VIDEO: Awake Cardiac Surgery

Cardiac surgery
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.

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]

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.[27]

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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”[28] associated with mechanical heart valve implants and characterized by irrational fear, anxiety, depression, sleep disorder, and weakness.

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.[31] In addition, the researchers found that preoperative physical therapy decreased the length of hospital stay by more than three days on average.[31]

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.[32]

There is evidence that quitting smoking at least four weeks before surgery may reduce the risk of postoperative complications

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]

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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]

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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.

VIDEO: Awake Cardiac Surgery

Coronary artery bypass surgery is conventionally performed using cardiopulmonary bypass (CPB). The complications due to CPB by aortic cannulation, cross clamping, immunological changes, and organ injuries (pulmonary, renal, cardiac, and cerebral) have been avoided to some extent in recent times by performing off-pump coronary artery bypass (OPCAB). Availability of surgeon-friendly epicardial stabilization devices has made it possible for surgeons to perform OPCAB frequently.

Watch the full procedure below: