VALVULAR CARDIAC SURGERY - PowerPoint Presentation

Slide1

VALVULAR CARDIAC SURGERY

Slide2

Outline

Heart and Heart Valve A & P

Valvular Pathology

Valvular Diagnostics

Open Heart Patient Preparation

Supplies, Instrumentation, and Equipment

Valve Surgery (aortic, mitral, tricuspid)

Ventricular Aneurysmectomy

Slide3

A & P

Your Heart’s Valves

Slide4

Normal Circulation

Blood comes back to heart for reoxygenation via the superior and inferior vena cava entering into the right atrium

Passes through the

tricuspid valve

into the right ventricle, then through the

pulmonic valve

into the pulmonary artery

Blood is reoxygenated in the lungs and returns via the pulmonic veins into the left atrium

There it goes through the

mitral valve

into the left ventricle through the

aortic valve

pushing oxygenated blood into the coronary ostia as it passes them and throughout the rest of the body where oxygen is needed by all the organs and tissues

Slide5

CARDIAC VALVES

Tricuspid valve lies between the right atrium and right ventricle

Blood returns to the heart through the superior and inferior vena cavae into the right atrium where it passes through the tricuspid valve into the right ventricle where it is pumped through the pulmonic valve into the pulmonary artery to be taken to the lungs for re-oxygenation

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CARDIAC VALVES

Mitral Valve lies between the left atrium and the left ventricle

Blood returns via the pulmonary veins (after re-oxygenation) into the left atrium, passes through the mitral valve and into the left ventricle, where it is pumped through the aortic valve

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CARDIAC VALVES

Aortic valve lies between the aorta and the left ventricle

Blood is pumped from the left ventricle through the aorta to the coronary ostia, head vessels, upper and lower extremities, and the abdominal organs, via the aorta

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Clarification

The aortic and pulmonic are often referred to as semi-lunar, meaning they have three half moon shaped cusps

The mitral and tricuspid are often referred to as atrioventricular valves, as they separate the atria and ventricles

The tricuspid valve is “three-cusped”

The mitral valve is “two-cusped” or bicuspid

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Mitral Valve

Has two cusps (a posterior and anterior leaflet)

Often referred to as the bicuspid valve

Leaflets are attached and anchored to the endocardial papillary muscles by cords called cordae tendineae

Cordae tendinae keep the valve from prolapsing

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Cardiac Conduction

Coordinates cardiac conduction

SA Node (sinoatrial) “the pacemaker”

AV Node (atrioventricular)

Bundle of HIS or AV Bundle

Down R/L insulated branched bundles in ventricular septum

Purkinge Fibers non-insulated and feed into R/L ventricles

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Cardiac Conduction

SA node initiates impulse > atria contract (blood forced into ventricles)> stimulus picked up by AV node > AV Bundle (signal slightly delayed) > brnached bundles > purkinge fibers > ventricles stimulated and contract (blood forces atrioventricular valves to close and semilunar valves to open)

These valves should go one-way

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Pathology of Valves

Obstruction of the valves is usually caused by stenosis or fusion of the leaflets causing diminished blood flow resulting in poor oxygenation or backup of blood into the respective ventricles

Backup of blood damages the ventricular endocardium and myocardium over time, which can cause ventricular aneurysm (thinning and enlargement of the ventricle)

Can be regurgitant or insufficient due to leaflet damage (may not necessarily be stenosed)

In the case of the mitral valve, damage can be to the cordae tendineae, causing elongation, rupture, or shortening

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Aortic Stenosis

Calcification of the aortic valve cusps

LV hypertrophy develops as result of restricted blood flow into the aorta

Sx: fatigue, DOE, palpitations, dizziness, fainting, angina (chest pain)

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Pulmonic Stenosis

Calcification of pulmonic valve cusps

Restricts flow into PA

RV hypertrophy

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Mitral Regurgitation

Blood flows back (regurgitates) into the

LA

through the incompetent mitral valve

LV hypertrophy

Sx

: fatigue,

palpitations,

orthopnea (need to sit up to breath), PND (paroxysmal nocturnal dyspnea, after sleeping wakes up needing air)

