Cardiac surgery

Cardiac surgery

Two cardiac surgeons performing coronary artery bypass surgery. Note the use of a steel retractor to forcefully maintain the exposure of the heart.
ICD-9-CM 35-37
MeSH D006348
OPS-301 code 5-35...5-37

Cardiac surgery, or cardiovascular surgery, is surgery on the heart or great vessels performed by cardiac surgeons. It is often used to treat complications of ischemic heart disease (for example, with coronary artery bypass grafting); to correct congenital heart disease; or to treat valvular heart disease from various causes, including endocarditis, rheumatic heart disease, and atherosclerosis. It also includes heart transplantation.

History

19th century

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),[1] Dominique Jean Larrey (1810), Henry Dalton (1891), and Daniel Hale Williams (1893).[2] The first surgery on the heart itself was performed by Axel Cappelen on 4 September 1895 at Rikshospitalet in Kristiania, now Oslo. Cappelen ligated a bleeding coronary artery in a 24-year-old man who had been stabbed in the left axilla 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 a fever and died three days after the surgery from mediastinitis.[3][4]

The first successful surgery on the heart, without any complications, was performed by Dr. Ludwig Rehn of Frankfurt, Germany, who repaired a stab wound to the right ventricle on 7 September 1896.[5][6]

20th century

Surgery on the great vessels (e.g., aortic coarctation repair, Blalock-Thomas-Taussig shunt creation, closure of patent ductus arteriosus) became common after the turn of the century. However, operations on the heart valves were unknown until, in 1925, Henry Souttar operated successfully on a young woman with mitral valve stenosis. He made an opening in the appendage of the left atrium and inserted a finger in order to palpate and explore the damaged mitral valve. The patient survived for several years,[7] but Souttar's colleagues considered the procedure unjustified, and he could not continue.[8][9]

Cardiac surgery changed significantly after World War II. In 1947, Thomas Holmes Sellors (1902–1987) of Middlesex Hospital in London operated on a Tetralogy of Fallot patient with pulmonary stenosis and successfully divided the stenosed pulmonary valve. In 1948, Russell Brock, probably unaware of Sellors's work, used a specially designed dilator in three cases of pulmonary stenosis. Later that year, he designed a punch to resect a stenosed infundibulum, which is often associated with Tetralogy of Fallot. Many thousands of these "blind" operations were performed until the introduction of cardiopulmonary bypass made direct surgery on valves possible.[8]

Also in 1948, four surgeons carried out successful operations for mitral valve stenosis resulting from rheumatic fever. Horace Smithy (1914–1948) of Charlotte used a valvulotome to remove a portion of a patient's mitral valve,[10] while three other doctors—Charles Bailey (1910–1993) of Hahnemann University Hospital in Philadelphia; Dwight Harken in Boston; and Russell Brock of Guy's Hospital in London—adopted Souttar's method. All four men began their work independently of one another within a period of a few months. This time, Souttar's technique was widely adopted, with some modifications.[8][9]

The first successful intracardiac correction of a congenital heart defect using hypothermia was performed by Drs. C. Walton Lillehei and F. John Lewis at the University of Minnesota on 2 September 1952. In 1953, Alexander Alexandrovich Vishnevsky conducted the first cardiac surgery under local anesthesia. In 1956, Dr. John Carter Callaghan performed the first documented open heart surgery in Canada.

Alfred Blalock, Helen Taussig and Vivien Thomas performed the first successful pediatric cardiac operation at Johns Hopkins Hospital on November, 29 1944, a total repair of Tetralogy of Fallot in a one-year-old girl.[11]

Types of cardiac surgery

Open heart surgery

In open heart surgery, the patient's heart is opened and surgery is performed on its internal structures.

Dr. Wilfred G. Bigelow of the University of Toronto found that such procedures could be performed better in a bloodless and motionless environment. Therefore, during open heart surgery, the heart is temporarily stopped, and the patient is placed on cardiopulmonary bypass, meaning a machine pumps their blood and oxygen. Because the machine cannot function the same way as the heart, surgeons try to minimize the time a patient spends on it.[12]

Cardiac surgery at Gemelli Hospital in Rome.

Cardiopulmonary bypass was developed after surgeons realized the limitations of hypothermia in cardiac surgery: Complex intracardiac repairs take time, and the patient needs blood flow to the body (particularly to the brain), as well as heart and lung function. In 1953, Dr. John Heysham Gibbon of Jefferson Medical School in Philadelphia reported the first successful use of extracorporeal circulation by means of an oxygenator, but he abandoned the method after subsequent failures. In 1954, Dr. Lillehei performed a series of successful 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 was the first to use a Gibbon-type pump-oxygenator.

Nazih Zuhdi performed the first total intentional hemodilution open heart surgery on Terry Gene Nix, age 7, on 25 February 1960 at Mercy Hospital in Oklahoma City. The operation was a success; however, Nix died three years later.[13] 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 continues beating during surgery, but is stabilized to provide an almost still work area in which to connect a conduit vessel that bypasses a blockage using a technique known as endoscopic vessel harvesting (EVH).

Heart transplant

In 1945, the Soviet pathologist Nikolai Sinitsyn successfully transplanted a heart from one frog to another frog and from one dog to another dog.

Norman Shumway is widely regarded as the father of human heart transplantation, although the world's first adult heart transplant was performed by a South African cardiac surgeon, Christiaan Barnard, using techniques developed by Shumway and Richard Lower.[14] Barnard performed the first transplant on Louis Washkansky on 3 December 1967 at Groote Schuur Hospital in Cape Town.[14][15] Adrian Kantrowitz performed the first pediatric heart transplant on 6 December 1967 at Maimonides Hospital (now Maimonides Medical Center) in Brooklyn, New York, barely three days later.[14] Shumway performed the first adult heart transplant in the United States on 6 January 1968 at Stanford University Hospital.[14]

Coronary artery bypass grafting

Coronary artery bypass grafting, also called revascularization, is a common surgical procedure to create an alternative path to deliver blood supply to the heart and body, with the goal of preventing clot formation. This can be done in many ways, and the arteries used can be taken from several areas of the body.[16] Arteries are typically harvested from the chest, arm, or wrist and then attached to a portion of the coronary artery, relieving pressure and limiting clotting factors in that area of the heart.[17]

The procedure is typically performed because of coronary artery disease (CAD), in which a plaque-like substance builds up in the coronary artery, the main pathway carrying oxygen-rich blood to the heart. This can cause a blockage and/or a rupture, which can lead to a heart attack.[17]

Minimally invasive surgery

As an alternative to open heart surgery, which involves a five- to eight-inch incision in the chest wall, a surgeon may perform an endoscopic procedure by making very small incisions through which a camera and specialized tools are inserted.[18]

In robot-assisted heart surgery, a machine controlled by a cardiac surgeon is used to perform a procedure. The main advantage to this is the size of the incision required: three small holes instead of an incision big enough for the surgeon's hands.

Post-surgical procedures

As with any surgical procedure, cardiac surgery requires postoperative precautions to avoid complications. Incision care is needed to avoid infection and minimize scarring. Swelling and loss of appetite are common.[19][20]

Recovery from open heart surgery begins with about 48 hours in an intensive care unit, where heart rate, blood pressure, and oxygen levels are closely monitored. Chest tubes are inserted to drain blood around the heart and lungs. After discharge from the hospital, compression socks may be recommended in order to regulate blood flow.[21]

Risks

The advancement of cardiac surgery and cardiopulmonary bypass techniques has greatly reduced the mortality rates of these procedures. For instance, repairs of congenital heart defects are currently estimated to have 4–6% mortality rates.[22][23]

A major concern with cardiac surgery is neurological damage. Stroke occurs in 2–3% of all people undergoing cardiac surgery, and the rate is higher in patients with other risk factors for stroke.[24] A more subtle complication attributed to cardiopulmonary bypass is postperfusion syndrome, sometimes called "pumphead". The neurocognitive symptoms of postperfusion syndrome were initially thought to be permanent,[25] but turned out to be transient, with no permanent neurological impairment.[26]

The most common complications after heart surgery include atrial fibrillation, which occurs in nearly 1 in 3 patients; retained blood syndrome, which occurs in 1 in 4 patients; bloody pleural effusions, which occur in 1 in 10 patients; and infections, which 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.[27] Readmissions are primarily related to the four most common complications, and recent efforts have focused on preventing problems like chest tube clogging that contribute to these complications.

