Heart disease requiring surgery. Open heart surgery. 18 Closure of the chest

Heart valve replacement
- Possible complications and recommendations for care

Heart surgery is performed only when necessary. The most common of these are heart valve replacement and coronary artery bypass grafting. The first is necessary if the patient is concerned about valvular stenosis. It should be noted that heart surgeries pose a serious risk to the life of the patient, they are carried out with maximum precision and caution. Heart surgery sometimes leads to numerous problems and complications, in order to avoid this, you can use an alternative technique - valvuloplasty.

The procedure can replace replacement surgery, help normalize the activity of the heart muscles. In the process, a special balloon is inserted into the opening of the aortic valve, at the end this balloon is inflated. It is worth considering: if a person is in old age, valvuloplasty does not give a lasting effect.

Heart valve replacement

To decide on such a procedure, it is necessary to establish a diagnosis.

The operation is carried out immediately or some time after the test.

In some situations, the results indicate that a person needs bypass surgery. Valve replacement is an open procedure that can be performed using minimally invasive surgery. It should be remembered that heart valve replacement is a very complicated procedure, despite this, it is carried out very often.

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Stages of the procedure and further rehabilitation

First you need to open the chest. Next, the doctor connects the patient to a special apparatus that provides artificial circulation. The device temporarily replaces the heart. The patient's circulatory system is connected to the device, after which the natural valve is removed and replaced. When this manipulation is completed, the device is turned off. In most cases, heart surgery goes well, but a scar forms on the organ.

After recovery from anesthesia, the breathing tube is removed from the lungs. If you want to remove excess fluid, such a tube should be left for a while. After a day, it is allowed to drink water and liquid, you can walk only after two days. After such an operation, pain in the chest area can be felt, and on the fifth day the patient is completely discharged. If there is a risk of complications, the hospital stay must be extended by 6 days.

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Can there be complications after valve replacement?

A person can face such problems at different stages of the disease. During the operation, there is a risk of heavy bleeding, in addition, difficulties with anesthesia may arise. Possible risk factors include internal bleeding, seizures, possible infections. A heart attack can also happen, but this happens very rarely. As for the greatest danger, it lies in the appearance of tamponade of the pericardial cavity. This phenomenon occurs when blood fills its heart sac. This causes serious malfunctions in the functioning of the heart. Operations on the heart cannot but affect the general condition of a person. During the rehabilitation period, strict medical supervision is required. The need to visit the surgeon arises after 3-4 weeks after the operation. It is important to maintain the general well-being of the patient. An optimal dose of physical activity should be prescribed, it is important to stick to a diet.

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What is coronary artery bypass grafting?

Coronary artery bypass grafting is a type of surgery that restores blood flow in the arteries. The procedure is necessary to eliminate coronary heart disease. The disease manifests itself when the lumen of the coronary vessels narrows, as a result of which an insufficient amount of oxygen enters the heart muscle. Coronary artery bypass surgery aims to prevent changes in the myocardium (heart muscle). After the operation, he should fully recover and contract better. It is necessary to restore the affected area of the muscle, for this the following procedure is carried out: everyday shunts are applied between the aorta and the coronary vessel that is affected. Thus, the formation of new coronary arteries occurs. They are designed to replace the narrowed ones. After the shunt is applied, blood from the aorta flows through a healthy vessel, thanks to which the heart produces a normal blood flow.

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What is the operation for?

This procedure will be required if the left coronary artery of the vessel that provides flow to the heart is affected. It is also needed if all coronary vessels are damaged. The procedure can be double, triple, single - it all depends on how many shunts the doctor needs. With coronary heart disease, the patient may need one shunt, in some cases two or three. Bypass surgery is a procedure that is often used for atherosclerosis of the heart vessels. This happens when angioplasty is not possible. As a rule, a shunt can serve for a long time, its functional suitability is 12-14 years.

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Carrying out coronary artery bypass grafting

The duration of the operation is 3-4 hours. The procedure requires maximum concentration and attention. The doctor needs to gain access to the heart, for this it is necessary to dissect the soft tissues, then open the sternum and perform a stenotomy. During the operation, a procedure is carried out that is necessary for temporary, it is called cardioplegia. The heart must be cooled with very cold water, then a special solution should be injected into the arteries. To attach shunts, the aorta must be temporarily blocked. To do this, it is necessary to pinch it and connect the heart-lung machine for 90 minutes. Plastic tubes should be placed in the right atrium. Next, the doctor performs procedures that contribute to the flow of blood into the body.

