How are operations performed? What are heart surgeries Cardiovascular surgery
Heart surgeries are very common these days. Modern cardiac surgery and vascular surgery are very advanced. Surgical intervention is prescribed in the case when conservative drug treatment does not help, and, accordingly, the normalization of the patient's condition is impossible without surgery.
For example, heart disease can only be cured by surgery, this is necessary in the case when blood circulation is severely disturbed due to pathology.
And as a result, a person feels bad and severe complications begin to develop. These complications can lead not only to disability, but also to death.
Often prescribed surgical treatment of coronary heart disease. Since it can lead to myocardial infarction. Due to a heart attack, the walls of the cavities of the heart or aorta become thinner and protrusion appears. This pathology can also be cured only by surgery. Quite often, operations are performed due to disturbed heart rhythm (RFA).
They also perform heart transplantation, that is, a transplant. This is necessary when there is a complex of pathologies due to which the myocardium is not able to function. Today, such an operation prolongs the life of the patient by an average of 5 years. After such an operation, the patient is put on disability.
Operations can be carried out urgently, urgently, or a planned intervention is prescribed. It depends on the severity of the patient's condition. An emergency operation is performed immediately, immediately after the diagnosis is established. If such an intervention is not carried out, then the death of the patient may occur.
Such operations are often performed on newborns immediately after birth with congenital heart disease. In this case, even minutes are important.
Urgent operations do not require fast execution. In this case, the patient is prepared for some time. As a rule, it is several days.
A planned operation is prescribed if at this time there is no danger to life, but it must be carried out to prevent complications. Doctors prescribe surgery on the myocardium only if it is necessary.
Invasive Research
Invasive methods for examining the heart are to conduct catheterization. That is, the study is carried out through a catheter, which can be installed both in the cavity of the heart and in the vessel. With the help of these studies, you can determine some indicators of the work of the heart.
For example, blood pressure in any part of the myocardium, as well as determine how much oxygen is in the blood, evaluate cardiac output, vascular resistance.
Invasive methods allow you to study the pathology of the valves, their size and degree of damage. This study takes place without opening the chest. Cardiac catheterization allows you to take an intracardiac electrocardiogram and phonocardiogram. This method is also used to monitor the effectiveness of drug therapy.
Such studies include:
With selective coronary angiography, contrast is injected into one of the coronary arteries (right or left).
Coronary angiography is often performed in patients with angina pectoris 3-4 functional class. In this case, it is resistant to drug therapy. Doctors need to decide what type of surgical treatment is needed. It is also important to carry out this procedure for unstable angina.
Also, invasive procedures include punctures and probing of the heart cavities. With the help of probing, it is possible to diagnose heart defects and pathologies in the LV, for example, it can be tumors, or thrombosis. To do this, use the femoral vein (right), a needle is inserted into it through which the conductor passes. The needle diameter becomes about 2 mm.
When performing invasive studies, local anesthesia is used. The incision is small, about 1-2 cm. This is necessary to expose the desired vein for the installation of the catheter.
These studies are carried out in different clinics and their cost is quite high.
Surgery for heart disease
Heart defects include
- stenosis of the heart valves;
- insufficiency of heart valves;
- septal defects (interventricular, interatrial).
valve stenosis
These pathologies lead to many disorders in the work of the heart, that is, the goals of operations for defects are to relieve the load from the heart muscle, restore the normal functioning of the ventricle, as well as restore contractile function and reduce pressure in the heart cavities.
To eliminate these defects, the following surgical interventions are performed:
Often, after heart disease surgery, a person is given a disability.
Operations on the aorta
Open surgeries include:
- Prosthetics of the ascending aorta. At the same time, a valve-containing conduit is installed; this prosthesis has a mechanical aortic valve.
- Prosthetics of the ascending aorta, while the aortic valve is not implanted.
- Prosthetics of the ascending artery and its arch.
- Surgery to implant a stent graft in the ascending aorta. This is an endovascular intervention.
Prosthetics of the ascending aorta is the replacement of this section of the artery. This is necessary in order to prevent serious consequences, for example, a break. To do this, prosthetics are used by opening the chest, and endovascular or intravascular interventions are also performed. In this case, a special stent is installed in the affected area.
Of course, open-heart surgery is more effective, since in addition to the main pathology - aortic aneurysm, it is possible to correct the concomitant one, for example, stenosis or valve insufficiency, etc. And the endovascular procedure gives a temporary effect.
When prosthetics of the aortic arch are used:
- Open distal anastomosis. This is when the prosthesis is installed, so that it does not affect its branches;
- Arc semi-replacement. This operation consists in replacing the artery where the ascending aorta passes into the arch and, if required, replacing the concave surface of the arch;
- Subtotal prosthetics. This is when the replacement of branches (1 or 2) is required during prosthetics of the arterial arch;
- Complete prosthetics. In this case, the arch is prosthetized together with all supra-aortic vessels. This is a complex intervention that can cause neurological complications. After such an intervention, a person is given a disability.
Coronary artery bypass grafting (ACS)
CABG is open-heart surgery that uses a patient's vessel as a shunt. This heart operation is needed in order to create a bypass for the blood, which will not affect the occlusive section of the coronary artery.
