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| Cardiac surgery | |
|---|---|
 Two cardiac surgeons performingcoronary artery bypass surgery. Note the use of a steelretractor to forcefully maintain the exposure of the heart. | |
| ICD-9-CM | 35-37 |
| MeSH | D006348 |
| OPS-301 code | 5-35...5-37 |
| Cardiac surgery | |
|---|---|
| Specialty | Cardiothoracic surgery |
Cardiac surgery, orcardiovascular surgery, is asurgery on theheart orgreat vessels performed by cardiacsurgeons. It is often used to treat complications ofischemic heart disease (for example, withcoronary artery bypass grafting); to correctcongenital heart disease; or to treatvalvular heart disease from various causes, includingendocarditis,rheumatic heart disease,[1] andatherosclerosis.[2] It also includesheart transplantation.[3]
The earliest operations on thepericardium (the sac that surrounds the heart) took place in the 19th century and were performed byFrancisco Romero (1801) in the city ofAlmería (Spain),[4]Dominique Jean Larrey (1810),Henry Dalton (1891), andDaniel Hale Williams (1893).[5] The first surgery on the heart itself was performed byAxel Cappelen on 4 September 1895 atRikshospitalet in Kristiania, nowOslo. Cappelenligated a bleedingcoronary artery in a 24-year-old man who had been stabbed in the leftaxilla and was in deepshock upon arrival. Access was through a leftthoracotomy. The patient awoke and seemed fine for 24 hours but became ill with afever and died three days after the surgery frommediastinitis.[6][7]
Surgery on thegreat vessels (e.g.,aortic coarctation repair,Blalock–Thomas–Taussig shunt creation, closure ofpatent ductus arteriosus) became common after the turn of the century. However, operations on theheart valves were unknown until, in 1925,Henry Souttar operated successfully on a young woman withmitral valve stenosis. He made an opening in the appendage of the leftatrium and inserted a finger in order to palpate and explore the damagedmitral valve. The patient survived for several years,[8] but Souttar's colleagues considered the procedure unjustified, and he could not continue.[9][10]
Alfred Blalock,Helen Taussig, andVivien Thomas performed the first successful palliativepediatric cardiac operation atJohns Hopkins Hospital on 29 November 1944, in a one-year-old girl with Tetralogy of Fallot.[11] Their work on patientEileen Saxon was dramatically portrayed byHBO in the 2004television filmSomething The Lord Made as the birth of modern cardiac surgery.
Cardiac surgery changed significantly afterWorld War II. In 1947,Thomas Sellors ofMiddlesex Hospital in London operated on aTetralogy of Fallot patient withpulmonary stenosis and successfully divided the stenosedpulmonary valve. In 1948,Russell Brock, probably unaware of Sellors's work,[12] used a specially designed dilator in three cases of pulmonary stenosis. Later that year, he designed a punch to resect a stenosedinfundibulum, which is often associated with Tetralogy of Fallot. Many thousands of these "blind" operations were performed until the introduction ofcardiopulmonary bypass made direct surgery on valves possible.[9]
Also in 1948, four surgeons carried out successful operations for mitral valve stenosis resulting fromrheumatic fever.Horace Smithy of Charlotte used avalvulotome to remove a portion of a patient's mitral valve,[13] while three other doctors—Charles Bailey ofHahnemann University Hospital in Philadelphia;Dwight Harken in Boston; and Russell Brock ofGuy'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.[9][10]
The first successful intracardiac correction of acongenital heart defect usinghypothermia was performed by lead surgeon Dr.F. John Lewis[14][15] (Dr.C. Walton Lillehei assisted) at theUniversity of Minnesota on 2 September 1952. In 1953,Alexander Alexandrovich Vishnevsky conducted the first cardiac surgery underlocal anesthesia. In 1956, Dr. John Carter Callaghan performed the first documented open-heart surgery in Canada.[16]
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Open-heart surgery is any kind of surgery in which a surgeon makes a large incision (cut) in the chest to open the rib cage and operate on the heart. "Open" refers to the chest, not the heart.[citation needed] Depending on the type of surgery, the surgeon also may open the heart.[17]
Dr.Wilfred G. Bigelow of theUniversity of Toronto found that procedures involving opening the patient's heart could be performed better in a bloodless and motionless environment. Therefore, during such surgery, the heart is temporarily stopped, and the patient is placed oncardiopulmonary 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.[18]
Cardiopulmonary bypass was developed after surgeons realized the limitations ofhypothermia 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 July 1952,Forest Dodrill was the first to use a mechanical pump in a human to bypass the left side of the heart whilst allowing the patient's lungs to oxygenate the blood, in order to operate on the mitral valve.[19] In 1953, Dr.John Heysham Gibbon ofJefferson Medical School in Philadelphia reported the first successful use ofextracorporeal circulation by means of anoxygenator, but he abandoned the method after subsequent failures.[20] In 1954, Dr. Lillehei performed a series of successful operations with the controlledcross-circulation technique, in which the patient's mother or father was used as a "heart-lung machine".[21] Dr.John W. Kirklin at theMayo Clinic was the first to use a Gibbon-type pump-oxygenator.[20][22]
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.[23] In March 1961, Zuhdi, Carey, and Greer performed open-heart surgery on a child, aged3+1⁄2, using the total intentional hemodilution machine.