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Mitral Stenosis

Calcified mitral valve

Impedes flow of blood into LV

LA hypertrophy or enlargement

Sx

: fatigue, palpitations, DOE, orthopnea, PND, pulmonary edema

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Tricuspid Regurgitation

Blood flows back (regurgitates) into RA due to incompetent tricuspid valve

Sx: engorged pulsating neck veins, liver enlargement, RV hypertrophy, thrill at left sternum

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Tricuspid Stenosis

Calcification of tricuspid valve

Impedes blood flow into RV

Sx: diminished arterial pulse, jugular venous prominence

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Valvular Disease

Causes:

CAD and MI

Degenerative disease due to age

Rheumatic heart disease (a complication of bacterial strep)

Congenital disease

Obstruction results in left ventricular myocardial overload due to backflow of blood, which stresses the myocardium over time

IV Drug Abuse

Dental Infections

Lupus

Marfan’s Syndrome

Scleroderma

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Symptoms of Valvular Disease

Fatigue

Weakness

Dyspnea with or without exertion, stress, or pregnancy

Pulmonary edema

1

° cause rheumatic fever

May go from mild to total disability in 5- 10 years

May be asymptomatic 10-20 years after initial damage to valve

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Diagnosis

NONINVASIVE

H & P

ECG/EKG

Exercise EKG (stress test)

Echocardiogram

(echocardiography is the Gold Standard for diagnosing valvular disease)

Chest x-ray

Slide22

Diagnosis

INVASIVE

Cardiac catheterization ( may be in conjunction with echocardiogram)

Trans-esophageal echocardiogram (usually done preoperatively in the OR suite in conjunction with valve surgery)

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Anesthesia

General

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Medications

Warm saline with antibiotic solution

Topical hemostatic agents of choice: surgicel, gelfoam and thrombin, gelfoam/thrombin/antibiotic rolled into balls for sternal bone application, bone wax for sternum with raytex underneath to prevent surgeon from ripping gloves on rough edges

Extra NS for valve rinsing if is a xenograft

Will rinse x 3 in 250cc NS each rinse for 2 minutes each or per manufacturer’s recommendations

Some surgeons may want antibiotic added to 2

nd

or 3

rd

rinse

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Patient Positioning

Supine position

Arms padded and tucked

May want a shoulder roll to elevate the sternum (optional)

Headrest

Pillow under knees (preferable)

Heel pads (preferable)

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Prep

Begin at anterior thorax prepping outward in a circular motion to the bedline, prep to top of thighs/ bilateral groins, then pubis

With a separate sponge prep both legs to knees to the bedline

Use betadine soap, then paint

May use gel or spray

Should do minimum of two coats of paint

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PREP

For a CABG and valve replacement, will prep sternum to neck, bedline to bedline, groins, pubis, then each leg circumferentially to ankles or feet (institutional policy)

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Equipment

Two large tables (back table and Mayfield)

Mayo stand (for saw)

Double ring

Prep tables x 2

Slush machine/warmer

ECU x 2

Cell saver

CPB machine

Off-table suction

External Pacing box

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Instumentation

Open heart Trays

Valve Tray

Suture Guide Holder

Sternal retractor (Ankinney for aortic valve) and (Cosgrove or Korous for mitral or tricuspid)

Finochetti

Sternal saw

Internal defibrillator paddles

Doctor’s specials

Micro instruments needed if CABG done with valve surgery

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Supplies

Valve Custom Pack (Coronary pack for CABG/Valve)

CV Drape Pack

Gloves

Chest tubes

Suture guide inserts

Valve Sizers for appropriate valve

Appropriate valves of surgeon request in the room

Misc. suture: pericardial suture, cannulation suture, aortic retraction suture (for aortic valve only), valve repair or replacement suture, suture to close aorta or atrium, pacing wires, suture to sew in pacing wires, cutting needles to sew in chest tubes and pacing wires, sternal wires, fascia suture, subcutaneous, subcuticular

