Two cardiac surgeons performing a cardiac surgery known as coronary artery bypass surgery. Note the use of a steel retractor to forcefully maintain the exposure of the patient's heart.
Cardiovascular (heart) surgery is surgery on the heart or great vessels performed by cardiac surgeons. Frequently, it is done to treat complications of ischemic heart disease (for example, coronary artery bypass grafting), correct congenital heart disease, or treat valvular heart disease from various causes including endocarditis, rheumatic heart disease and atherosclerosis. It also includes heart transplantation.
The development of cardiac surgery and cardiopulmonary bypass techniques has reduced the mortality rates of these surgeries to relatively low ranks. For instance, repairs of congenital heart defects are currently estimated to have 4–6% mortality rates. A major concern with cardiac surgery is the incidence of neurological damage. Stroke occurs in 2–3% of all people undergoing cardiac surgery, and is higher in patients at risk for stroke. A more subtle complication of neurocognitive deficits attributed to cardiopulmonary bypass is known as postperfusion syndrome, sometimes called "pumphead". The symptoms of postperfusion syndrome were initially felt to be permanent, but were shown to be transient with no permanent neurological impairment.
The most common complications after heart surgery include postoperative atrial fibrillation, which occurs in nearly 1 in 3 patients, retained blood syndrome, which occurs in 1 in 4 patients, bloodypleural effusions which occur in 1 in 10 patients, and infections, that occur in approximately 1 in 20 patients. Hospital readmissions often occur in cardiac surgery patients; in 2010, approximately 18.5% of patients who had a heart valve procedure in the United States were readmitted within 30 days of the initial hospitalization. Readmissions are primarily related to these common complications such as postoperative atrial fibrillation, retained blood syndrome and pleural effusions and infections, thus prompting new efforts to prevent problems like chest tube clogging that contribute to these problems. Reducing costs, complications and readmissions primarily focus on addressing these common complications.
In order to assess the performance of surgical units and individual surgeons, a popular risk model has been created called the EuroSCORE. This takes a number of health factors from a patient and using precalculated logistic regression coefficients attempts to give a percentage chance of survival to discharge. Within the UK this EuroSCORE was used to give a breakdown of all the centres for cardiothoracic surgery and to give some indication of whether the units and their individuals surgeons performed within an acceptable range. The results are available on the CQC website.
Another important source of complications include the neuropsychological and psychopathologic changes following open heart surgery have been recognized from the very beginning of modern heart surgery. Variables correlated with nonpsychotic mental disorder after cardiac surgery must be divided into pre-, intra- and postoperative. The incidence, phenomenology, and duration of symptoms diverge from patient to patient, and are difficult to define. One wonders whether any of the patients in either group in this analysis underwent any mechanical cardiac valve replacement. If so, one has to consider Skumin syndrome, described by Victor Skumin in 1978 as a "cardioprosthetic psychopathological syndrome" associated with mechanical heart valve implant and manifested by irrational fear, anxiety, depression, sleep disorder, and asthenia.
Complication risk reduction
A 2012 Cochrane systematic review found evidence that preoperative physical therapy reduced postoperative pulmonary complications in patients undergoing elective cardiac surgery such as pneumonia and atelectasis. In addition, the researchers found that preoperative physical therapy decreased the length of hospital stay (on average by more than three days).
Additionally, investigators have identified that even simple maneuvers such as preventing chest tubes from clogging, which can result in retained blood syndrome, postoperative atrial fibrillation, and infection, can reduce costs and complications in patients recovering from heart surgery.
The earliest operations on the pericardium (the sac that surrounds the heart) took place in the 19th century and were performed by Francisco Romero (1801), Dominique Jean Larrey (1810), Henry Dalton (1891), and Daniel Hale Williams (1893). The first surgery on the heart itself was performed by Norwegian surgeon Axel Cappelen on 4 September 1895 at Rikshospitalet in Kristiania, now Oslo. He ligated a bleeding coronary artery in a 24-year-old man who had been stabbed in the left axillae and was in deep shock upon arrival. Access was through a left thoracotomy. The patient awoke and seemed fine for 24 hours, but became ill with increasing temperature and he ultimately died from what the post mortem proved to be mediastinitis on the third postoperative day. The first successful surgery of the heart, performed without any complications, was by Dr. Ludwig Rehn of Frankfurt, Germany, who repaired a stab wound to the right ventricle on September 7, 1896.
Surgery in great vessels (aortic coarctation repair, Blalock-Thomas-Taussig shunt creation, closure of patent ductus arteriosus) became common after the turn of the century and is cardiac surgery, but not open heart surgery.
Early approaches to heart malformations
In 1925, operations on the heart valves were unknown. Henry Souttar operated successfully on a young woman with mitral stenosis. He made an opening in the appendage of the left atrium and inserted a finger into this chamber in order to palpate and explore the damaged mitral valve. The patient survived for several years but Souttar's physician colleagues at that time decided the procedure was not justified and he could not continue.
