Abdominal heart surgery. How is heart surgery performed using stenting? How is the operation performed?

Let's try to lift the veil of secrecy about their work and find out what types of heart operations exist and are performed today. Is it possible to perform heart surgery without opening it? chest?

When the heart is in the palm of your hand or open surgery

Operations on open heart so called because the heart surgeon “opens” the patient’s chest, cuts the sternum and that’s it soft fabrics, performs an opening of the chest. Such interventions are usually performed with the connection of a heart-lung machine (hereinafter referred to as the artificial blood circulation machine), which is a temporary replacement for the heart and lungs of the person undergoing surgery. This device is a complex device of quite impressive size that continues to pump blood throughout the body when the patient’s heart is artificially stopped.

With AIC, open-heart surgery can be extended over many hours if necessary. Open operations are used when replacing valves, coronary artery bypass grafting can also be performed in this way, many heart defects are eliminated by performing open interventions. It should be noted that AIK is not always used when conducting them.

The body cannot always tolerate the intervention of a foreign cardiac substitute: the use of an artificial cardiac circuit is fraught with complications such as renal failure, disturbance of cerebral blood flow, inflammatory processes, blood rheology disorders. Therefore, some open-heart operations are performed under operating conditions, without connecting the artificial blood pressure pump.

Such interventions on a beating heart include coronary artery bypass surgery; during this operation on a beating heart, the area of the heart that the surgeon needs is temporarily switched off from work, and the rest of the heart continues to work. Such manipulations require high qualifications and skills of the surgeon, and also have a much lower risk of complications; they are perfect for people over 75 years of age, patients with a large arsenal of chronic diseases, and patients with diabetes mellitus than operations on an organ that is excluded from the circulation.

But all the pros and cons are, of course, determined by the cardiac surgeon. Only the doctor decides to leave the heart beating or stop it temporarily. Open operations are the most traumatic, having a higher percentage of complications; after surgery, a scar remains on the patient’s chest. But sometimes only such an operation can save a person’s life, improve his health, and return him to a full, happy life.

Intact heart or closed operations

If during the surgical intervention the sternum, heart chambers and the heart muscle itself were not opened, then these are closed heart operations. When performing such operations, the surgical scalpel does not touch the heart, and the surgeon’s work consists of surgical treatment of large vessels, cardiac arteries and the aorta, and the chest is not opened, only a small incision is made on the chest.

In this way, a pacemaker can be installed, heart valve correction, balloon angioplasty, bypass surgery, and vascular stenting can be performed. Closed operations are less traumatic and have a lower percentage of complications, unlike open ones. Closed vascular surgery can often be the first step before subsequent cardiac surgery.

Indications for their implementation are always determined by the doctor.

Achievements of modern cardiac surgery or minimally invasive operations

Cardiac surgery is confidently moving forward, and an indicator of this is the increasing percentage of low-traumatic, high-tech manipulations that make it possible to get rid of the pathology of the heart and blood vessels with minimal intervention and impact on human body. What are minimally invasive interventions? This surgical operations, carried out by introducing instruments or special devices, through mini-accesses - 3-4 centimeter incisions, or without any incisions at all: when carrying out endoscopic operations the incisions are replaced by punctures.

When performing minimally invasive manipulations, the path to the heart and blood vessels can lie through the femoral vessels, for example - these operations are called endovascular, they are performed under X-ray control. Elimination birth defects, heart valve replacement, all operations on blood vessels (from blood clot removal to lumen expansion) - all these interventions can be performed using minimally invasive technologies. Modern cardiac surgery places emphasis on them, since the low risk of complications and minimal impact on the body are huge advantages that patients can appreciate literally on the operating table.

Anesthesia is not required during endoscopic procedures; it is enough to numb the puncture site. Recovery after heart surgery performed using minimally invasive techniques is tens of times faster. Such methods are also irreplaceable in diagnostics - coronary angiography, a method for studying the vessels of the heart by introducing contrast and subsequent X-ray control. In parallel with diagnostics, according to indications, the cardiac surgeon can also perform therapeutic manipulations on blood vessels - installation of a stent, balloon dilatation in a narrowed vessel.