What is routine vascular bypass surgery? This method involves the implantation of special implants into the coronary vessels outside the obstruction, the end of the shunt is sutured to the aorta. In order to be able to use the internal mammary arteries, it is necessary to carry out the procedure with the expenditure of more time. This is due to the need to separate the arteries from the chest wall. Upon completion of the operation, the doctor carefully fastens the chest, for this a special wire is used. With its help, a soft tissue incision is sutured, then drainage tubes are applied to remove residual blood.

Sometimes bleeding occurs after the operation, it continues throughout the day. The installed drainage tubes should be removed after 12-17 hours after the procedure. At the end of the operation, the breathing tube must be removed. On the second day, the patient can get out of bed and move around. Restoration of the heart rhythm takes place in 25% of patients. As a rule, it lasts for five days. As for arrhythmia, this disease can be eliminated within 30 days after surgery, for this conservative methods of therapy are used.

The operation on the heart, which at one time was compared with the first manned flight into space, is exactly 50 years old. It is very pleasant that our surgeon Vasily Kolesov conceived and executed it. Now it is one of the most common procedures in the world to prevent a heart attack and bears the name of its developer.

"The Soviet surgeon dared to raise his hand on his heart" - in 1964 this news outraged the entire world medical community. No one believed that coronary heart disease could be treated with surgery. Numerous experiments on animals ended unsuccessfully. But Vasily Ivanovich Kolesov, a professor at the Leningrad Medical University, proves that operating on a healthy heart in dogs and a diseased heart in humans is not the same thing, and he decides on a bold experiment.

Stanislav Pudyakov then assisted the surgeon. He recalls: a 44-year-old patient was tormented by severe pain in the region of the heart.

“His idea, if compared historically, is similar to the thoughts of Tsiolkovsky, who said that tomorrow we will be on the moon. They didn’t believe him until they really flew. And until Vasily Ivanovich did this first operation, no one believed in it” - says Stanislav Pudyakov.

The surgeon operated on a beating heart, which was also hard to believe. No one had done this before Kolesov, neither in our country nor in the world. Moreover, the doctor literally felt the sore spot with his hands. The equipment for diagnosing heart diseases simply did not exist then.

To restore the normal blood supply to the heart, Kolesov singled out the internal thoracic artery and sewed it to the coronary artery below the narrowing caused by the so-called atherosclerotic plaque. The blood flow went around, the patient was saved from a heart attack.

After the operation, people quickly returned to normal life and forgot about the pills forever. About operations that saved people from heart attacks and pains in the heart, they started talking abroad as a sensation. American magazines wrote about Kolesov: "Pioneer of coronary surgery."

“There were confessions among colleagues, among foreigners. A lot of Americans, Germans, French came, they looked at these operations with great curiosity and really wanted to continue what was started here,” says surgeon Alexander Nemkov.

Vasily Kolesov immediately warned: it would not be easy for young surgeons to repeat this. From now on, operations must be performed on a stopped heart. The advice was regarded as a guide to action. In 1967, American surgeons put them on stream.

The method of treatment of coronary heart disease, proposed by Vasily Ivanovich Kolesov, is considered the most effective after 50 years. Operations are performed by the best cardiac surgeons in clinics around the world. This is aerobatics, because, in fact, doctors must restart the main human organ.

“Speaking specifically about the operation of Vasily Ivanovich Kolesov, it is now being performed widely on a beating heart. What he did is incredible. The range of suture material that we use has changed, the needle holders that we use have changed incredibly. We use special magnifying lenses and we see this artery magnificently, which can be a millimeter, a millimeter and a half,” says surgeon Leo Bokeria.

Like half a century ago, coronary heart disease is the most common disease in the world. Now we can say with confidence that doctors have learned to deal with it. Thanks to the revolutionary method of Vasily Kolesov, even the most difficult patients can be saved.

Surgical interventions on the heart are necessary in the treatment of many pathologies of the cardiovascular system that are not amenable to standard drug therapy. With the implementation of 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 operations, which differ in their technique.

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Operations classification

Cardiac surgery is aimed at the treatment of cardiac pathologies through indirect or direct effects on this organ. There are such types of heart operations:

Closed, while the heart itself is not affected. Such operations are performed outside the heart, so they do not need to use 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 a surgical intervention 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 cavity of the heart or the lumen of the vessel to correct the defect. The progress of such an operation is controlled using the monitor screen.