Cardiac surgery changed significantly after World War II. In 1948, four surgeons carried out successful operations for mitral stenosis resulting from rheumatic fever. Horace Smithy (1914–1948) of Charlotte, revived an operation due to Dr Dwight Harken of the Peter Bent Brigham Hospital using a punch to remove a portion of the mitral valve. Charles Bailey (1910–1993) at the Hahnemann University Hospital, Philadelphia, Dwight Harken in Boston and Russell Brock at Guy's Hospital all adopted Souttar's method. All these men started work independently of each other, within a few months. This time Souttar's technique was widely adopted although there were modifications.
In 1947, Thomas Holmes Sellors (1902–1987) of the Middlesex Hospital operated on a Fallot's Tetralogy patient with pulmonary stenosis and successfully divided the stenosed pulmonary valve. In 1948, Russell Brock, probably unaware of Sellor's work, used a specially designed dilator in three cases of pulmonary stenosis. Later, in 1948, he designed a punch to resect the infundibular muscle stenosis which is often associated with Fallot's Tetralogy. Many thousands of these "blind" operations were performed until the introduction of heart bypass made direct surgery on valves possible.
Open heart surgery
Open heart surgery is a surgery in which the patient's heart is open and surgery is performed on the internal structures of the heart. It was soon discovered by Dr. Wilfred G. Bigelow of the University of Toronto that the repair of intracardiac pathologies was better done with a bloodless and motionless environment, which means that the heart should be stopped and drained of blood. The first successful intracardiac correction of a congenital heart defect using hypothermia was performed by Dr. C. Walton Lillehei and Dr. F. John Lewis at the University of Minnesota on September 2, 1952. In 1953 Soviet surgeon Alexander Alexandrovich Vishnevsky conducted the first cardiac surgery under local anesthesia. During this surgery, the heart is exposed and the patient's blood is made to bypass it. In 1956 Dr. John Carter Callaghan performed a number of firsts in heart surgery, including the first documented open-heart surgery in Canada.
There are many different types of heart surgeries that are common in order to either avoid further damage to the heart or to repair it. According to the U.S. National Library of Medicine there are full open-heart surgeries where a surgeon will cut a five to eight inch surgical cut into the chest wall. Aside from a full open heart surgery, there is endoscopic surgery where a surgeon will cut very small holes and then complete the surgery using a camera and specific endoscopic tools.
Diving into cardiac surgery there are many kinds of surgeries that one can discuss and aside from that, there are many reasons why a patient may undergo cardiac surgery. Included in the many types of cardiac surgeries that occur, one surgery that is the most visual in the field is open-heart surgery. Open-heart surgery is when there is about an 8-inch incision that a patient receives over their chest and then the surgeon continues with the procedure and follows it with closing the incision.
During open-heart surgery, the heart is temporarily stopped. Knowing that the heart controls the circulation of blood and oxygen in the human body, one may question how the body functions at this time. Patients undergoing an open-heart surgery are placed on cardiopulmonary bypass, meaning a machine will pump their blood and oxygen for them. A machine will never function the same as a normal heart, therefore, similar to many surgical procedures, the time on this machine is kept to a minimum.
Surgeons realized the limitations of hypothermia: complex intracardiac repairs take more time and the patient needs blood flow to the body, particularly to the brain. The patient needs the function of the heart and lungs provided by an artificial method, hence the term cardiopulmonary bypass. Dr. John Heysham Gibbon at Jefferson Medical School in Philadelphia reported in 1953 the first successful use of extracorporeal circulation by means of an oxygenator, but he abandoned the method, disappointed by subsequent failures. In 1954 Dr. Lillehei realized a successful series of operations with the controlled cross-circulation technique in which the patient's mother or father was used as a 'heart-lung machine'. Dr. John W. Kirklin at the Mayo Clinic in Rochester, Minnesota started using a Gibbon type pump-oxygenator in a series of successful operations. Nazih Zuhdi performed the first total intentional hemo-dilution open heart surgery on Terry Gene Nix, age 7, on February 25, 1960, at Mercy Hospital, Oklahoma City, OK. The operation was a success; however, Nix died three years later in 1963. In March, 1961, Zuhdi, Carey, and Greer, performed open heart surgery on a child, age 3 1⁄2, using the total intentional hemodilution machine.
Modern beating-heart surgery
In the early 1990s surgeons began to perform Off-pump coronary artery bypass, done without cardiopulmonary bypass. In these operations, the heart is beating during surgery, but is stabilized to provide an almost still work area in which to connect the conduit vessel that bypasses the blockage using a technique known as endoscopic vessel harvesting (EVH).
Minimally invasive surgery
A new form of heart surgery that has grown in popularity is robot-assisted heart surgery. This is where a machine is used to perform surgery while being controlled by the heart surgeon. The main advantage to this is the size of the incision made in the patient. Instead of an incision being at least big enough for the surgeon to put his hands inside, it does not have to be bigger than 3 small holes for the robot's much smaller hands to get through.
Pediatric cardiovascular surgery
Pediatric cardiovascular surgery is surgery of the heart of children. Russell M. Nelson performed the first successful pediatric cardiac operation at the Salt Lake General Hospital in March 1956, a total repair of tetralogy of Fallot in a four-year-old girl.
In 1945 the Soviet Pathologist Nikolai Sinitsyn successfully transplanted a heart from one frog to another frog and from one dog to another without killing any. Norman Shumway is widely regarded as the father of heart transplantation although the world's first adult human heart transplant was performed by a South African cardiac surgeon, Christiaan Barnard, utilizing the techniques developed and perfected by Shumway and Richard Lower. Barnard performed the first transplant on Louis Washkansky on December 3, 1967 at the Groote Schuur Hospital in Cape Town, South Africa. Adrian Kantrowitz performed the world's first pediatric heart transplant on December 6, 1967, at Maimonides Hospital (now Maimonides Medical Center) in Brooklyn, New York, barely three days after Christiaan Barnard's pioneering procedure. Norman Shumway performed the first adult heart transplant in the United States on January 6, 1968, at the Stanford University Hospital.
Coronary Artery Bypass Grafting
Coronary Artery Bypass Grafting is the most common type of open-heart surgery according to the National Heart, Lung, and Blood institute. This is a surgical procedure done in order to give blood another path to travel in order to supply the heart and the body. Another way of describing this procedure is known as revascularization. Revascularization means that there is another supply of blood created in order to avoid and limit clot formation. This can be done in many different ways and the arteries that create this revascularization can be taken from several different areas of the body.
The goal of the entire procedure is to be as minimally invasive as possible. Because the steps of this operation involve more than just cutting open the patients chest, it is important to recognize that keeping other portions of the operation minimal is imperative. The University of Rochester Medical center discusses how veins are taken from the patients' legs to then be stitched onto the aorta and the coronary artery, relieving some blood flow from those specific valves in the heart. Arteries are typically harvested from the chest, arm or wrist to then be attached to another portion of the coronary artery again taking pressure away and limiting clotting factors in that area of the heart. The typical reason that a coronary artery bypass grafting procedure takes place is because of coronary heart disease. This is a disease where one has a buildup of a plaque like substance in their coronary artery. With the coronary artery being the main path of oxygen-rich blood to the heart it is imperative that it is not only functioning properly but to be sure that any type of blockage does not buildup in the pathway. If plaque builds this not only causes a blockage but can also cause a rupture, which can lead to something known as chest angina or "pain in the chest." With a plaque rupture built on top of a blockage, what can likely happen is for an individual to undergo a heart attack. The purpose of the coronary artery bypass grafting is to eliminate the risks of furthering heart disease that could cause the heart to fail. It is important to find the risks of the plaque blockages sooner than later in order to avoid the chances of any worse attack or diseases to occur.
Following an open-heart procedure, along with many other surgical procedures, there are certain steps that a patient needs to take post-operation. Incision care is very important to not only heal the scar that occurred from the surgery in the best way possible, but also to avoid getting any infections that could occur if the incision is not cleaned properly. Aside from taking care of the incisions and scarring that is present, it is important to understand that one's body is still getting accustomed to something new therefore other side effects may occur. Not having an appetite along with swelling can be common side effects to any surgery therefore it is beneficial to expect these changes when approaching a surgery as serious as open-heart surgery.
Chest tubes are inserted to evacuate any shed blood around the heart and lungs in the early hours of recovery. It is important to specifically avoid chest tube clogging during early recovery to avoid complications such as retained blood syndrome and other complications.
There is recovery that takes place in the hospital along with recovery that is imperative at home as well. The National Heart, Lung, and Blood Institute discuss the different recovery procedures important to an open-heart surgery procedure. Dependent on how a patient is healing, recovery in the hospital will always include about 48 hours in an intensive care unit where a patient will be checked regularly in order to be sure that one's heart rate, blood pressure and oxygen levels are at a safe and healthy level for the patient. Recovery in the hospital that can lead to more recovery at home would be the recommendation to wear things like compression socks in order to regulate blood flow in a different manner. Carrying out these healing processes at home, knowing what to look for to avoid infection and excessive scarring, is very important for a patient to understand prior to leaving the hospital and caring for him or herself at home.
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|Wikimedia Commons has media related to Cardiac surgery.|
- Overview at American Heart Association
- "Congenital Heart Disease Surgical Corrective Procedures", a list of surgical procedures at learningradiology.com
- What to expect before, during and after heart surgery from Children's Hospital and Regional Medical Center (Seattle)
- MedlinePlus Encyclopedia Minimally invasive heart surgery
- Horace Gilbert Smithy, Jr., MD Papers Waring Historical Library