In order to assess the performance of surgical units and individual surgeons, a popular risk model has been created called the EuroSCORE. It takes a number of health factors from a patient and, using precalculated logistic regression coefficients, attempts to quantify the probability that they will survive to discharge. Within the United Kingdom, the EuroSCORE was used to give a breakdown of all cardiothoracic surgery centres and to indicate whether the units and their individuals surgeons performed within an acceptable range. The results are available on the Care Quality Commission website.[28]

Another important source of complications are the neuropsychological and psychopathologic changes following open heart surgery. One example is Skumin syndrome, described by Victor Skumin in 1978, which is a "cardioprosthetic psychopathological syndrome"[29] associated with mechanical heart valve implants and characterized by irrational fear, anxiety, depression, sleep disorder, and weakness.[30][31]

Risk reduction

A 2012 Cochrane systematic review found evidence that preoperative physical therapy reduced postoperative pulmonary complications, such as pneumonia and atelectasis, in patients undergoing elective cardiac surgery.[32] In addition, the researchers found that preoperative physical therapy decreased the length of hospital stay by more than three days on average.[32]

A 2013 Cochrane review showed that both pharmacological and non-pharmacological prevention reduce the risk of atrial fibrillation after an operation and reduced the length of hospital stays. No difference in mortality could be shown.[33]

There is evidence that quitting smoking at least four weeks before surgery may reduce the risk of postoperative complications.[34] Additionally, investigators have found that simple measures 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.