That is, this shunt is installed on the aorta and brought to the area of the coronary artery not affected by atherosclerosis.
This method is quite effective in the treatment of coronary heart disease. Due to the installed shunt, the blood flow to the heart increases, which means that ischemia and angina pectoris do not appear.
CABG is prescribed if there is angina pectoris, in which even the smallest loads cause seizures. Also, indications for CABG are lesions of all coronary arteries, and if an aneurysm of the heart has formed.
During CABG, the patient is put into general anesthesia, and then, after opening the chest, all manipulations are performed. This operation can be performed with or without cardiac arrest. And also, depending on the severity of the pathology, the doctor decides whether it is necessary to connect the patient to a heart-lung machine. The duration of CABG can be 3-6 hours, it all depends on the number of shunts, that is, on the number of anastomoses.
As a rule, the role of the shunt is performed by a vein from the lower limb, and sometimes a part of the internal thoracic vein, the radial artery, is also used.
Today, CABG is performed, which is performed with minimal access to the heart, while the heart continues to work. Such an intervention is considered not as traumatic as the others. In this case, the chest is not opened, the incision is made between the ribs and a special expander is also used so as not to affect the bones. This type of CABG lasts 1 to 2 hours.
The operation is performed by 2 surgeons, while one makes an incision and opens the sternum, the other operates on the limb to take a vein.
After carrying out all the necessary manipulations, the doctor installs drains and closes the chest.
CABG significantly reduces the likelihood of a heart attack. Angina pectoris does not appear after surgery, which means that the quality and duration of the patient's life increase.
Radiofrequency ablation (RFA)
RFA is a procedure that is performed under local anesthesia, since the basis is catheterization. Such a procedure is carried out in order to exfoliate the cells that cause arrhythmia, that is, the focus. This happens through a catheter-conductor, which conducts an electric current. As a result, tissue formations are removed by RFA.
After conducting an electrophysical study, the doctor determines where the source is located, which causes a rapid heartbeat. These sources can be formed along the conducting paths, as a result of which an anomaly of the rhythm manifests itself. It is RFA that neutralizes this anomaly.
RFA is carried out in case of:
- when drug therapy does not affect the arrhythmia, and also if such therapy causes side effects.
- If the patient has Wolff-Parkinson-White syndrome. This pathology is perfectly neutralized by RFA.
- If a complication may occur, such as cardiac arrest.
It should be noted that RFA is well tolerated by patients, since there are no large incisions and opening of the sternum.
The catheter is inserted through a puncture in the thigh. Only the area through which the catheter is inserted is anesthetized.
The guide catheter reaches the myocardium, and then a contrast agent is injected. With the help of contrast, the affected areas become visible, and the doctor directs the electrode to them. After the electrode acted on the source, the tissues are scarred, which means that they will not be able to conduct the impulse. After RFA, a bandage is not needed.
Carotid surgery
There are such types of operations on the carotid artery:
- Prosthetics (used with a large lesion);
- Stenting is performed if stenosis is diagnosed. In this case, the lumen is increased by installing a stent;
- Eversion endarterectomy - at the same time, atherosclerotic plaques are removed along with the inner lining of the carotid artery;
- Carotid endarectomy.
These operations are performed under both general and local anesthesia. More often under general anesthesia, as the procedure is performed in the neck and there are discomfort.
The carotid artery is occluded, and in order to continue the blood supply, shunts are installed, which are bypass routes.
Classical endarterectomy is done if long plaque lesions are diagnosed. During this operation, the plaque is peeled off and removed. Next, the vessel is washed. Sometimes it is still necessary to fix the inner shell, this is done with special seams. At the end, the artery is sutured with a special synthetic medical material.
Endarterectomy of the carotid arteries
Eversion endartectomy is performed in such a way that the inner layer of the carotid artery at the site of the plaque is removed. And after that they fix, that is, sew. For this operation, the plaque should be no more than 2.5 cm.
Stenting is performed using a balloon catheter. This is a minimally invasive procedure. When the catheter is located at the site of stenosis, it inflates and thereby expands the lumen.
Rehabilitation
The period after heart surgery is no less important than the operation itself. At this time, the patient's condition is monitored by doctors, and in some cases, cardio training, therapeutic diets, etc. are prescribed.
Other recovery measures are also needed, such as wearing a bandage. The bandage at the same time fixes the seam after the operation, and of course the entire chest, which is very important. Such a bandage should be worn only if the operation is performed on the open heart. The cost of these items may vary.
The bandage that is worn after heart surgery looks like a T-shirt with tightness clamps. You can purchase male and female versions of this bandage. The bandage is important to prevent lung congestion by coughing regularly.
Such prevention of stagnation is quite dangerous because the seams can disperse, the bandage in this case will protect the seams and contribute to strong scarring.
Also, the bandage will help prevent swelling and bruising, promotes the correct location of organs after heart surgery. And the bandage helps to relieve the load from the organs.
After heart surgery, the patient needs rehabilitation. How long it will last depends on the severity of the lesion and the severity of the operation. For example, after CABG, immediately after heart surgery, you need to start rehabilitation, this is a simple exercise therapy and massage.