And diagnosis and treatment by puncture on the femoral artery? Isn't this a miracle? Such miracles are becoming routine for cardiac surgeons. The contribution of endovascular treatment methods is also invaluable in cases where the threat to the patient’s life is especially acute and minutes count. These are situations of acute coronary syndrome, thromboembolism, aneurysm. In many cases, the presence necessary equipment and qualified personnel, allows you to save the lives of patients.

When is surgery indicated?

Deciding whether surgery is indicated, as well as deciding on the type of surgical intervention on the heart and blood vessels, is the job of an experienced cardiac surgeon or a council of doctors. The doctor can make a conclusion after a thorough examination, familiarization with the history of the development of the disease, and observation of the patient. The doctor must know very well the ins and outs of the disease: how long the patient has been suffering from cardiac pathology, what medications he is taking, what chronic diseases has when he felt worse... Having assessed all the pros and cons, the doctor makes his verdict: to have surgery or not. If the situation develops according to the scheme described above, then we are dealing with a planned cardiac surgery.

It is shown to the following people:

lack of effect from adequate drug therapy;
rapidly progressive deterioration of well-being during treatment with tablets and injections;
severe arrhythmias, angina pectoris, cardiomyopathies, congenital and acquired heart defects requiring correction.

But there are situations when there is no time for thinking, questioning and analyzing the medical history. We are talking about life-threatening conditions - a blood clot has broken off, an aneurysm has dissected, or a heart attack has occurred. When time ticks by minutes, emergency cardiac surgery is performed. Stenting, coronary artery bypass surgery, thrombectomy of the coronary arteries, and radiofrequency ablation can be performed urgently.

Let's look at the most common types of heart surgery

CABG - coronary artery bypass grafting is “heard of” by many, probably because it is performed with coronary disease heart disease, which is extremely common among the population. CABG can be performed both open and closed, and combined techniques with endoscopic inclusions are also performed. The essence of the operation is to create bypass pathways for blood flow through the vessels of the heart, restoring normal blood supply to the myocardium, which ensures a better supply of oxygen to the heart muscle.
RFA - radiofrequency ablation. This type of surgical intervention is used to eliminate persistent rhythm disturbances when drug therapy is powerless in the fight against arrhythmias. This is a minimally invasive intervention, which is performed under local anesthesia; a special conductor is inserted through the femoral or subclavian vein, supplying an electrode to the focus of pathological impulses in the heart; the current flowing through the electrode to the pathological focus destroys it. And the absence of a focus of pathological impulses means the absence of arrhythmia. 12 hours after the manipulation, the patient is allowed to get up.
Prosthetic or plastic surgery of heart valves. Prosthetics means complete valve replacement; the prosthesis can be mechanical or biological. And plastic surgery implies the elimination of defects in the “native” valve or valve apparatus. There are certain indications for these interventions, which are clearly known to cardiac surgeons.
Installation of a pacemaker. Heart rhythm disturbances and severe bradycardia may be indications for installation, which, thanks to modern technologies, can also be performed endoscopically.

Surgical interventions on the heart are necessary in the treatment of many pathologies of cardio-vascular system resistant to standard drug therapy. When implementing surgical treatment, it becomes possible to improve the general condition of the patient and prolong his life. But depending on the pathology, there are different heart surgeries, which differ in their technique.

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Classification of operations

Cardiac surgery is aimed at treating cardiac pathologies by indirectly or directly affecting this organ. There are the following types of heart surgeries:

Closed, but the heart itself is not affected. Such operations are performed outside the heart, so they do not require the use of special equipment, with the exception of classical surgical instruments. The cavities of the heart remain closed, hence the name of this category.
Open, they require opening the cavities of the heart, which requires the use of special equipment, such as a heart-lung machine. At the time when such surgery is performed, the heart and lungs are not functioning, which allows the specialist to work with a stopped heart.
X-ray surgery, in which special catheters and devices attached to them are used, they are inserted into the heart cavity or the lumen of a vessel to correct the defect. The progress of such an operation is monitored using a monitor screen.

In addition, types of surgical interventions in cardiac surgery are classified according to the patient’s condition and type of defect, as well as the approach to treatment.

