels of the heart. The goal is to bypass the stenotic lesions in native heart arteries using arterial or venous conduits or grafts, thus restoring adequate blood supply to the previously ischemic heart. This reverses ischemia and provides symptomatic improvement to patients, which in turn increases life expectancy.

There are two main approaches. The first utilizes a cardiopulmonary bypass machine, i.e., on pump, and with the heart in arrest (while protected), anastomoses of arterial or venous conduits are constructed. In the other approach, called off-pump coronary artery bypass graft (OPCABG) or beating heart surgery, anastomoses are constructed while the heart is still beating. The anastomosis supplying the left anterior descending branch (LAD) is the most significant one, and usually, the left internal mammary artery (LIMA) is used as the graft. Other commonly employed conduits are the right internal mammary artery (RIMA), the radial artery, or the great saphenous vein (SVG).

In total arterial grafting (TAR), only arterial conduits are used, namely the LIMA, RIMA, radial artery, and rarely the gastroepiploic artery.

CABG has become the primary option for treating severe CAD.

Aortic Valve Replacement

Aortic valve replacement is a procedure whereby the failing aortic valve of a patient's heart is replaced with an artificial heart valve. The aortic valve may need to be replaced because:

The valve is leaky (aortic insufficiency, also known as aortic regurgitation)

The valve is narrowed and doesn't open fully (aortic stenosis)

Bentall’s procedure

The Bentall procedure is a type of cardiac surgery involving composite graft replacement of the aortic valve, aortic root, and ascending aorta, with re-implantation of the coronary arteries into the graft. This operation is used to treat combined disease of the aortic valve and ascending aorta, including lesions associated with Marfan syndrome. The diseases specifically include ascending aortic and arch aneurysm and aortic dissection.

Chronic constrictive pericarditis

The pericardium is a layer of tissue covering the heart. Due to infection or other reasons , this layer becomes thickened and compresses the heart, obstructing the normal flow of blood. Pericardiectomy is the surgical removal of the constricting pericardium in order to alleviate the symptoms of constriction.

Pulmonary thrombo-embolectomy

Pulmonary thromboembolism is caused by a blood clot that forms in the leg veins (DVT) and then moves to the pulmonary arteries (embolism).A large clot can cause significant distress and heart failure, which require open heart surgery to remove the clot.

Cardiac surgery for congestive heart failure

Heart failure is a global term for the physiological state in which cardiac output is insufficient for the body's needs. It is a condition in which there is a problem with the structure or function of the heart, which impairs the ability to supply sufficient blood flow to meet the body's needs. Heart failure affects nearly 5.7 million people. Roughly 670,000 people are diagnosed with heart failure each year. It is the leading cause of hospitalization in people with diagnosed heart diseases. If not optimally treated, up to 42% of patients die of HF within 5 years of hospitalization for HF. Sudden cardiac death is 6–9 times more likely in a HF patient as compared to the general population.

Clinical Types
Acute heart failure:
A sudden change in heart function related to some new event that has caused damage to the heart.
Chronic heart failure:
A gradual decline in heart function over a period of time. Often, the body compensates slowly for the loss of heart function.

Causes
Acute Heart Failure
1. Myocardial Infarction
2. Pulmonary Embolism
3. Myocarditis
4. Post-partum Cardiomyopathy
5. Acute worsening of CHF
6. Acute HTx Rejection
7. Trauma
Chronic Heart Failure
8. Coronary artery disease
9. Idiopathic cardiomyopathy
10. Dilated cardiomyopathy
11. Ischemic cardiomyopathy
12. Valvular heart disease
13. Congenital heart disease

Acute Heart Failure – treatment Options
1. IABP - INTRA AORTIC BALLOON PULSATION - acute cardiogenic shock
2. ECMO - EXTRACORPOREAL MEMBRANE OXYGENATION - acute cardiorespiratory failure
IABP: Device placed via the femoral artery (in the leg) to augment coronary blood flow, reduce afterload
ECMO: Blood is removed from the venous system either peripherally via cannulation of a femoral vein or centrally via cannulation of the right atrium, oxygenated, Extract carbon dioxide via membrane oxygenator. Blood is then returned back to the body peripherally via a femoral artery through a Centrifugal pump.

CHF – treatment Options
1. CABG
2. Valve Replacement / Repair Surgery
3. Surgical Ventricular Restoration
4. Restraint Devices
5. Ventricular Assist Devices
6. Total Artificial Heart
7. Heart Transplant

CABG
1. CAD with LV systolic dysfunction
2. CAD suitable for CABG anatomically (TVD, DVD and SVD not suitable for PTCA)
3. Left main CAD ≥ 50% stenosis
4. Class III angina or greater
5. Viable (Hibernating) myocardium–Cardiac MRI/Dobutamine stress echo/ Thallium scan/PET scan
In patients with HF, LVD and CAD amenable to surgical revascularization, CABG added to intensive medical therapy (MED) will decrease all-cause mortality compared to MED alone.

AVR
1.Symptomatic HF in AS/AR
2.Asymptomatic patients with sev AS/AR & EF < 50%.

Ischemic MR is a ventricular problem
• Papillary muscle rupture.
• Stretching/tenting of mitral leaflet
• Alteration in LV geometry, annular dilatation contributes to volume overload, ↑ wall tension, exacerbate failure Surgery will reverse the cycle of excess ventricular volume, ventricular unloading and promoting myocardial remodeling.
1. Annuloplasty + CABG with chordal shortening/relocation
2. Mitral valve replacement with chordal preservation.
3. Isolated MVR not recommended.

Mitral valve replacement for severe MS/MR, infective endocarditis Early Sx before severe pulmonary hypertension, LV and RV dysfunction sets in, Outcomes are poor with EF < 30%

Tricuspid valve regurgitation: Can be Functional or Organic with symptoms of right heart failure
Surgical - Tricuspid valve ring annuloplasty

Rare causes
1. Intracardiac tumor
2. Infective endocarditis
3. Pulmonary thromboembolism Acute Chronic
4. Aortic Dissection
5. Aortic Aneurysm
6. GUCH - Grown up congenital heart disease ASD, VSD, TOF, etc. Present usually with severe TR with severe PAH. Eisenmengerization – Inoperable

HEART TRANSPLANT

Cardiac transplantation is currently the only established surgical approach (excluding AVR and CABG) for the treatment of refractory HF as listed in the 2005 ACC/AHA heart failure guidelines. But Small number of available donor hearts. Inapplicable in older pts or those with comorbid conditions.

Conclusion: The cause of heart failure when amenable to surgical correction should always be treated surgically, as it greatly improves the symptomatology and survival of patients.