After all types of heart surgery, medical rehabilitation, that is, supportive therapy, is needed. In almost all situations, the use of antiplatelet agents is mandatory.
If there is high blood pressure, then ACE inhibitors and beta-blockers are prescribed, as well as drugs to lower blood cholesterol (statins). Sometimes the patient is prescribed physical procedures.
Disability
It should be noted that disability is given to people with diseases of the cardiovascular system even before surgery. There must be evidence for this. From medical practice, it can be noted that they necessarily give disability after coronary artery bypass grafting. Moreover, there may be a disability of both 1 and 3 groups. It all depends on the severity of the pathology.
People who have circulatory disorders, grade 3 coronary insufficiency, or have had a myocardial infarction are also entitled to disability.
Regardless of whether the operation was performed or not yet. Patients with grade 3 heart defects and combined defects can apply for disability if there are persistent circulatory disorders.
Clinics
| Clinic name | Address and phone | Type of service | Price |
|---|---|---|---|
| NII SP im. N. V. Sklifosovsky | Moscow, Bolshaya Sukharevskaya sq., 3 |
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| KB MGMU them. Sechenov | Moscow, st. B. Pirogovskaya, 6 |
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| FSCC FMBA | Moscow, Orekhovy Boulevard, 28 |
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| NII SP im. I.I. Janelidze | St. Petersburg, st. Budapestskaya, 3 |
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| SPGMU them. I.P. Pavlova | St. Petersburg, st. L. Tolstoy, 6/8 |
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| MC "Shiba" | Derech Sheba 2, Tel Hashomer, Ramat Gan |
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| link to article.
Cardiovascular diseases, unfortunately, occupy one of the first places in terms of mortality in our country. But cardiology does not stand still, but is constantly being improved. In this area, new methods of treatment are constantly emerging and the most modern technologies are being introduced. Naturally, people suffering from severe heart diseases are interested in all the innovations in cardiology, and therefore in various methods of surgical interventions.
When is Cardiac Surgery Used?
Absolutely not any violation in the work of cardiac activity entails surgical intervention. There are absolutely clear criteria on which the attending physician relies, recommending this or that cardiological operation. Such indications may be:
- Significant and rapidly progressive deterioration of the patient's condition associated with chronic heart failure.
- Acute conditions that threaten the life of the patient.
- Extremely low efficiency of simple drug treatment with clear dynamics to the deterioration of the general condition.
- The presence of advanced cardiac pathologies that developed against the background of a late visit to the doctor and the lack of adequate treatment.
- both congenital and acquired.
- Ischemic pathologies leading to the development of a heart attack.
Types of heart surgery
Today, there are many different surgical manipulations on the human heart. All these operations can be divided according to several basic principles.
- Urgency.
- Technique.
Operations differing in urgency
Any surgical intervention will fall into one of the following groups:
- emergency operations. The surgeon performs such heart operations if there is a real threat to the patient's life. It can be a sudden thrombosis, myocardial infarction, the onset of aortic dissection, heart injury. In all these situations, the patient is sent to the operating table immediately after the diagnosis is made, usually even without further tests and examinations.
- Urgent. In this situation, there is no such urgency, it is possible to conduct clarifying examinations, but it is also impossible to postpone the operation, as a critical situation may develop in the near future.
- Planned. After a long observation by the attending cardiologist, the patient receives a referral to the hospital. Here he undergoes all the necessary examinations and preparation procedures before surgery. The cardiac surgeon clearly sets the time of the operation. In case of problems, for example, a cold, it can be postponed to another day or even a month. There is no threat to life in such a situation.
Differences in technique
In this group, all operations can be divided into ongoing:
- Opening the chest. This is a classic method that is used in the most severe cases. The surgeon makes an incision from the neck to the navel and opens the chest completely. Thus, the doctor gets direct access to the heart. Such manipulation is carried out under general anesthesia and the patient is transferred to the cardiopulmonary bypass system. As a result of the fact that the surgeon works with a "dry" heart, he can eliminate even the most severe pathologies with a minimal risk of complications. This method is resorted to in the presence of problems with the coronary artery, aorta and other great vessels, with severe atrial fibrillation and other problems.
- Without opening the chest. This type of surgical intervention belongs to the so-called minimally invasive techniques. There is absolutely no need for open access to the heart. These techniques are much less traumatic for the patient, but they are not suitable in all cases.
- X-ray surgical technique. This method in medicine is relatively new, but it has already proven itself very well. The main advantage is that after these manipulations the patient recovers very quickly and complications are extremely rare. The essence of this technique lies in the fact that a device similar to a balloon is introduced to the patient using a catheter to expand the vessel and eliminate its defect. This whole procedure is carried out using a monitor and the progress of the probe can be clearly controlled.
The difference in the amount of assistance provided
All surgical manipulations in people with heart problems can be divided both in terms of the volume and direction of the problems to be eliminated.
- Correction is palliative. Such surgical intervention can be attributed to auxiliary techniques. All manipulations will be aimed at bringing blood flow back to normal. This may be the end goal or preparation of the vessel for further surgical procedures. These procedures are not aimed at eliminating the existing pathology, but only eliminate its consequences and prepare the patient for full treatment.