In addition, the 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.

According to the patient's condition and the type of defect, there are:

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 requires surgical treatment:

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 a radical intervention.

RF ablation

Such surgical intervention as radiofrequency ablation refers to X-ray surgical procedures. It is carried out to improve the condition of the patient suffering from heart failure and arrhythmia, and is characterized by low rates of side effects and complications.

Manipulations during the operation are carried out with special catheters, which are introduced to the patient under local anesthesia. The place of introduction of the catheter, remote from the heart itself, therefore, local anesthesia is carried out at the site of the future introduction of the catheter. In most cases, it is injected into the inguinal vein or femoral artery. After entering the organ, the catheters give electrical impulses to restore the heart rhythm.

Due to such a supply of impulses that 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 prosthetics

Prosthetic heart valves are used when a valve is insufficiency or stenosis, which interferes with the normal passage of blood through it. Valve replacement can be performed during open surgery, endovascular or mini-access.

In the first case, the patient under general anesthesia is treated with the anterior surface of the chest, 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 cavity of the heart, the modified structures of the valve are removed, it is replaced with an artificial one, and the myocardium is sutured. After that, the surgeon "starts" the heart with an electrical impulse or by performing a direct heart massage, and turns off the heart-lung machine.

After examining the postoperative view of the heart, pericardium and pleura, blood is removed from the cavities and the surgical wound is sutured in layers.

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

If the option with a mini-access was chosen, then the surgeon makes an incision 2-5.5 cm long on the anterior wall of the sternum in the area of the projection of the apex of the heart. Then, through the apex of the heart, a catheter is inserted into the organ, 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 in the future will need to constantly take blood thinners.
Biological - they consist of animal tissues and do not require further use of drugs, but after a few decades they need to be replaced.

Installing a pacemaker

In the event that 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 an operation is simple. On the right or left under the left clavicle, local anesthesia is performed with novocaine or lidocaine, 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 chooses a convenient place for optimal stimulation of the heart muscle, during the search he constantly records ECG changes. When a place is found, the electrode is fixed in the myocardial wall from the inside with the help of antennae or a corkscrew-like attachment. After fixation, it is required to hem a titanium case under the patient's arm, which is installed in 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 common heart surgery. It is prescribed when atherosclerotic plaques accumulate on the inner walls of the coronary vessels that feed the heart, disrupting blood flow. In addition, indications can be:

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

Before the operation, the patient is intravenously administered sedatives and tranquilizers, and the intervention itself is carried out under general anesthesia. Operative access is done by dissection of 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. Manipulation can be carried out both with the connection of the patient to the heart-lung machine, and without it.

The aorta is clamped and connected to the machine, then a vessel is isolated, which will become a bypass. 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, the blood will go 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, soft tissues are sutured and an aseptic dressing is applied. In addition, drainage is removed from the pericardial cavity so that there is an outflow of hemorrhagic fluid.

Operations Glenn and Ross

The Glenn operation is otherwise known as a bidirectional cavopulmonary connection. In this case, anastomosis of the upper part of the superior vena cava with the right pulmonary artery is performed according to the "end to side" principle.

Ross surgery is the replacement of a patient's damaged aortic valve with his pulmonary valve, and the removed pulmonary valve is replaced with a prosthesis.

Operations on the heart and blood vessels are performed by such a branch of medicine as cardiac surgery.

With the help of cardiac surgeons, many vascular and cardiac diseases can be effectively treated, thereby significantly prolonging the life of the patient.

Operations on the heart and blood vessels can significantly improve the general well-being of the patient.

They should be performed only after a thorough diagnosis and preparation of the patient.

It is very important to follow all the instructions of the specialist exactly.

Regardless of what kind of disease was detected in a person, there are the following general indications for operations on the heart and blood vessels:

Rapid deterioration of the patient's condition and progression of the underlying disease of the heart or blood vessels.
The lack of positive dynamics from the use of traditional drug therapy, that is, when taking pills no longer helps a person to maintain his condition in a normal way.
The presence of acute signs of deterioration of the underlying myocardial disease, which cannot be eliminated by conventional analgesics or antispasmodics.
The neglect of the underlying disease, in which the patient hesitated to contact the doctor, which led to very severe symptoms of the disease.

These procedures are indicated for patients with heart defects (regardless of whether they are congenital or acquired). Moreover, thanks to current techniques, this disease can be treated even in newborn babies, thereby providing them with a healthy life.