Depending on the patient’s condition and type of defect, the following are distinguished:

Emergency operations - when you need to act immediately after the diagnosis has become clear, otherwise the pathology threatens the patient’s life.
Urgent - they do not require a lightning-fast reaction and a quick start of action. They are prepared for several days, but not longer, due to the high risks of complications or death.
Planned - interventions, the implementation of which is desirable, but not essential in the near future. They are prescribed by surgeons after consultation with patients.

Depending on what approach surgical treatment requires:

Radical - they are aimed at the complete elimination of vices.
Palliative - they are additional or auxiliary, their goal is to improve the patient's condition or prepare him for radical intervention.

Radiofrequency ablation

Surgical intervention such as radiofrequency ablation refers to x-ray surgical procedures. It is carried out to improve the condition of a patient suffering from heart failure and arrhythmia, and is characterized low performance side effects and complications.

Manipulations during the operation are carried out using special catheters, which are administered to the patient under local anesthesia. The catheter insertion site is distant from the heart itself, therefore local anesthesia carried out at the site of future catheter insertion. In most cases it is injected into the inguinal vein or femoral artery. Once in the organ, electrical impulses are given through the catheters to restore the heart rhythm.

Because of this delivery of impulses, which eliminate a small area of cardiac tissue that causes pathological excitation of the myocardium, the technique received a second name - cauterization of the heart.

Valve replacement

Heart valve replacement is used when there is insufficiency or stenosis of the valve, which prevents the normal passage of blood through it. Valve replacement can be performed during open surgery, endovascularly or with a mini-access.

In the first case, the patient is under general anesthesia the anterior surface of the chest is processed, the sternum is dissected longitudinally, and the pericardial cavity is opened. To disconnect the heart from blood circulation, the patient is connected to a heart-lung machine, and the myocardium is systematically treated with cold saline during the entire operation in order to avoid its hypoxia.

To install the prosthesis, a longitudinal incision is made, opening the heart cavity, the modified valve structures are removed, it is replaced with an artificial one, and the myocardium is sutured. After this, the surgeon “starts” the heart with an electrical impulse or by performing direct cardiac massage, and turns off the heart-lung machine.

After inspection postoperative appearance heart, pericardium and pleura, remove blood from the cavities and suture the surgical wound layer by layer.

During endovascular surgery there is no need to “disconnect” the heart from circulation. It is carried out through the leg, namely by inserting a catheter with an implantable valve into the femoral artery or vein. After the fragments of the damaged valve are destroyed and removed, a prosthesis is placed in its place, which itself straightens, having a flexible stent frame.

If the option with a mini-access was chosen, then the surgeon makes a 2–5.5 cm long incision on the anterior wall of the sternum in the area of the projection of the apex of the heart. Then a catheter is inserted into the organ through the apex of the heart, advancing it to the affected valve, and replacing it.

In the case of valve replacement, there are several types of implants:

Mechanical - they are made of metal or plastic. When choosing such an implant, the patient will need to constantly take blood thinning medications in the future.
Biological - they consist of animal tissues and do not require further use of drugs, but after several decades they need to be replaced.

Pacemaker installation

If the patient suffers from heart failure, cardiomyopathy and cardiac arrhythmias, the specialist may prescribe a minor operation to install a pacemaker.

The technique for performing such surgical intervention is simple. Local anesthesia with novocaine or lidocaine is performed on the right or left under the left clavicle, after which an incision is made in the skin and subclavian vein to insert a conductor into it, and through it into the superior vena cava and into the heart - an electrode. When the tip of the electrode enters the cavity of the right atrium, the doctor selects a convenient place for optimal stimulation of the heart muscle, and during the search he constantly records ECG changes. When the location is found, the electrode is fixed in the myocardial wall from the inside using antennae or a corkscrew-shaped fastening. After fixation, it is necessary to sew a titanium case under the patient’s arm, which is installed into the thickness of the pectoral muscle on the left. The wound is sutured and an aseptic bandage is applied.

Coronary artery bypass grafting

Coronary artery bypass grafting is a frequently performed heart surgery. It is prescribed when internal walls atherosclerotic plaques accumulate in the coronary vessels supplying the heart, disrupting blood flow. In addition, indications may include:

Stable angina pectoris 3–4 functional class.
Acute coronary syndrome.
Acute myocardial infarction during the first 4–6 hours from the onset of pain.
Severe ischemia without pain.

