Heart operations, may be; CLOSED heart surgery - while the heart is beating - CMC - OPCAB - closure PDA

- coarctation of aorta OPEN heart surgery - non beating heart - valve replacement - repair of congenital defects (ASD, VSD) - coronary surgery (ON-PUMP)

Myocardial preservation = hypothermia MR & oxygen demand 1. Coronary perfusion hypothermia - cardioplegic solution (cold, 4oC, KCl) i) infused into aortic arch ii) direct into coronary ostia in aortic regurge iii) retrograde thru coronary sinus in LMCA disease 2. Local hypothermia - ice / cold saline on the heart 3. Systemic hypothermia Mild Moderate Severe Profound (total circulatory arrest) * in case of extensive aortic aneurysm

EXTRACORPORIAL CIRCULATION (ECC) HEART LUNG MACHINE CARDIO-PULMONARY BYPASS (CPB) Definition: a machine that replaces the function of the heart (pumping) & lung (oxygenation) during cardiac surgery Target: 1. Bloodless field 2. Motionless heart 3. Protection of vitas organ 4. Myocardial protection 5. Preservation of blood Components: 1. Reservoir 2. Oxygenator 3. Roller pump 4. Heater-cooler Steps of procedure 1. Mid sternotomy 2. Heparin 3. Cannulation - SVC + IVC - aortic arch 4. Deox. blood reservoir oxygenator 5. Oxygenated blood roller pump ascending aorta 6. Filter 7. Cooling 8. Aortic cross clamp @ ascending aorta 9. Cardioplegia @ aortic root 10. Protamine sulphate (neutralize heparin)

32 oC 25 oC 20 oC 16-18 oC

Complications of ECC 1. Cerebral stroke & neurocognitive defect 2. Psychological changes - psychosis - depression 3. Bleeding - 2ry to platelet dysfx 4. Renal insufficiency 5. Pulmonary insufficiency, lung atelectasis, ARDS, post perfusion lung 6. Cardiac complications - peri-operative MI - low COP syndrome - stone heart syndrome 7. Immunosupression 8. GIT complications - ileus - stress ulcer - acute pancreatitis

ISCHAEMIC HEART DISEASE Anatomy of coronary artery RIGHT CORONARY LEFT MAIN CORONARY ARTERY ARTERY PDA LAD Cx Diagonal OM branch branch

CORONARY ARTERY BYPASS GRAFT SURGERY (CABG) Indications 1. Left main stem coronary stenosis 2. 3 vessels disease 3. IHD in diabetic pt 4. Combined CABG & valvular surgery Approach = median sternotomy Grafts (conduits) Arterial Free arterial graft: - radial artery - right gastroepiploic artery Pedicle graft: - internal mammary artery

Venous Reversed long saphenous vein

*most commonly used graft = saphenous vein graft (lengthy, can be used for revascularization of many diseased vessels) *best graft used = internal mammary artery (long term patency) OFF-PUMP CABG (beating heart) - bleeding intracoronary shunt - conserve blood cell saver - heart movement stabilizer Complications 1. Peri-operative infarction 2. Low COP state 3. Arrythmias 4. Bleeding 5. Non-cardiac complications of other organs (brain, lung, kidney)