The next common indication is myocardial ischemia. In this case, surgery may be required when the underlying disease is aggravated by a heart attack. In this condition, the sooner surgery is performed, the greater the chance that the person will survive.

A significant indication for the need for surgical intervention can be acute heart failure, which provokes abnormal contraction of the myocardial ventricles. At the same time, it is important that the patient prepares for the operation in advance (to avoid postoperative complications in the form of a blood clot).

Often, surgery is required for myocardial valve disease, which was triggered by trauma or an inflammatory process. Rarely, other causes contribute to its appearance.

A serious reason for the urgent intervention of surgeons is the diagnosis of narrowing of the coronary valve of the artery, as well as endocarditis of infectious origin.

Additional conditions that may require a person to have myocardial surgery include:

Severe aortic aneurysm, which may result from trauma or be congenital.
Rupture of the ventricle of the heart, because of which the blood flow was disturbed.
Various types of arrhythmias that can be eliminated by inserting or replacing an already installed pacemaker. They are commonly used for atrial fibrillation and bradycardia.
Diagnosis of an obstruction in the myocardium in the form of tamponade, due to which the heart cannot pump the required volume of blood normally. This condition can occur under the influence of viral infections, acute tuberculosis and heart attack.
Acute insufficiency of the left ventricles of the myocardium.

Cardiac surgery is not always necessary for the above indications. Each case is individual and only the attending physician can decide what is best for a particular patient - traditional drug therapy or a planned (urgent) operation.

In addition, it should be noted that heart surgery may be required in case of exacerbation of the underlying disease, as well as if the first surgical intervention did not give the expected results. In this case, the patient may need to repeat manipulation. Its cost and preparation features (diet, medication) depend on the complexity of the operation.

Surgical interventions can be practiced both on the open myocardium and on the closed one, when the heart and its cavity are not completely affected. The first type of operations involves dissection of the chest and connecting the patient to artificial respiration equipment.

During open-type operations, surgeons artificially stop the heart for a while, so that within a few hours they can perform the necessary surgical procedures on the organ. These interventions are considered very dangerous and traumatic, but even very complex myocardial diseases can be eliminated with their help.

Closed type operations are more secure. They are usually used to correct minor heart and vascular defects.

There are the following most common types of myocardial operations, which are most often practiced in cardiac surgery:

Installation of artificial valves.
Operations according to the method of Glenn and Ross.
Coronary artery bypass grafting and stenting of arteries.
Ablation of radiofrequency type.

An operation called radiofrequency ablation is a low-traumatic procedure that allows you to achieve significant improvements in heart failure and various types of arrhythmias. It rarely causes side effects and is well tolerated by patients.

RA is performed using special catheters that are inserted under X-ray control. The patient is then given local anesthesia. During this operation, a catheter is inserted into the organ and, thanks to electrical impulses, the normal heart rhythm is restored to the person.

The next type of surgery is prosthetic heart valves. This intervention is very often practiced, since such a pathology as myocardial valve insufficiency is extremely common.

It should be noted that in the event of a severe failure in the patient's heart rhythm, he may need to install a special device - a pacemaker. It is needed to normalize the rhythm of the heart.

When prosthetic heart valves can be used the following types of implants:

Mechanical prostheses that are made of metal or plastic. They serve for a very long time (for several decades), however, they require a person to constantly take drugs to thin the blood, because due to the introduction of a foreign object in the body, a tendency to form blood clots actively develops.
Biological implants are made from animal tissues. They are very durable and do not require special preparations. Despite this, patients after a couple of decades often require a second operation.

Glenn and Ross operations are commonly used to treat children with congenital myocardial defects. The essence of these interventions is to create a special connection for the pulmonary artery. After this operation, the child can live for a long time, with little or no need for maintenance therapy.

During the Ross operation, the patient is replaced by a diseased myocardial valve with a healthy one, which will be removed from his own pulmonary valve.

Cardiac bypass surgery: indications and conduct

Coronary artery bypass grafting is a surgical intervention on the heart, during which an additional vessel is sewn in order to restore the disturbed blood supply in the clogged blood arteries.

Cardiac bypass surgery is practiced when the narrowed vessels of the patient are no longer amenable to drug treatment and the blood cannot circulate normally in the heart, causing ischemic attacks.

A direct indication for cardiac bypass surgery is acute coronary aortic stenosis. Most often, a neglected form of atherosclerosis leads to its development, which contributes to clogging of blood vessels with cholesterol plaques.