Before surgery, the patient is given intravenous sedatives and tranquilizers, and the intervention itself is performed under general anesthesia. Online access done by dissecting the sternum or from a mini-access, making an incision in the intercostal space on the left in the area of the projection of the heart. The manipulation can occur either with or without connecting the patient to the artificial blood circulation machine.

The aorta is clamped and connected to the device, then a vessel is isolated that will become a shunt. This vessel is brought to the affected coronary artery and its other end is sutured to the aorta. As a result, from the aorta, bypassing the area affected by plaques, blood will flow to the coronary arteries without difficulty.

Depending on how many arteries supplying the heart are affected and at what intervals, the number of shunts can vary from 2 to 5.

When the shunts are fixed, metal staples are applied to the edges of the sternum, the soft tissue is sutured and an aseptic dressing is applied. In addition, drainage is removed from the pericardial cavity so that there is an outflow hemorrhagic fluid.

Glenn and Ross operations

Glenn's procedure is otherwise called a bidirectional cavopulmonary connection. In this case, the upper part of the superior vena cava is anastomosed with the right pulmonary artery according to the “end to side” principle.

The Ross procedure involves replacing a patient's damaged aortic valve with their pulmonary valve, and replacing the removed pulmonary valve with a prosthetic valve.

The treatment of heart disease using surgery is the field of surgery and cardiology, which is called cardiac surgery. Today, cardiac surgery is the most effective method of treating certain types of heart defects, coronary heart disease and helps prevent the development of myocardial infarction, as well as eliminate its consequences - aneurysms.
Surgery used only in cases where conservative methods Treatments stop helping and the patient’s condition worsens. A patient’s failure to see a doctor in a timely manner can also lead to heart surgery. the only way The only help left is surgery.

Today, cardiac surgery is one of the most actively developing and technically equipped branches of medicine. Open heart surgery is performed on 700 patients every year. The bulk of operations are in the United States. In Europe, the number of operations is 4 times less. In Asian countries, cardiac surgery is practically absent. In Russia, the number of heart surgeries performed is below the required minimum. This statistic is due to the fact that heart surgery is expensive. In addition to open-heart surgery, surgery is also performed without opening the parts of the heart (for example, implantation of pacemakers, angioplasty).

Surgical intervention is required for diseases such as:

1. Coronary heart disease and its consequences (myocardial infarction);
2. Heart defects.
3. Heart rhythm disturbance.

Cardiac ischemia

Coronary heart disease occurs as a result of insufficient blood supply to the working myocardium. The main cause of coronary heart disease is atherosclerosis (the formation of plaques on the walls of blood vessels). A slight narrowing of the lumen of the vessel leads to angina pectoris (a person feels pain only when the heart’s need for oxygen increases, for example, when physical activity). A strong narrowing of the lumen of the vessel causes pain even at rest, and the duration of painful attacks can also become more frequent and longer - unstable angina. If coronary blood flow is severely impaired, the muscle fibers of the heart die - this is myocardial infarction.

One of severe complications myocardial infarction is the formation of a post-infarction aneurysm of the left ventricle. An aneurysm is a bubble-like protrusion. It forms when dead tissue is replaced by scar tissue, which in turn is unable to contract. Under the pressure of healthy contracting fibers, the scar tissue bulges, and some of the blood is retained in the ventricle in the area of aneurysmal expansion. With each contraction, organs and tissues receive less blood in an amount equal to the volume of the aneurysm. This is its main negative meaning. Very often, blood clots form in the area of the aneurysm, which can break off and be carried by the bloodstream to any organ, causing a heart attack (death of part or all of the organ). When a blood clot enters the brain, a stroke occurs.

Surgical intervention (heart surgery) for coronary heart disease is aimed at restoring normal nutrition to all parts of the heart. The degree of damage to the coronary arteries will determine what kind of surgery should be done. Analysis of the condition of the vessels is carried out using coronary angiography - this is a radiopaque research method that allows you to determine the location, nature and degree of narrowing of the coronary artery. Most often, stenting is performed on the coronary artery that causes pain. In case of severe atherosclerotic damage to the coronary vessels, the patient requires coronary artery bypass surgery.