Coronary ostia perfusion catheters (auto-inflating, gummy tip, or spencers (for aortic only)

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Supplies continued

Aortic cannula

Venous cannula (need two for bicaval cannulation-need for mitral valve surgery)

Antegrade cannula (may just use retrograde and place this after aorta closed for aortic valve surgery/is placed for mitral valve surgery)

Retrograde cannula

Medusa

Cardiac insulation pad

Myocardial temperature probe

Extra saline

Three cytals for washing valve if using a xenograft (porcine or bovine)

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Valve Replacement Options

Mechanical

Biological

Diseased valve excised and replaced

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Valve Replacement Options

(Aortic and Mitral)

1. Mechanical:

St. Jude or Starr-Edwards

valve only

conduit/valve available for aortic

Durable

Used primarily in young patients

Patient requires long-term anticoagulant therapy (not for elderly)

Complications: emboli and bleeding from other injury due to anticoagulant therapy

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Valve Replacement Options (Aortic or Mitral)

2. Heterograft/Xenograft

Biologic

May be bovine or porcine

Bovine pericardium is the new rage

Old porcine has a duration of 15 years

Bovine pericardial are thought to last longer/research inconclusive due to recent development

No anticoagulant therapy needed

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Valve Replacement Option (Aortic)

3. Aortic Stentless

Biologic

Porcine

Durability good over age of 60

No anticoagulant therapy needed

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Valve Replacement Options (Aortic, Mitral, Pulmonic)

4. Allograft/Homograft

Biologic

Cadaver from organ donor

Will measure annulus size with TEE

Will choose graft before incision made or as opening chest

Time will be required for proper thawing procedure to be implemented to prevent damage to the graft

Long term

Limited availability

Slide40

Valve Replacement Option (Aortic)

5. Autograft (ROSS Procedure)

Requires expert valve surgeon

Excision of patient’s pulmonic valve to be used as the patient’s new aortic valve

A pulmonic allograft will be used to replace excised pulmonic valve

Long term

Limited availability of pulmonic allograft

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Valve Repair Options

Annuloplasty rings

Mitral annuloplasty rings

Tricuspid annuloplasty rings

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Replacement verses Repair

Aortic and Mitral are replaced

Tricuspid in extreme situations can be replaced with a mitral valve

Mitral and tricuspid usually repaired with annuloplasty rings

Mitral may have to be replaced if attempted repair is unsuccessful

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Annuloplasty Rings

Used for repairing of the mitral or tricuspid valves

Mitral rings are a near to complete circle

Tricuspid rings are an incomplete circle or half-circle

Sizers are half moon shaped and have T or M on them (will come with a malleable handle-bend it slightly for ease of sizing)

Are differentiated between by T or M on the tag (remove the Minnie-Pearl tag before passing it to the surgeon)

Provide reduction of the dilated annulus

Often the tricuspid function will return to normal with the repair of the mitral

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Valve Repair/Replacement Procedure

Incision with #10 blade

Cautery

May use curved mayo scissors to ream under the xiphoid to loosen the fascia from the sternum

Sternal saw

Bone wax or gelfoam powder mixed with saline or thrombin to make soft balls to spread on sternum

Wet laps folded in half (should have been soaked in antibiotic NS and wrung out)

Sternal retractor

Cautery and debakeys to open/dissect the pericardium

Pericardial sutures (may use pop-off silk or neurolon)

Slide48

Valve Repair/Replacement Procedure

Dissect aorta from pulmonary artery to provide room to place aortic cross-clamp

Purse-string cannulation stitches for aortic cannula (x2), venous cannula, and retrograde cannula, each is rommeled

Heparin is administered by anesthesia at surgeon prompt

Cannulas are placed, aortic first, stab blade (#11), aortic cannula, heavy tie or umbilical tape, tube clamp, bowl and scissors to cut aortic pump line, hook to CPB tubing, make sew cannula to patient/drape or clamp with non-penetrating towel clip