- radical intervention. With such manipulations, the surgeon sets himself the goal - if possible, the complete elimination of the developed pathology.
Most common heart surgeries
People with problems of the cardiovascular system are often interested in what types of heart surgeries are and how long they last. Let's look at some of them.
RF ablation
A fairly large number of people have problems with a violation in the direction of its increase - tachycardia. In difficult situations today, cardiac surgeons offer radiofrequency ablation, or "cautery of the heart." This is a minimally invasive procedure that does not require an open heart. It is performed using X-ray surgery. The pathological part of the heart is affected by radio frequency signals, which damage it, and therefore eliminate the additional path along which the impulses pass. Normal pathways are at the same time fully preserved, and the heart rate gradually returns to normal.
Coronary artery bypass grafting
With age or due to other circumstances, atherosclerotic plaques can form in the arteries, which narrow the lumen for blood flow. Thus, the flow of blood to the heart is greatly impaired, which inevitably leads to very deplorable results. In the event that the narrowing of the lumen reaches a critical state, surgery recommends that the patient undergo coronary artery bypass grafting.
This type of surgery involves creating a bypass from the aorta to the artery using a shunt. The shunt will allow blood to bypass the narrowed area and normalize blood flow to the heart. Sometimes it is required to install not one, but several shunts at once. The operation is quite traumatic, like any other, performed at the opening of the chest and lasts a long time, up to six hours. Coronary artery bypass surgery is usually performed on the open heart, but today alternative methods are gaining more and more popularity - coronary angioplasty (insertion of an expanding balloon through a vein) and stenting.
Like the previous method, it is used to increase the lumen of the arteries. It is referred to as a minimally invasive, endovascular technique.
The essence of the method consists in introducing an inflated balloon in a special metal frame into the artery into the pathology zone, using a special catheter. The balloon inflates and opens the stent - the vessel also expands to the desired size. Next, the surgeon removes the balloon, the metal structure remains, creating a strong skeleton of the artery. Throughout the procedure, the doctor monitors the progress of the stent on the screen of the X-ray monitor.
The operation is practically painless and does not require long and special rehabilitation.
Heart valve replacement
With congenital or acquired pathology of the heart valves, the patient is often shown their prosthetics. Regardless of what type of prosthesis will be installed, surgery most often takes place on the open heart. The patient is put to sleep under general anesthesia and transferred to the cardiopulmonary bypass system. Given this, the recovery process will be long and fraught with a number of complications.
An exception to the procedure for valvular replacement is aortic valve replacement. This procedure can be performed using a gentle endovascular technique. The surgeon inserts a biological prosthesis through the femoral vein and places it in the aorta.
Operations Ross and Glenn
Often, heart surgery is performed on children who are diagnosed with congenital heart defects. Most often, operations are performed according to the methods of Ross and Glenn.
The essence of the Ross system is to replace the aortic valve with the pulmonary valve of the patient. The biggest advantage of such a replacement can be considered that there will be no threat of rejection, like any other valve taken from a donor. In addition, the annulus will grow with the child's body and can last a lifetime. But, unfortunately, an implant must be placed in place of the removed pulmonary valve. It is important that the implant at the site of the pulmonary valve lasts much longer without replacement than the same one at the site of the aortic valve.
The Glenn technique was developed for the treatment of children with pathology of the circulatory system. This is a technology that allows you to create an anastomosis to connect the right pulmonary artery and the superior vena cava, which normalizes the movement of blood flow through the systemic and pulmonary circulation.
Despite the fact that surgical intervention significantly prolongs the life of the patient and improves its quality, it is still mostly an extreme case.
Any doctor will try to do everything possible so that the treatment is conservative, but, unfortunately, sometimes this is completely impossible. It is important to understand that any surgical intervention in the work of the heart is a very difficult procedure for the patient, and it will require high-quality rehabilitation, sometimes quite lengthy.
Recovery time
Rehabilitation after heart surgery is a very important stage in the treatment of patients.
The success of the operation can only be judged after the end, which can last quite a long time. This is especially true for patients who underwent open heart surgery. Here it is extremely important to follow the recommendations of doctors as accurately as possible and have a positive attitude.
After surgery with an opening of the chest, the patient is discharged home in about a week or two. The doctor makes clear instructions for further treatment at home - it is especially important to follow them.
trip home
Already at this stage, it is important to take measures so that you do not have to go back to the hospital urgently. It is important to remember here that all movements should be as slow and smooth as possible. In the event that the road takes more than one hour, you need to periodically stop and get out of the car. This must be done to avoid stagnation of blood in the vessels.
Relations with relatives
Both relatives and the patient need to understand that people who have undergone major operations under general anesthesia are extremely prone to irritability and mood swings. These problems will pass with time, you just need to treat each other with maximum understanding.
Taking medications
This is one of the most important moments in life after heart surgery. It is important for the patient to always have all the necessary medicines with him. It is especially important not to show excessive self-activity and not to take drugs that are not prescribed. In addition, you should not stop taking medication prescribed by your doctor.
seam care
The patient should calmly perceive a temporary sensation of discomfort in the suture area. In the beginning, it can be pain, a feeling of tightness and itching. Painkillers can be prescribed by a doctor to relieve pain; special ointments or gels can be used to relieve other symptoms, but only after consulting a surgeon.