See also

References

  1. ↑ Aris A. (September 1997). "Francisco Romero the first heart surgeon". Ann. Thorac. Surg. 64 (3): 870–1. PMID 9307502. doi:10.1016/S0003-4975(97)00760-1.
  2. ↑ "Pioneers in Academic Surgery". U.S. National Library of Medicine.
  3. ↑ Westaby, Stephen; Bosher, Cecil. Landmarks in Cardiac Surgery. ISBN 1-899066-54-3.
  4. ↑ Baksaas ST; Solberg S (January 2003). "Verdens første hjerteoperasjon". Tidsskr Nor Lægeforen. 123 (2): 202–4.
  5. ↑ Absolon KB, Naficy MA (2002). First successful cardiac operation in a human, 1896: a documentation: the life, the times, and the work of Ludwig Rehn (1849–1930). Rockville, MD : Kabel, 2002
  6. ↑ Johnson SL (1970). History of Cardiac Surgery, 1896–1955. Baltimore: Johns Hopkins Press. p. 5.
  7. ↑ Dictionary of National Biography – Henry Souttar (2004–08)
  8. 1 2 3 Harold Ellis (2000) A History of Surgery, page 223+
  9. 1 2 Lawrence H Cohn (2007), Cardiac Surgery in the Adult, page 6+
  10. ↑ "About Horace G. Smithy, MD". Medical University of South Carolina. Retrieved 2017-05-05.
  11. ↑ To Heal the Heart of a Child: Helen Taussig, M.D. Joyce Baldwin, Walker and Company New York,1992
  12. ↑ http://www.texasheart.org/HIC/Topics/Proced/
  13. ↑ Warren, Cliff, Dr. Nazih Zuhdi – His Scientific Work Made All Paths Lead to Oklahoma City, in Distinctly Oklahoma, November, 2007, p. 30–33
  14. 1 2 3 4 McRae, D. (2007). Every Second Counts. Berkley.
  15. ↑ "Memories of the Heart". Doylestown, Pennsylvania: Daily Intelligencer. November 29, 1987. p. A–18.
  16. ↑ "What Is Coronary Artery Bypass Grafting? - NHLBI, NIH". www.nhlbi.nih.gov. Retrieved 2016-07-08.
  17. 1 2 https://www.urmc.rochester.edu/surgery/cardiac/procedures/open-heart.aspx
  18. ↑ Open heart surgery: MedlinePlus Medical Encyclopedia. (2016, February 2). Retrieved February 15, 2016, from https://www.nlm.nih.gov/medlineplus/ency/article/002950.htm
  19. ↑ "Heart Surgery | Incision Care". my.clevelandclinic.org. Retrieved 2016-07-08.
  20. ↑ "What to Expect After Heart Surgery" (PDF). sts.org. Retrieved 8 July 2016.
  21. ↑ "What To Expect After Coronary Artery Bypass Grafting - NHLBI, NIH". www.nhlbi.nih.gov. Retrieved 2016-07-08.
  22. ↑ Stark J; Gallivan S; Lovegrove J; et al. (March 2000). "Mortality rates after surgery for congenital heart defects in children and surgeons' performance". Lancet. 355 (9208): 1004–7. PMID 10768449. doi:10.1016/S0140-6736(00)90001-1.
  23. ↑ Klitzner TS; Lee M; Rodriguez S; Chang RK (May 2006). "Sex-related disparity in surgical mortality among pediatric patients". Congenit Heart Dis. 1 (3): 77–88. PMID 18377550. doi:10.1111/j.1747-0803.2006.00013.x.
  24. ↑ Naylor AR, Bown MJ (2011). "Stroke after cardiac surgery and its association with asymptomatic carotid disease: an updated systematic review and meta-analysis". Eur J Vasc Endovasc Surg. 41 (5): 607–24. PMID 21396854. doi:10.1016/j.ejvs.2011.02.016.
  25. ↑ Newman M; Kirchner J; Phillips-Bute B; Gaver V; Grocott H; et al. (2001). "Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery". N Engl J Med. 344 (6): 395–402. PMID 11172175. doi:10.1056/NEJM200102083440601.
  26. ↑ Van Dijk D; Jansen E; Hijman R; Nierich A; Diephuis J; et al. (2002). "Cognitive outcome after off-pump and on-pump coronary artery bypass graft surgery: a randomized trial". JAMA. 287 (11): 1405–12. PMID 11903027. doi:10.1001/jama.287.11.1405.
  27. ↑ Weiss AJ, Elixhauser A, Steiner C. Readmissions to U.S. Hospitals by Procedure, 2010. HCUP Statistical Brief #154. Agency for Healthcare Research and Quality. April 2013.
  28. ↑ "Archived copy". Archived from the original on 2011-11-05. Retrieved 2011-10-21. CQC website for heart surgery outcomes in the UK for 3 years ending March 2009
  29. ↑ Bendet IaA, Morozov SM, Skumin VA (1980). "[Psychological aspects of the rehabilitation of patients after the surgical treatment of heart defects]". Kardiologiia (in Russian). 20 (6): 45–51. PMID 7392405.
  30. ↑ Skumin, V. A. (1982). Nepsikhoticheskie narusheniia psikhiki u bol'nykh s priobretennymi porokami serdtsa do i posle operatsii (obzor) [Nonpsychotic mental disorders in patients with acquired heart defects before and after surgery (review)]. Zhurnal nevropatologii i psikhiatrii imeni S.S. Korsakova. 82: 130–5. OCLC 112979417. PMID 6758444.
  31. ↑ Ruzza, Andrea. "Nonpsychotic mental disorder after open heart surgery" Asian Cardiovascular and Thoracic Annals (2013)
  32. 1 2 Hulzebos, EHJ; Smit Y; Helders PPJM; van Meeteren NLU (14 November 2012). "Preoperative physical therapy for elective cardiac surgery patients". Cochrane Database of Systematic Reviews (11). doi:10.1002/14651858.CD010118.pub2. Retrieved 27 June 2013.
  33. ↑ Arsenault, Kyle A; Yusuf, Arif M; Crystal, Eugene; Healey, Jeff S; Morillo, Carlos A; Nair, Girish M; Whitlock, Richard P (2013-01-31). Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd. doi:10.1002/14651858.cd003611.pub3.
  34. ↑ Institute for Quality and Efficiency in Health Care (IQWiG). "Complications after surgery: Can quitting smoking before surgery reduce the risks?". Informed Health Online. IQWiG (Institute for Quality and Efficiency in Health Care). Retrieved 27 June 2013.

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