1. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 1

2. 2 CHAPTER 22 Cardiothoracic Surgery

3. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 3 Objectives After studying this chapter, you will be able to: –Recognize the relevant anatomy of the cardiovascular and respiratory systems –Summarize the pathology that prompts cardiac or thoracic surgical intervention and the related terminology –Determine any special preoperative diagnostic procedures/tests for the patient undergoing cardiac or thoracic surgery

4. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 4 Objectives (cont’d.) –Determine any preoperative preparation procedures –Indicate the names and uses of cardiovascular and thoracic equipment, instruments, and supplies –Summarize the surgical steps of the cardiac and thoracic procedures –Interpret the purpose and expected outcomes of the cardiac and thoracic procedures

5. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 5 Objectives (cont’d.) –Recognize the immediate postoperative care and possible complications of the cardiac and thoracic procedures –Assess any specific variations related to the preoperative, intraoperative, and postoperative care of the patient undergoing a cardiac or thoracic procedure

6. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 6 Part I: Thoracic Surgical Procedures Introduction –Thoracic surgical procedures Primary focus is the lungs Includes treatment of chest wall deformities and identification of lesions within the mediastinum

7. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 7 Diagnostic Procedures and Tests Imaging studies used in diagnosis of thoracic diseases and disorders –Standard X-rays Anteroposterior (AP) and lateral –CT scanning and MRI Useful for evaluation of pericardial and intracardiac masses –Pulmonary angiography Primarily used to detect pulmonary embolism and other blockages

8. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 8 Diagnostic Procedures and Tests (cont’d.) Other useful diagnostic procedures for the evaluation of cardiac disease –Electrocardiography –Echocardiography –Cardiac catheterization

9. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 9 Instrumentation, Routine Equipment and Supplies Instrumentation –Thoracic procedures: instruments needed to remove a rib (e.g., Bethune rib shears and Matson rib stripper/elevator) and expose and repair the organs of the thorax –Thoracotomy: vascular instrument set and thoracotomy instrument set Refer to Tables 22-1 and 22-2

10. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 10 Instrumentation, Routine Equipment and Supplies (cont’d.) Anesthesia monitoring equipment –Swan-Ganz and arterial catheters –Electrocardiography equipment –Oxygen saturation equipment –Temperature equipment –Blood pressure equipment –Double-lumen endotracheal tube Supplies –Refer to text for a list of routine supplies

11. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 11 Thoracic Surgical Procedures Include: –Bronchoscopy –Mediastinoscopy –Video-assisted thoracic surgery (VATS) –Nuss pectus excavatum repair by VATS –Pulmonary thromboendarterectomy –Decortication of the lung –Upper lobectomy –Pneumonectomy

12. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 12 Part II: Adult Cardiac Surgical Procedures Introduction –Cardiac surgery is typically performed in the largest room of the OR suite Must accommodate a larger number of OR personnel and equipment –Cardiac patient may come from the cardiac care unit on an ICU bed with monitoring lines in place Occasionally, the patient will be brought over from the cardiac catheterization lab

13. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 13 Diagnostic Procedures and Tests Useful diagnostic procedures for the evaluation of cardiac disease –Chest X-ray –CT scan and MRI –Electrocardiography –Echocardiography –Electrophysiology studies –Cardiac catheterization –Arteriograms

14. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 14 Routine Instrumentation, Equipment, and Supplies Most cardiac procedures require the same instrumentation, equipment, and supplies –Specialty items are added that are unique to the procedure Instrumentation –Cardiac instrument set: refer to Table 22-3 Equipment –Refer to text for a list of routine equipment

15. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 15 Anatomy and Physiology of the Heart Role of the heart within the cardiovascular system –Essential for blood circulation Carries waste substances away from cells to excretory organs for elimination Brings vital nutrients and oxygen from the respiratory and digestive organs to cells throughout the body

16. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 16 Anatomy and Physiology of the Heart (cont’d.) Location of the heart –Refer to Figure 22-15 Coverings of the heart –Refer to Figure 22-16 The heart wall: layers –Epicardium, myocardium, and endocardium The heart chambers –Two atria and two ventricles

17. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 17 Anatomy and Physiology of the Heart (cont’d.) The heart valves –Atrioventricular valve –Tricuspid valve –Pulmonary semilunar valve –Mitral valve –Aortic semilunar valve –Chordae tendineae

18. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 18 Anatomy and Physiology of the Heart (cont’d.) Blood flow through the heart and blood supply for the heart –Refer to text for detailed description Cardiac conduction –Cardiac conduction system coordinates the events of the cardiac cycle Specialized areas of tissue transmit electrical impulses throughout the myocardium for the rhythmical activity of the heart

19. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 19 Anatomy and Physiology of the Heart (cont’d.) Techniques of cardiopulmonary bypass: refer to Figures 22-17 through 22-20 –Aortic cannulation –Venous cannulation –Left ventricular vent placement via the left atrium

20. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 20 Adult Cardiac Surgical Procedures Include: –Coronary artery bypass with grafting (CABG) –MID-CABG –OPCAB –Intra-aortic balloon pump (IABP) –Ventricular assist device (VAD) insertion –Orthotopic heart transplant –Ventricular aneurysm repair –Aortic valve replacement

21. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 21 Mitral Valve Replacement Procedure is similar to aortic valve replacement –Decision to replace the mitral valve depends on the severity of symptoms Graded by New York Heart Association method Mitral valve can be either repaired or replaced –Refer to text and Figures 22-32 and 22-33

22. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 22 Mitral Valve Replacement (cont’d.) Technique –Replacement of the mitral valve with a prosthesis –Refer to text and Figure 22-34

23. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 23 Part III: Pediatric Cardiac Procedures Introduction –Surgical procedures for repair of congenital heart defects Repair of atrial septal defect (ASD) and ventricular septal defect (VSD) Closure of patent ductus arteriosus (PDA) Repair of coarctation of the aorta Repair of tetralogy of Fallot (TOF)

24. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 24 Part III: Pediatric Cardiac Procedures (cont’d.) Preoperative preparation –Pediatric cardiac instruments are smaller and more delicate –Pediatric patients are at greater risk of hypothermia, therefore, OR temperature is generally raised –Blood loss should be closely monitored by the surgical team because of the pediatric patient’s low blood volume

25. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 25 Pediatric Cardiac Procedures Include: –Repair of ASD –Closure of patent ductus arteriosus (PDA) –Repair of coarctation of the aorta –Repair of TOF

26. ©2014 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 26 Summary This chapter reviewed: –Anatomy of the cardiovascular and respiratory systems –The pathology that prompts cardiac or thoracic surgical intervention –Diagnostic procedures and tests –Cardiovascular and thoracic equipment, instruments, and supplies –Cardiac and thoracic surgical procedures