The seam should be dry, without excessive redness or swelling. This needs to be watched closely. The place of the seam must be constantly treated with brilliant green, and the first water procedures are allowed to be taken after about two weeks. Such patients are allowed only a shower, and taking a bath and sudden changes in temperature are contraindicated. It is recommended to wash the seam only with ordinary soap and gently blot with a towel.
In a situation where the patient's temperature rises sharply to 38 degrees, severe swelling appears with redness at the site of the suture, fluid is released or severe pain is disturbing, you should immediately consult a doctor.
It is important for a person who has undergone heart surgery to set a goal - maximum recovery. But the main thing here is not to rush, but to do everything gradually and very carefully.
In the first days after returning home, you need to try to do everything as smoothly and slowly as possible, gradually increasing the load. For example, in the early days, you can try to walk from one hundred to five hundred meters, but if fatigue appears, you should rest. Then the distance should be gradually increased. It is best to walk outdoors and on flat terrain. After a week of walking, you should try to climb the stairs for 1-2 flights. At the same time, you can try to do simple housework.
Approximately two months later, the cardiologist will perform a stitch healing test and give permission to increase physical activity. The patient may begin to swim or play tennis. He will be allowed to work lightly in the garden with the lifting of small weights. Another test the cardiologist should conduct in three or four months. By this time, it is desirable for the patient to restore all the basic motor activity.
Diet
This aspect of rehabilitation also needs to be paid close attention.
The first time after the operation, the patient often lacks appetite and at this time any restrictions are not very relevant. But over time, a person recovers and his desire to eat familiar foods is restored. Unfortunately, there are a number of strict restrictions that will now always have to be observed. In the diet, you will have to severely limit fatty, spicy, salty and sweet. Cardiologists advise what you can eat after heart surgery - vegetables, fruits, various cereals, fish and lean meat. It is extremely important for such people to monitor their weight, and hence the caloric content of food.
Bad habits
Patients who have undergone heart surgery, of course, are strictly prohibited from smoking and using drugs. Drinking alcohol during the rehabilitation period is also prohibited.
Life after surgery can become full and rich. After a period of rehabilitation, many patients return to life without pain, shortness of breath and, most importantly, fear.
Tuesday is surgery day. The team is preparing for a long morning work. During the operation, the chest is opened and the heart is prepared for vessel transplantation.
Disease history
Mr. Thomas, a 59-year-old tanker driver, is married with two adult children. He had shingles on the right side of his neck, followed by an uncomfortable constriction in his throat, accompanied by sweating and nausea. He first felt these symptoms while walking up the steps of his truck. They continued, and Thomas decided to seek the advice of a therapist.Thomas's high blood pressure, obesity, and long history of smoking were reason enough for an ECG. Her results showed the presence of coronary heart disease. Thomas was referred to a cardiac expert (a cardiac internist, not a surgeon). Despite the applied medical treatment, the pain continued.
Tests confirmed the presence of the disease, in particular an angiogram (a test using a dye injected into the artery to detect narrowing) revealed a narrowing in the left main coronary artery with damage to the left and right vessels. Since medical treatment was unsuccessful and angioplasty (stretching a narrowed vessel using a catheter) was not an option, Mr. Thomas was referred for surgery.
Monday
Mr. Thomas is hospitalized. His anamnesis, data of examinations and tests were analyzed. Two units of blood for transfusion are tested for compatibility. The patient is explained the essence of the operation and warned about the risk associated with it. Obtain written consent for CABG.Tuesday
Early in the morning, Mr. Thomas is being prepared for the operation.7:05 Premedication and anesthesia
8:15 a.m. Mr. Thomas was sedated 70 minutes ago and a ventilation tube has already been placed in his airway. After the application of anesthesia and paralyzing agents, his breathing is supported by a ventilator. Prior to transferring Mr. Thomas to the operating room, the anesthesiologist establishes monitoring of venous and arterial blood flow.8:16 OR Mr. Thomas is set up. On the left - a table with instruments, on the right - a ready-to-use heart-lung apparatus.
8:25 Patient in the operating room. The skin of his chest and legs are treated with an antiseptic solution to reduce the risk of infection.
8:40 Opening of the chest
The skin has already been processed, the patient is dressed in sterile clothes. One of the surgeons makes an incision in the leg to extract the vein, and the second cuts the skin on the chest. After a preliminary incision with an ordinary scalpel, he uses an electric one, which cuts the vessels, stopping the bleeding.8:48 The surgeon cuts the sternum bone with an electric saw with a pneumatic drive.
8:55 Artery and vein removal
View of the internal thoracic (mammary) artery in the mirror in the center of the surgical lamp. This artery is very elastic. The top end of it will remain in place, it will be cut off at the bottom and then connected to the coronary artery.An angled retractor is placed along the left edge of the sternum to lift it and expose the mammary artery that runs along the inside of the chest.
At the same time, one of the main veins on the leg - the great saphenous vein - is prepared for transplantation. It is almost completely removed from the left thigh.
9:05 Connecting to the heart-lung machine
The heart-lung machine is not yet connected to the patient. One of the five rotating pumps circulates the blood, while the rest are used as side pumps to transport separated blood to prevent blood loss during surgery. The patient needs to enter heparin - a means to thin the blood and prevent the formation of clots during its passage through plastic tubes.Tubes to the heart-lung apparatus. On the left, with bright red blood, is the arterial return line, which carries blood back into the patient's aorta. On the right - two tubes that drain blood from the inferior and superior vena cava under the influence of gravity. The incision in the sternum is fixed with a spacer.
Part of the heart-lung apparatus is a membrane oxygenating device that maintains blood circulation in the patient's body. At the moment, the device is filled with blood, carbon dioxide is removed from it. The blood is re-oxygenated and returned to the patient's body.
An arterial return tube is inserted into the aorta (the main artery of the body) and two venous drains are inserted into the vena cava (the main vein of the body).
9:25 Cardiac arrest
On the main artery - the aorta - a clamp is placed to isolate the heart from artificial blood circulation. Chilled fluid is injected into the isolated aorta to stop the heart. The surgeon puts on special glasses for microsurgery with loupes that give a magnification of 2.5 times. The blood vessels he will transplant are 2-3 mm in diameter, and the sutures are the diameter of a human hair.A thorough examination of the heart is carried out to confirm the data obtained using the angiogram. It is specified which coronary arteries need to be bypassed. It was decided to make two shunts.
After stopping the blood flow in the left anterior descending artery, a 1 cm long incision is made at the bypass site using a surgical loop.
10:00 First bypass
Close-up of the heart. The left internal mammary (mammary) artery - in the upper left corner - is sutured to the left anterior descending artery so that blood flow to the heart is restored. Arteries are hidden by epicardial fat.The end of the left internal mammary artery is sutured laterally to the left anterior descending artery. This forms the first bypass shunt.
The position of the first performed shunt. The end of the lower part of the left internal mammary artery - a blood vessel with a diameter of 3 mm - is completely sutured to the left anterior descending artery.
10:22 Second bypass
The second bypass shunt is sutured with the upper end to the aorta, and with the lower end to the right posterior descending artery. The transverse clamp is removed, blood flow through the heart is restored.The upper end of the venous shunt is connected to the aorta. Part of the aorta is isolated with an arcuate clamp and a hole is made into which a vein is sutured.
End of both bypass processes. The second shunt, shown on the left side of the diagram, is formed from the saphenous vein of the leg.
11:18 Chest closure
Circulation is restored, the heart contracts after an electric shock with the transition from ventricular fibrillation to sinus mode. Two drains are installed in the anterior and posterior parts of the heart. The blood thinning effect of heparin was eliminated by the drug protamine. The surgeon sews the separated halves of the sternum together. The skin will be closed with an internal absorbable suture.The nurse applies tape to the suture and to the drainage tubes leading from the patient's chest. Soon the patient will be placed in the intensive care unit, where he will be observed.
The human body. Outside and inside. №1 2008
Morning. Petroverigsky lane, 10. At this Moscow address in the Kitay-Gorod area, I arrived at the angiography.su federal center for the diagnosis and treatment of cardiovascular diseases, which is part of the state research center for preventive medicine, to put on a sterile suit again and visit in the operating room.
Angiography is a method of examining blood vessels using x-rays and contrast fluid. It is used to detect damage and defects. Without it, the operation that I am going to talk about - stenting - would not have been possible.
There will still be some blood. I think I should warn impressionable people about this before they open the post in its entirety.
Who has never heard of cholesterol plaques, he did not watch the show of Elena Malysheva. Plaques are deposits on the inner walls of blood vessels that have accumulated over the years. They are similar in texture to thick wax. The plaque consists not only of cholesterol, calcium in the blood sticks to it, making the deposits even more dense. And this whole structure slowly but surely clogs the vessels, preventing our fiery motor, or rather the pump, from delivering nutrients and oxygen to various organs, including the heart itself.
Before the advent of the stenting method, which will be discussed, the doctors were armed with only the surgical method of bypass surgery, which became popularly famous thanks to Boris Nikolayevich Yeltsin's heart surgery in 1996 in a round operating room. I remember this case vividly (a memory from childhood), although a lot of famous people have done a similar operation.
Shunting is an abdominal operation. A person is given anesthesia, they cut the chest (they cut it, they can’t do it with one scalpel), they stop the heart and start the artificial circulation system. The beating heart beats very strongly and interferes with the operation, so it has to be stopped. To get to all the arteries and shunt, you need to get the heart and turn it over. A shunt is a donor artery taken from the patient himself, for example, from the arm. A lot of stress on the body.
During stenting, the patient remains conscious (everything happens under local anesthesia), can hold his breath or take deep breaths at the request of the doctor. Blood loss is minimal, and the incisions are tiny, because the arteries are entered through a catheter, which is usually inserted into the femoral artery. And they put a stent - a mechanical vasodilator. All in all, an elegant operation (-:
The operation for Sergei Iosifovich was done in three stages. I ended up on the final operation in the series. You cannot place all stents at once.
The surgical table and the angiograph (a semicircular device hanging over the patient) form a single mechanism that works together. The table moves back and forth, and the machine rotates around the table to take x-rays of the heart from different angles.
The patient is placed on the table, fixed and connected to the heart monitor.
To make it clear the device of the angiograph, I will show it separately. It's a small angiograph, not as big as the ones in the operating room. If necessary, it can even be brought to the ward.
It works quite simply. An emitter is installed below, a converter is installed at the top (a smile is pasted on it), from which a signal with an image is already transmitted to the monitor. Scattering of X-rays in space does not actually occur, however, everyone present in the operating room is protected. About eight such operations are performed per day.
Through a vessel on the arm or thigh, as in our case, a special catheter is inserted.
A thin metal wire, a conductor, is inserted through the catheter into the artery to deliver the stent to the site of the blockage. I was amazed at its length!
The stent - a mesh cylinder - is attached to the end of this wire in a compressed state. It is mounted on a balloon that will be inflated at the right time to deploy the stent. Initially, this design is not thicker than the conductor itself.
This is what an open stent looks like.
And this is a scale model of a different type of stent. In the case when the walls of the vessels are damaged, they are installed with a membrane. They not only support the vessel in the open state, but also serve as the walls of the vessels.
All through the same catheter, an iodine-containing contrast agent is injected. With the blood flow, it fills the coronary arteries. This allows the x-ray to visualize them and calculate the blockage sites, on which stents will be placed.
Here is such an Amazon basin obtained by injecting contrast.
All eyes on monitors! The entire stent placement process is observed through X-ray television.
After the stent is delivered into place, the balloon on which it is attached must be inflated. This is done using a device with a manometer (pressure meter). This device, which looks like a large syringe, is visible in the photo with long conductor wires.
The stent expands and is pressed into the inner wall of the vessel. To ensure that the stent has expanded correctly, the balloon remains inflated for twenty to thirty seconds. It is then deflated and pulled out of the artery on a wire. The stent remains and maintains the lumen of the vessel.
Depending on the size of the affected vessel, one or more stents may be used. In this case, they are overlapped one after the other.
And here's how the stent works. Below are screenshots from the X-ray TV. In the first picture, we see only one artery, a curly one. But another one should be visible, below it. Because of the plaque, the blood flow is completely blocked.
The thick sausage on the second is a stent that has just been deployed. The arteries are not visible because the contrast is not running in them, but the wires are just visible.
The third one shows the result. An artery appeared, blood flowed. Now compare the first picture with the third one again.
The concept of expanding the affected areas of the vessel with the help of a certain frame was proposed by Charles Dotter forty years ago. The development of the method took a long time, the first operation using this technology was performed by a group of French surgeons only in 1986. And only in 1993, the effectiveness of the method was proven to restore the patency of the coronary artery and keep it in a new state in the future.
Currently, foreign companies have developed about 400 different models of stents. In our case, this is Cordis from Johnson & Johnson. Artem Shanoyan, head of the department of X-ray endovascular diagnostic and treatment methods at the center, answered my question about Russian stent manufacturers that they simply do not exist.
The operation takes about half an hour. A pressure bandage is applied to the puncture site. From the operating room, the patient is sent to the intensive care unit, and two hours later to the general ward, from where you can already scribble joyful SMS to relatives. And in a few days they will be able to see each other at home.
Lifestyle restrictions typical for heart patients are usually removed after stenting, the person returns to normal life, and observation is carried out periodically by a doctor at the place of residence.
But now, the diagnosis has been made and the doctors understand what needs to be done next. I would like you to understand well by this moment, what will be discussed when they will explain everything in detail to you, what was found during the examination, what diagnosis was made, what needs to be done and when to choose the best way of treatment.
Here and now the main questions are being decided, and you must exactly imagine what you want to know before you make a decision on which a lot depends.
There are several options for conversation.
- You will be offered operation, as the only way out, and doctors believe that it needs to be done urgently.
- You are offered an operation, but they say that it can be postponed for a while.
- You are denied an operation for a variety of reasons.
You need to understand what is being said and prepare for the conversation. Try to be calm and confident in yourself and in the doctors who want to help you. You must be together, on the same side, in the fight for the future of the child. Discuss everything, but your questions should be literate. Believe me, a lot depends on this too.
What do you need to know about in order to ask the right question? What are the operations? What should the child do? How will it all be? Who will do it? Let's talk about it calmly.
Today, all interventions, or operations, for congenital heart defects can be divided into three categories: "closed" operations, "open" and "X-ray surgery".
✔ Closed Operations These are surgical interventions in which the heart itself is not affected. They are performed outside of it, and therefore do not require the use of any special equipment other than conventional surgical instruments. The cavities of the heart are not “opened” with them, which is why they are called “closed”, and they are widely performed as the first stage of surgical intervention.
✔ Open Operations- These are surgical interventions in which it is necessary to open the cavities of the heart in order to eliminate the existing defect. For this, a special apparatus is used - a heart-lung machine (AIC), or "heart-lungs". For the period of the operation, both the heart and the lungs are switched off from the circulation, and the surgeon gets the opportunity to perform any operation on the so-called "dry", stopped heart.
All the patient's venous blood is sent to the apparatus, where, passing through an oxygenator (artificial lung), it is saturated with oxygen and gives off carbon dioxide, turning into arterial. Then the arterial blood is pumped into the patient's aorta by a pump, i.e. into the systemic circulation. Modern technologies allow all the internal parts of the device (including the oxygenator), with which the patient's blood comes into contact, to be made "disposable", i.e. use them only once and only for one patient. This dramatically reduces the number of possible complications.
Today, thanks to AIC, it is possible without much risk to turn off the heart and lungs from work for several hours (and the surgeon has the opportunity to operate on the most complex defects).
✔ X-ray surgery appeared relatively recently, but, thanks to the incredible progress of modern technologies, they have already taken their rightful place in the arsenal of cardiac surgery. More and more doctors are now using thin catheters, the ends of which are fitted with balloons, patches, or expandable tubes (folded like a folding umbrella). With the help of a catheter, these devices are carried into the cavity of the heart, or into the lumen of the vessel, and then, expanding the balloon, break the narrowed valve with pressure, increase or create a defect in the septum, or, conversely, by opening the patch umbrella, this defect is closed. The tubes are inserted into the lumen of the desired vessel and create a wider lumen. In adults, they even try to pass an artificial aortic valve through the catheter in this way, but so far these are only attempts. Doctors monitor the course of an X-ray surgical operation on the monitor screen and clearly control all manipulations with the probe, and therefore the advantage of such operations is not only less trauma, but also high safety and efficiency. X-ray surgery has not yet supplanted traditional surgical methods, but it is gaining more and more space both as an independent method and as an “auxiliary”, i.e. which can be applied not instead of, but together with the usual operation, sometimes simplifying and supplementing it in many ways.
Depending on the type of defect and the condition of the child, surgical operations can be emergency, urgent and elective, i.e. planned.
emergency heart surgery are the ones that should be done immediately after the diagnosis is made, because any delay threatens the life of the child. With congenital malformations, such situations are not uncommon, especially when it comes to newborns. Here the question of life is often decided by hours and minutes.
Emergency operations- those for whom there is no such insane urgency. The operation does not need to be done right now, but you can calmly wait a few days, prepare both you and the child, but it must be done urgently, because then it may be too late.
Planned, or elective, operation- this is an intervention made at the time chosen by you and the surgeons, when the child's condition does not inspire fear, but the operation, nevertheless, should not be postponed.
No cardiac surgeon will ever suggest surgery if it can be avoided. So, anyway, it should be.
Depending on the approach to surgical treatment, radical and palliative operations are distinguished.
✔ Radical heart surgery is a correction that completely eliminates the defect. It can be done with an open ductus arteriosus, septal defects, complete transposition of the main vessels, abnormal pulmonary vein drainage, atrioventricular communication, Fallot's tetrad and some other defects, in which the heart is fully formed, and the surgeon has the opportunity to completely separate the circulatory circles, while maintaining normal anatomical relationships. Those. the atria will connect to their ventricles through correctly positioned valves, and the corresponding great vessels will depart from the ventricles.
✔ Palliative heart surgery- auxiliary, “facilitating”, aimed at normalizing or improving blood circulation and preparing the vascular bed for radical correction. Palliative operations do not eliminate the disease itself, but significantly improve the child's condition. With some very complex defects, which until recently were generally inoperable, the child will have one, and sometimes two palliative operations, before the final radical stage becomes possible.
During a palliative operation, another "defect" is surgically created, which the child does not initially have, but due to which the circulatory pathways disturbed by the defect in the large and small circles are changed. These include surgical expansion of the atrial septal defect, all variants of intervascular anastomoses - i.e. additional shunts, messages between circles. The Fontan operation is the most “radical” of all such methods, after which a person lives without a right ventricle at all. With some of the most complex heart defects, it is impossible to correct the anatomically, and surgical treatment aimed at correcting blood flow can be called the “final” palliative correction, but by no means a radical operation.
In other words, with heart defects, when the intracardiac anatomy - the structure of the ventricles, the condition of the atrioventricular valves, the location of the aorta and the pulmonary trunk - are so changed that they do not allow for a real radical correction, today's surgery follows the path of eliminating poorly compatible with life of circulatory disorders, and then - long-term palliation. The first stage of this path is saving lives and preparing for further treatment, and protection from future complications, the second is the final stage of treatment. All together - this is a long way to the final operation, and on it one, two, and sometimes three steps must be overcome, but, ultimately, to make the child healthy enough for him to develop, learn, lead a normal life, which this long-term palliation will provide him. Check it out, not so long ago - 20-25 years ago it was simply impossible, and children born with the defects of this group were doomed to death.
Such a “final palliation” is the only way out in many cases; although it does not correct the defect itself, it provides the child with an almost normal life by improving the mixing of arterial and venous blood flows, the complete separation of circles, and the elimination of obstructions to blood flow.
Obviously, the very concept of radical and palliative treatment for some complex congenital heart defects is largely arbitrary, and the boundaries are erased.