Due to vasoconstriction, blood cannot circulate normally and deliver oxygen to myocardial cells. This leads to its defeat and the risk of a heart attack.

Today, heart vessel bypass surgery can be performed both on a beating heart and on an artificially stopped one. At the same time, it should be noted that if shunting is done on a working myocardium, then the likelihood of postoperative complications is much higher than when performing a procedure on a stopped myocardium.

The course of this operation consists in blocking the main aorta and implanting artificial vessels into the affected coronary arteries. Usually, a vessel in the leg is used for shunting. It is used as a biological implant.

Contraindications to this surgical intervention may be an existing pacemaker or an artificial valve in the heart, the functions of which may be impaired during such an operation. In general, the need for shunting is determined individually by the doctor for each individual patient, based on the diagnostic data and the patient's symptoms.

After bypass surgery, the recovery period is usually fast, especially if the patient does not have any complications after the procedure. Within a week after the operation, the patient must comply with bed rest. Until the stitches are removed, a person needs to do wound dressings daily.

After ten days, a person can get out of bed and begin to perform simple movements of physiotherapy exercises in order to restore the body.

After the wound has completely healed, the patient is advised to go swimming and walk regularly in the fresh air.

It should be noted that the wound after shunting is not sewn with threads, but with special metal staples.. This is justified by the fact that the dissection falls on a large bone, so it needs to grow together as carefully as possible and ensure peace.

To make it easier for a person to move around after the operation, he is allowed to use special medical support bandages. They look like a corset and perfectly support the seams.

After surgery, due to blood loss, a person may experience anemia, which will be accompanied by weakness and dizziness. To eliminate this condition, the patient is advised to eat right and enrich his diet with beets, nuts, apples and other fruits.

To reduce the likelihood of re-constriction of blood vessels, alcohol, fatty and fried foods should be completely excluded from the menu.

The operation of stenting of the vessels of the heart: indications and features of the conduct

Arterial stenting is a low-traumatic angioplasty procedure, which involves the imposition of a stent into the lumen of the affected vessels.

The stent itself is similar to a conventional spring. It is injected into the vessel after it has been artificially dilated.

Indications for cardiac stenting surgery are:

IHD (ischemic heart disease), which leads to impaired blood circulation and oxygen starvation of the myocardium.
Myocardial infarction.
Clogging of blood vessels with cholesterol plaques, which lead to a narrowing of their lumen.

Additional contraindications to this procedure are the patient's individual intolerance to iodine, which is invariably used during stenting, as well as the case when the total size of the diseased artery is less than 2.5 mm (in this case, the surgeon simply cannot install the stent).

An operation is performed to stent the vessels of the heart by introducing a special balloon that will expand the lumen of the diseased vessel. Further, a filter is installed in this place, which prevents subsequent blood clots and stroke.

After that, a stent is inserted into the vessel; it will support the vessel from narrowing, serving as a certain frame.

The surgeon monitors the entire course of the operation through a monitor. At the same time, he will see the stent and the vessel well, since even at the beginning of the procedure, the patient is injected with an iodine solution, which will reflect all the actions of the surgeon.

The advantage of stenting is that this operation has a low risk of complications. Moreover, it is performed under local anesthesia and does not require a long period of hospitalization.

After stenting, the patient must remain in bed for a certain time (usually for a week). After that, if there are no complications, the person is allowed to go home.

It is very important to exercise regularly after this operation. At the same time, it is worth controlling your condition and not allowing physical overwork.

Every two weeks after the procedure, the patient must necessarily come to the doctor and undergo a follow-up examination. When pain occurs, a person should immediately report it to the doctor.

To recover faster, the patient should take all the drugs prescribed by the doctor. Sometimes drug therapy lasts a long time, more than one month in a row.

Be sure to follow a dietary diet after stenting.

It provides for the following:

Complete abstinence from alcohol and smoking.
Ban on all animal fats. Also, you can not eat caviar, chocolate, fatty meat and sweet confectionery.
The basis of the diet should be vegetable soups, fruit mousses, cereals and greens.
You need to eat at least six times a day, but at the same time, portions should not be large.
You should completely limit the consumption of salt and salted fish.
It is important to drink plenty of fluids to maintain normal water balance in the body. It is recommended to drink fruit compotes, juices and green tea. You can also use a rosehip decoction.

In addition, a person needs to control their blood pressure and blood sugar levels. This is especially important in the presence of already existing hypertension and diabetes, because these diseases can worsen the functioning of the heart.

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