Kinds surgical intervention for coronary heart disease

Angioplasty and stenting of coronary arteries

Angioplasty and stenting are aimed at removing obstructions to blood flow by widening the artery from the inside.
The operation is carried out as follows: using special equipment, a catheter is inserted through a puncture in the thigh area under the control of a fluorographic drug into the artery that feeds the heart. It must reach the site of narrowing of the artery, where a special balloon with a stent is inflated - a device that does not allow the artery to collapse. The stent remains in the artery, and the catheter is brought out through the same hole in the thigh.

Coronary artery bypass grafting (CABG)

Coronary artery bypass surgery - restoration of blood supply to the heart muscle by creating a new path for blood flow bypassing the affected area coronary vessel using shunts - pieces of arteries or veins taken from the patient himself (for example, in the area of a limb). This operation is aimed at preventing myocardial infarction. Today, CABG operations are performed both using a heart-lung machine and on a beating heart (immobility of the heart only in the operated area).
One of the types of coronary bypass surgery is mammary coronary artery bypass grafting (MCBG). The internal mammary artery is used as a shunt. The use of this vessel is advantageous, since in this case there is no need to make additional incisions due to the close location of the thoracic artery and the heart, and also because atherosclerotic plaques do not form in the artery, and therefore the service life of such a shunt is quite long.

Plastic surgery of post-infarction left ventricular aneurysm

The essence of the intervention is to reduce the volume of the left ventricle by delineating the area of aneurysmal dilatation and the healthy part of the left ventricle. The surgeon removes the resulting blood clots in the area of the aneurysm, then sews a septum made of dense elastic human tissue across the cavity of the left ventricle. Two cavities are formed: one with normal, actively contracting walls, the other - from scar tissue that is not capable of contracting, but does not interfere normal operation hearts. Thus, blood circulation is restored and the danger of blood clot rupture is eliminated.

Heart defects

Heart defects are defects in the structure of the heart that lead to disruption of normal blood circulation, stagnation of blood occurs in the small or big circle blood circulation
The following violations are identified:

- stenosis (narrowing) of the valve apparatus;
With valve stenosis, it stops allowing the required volume of blood through the reduced opening.
- insufficiency of the valve apparatus;
The valve flaps cannot close tightly and allow blood to flow in the opposite direction to normal blood flow.

-defects of the interventricular and interatrial septum;
If these septa are defective, blood enters from a cavity with high pressure into a cavity with lower pressure, and deoxygenated blood, poor in oxygen, mixes with oxygenated arterial, which leads to oxygen starvation fabrics.
Heart defects can be congenital or acquired. Most of them do not require surgery. Sometimes the disease proceeds unnoticed by the patient. Congenital heart disease can improve with age, but if this does not happen and signs of heart failure increase, then surgical intervention is required.

Treatment of heart defects is aimed at correcting the existing mechanical defect in the functioning of the heart.

The following types of surgical intervention are distinguished:

Prosthetics and plastic surgery of heart valves

Operations to install prostheses are performed on an open heart, using a heart-lung machine.
Valve prostheses can be mechanical or biological.

Mechanical valves

Mechanical valves are made of metal and plastic. The validity period of such prostheses is about 80 years. However, when using them, a person has to take anticoagulants daily, since blood clots easily form on prostheses, which contribute to the formation of blood clots. In rare cases, a mechanical prosthesis may break, which most often leads to the death of the patient. Mechanical valve prostheses can be in the form
- rotating disk
The disc completely covers the hole, but is secured only at one end. Blood moving in the right direction presses on the disc, rotates it on a hinge and opens the hole; when the blood flows back, the disc completely blocks the hole.
- built on the principle of a ball in a grid
The blood flow in the right direction pushes the ball out of the hole, pressing it to the bottom of the mesh and thereby creating the possibility of further passage of blood; reverse blood flow pushes the ball into the hole, which is thus closed and does not allow blood to pass through.