Venous cannula placed, metz, cannula (some surgeons may use a satinsky to clamp the atrial appendage before incising it), heavy tie or umbilical tape, tube clamp or not and hook to venous line from CPB machine

Surgeon will say to perfusion, “Go on bypass”

Slide49

Valve Repair/Replacement Procedure

Hypothermia will begin by perfusion who can cool the blood he is circulating

Cross Clamp will be placed across the aorta

Cardiac insulation pad may be placed

Myocardial temp probe may be placed near the apex of the left ventricle

Ice may be applied to the heart as well

Slide50

Aortic Valve Replacement

AORTIC

Once temperature is where surgeon wants it, he will take a metz and cut the aorta open above the aortic valve and below the aortic cross clamp

He may want stay sutures or retraction sutures

He may continue to perfuse the heart with cardioplegia fluid directly into the coronary ostia via the medusa and coronary perfusion cannula that is attached (his/her preference)

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Aortic Valve Replacement

He/She will begin to excise the valve using metz, a pituitary ronguer, knife (#15c or #11)

Be prepared to wipe ronguer , metz, and forceps frequently with a moist lap

Retraction may be provided by the assistant with a hand-held aortic retractor

Off-table suction will be used to “vacuum” (tonsil suction without tip) as plaque is removed

Care is taken NOT to get debris into the ventricle as it could cause stroke later

Cold NS Irrigation provides thorough cleaning using an asepto

Slide52

Mitral Valve Repair/Replacement

Caval tapes will be used with a ligature passer or right angle and long dacron or polyester tapes and rommeled to provide a tight seal around the cavae and their cannuli to prevent blood from coming into the field around the cannuli

Heart is turned over and left atrium is exposed

Surgeon will take an #11 or #15 blade to open the atrium, long metz to widen the incision

Mitral retraction will be achieved with a hand-held mitral/atrial retractor or placement of the arm attachments for the cosgrove or korous retractor

Two long, blunt nerve hooks will be passed to the surgeon for him to manipulate the valve leaflets and determine location/extent of damage

Will repair by removing a leaflet, repairing the cordae tendineae with gortex (PTFE) or prolene suture (have knife, metz, and nerve hooks available)

One of the leaflets may be left to maintain ventricular configuration (if one passed to you, ask if it is the anterior or posterior for proper specimen labeling)

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Mitral Valve Repair/Replacement

Once the annulus is cleaned or the cordae are repaired, the annulus will be sized using mitral sizers for the appropriate valve being used

Clarify the valve before obtaining it from the circulator

Valve sutures will be placed (double load pledgeted valve sutures)

Once valve sutures are in hand up three NH as you will assist with loading the valve sutures in order to place through the annuloplasty ring or valve

Be sure you keep up with how many sutures are used

Slide54

Valve Repair/Replacement Procedure

Once valve annulus is clean, annulus is sized with appropriate sizer

Valve is passed to field after being verified by the circulator, scrub, and surgeon

Bovine and porcine valves require a rinsing process (2 minutes in a minimum of 250ml NS times three)

Baxter-Edwards only require one minute x 3

Sutures for valve are placed (pledgeted 2-0 RB-1 ethibond or CV-316 Ticron

Pledgeted sutures are used for valve

replacement/Non-pledgeted for Repair

Sutures will be passed double loaded as all pledgeted sutures should

Once sutures are in, if valve is ready, three short NH will be passed up and the assistant, scrub, PA, and surgeon will work their way around the suture guide loading each needle in sequence for the surgeon to pass through the valve

The sutures should have been counted before valve is up so the surgeon knows how far apart to place the sutures in the cuff of the valve

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Valve Repair/Replacement Procedure

After sutures are in surgeon will ask for 2 kellys and you or he will cut the needles

He will pass them to you attached to the other kelly

He will work the valve into the annulus of the excised valve (you should moisten the strings with NS as he seats the valve)

