Heart Surgery - Medical specialists

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Heart Surgery - Further information

Cardiac surgery background

Cardiac surgery and open heart surgery have now obtained an established role in the treatment of heart disease. A wide range of surgical methods are used for the treatment of cardiac disease. These include such frequent operations as bypass or mitral valve surgery. Less common are rhythm surgery or corrections of congenital heart defects.

The heart is the organ that keeps the body alive. The beating and pumping of the heart keeps the blood in motion. In this way, all the organs can be supplied with blood and therefore also with energy. In addition the blood transports oxygen in and out and disposes of other waste products.

This brief summary of the extremely important organ the heart demonstrates what fatal consequences cardiac disease can have for the human body.

Particularly also anatomic congenital heart defects in terms of cardiac construction that to a great extent determine the functioning of the heart. The correction of such congenital heart defects, for example, is in the area of work of paediatric cardiac surgery and can include particularly complex cardiac surgical procedures.

When is cardiac surgery indicated?

Cardiac surgery includes several complex procedures that can treat serious heart disease or congenital heart defects. In this way the total functioning of the human organism can be maintained and improved, because heart disease can have significant consequences. If, for example, coronary heart disease (CHD) cannot be treated through a change in habits or medication, the cardiac surgeon must be called in. With regard to coronary heart disease, for example, a narrowed vessel is removed so that the blood can once again be pumped through the heart and the body without obstruction.

Techniques of cardiac surgery

The techniques of cardiac surgery can vary considerably and depend to a great extent on the disease in question. In any case both a cardiologist and an expert in cardiac surgery must be involved in a case of heart disease so that it can be assessed and treated optimally. The cardiac surgery specialist can then correct the relevant problem.

Most cardiac surgical interventions take place in the context of major, invasive surgery. In this way, all the structures involved as well as the complex operative field can be visualised. Normally, during such surgery the heartbeat is suspended and the human cardiovascular system placed on an artificial heart-lung machine.

The use of the heart-lung machine can currently only be omitted during minimally invasive cardiac procedures. So-called minimal heart surgery can only be performed by decidedly expert cardiac surgeons, since this only allows a small field of view and demands extreme precision work within the thorax.

A detailed example of cardiac surgery - the aortocoronary bypass operation

Aortocoronary bypass surgery is among the most frequent operative interventions in cardiac surgery. This operation is carried out when narrowing in the coronary vessels is difficult to treat either medically or interventionally (through balloon catheter dilatation). In some instances, aortocoronary bypass surgery can now even be done while the heart is beating, that is to say without the use of the heart-lung machine.

When is aortocoronary bypass surgery indicated?

Bypasses are one of several treatment options for restricted coronary vessels (coronary stenosis). Most responsible for coronary stenosis is arteriosclerosis. In response to increasing narrowing of the coronary vessels, an imbalance occurs between the supply and demand of oxygen (coronary insufficiency) and thus shortness of breath and tightness in the chest (angina pectoris). A sudden closure can cause a myocardial infarction.

Stenoses of the coronary vessels can be treated in various ways. In many cases, medications or percutaneous transluminal coronary angioplasty (PTCA, balloon dilatation), possibly with additional stent implantation, can achieve sufficient success. The dilatation of a narrowed vessel by a balloon takes place in the context of coronary catheterisation studies and represents a possibility worth considering above all in cases of short, easily accessible stenoses without marked curvature. If, on the other hand, the patient has several or long restrictions or coronary stenoses at difficult to access locations, above all aortocoronary bypass surgery is usually used. An operation may also be indicated if PTCA and stent implantation have not led to the desired result or there have been recurrences at the treated locations. Serious hepatopathy or pulmonary disease can contra-indicate the bypass operation.

In aortocoronary bypass surgery the stenoses are not dilated or corrected but bridged through a bypass connection. If narrowing is present over a very long distance, there is the chance that no bypass can be connected or that it closes right away, so that once again medical treatment must be used.

Which specialist carries out aortocoronary bypass surgery?

The specialist for cardiac surgery is responsible for bypass surgery on coronary vessels.

Various procedures for coronary bypass surgery

Various methods are available for bridging restrictions or closures in coronary vessels.

During the actual aortocoronary bypass, a piece of the Vena saphena (leg) or - less frequently - the Arteria radialis (arm) is taken. One end of the artery or vein is connected to the relevant vessel, the other end to the Aorta ascendens, so that a bridging of the narrowed point is effected and the blood can flow normally once again.

Alternatively, the Arteria mammaria (inside of the chest wall) can be used for bridging. In a closer context we are not speaking here of aortocoronary bypass but, correctly, of arteria-mammaria-bypass. For reasons of simplicity, however, this is often referred to as aortocoronary bypass. In this procedure the artery is not completely removed, but only freed up from the inner chest wall and connected to the relevant vessel.

This method is preferred as often as possible today, since it has a lower re-stenosis rate, above all in comparison with venous bypass. Under certain conditions the Arteria-mammaria bypass can also be undertaken in a minimally invasive manner, so that only a small incision is required. So-called minimal surgery.

Aortocoronary bypass operation on the resting and beating heart

Classically, the aortocoronary bypass operation is carried out with the aid of the heart-lung machine (HLM) on the resting heart empty of blood. This means that for the period of the operation the heart and lungs are stopped and the heart-lung machine takes over both the pumping function of the heart and the gas exchange function of the lungs.

These days some aortocoronary bypass operations are also possible on the beating heart, that is to say without using the heart-lung machine. This procedure, however, is technically more demanding and requires a surgeon and experts in cardiac surgery with appropriate training.

After aortocoronary bypass surgery

After aortocoronary bypass surgery the patient recovers relatively rapidly. He can already stand up and walk around after one to three days. To an extent, his transfer to secondary medical care is even possible some ten to twelve days after bypass surgery.

Serious complaints after the operation are rare. During the first period after the aortocoronary bypass surgery, there may be a feeling of pulling in the chest and shoulder area. This can be helped by physiotherapy.

Bypass narrowings or complete closures are possible. It continues to apply after aortocoronary bypass surgery to rule out all risk factors for arteriosclerosis. Medications that inhibit coagulation can be used to help keep the bypasses open.

After aortocoronary bypass surgery, regular (annual) control follow-up visits should take place in order to identify and treat narrowings of the bypasses or the patient’s own coronary vessels.

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