Biological valves

Biological prostheses are usually made from animal heart tissue and are considered more effective. After their installation, there is no need for treatment with anticoagulants, which have many contraindications. Such a prosthesis lasts from 10 to 20 years, its aging occurs gradually and you can prepare in advance for its replacement as planned. Of course, in this case a repeat operation is needed.
Biological valves do not necessarily require the use of anticoagulants (although it is often recommended), but they wear out faster than mechanical valves.

Plastic surgery of atrial and interventricular septal defects

If the structure of the septum is damaged and the size of the defect is small (the hole size is no more than 3 cm), it is sutured, and if it is large, it is repaired with a patch (synthetic tissue or autopericardium is used)

Heart rhythm disturbance

Cardiac arrhythmias are disturbances in the sequence, rhythm and frequency of contractions of the heart. Arrhythmias may occur as a consequence metabolic disorders, for example, endocrine and vegetative, or the influences of certain medicines. They are also often caused by heart disease, and sometimes by intoxication.
The danger of arrhythmia is that it can lead to ventricular fibrillation (disjointed contraction of fibers).
Used to treat arrhythmia medicines, catheter ablation, or a pacemaker (pacemaker) is implanted.

Surgical methods for treating arrhythmias:

Radiofrequency ablation

It is minimally invasive surgical method, which is used for:
- high frequency heart rate with severe pulse deficiency;
- atrial fibrillation;
- progressive heart failure;
- supraventricular tachycardia.

The radiofrequency ablation method involves passing a special catheter to the area of the heart that causes an abnormal pathological rhythm. An electrical impulse is applied to this section, which destroys the area of tissue that sets the wrong rhythm.
Thanks to ablation, normal heart rhythm is restored.

Pacemaker implantation

The operation is performed on patients with heart rhythm disturbances that are life-threatening. A pacemaker aims to control and restore normal contraction of the heart.
Doctors implant a special device under the skin or under the pectoral muscle. Two or three electrodes extend from the pacemaker and connect to the chambers of the heart to transmit an electrical impulse to them.

Defibrillator implantation

The principle of operation of a defibrillator is similar to a pacemaker. Its distinctive feature is the elimination of too fast and too slow heart rates. Heart rhythm is assessed using electrodes. Installing a defibrillator is similar to installing a pacemaker.

Installation of a defibrillator is indicated for ventricular tachycardia.

Heart transplant

In critical cases, when the heart cannot perform its function and does not respond to any treatment, a heart transplant is resorted to. Thanks to this operation, doctors prolong the patient’s life by about 5 years. Research is currently underway to extend the life of people who have had heart transplants.

Postoperative recovery period

An important stage of recovery after surgery is the postoperative recovery period. Strict monitoring of human health is necessary. This period is different and individual for each patient. Patients are prescribed special cardio training and diets. Emotional calm is necessary.

Heart surgery is dangerous due to its complications. The main signs of complications are fever, pain in the operated area, tachycardia, drop in blood pressure, and shortness of breath. The ECG is recorded characteristic changes. Recovery period lasts six months to a year.

An example of monitoring the health of postoperative patients is the work of a doctor medical sciences, professor, arrhythmologist Andrei Vyacheslavovich Ardashev. He performs more than 200 operations per year. Postoperative monitoring of patients began in 2011 using the project. The doctor monitors both the cardiovisor conclusion and the ECG itself in postoperative patients. Using the website service helps monitor the recovery of the health of operated people via the Internet. This is a huge plus, since a large number of patients come to Moscow from all over Russia to undergo heart surgery. They pass the postoperative period at home. Using the Cardiovisor allows you to take ECG readings at home and send them to the doctor using the website.

Rostislav Zhadeiko, especially for the project.

Tuesday is the day of the operation. The team is preparing for a long morning of 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 with right side neck, and then there was an uncomfortable feeling of compression in the 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 advice from a therapist.

Thomas's high blood pressure, obesity and long history of smoking were enough reason to get an EKG. Her results showed the presence of coronary heart disease. Thomas was referred to a cardiac expert (a physician who specializes in heart problems - not a surgeon). Despite the applied drug treatment, the pain continued.

Tests confirmed the presence of the disease, including an angiogram (a test using dye injected into an artery to identify narrowing) that revealed a narrowing in the left main coronary artery, affecting both the left and right vessels. Because drug treatment was unsuccessful and angioplasty (stretching the narrowed vessel using a catheter) was not an option, Mr. Thomas was referred for surgery.

Monday

Mr. Thomas is hospitalized. His anamnesis, examination and test data were analyzed. Two units of blood for transfusion are examined for compatibility. The patient is explained the essence of the operation and warned about the risks associated with it. Obtain written consent for CABG.

Tuesday

Early in the morning, Mr. Thomas is prepped for surgery.

7:05 Premedication and anesthesia

8:15 Mr. Thomas was sedated 70 minutes ago and a ventilation tube is already in place. Airways. After applying anesthesia and paralyzing agents, his breathing is supported by a ventilator. Before Mr. Thomas is transferred to the operating room, the anesthesiologist monitors venous and arterial blood flow.

8:16 The operating room is ready for Mr. Thomas. On the left is a table with instruments, on the right is a ready-to-use heart-lung apparatus.

8:25 Patient in the operating room. Skin his chest and legs are treated antiseptic solution to reduce the risk of infection.

8:40 Chest opening

The skin has already been treated, the patient is dressed in sterile clothing. One of the surgeons makes an incision in the leg to remove the vein, and the second one cuts the skin on the chest. After making a preliminary cut with a regular scalpel, he uses an electric one, which cuts the vessels, stopping the bleeding.

8:48 The surgeon separates the breastbone with an air-powered electric saw.

8:55 Artery and vein removal

View of the internal mammary artery in the mirror in the center of the surgical lamp. This artery is very elastic. The top end 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 elevate it and expose the mammary artery running along the sternum. inside breasts

At the same time, one of the main veins in the leg - the great saphenous vein - is prepared for transplantation. It was almost completely removed from the left thigh.

9:05 Connection 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, and the rest are used as side pumps to transport the separated blood to prevent blood loss during surgery. The patient must be given heparin, a drug that thins the blood and prevents the formation of clots as it passes through plastic tubes.

Tubes for the heart-lung machine. On the left - with bright red blood - is the arterial return line, along which blood is flowing back into the patient's aorta. On the right are two tubes that drain blood from the inferior and superior vena cava under the influence of gravity. The incision in the sternum is secured with a spacer.

Part of the heart-lung machine is a membrane oxygenating device that maintains blood circulation in the patient's body. IN this 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

A clamp is placed on the main artery, the aorta, isolating the heart from artificial blood circulation. A cooled fluid is injected into the isolated aorta to stop the heart. The surgeon puts on special glasses for microsurgery with magnifying glasses that provide 2.5 times magnification. The blood vessels he will transplant have a diameter of 2-3 mm, and the sutures are the diameter of a human hair.

A thorough check of the heart is performed to confirm the findings from the angiogram. It is clarified 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 incision is made using a surgical loop at the bypass site.

10:00 First bypass

Close-up of a heart. The left internal mammary artery - in the upper left corner - is sutured to the left anterior descending artery so that blood flow to the heart is restored. The arteries are hidden by epicardial fat.

The end of the left internal mammary artery is sutured laterally to the left anterior descending artery. This creates the first bypass shunt.

Position of the first shunt performed. The end of the lower part of the left internal mammary artery - blood vessel with a diameter of 3 mm - completely sewn to the left anterior descending artery.

10:22 Second bypass

The second bypass shunt is sewn with its upper end to the aorta, and its lower end to the right posterior descending artery. The cross clamp is removed and blood flow through the heart is restored.

The upper end of the venous shunt connects to the aorta. Part of the aorta is isolated with an arcuate clamp, and a hole is made into which the vein is sutured.

End of both bypass processes. The second shunt, shown on the left side of the diagram, is formed from saphenous vein shins.

11:18 Closing the chest

Blood circulation is restored, the heart contracts after the electric shock with a transition from ventricular fibrillation to sinus mode. Two drains are installed in the front and back parts hearts. The blood thinning effect of heparin was eliminated by the drug protamine. The surgeon stitches the separated halves of the sternum. He will close the skin with an internal absorbable suture.

The nurse places tape on the stitch and on the drainage tubes leading from the patient's chest. The patient will soon be admitted to the ward intensive care where it will be observed.

The human body. Outside and inside. №1 2008