He may take a knife at that point to release the insert holding the valve to the handle

He will work his way around, tying in the interrupted sutures

When done, he will take long tenotomy scissors and cut the strands just above the knots

He will test the valve leaflets with NS on an asepto (may use several)

May want a short piece of a red-rubber catheter attached to asepto for visibility as he is squirting the NS to test the leaflets

If mechanical may use rubber shodded debakey forceps or long cotton-tip applicator to test leaflets

Slide56

Valve Repair/Replacement Procedure

Will close

aorta

with 2 prolene sutures usually pledgeted with a corresponding on a 3-0 or 4-0 tapered RB-1 or SH needle

Will close

atrium

with a 4-0 or 3-0 prolene on a tapered SH or MH needle (usually non-pledgeted)

Air is vented via antegrade placement (if was not in-aortic)

May need a 14 jelco on a 60 cc syringe to stab the apex/ventricle of the heart to remove air within before discontinuing bypass

Slide57

Valve Repair/Replacement Procedure

Topical hemostatic may be used (gelfoam pad strips with NS or thrombin)

Patient may need to be defibrillated (have ready when closing aorta or atrium)

CPB will be discontinued when patient is re-warmed (metz, tube clamps, metz)

Pacing wires will be placed (atrial and ventricular)

Chest tubes will be placed (1 mediastinal and 1 substernal)

Sternal wires placed twisted and cut with wire cutter, irrigation of NS with Antibx, fascial layer, subcutaneous, hook up pleurevac after suctioning out the chest tubes, subcuticular

Dressing, steri-strips, telfa, 4x4s, primapore

Fluffs or 4x4s to chest tubes and tape

Slide58

Ventricular Aneurysm Repair or Ventricular Aneurysmectomy

Result of myocardial damage after an MI causing myocardial replacement with scar tissue

Scar stretches with pressure resulting in aneurysm formation

Is the excision of the portion of the ventricle that has become aneurysmic and re-enforcing it with a patch of synthetic graft material (may be PTFE or hemashield)

Often a tube graft is used and a circular patch is cut with it

Slide59

Ventricular Aneurysm Repair or Ventricular Aneurysmectomy

May require CPB

Prep/Set up is as described for any Open Heart surgery with exception of if being done alone, you would not need a lot of the previously described items

Most frequently done in conjuction with CABG or Valve surgery

May hear referred to as the

DOR Procedure

Slide60

Ventricular Aneurysm Repair or Ventricular Aneurysmectomy

Procedure:

Incision made into the ventricle with a #15 or #11 blade extended with a metz

Will require retraction by the assistant with two allises or babcocks (are usually part of a valve tray of instruments)

Surgeon may remove or excise a part of the scar tissue

A neck will be created in the rim of the scarring with a prolene suture (2-0 or 3-0 on an SH, to pull the tissue back together)

Slide61

Ventricular Aneurysm Repair or Ventricular Aneurysmectomy

Interrupted pledgeted ticron or ethibond sutures will be placed (2-0 RB-1 or CV-316, SH or CV-305)

Patch will be passed up with 2 NH to place sutures through the patch

Patch will be eased down to cover the created neck

Myocardium will be closed with another 3-0 prolene SH

Epicardium will be closed with two thinly cut strips of teflon felt and two running 3-0 or 2-0 Prolene sutures on an SH or MH tapered needle

Slide62

Ventricular Aneurysm Repair or Ventricular Aneurysmectomy

Surgery proceeds with patient rewarming if was cooled and discontinuation of CPB

Routine open heart surgery closure

Slide63

Complications

Hypothermia

Infection

Myocardial contusion

Bleeding

Cardiac tamponade

Embolus

Valve malfunction

Slide64

Summary

Heart and Heart Valve A & P

Valvular Pathology

Valvular Diagnostics

Open Heart Patient Preparation

Supplies, Instrumentation, and Equipment

Valve Surgery (aortic, mitral, tricuspid)

Ventricular Aneurysmectomy