In the early 1990s, surgeons began to performoff-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. The conduit vessel that is often used is the saphenous vein. This vein is harvested using a technique known asendoscopic vein harvesting (EVH).
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 humanheart transplantation, although the world's first adult heart transplant was performed by aSouth African cardiac surgeon,Christiaan Barnard, using techniques developed by Shumway andRichard Lower.[24] Barnard performed the first transplant onLouis Washkansky on 3 December 1967 atGroote Schuur Hospital inCape Town.[24][25]Adrian Kantrowitz performed the first pediatric heart transplant on 6 December 1967 at Maimonides Hospital (nowMaimonides Medical Center) in Brooklyn, New York, barely three days later.[24] Shumway performed the first adult heart transplant in the United States on 6 January 1968 atStanford University Hospital.[24]
Coronary artery bypass grafting (CABG), 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 preventingclot formation. This can be done in many ways, and thearteries used can be taken from several areas of the body.[26] Arteries are typically harvested from the chest, arm, or wrist and then attached to a portion of the coronary artery, relieving pressure and limitingclotting factors in that area of the heart.[27]
The procedure is typically performed because ofcoronary 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 aheart attack.[27]
As an alternative to open-heart surgery, which involves a five- to eight-inch incision in thechest wall, a surgeon may perform anendoscopic procedure by making very small incisions through which a camera and specialized tools are inserted.[28] Recently, minimally invasive coronary artery bypass grafting demonstrated excellent outcomes and appears to be a safe method in well-selected patients with multivessel coronary artery disease.[29]
Inrobot-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 port holes instead of an incision big enough for the surgeon's hands.[30] The use of robotics in heart surgery continues to be evaluated, but early research has shown it to be a safe alternative to traditional techniques.[31]
As with any surgical procedure, cardiac surgery requires postoperative precautions to avoid complications. Incision care is needed to avoid infection and minimizescarring.Swelling andloss of appetite are common.[32][33]
Recovery from open-heart surgery begins with about 48 hours in anintensive care unit, whereheart rate,blood pressure, and oxygen levels are closely monitored.Chest tubes are inserted to drain blood around the heart and lungs. Postoperative pain control after cardiac surgery may involve chest-area nerve blocks for small, short-term reductions in pain or opioid use.[34]
After discharge from the hospital,compression socks may be recommended in order to regulate blood flow.[35]
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.[36][37]
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.[38] A more subtle complication attributed to cardiopulmonary bypass ispostperfusion syndrome, sometimes called "pumphead". Theneurocognitive symptoms of postperfusion syndrome were initially thought to be permanent,[39] but turned out to be transient, with no permanent neurological impairment.[40]
In order to assess the performance of surgical units and individual surgeons, a popular risk model has been created called theEuroSCORE. It takes a number of health factors from a patient and, using precalculatedlogistic regression coefficients, attempts to quantify the probability that they will survive to discharge. Within theUnited Kingdom, the EuroSCORE was used to give a breakdown of allcardiothoracic surgery centres and to indicate whether the units and their individuals surgeons performed within an acceptable range. The results are available on theCare Quality Commission website.[41][42]
Another important source of complications are the neuropsychological and psychopathologic changes following open-heart surgery. One example isSkumin syndrome [fr], described byVictor Skumin in 1978, which is a "cardioprosthetic psychopathological syndrome"[43] associated withmechanical heart valve implants and characterized by irrational fear,anxiety,depression,sleep disorder, andweakness.[44][45]
Pharmacological andnon-pharmacological prevention approaches may reduce the risk of atrial fibrillation after an operation and reduce the length of hospital stays, however there is no evidence that this improves mortality.[46]
Preoperativephysical therapy may reduce postoperative pulmonary complications, such aspneumonia andatelectasis, in patients undergoing elective cardiac surgery and may decrease the length of hospital stay by more than three days on average.[47] There is evidence that quittingsmoking at least four weeks before surgery may reduce the risk of postoperative complications.[48]
Beta-blocking medication is sometimes prescribed during cardiac surgery. There is some low certainty evidence that this perioperative blockade of beta-adrenergic receptors may reduce the incidence ofatrial fibrillation andventricular arrhythmias in patients undergoing cardiac surgery.[49]
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