Cardiac Surgery in KAUH Advances & Hopes

Introdoction

Cardiac surgery is well known as a fine sophisticated art that requires the cooperation of different multidisciplinary services. These included -Well trained and experienced cardiac surgeons, -Noninvasive and interventional cardiologists, -Cardiac anesthesia and intensive care unit (ICU). -The availability of professional nursing staff especially in the operating room, -ICU and the wards is very crucial. -Also Physiotherapy, -Blood bank -Surgical subspecialties are important supportive services for this highly demanding and comprehensive surgery.

Although cardiac surgery in KAUH started on 28 th Feb only one case weekly till may 2006 then irregularly 2 cases weekly until now, most variable techniques in adult cardiac surgery were performed including very high risk & challenging cases. Although cardiac surgery in KAUH started on 28 th Feb only one case weekly till may 2006 then irregularly 2 cases weekly until now, most variable techniques in adult cardiac surgery were performed including very high risk & challenging cases.

Surgery for coronary artery disease in KAUH CABG (coronary artery bypass graft) was done for ( 220 IHD cases ) Many cases were suffering from one or more of risk factores : Old age:>70 years -Females. - Acute coronary syndrome - Diabetes mellitus - Hypertension - Cerebrovascular accident - Dyslipidemia. - Renal impairment

Advances in CABG 1-Combined CABG+ valve surgery : This a very high risk complex operation done in 4 cases with excellent results without morbidity or mortality. 2- Combined CABG+ repair of left ventricular pseudoaneurysm : A 65 years old male admitted with NSTEMI. Transesophageal echocardiography showed posterior left ventricular aneurysm.

Cardiac catheterization revealed three coronary vessel disease and inferobasal bulge shadow. Intra operatively, there was a localized saccular inferobasal aneurysm,, about five cm in diameter.

On cardiopulmonary bypass and after cross clamping, the aneurysm was incised,clots evacuated and the the left ventricular defect was exposed.It measured about two X three cm (C),also notice the proximity of the defect to posterior papillary muscle of the mitral valve

The left ventricular cavity was washed with cold saline.Teflon patch was used to close the defect using continuous 000 polypropelene suture(D).Distal coronary bypass was done to the posterior descending,obtuse marginal,diagonal arteries using saphenous vein and the internal mammary artery to the anterior descending.The patient was weaned of cardiopulmonary bypass,on minimal inotropic support,after proper air evacuation. Postoperative course was straightforward and the patient was discharged home well

Pathophysiologically, pseudoaneurysms are usually contained left ventricular rupture post myocardial infarcions.The wall is composed of epicardium and usually filled with clots. Histopathoolgy did not show any signs of infection.

Surgery for valvular heart diseases Valve surgery ( 59 cases) -Mitral valve surgery : 23 cases -Combined Mitral valve surgery + tricuspid valve surgery : 10 cases. -Aortic valve replacement : 19 cases. -Combined Mitral valve surgery + tricuspid valve surgery + Aortic valve replacement : 2 cases -Combined Mitral valve surgery + Aortic valve replacement : 5 cases.

Rheumatic aortic valves Normal aortic valve

Different types of prosthetic valve

Advances in valve surgery A new method for repairing of tricuspid valve by autologous pericardial strip : 4 cases of sever tricuspid regurge secondary to mitral valve disease were repaired by using the pericardium of the patient to the keep the valve more physiologic rather than the old conventional techniques.

Conventional techniques of tricuspid valve repair : 1- Suture repair technique

2-OR prosthetic ring insertion

While in KAUH we use the autologous pericardium of the patient to repair the tricuspid valve

Operative field in cardiac surgery

Operating room for cardiac surgery

Noncardiac cases Noncardiac cases : PDA surgical ligation (7). : Pacemaker insertion. : Oesophageal enteric cyst excision. : AAA repair ( 2 ). : PA banding. : Fem-Pop bypass graft.

PACEMAKER INSERTION IN 30 DAYS OLD INFANT

PRE OP. POST OP. TERATOMA EXCSTION IN 17 Y OLD GIRL

C-T chest of 17 ys old girl showing Teratoma

SVC Aneurysm  CXR of 50 years old female

C-T chest of the same patient

C-T chest of 31 y old female with enteric cyst of the esophagus

RESULTS One case postoperative mortality Successes rate 98 % Mortality rate 2 %

MORBIDITY ( 1 ) Perioperative MI:- 4 cases - ↑ cardiac enzyme & troponin 3 cases - S-T changes 4 cases - S-T changes 4 cases - New Q wave 2 cases - New left bundle block 2 cases

(2) Postoperative bleeding ( Re-exploration) ( No Patients need re-exploration). ( No Patients need re-exploration). Avarage total drain : 370 ml Avarage blood given : 2 unit Avarage ffp given : 3 unit Avarage plat. Given : 2 unit

(3) Post operative Arrhythmia - Atrial fibrillation : 3 cases, all regained SR - Heart block : No cases - PVCs : 2 cases - Bigeminy : one case - V. T( NS ) : one case - V. F : No case

(4) Wound infection - Superficial wound infection in 5 cases, With frequent dressing healed within one With frequent dressing healed within one week. week. -One case of deep leg wound infection. -No cases of Deep sternal wound infection - No cases of mediastinitis

(5) Low cardiac output -Occurs in 3 cases:- - 2 cases Need IABP. - One case Need LVAD.

(6) Postoperative DVT One case P/ CABG developed DVT in unusual site, axillary & brachial veins, unusual site, axillary & brachial veins, (predisposed by central line insertion) (predisposed by central line insertion) - Readmitted to hospital and treated medically, - Improved and discharged.

Successful case of ascending aortic aneurysm repair  A 43 y old Indonesian man  12cm asc aortic aneurysm  Congestive heart failure  Renal and liver impairment

Ruptured interventricular septum  65 years male post acute anterior M.I.  Cardiogenic shock requiring I.A.B.P +Inotropes  Emergency open heart  Transventricular incision  Transventricular incision  Pericardial patch repair Teflon sheet enforced ventricular closure

- ICU stay : 2 – 6 days Mean 3 days - Hospital stay: 7 – 23 days Mean 11 days Mean 11 days

Surgery of the ascending aorta

Follow up All patients are followed up regularly in out patient clinic

FUTURE OF CARDIAC SURGERY IN KAUH 1- Increase the OR days up to 3 days weekly 2- Plan to sit Cardiac surgery for pediatrics 3- Private cases 4-Expand cardiology 5- Haematology clinic for valve patients

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