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limited by the sub-aortic bar beneath the non-coronary cusp. In an attempt to override this
problem, Marion Ionescu, surgeon at Leeds Inrmary, developed the use of pericardium.
Again, working with his wife, he made the rst pericardial valves. The orice area was considerably greater than with a porcine valve. The initial valves began to fail early as the suture lines
had been placed outside the stent posts and were tearing with the exing of the valve. Once this
problem had been resolved, the valve has gone on to be an established and excellent valve with
excellent haemodynamics and durability. There have been many iterations of tissue valve technology, but these two valve types remain dominant. The advice of Dr. Kirklin, “choose a valve
that has been around for a long time and use it for a long time”, rings very true (Personal
communication).
In the ensuing years, all aspects of valve and congenital surgery have developed apace,
alongside the developments in cardio-pulmonary bypass, intensive care and rened
diagnosis.
Perhaps later than might be expected, surgery for coronary artery disease developed in the
mid-1960s led by Dr. René Favaloro at the Cleveland Clinic. In 1910, Alexis Carrel, Nobel
Prize winner in Physiology or Medicine in 1912, had demonstrated that a vascular graft from
the descending aorta to the left main coronary artery was feasible and that it could be useful in
the management of syphilitic (the usual cause at that time) ostial coronary artery stenosis.
Despite this development in vascular surgery by Carrel in the early part of the twentieth century, it took half a century before coronary surgery became of age as an applicable operation.
In 1958, W.P.Longmire anastomosed the internal mammary artery to a coronary artery that
fell apart whilst attempting endarterectomy. Before this, in 1952, Vladimir Demikhov, the
pioneering transplant surgeon, had done the same operation successfully in Moscow, but as a
result of the communication blackout between the USSR and the USA, his work was not discovered until sometime later.
The advancement of the procedure relied on the development of coronary visualisation. In
1958, Mason Stones inadvertently injected radio-opaque dye into the right coronary artery of
a patient where the intent was to visualise the ascending aorta. Fearing the worst, Sones was
mightily relieved when the patient’s heart, which had paused for a long moment, began to beat
again. Inadvertently, this was the birth of coronary angiography.
Once the coronary arteries could be visualised, surgery could be planned with accuracy
paving the way for safe coronary artery bypass surgery, at one stage the most commonly performed operation in the modern world. Arterial revascularisation, using the internal mammary
artery, began with the Vineberg procedure. Arthur Vineberg of McGill University began this
work in 1946. The internal mammary artery was mobilised and ligated distally. The proximal
end was buried in a tunnel in the muscle of the left ventricle. Unlike free bleeding into a skeletal muscle where a large haematoma would form, this did not happen in the myocardium
which seemed to soak up the blood like a sponge. In 1950, he operated on the rst human
patient, who remarkably, 3 years later, reported feeling well and able to walk 10 miles through
the bush without symptoms. He began a programme of treatment, which included wrapping
the heart denuded of epicardium with mediastinal fat or greater omentum. Using the new
Sones angiography, he later showed that 70–80% of patients produced identiable anastomoses with the coronary circulation and with a mortality of only 2%.
Direct anastomosis of the internal mammary artery to an obstructed coronary artery was
described by Kolessov in 1967 and George Green in 1968. The success of this operation
began the widespread dissemination of the practice of coronary artery bypass surgery or colloquially referred to as CABG.René Favaloro then popularised saphenous vein grafting to
extend the utility of the procedure in patients with multi-vessel disease.
Corrective surgery of the aorta began with the introduction of the Dacron tube graft by Dr.
Michael DeBakey. Several materials, mainly nylon based, were tried as tube grafts but none
were successful. DeBakey discovered Dacron in a department store in Houston. It was sold as
backing for turn-ups on trousers and other dressmaking techniques. His mother was a seamstress and taught him how to create a tube graft. He then produced his own tube graft and
Preface
Preface
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bifurcation grafts. A patient of DeBakey’s happened to be a sock manufacturer, and following
a conversation with him about knitting they went on to develop the machine and plant to make
knitted Dacron grafts. This same process is used today. Initially, these grafts had to be soaked
in the fresh blood of the patient to form clots within the weave allowing the graft to be implanted
without catastrophic haemorrhage. In these modern times, the grafts are pre-coated with collagen and albumin, and pre-clotting is no longer needed.
A development that caused massive general interest in our speciality was the development
of heart transplantation. Seen from the perspective of Theodor Billroth, who berated even the
idea of surgery of any kind on the heart, this step was seen by many contemporary physicians,
ethicists and theologians as a step too far. The mystic quality of the heart and the need for
another human being to be deprived of their own heart in the state of brain death were viewed
as repugnant and a modern form of cannibalism. The facts of the matter however were very
different. Serious scientic work around, selection criteria, immunosuppression in the recipient and surgical management meant that by the early 1960s, laboratory work was showing
signicant promise. The outstanding problem however was that of satisfactory immunosuppression. Strides had been made in renal transplantation by Murray in Boston and Calne in
Cambridge, but there is of course a profound difference between renal and cardiac transplantation. A failed renal transplant can be replaced with dialysis. There was no such meaningful
long-term support for the ailing heart.
Once again, a leader in the eld by decades was Demikhov in Moscow, who had also transplanted the heart of a dog into another, which on the sixth day post-operatively managed to
climb the stairs of the Kremlin, before expiring with rejection a few days later. He also transplanted the head of a puppy to another dog which functioned for several days.
Norman Shumway in Stanford University had had been working tirelessly to develop the
procedure and to try to understand the process of rejection. A major step forward was the simplication of the operation of implantation. He modied the procedure from attempting to
anastomose all pulmonary veins, cavae and great vessels to the use of atrial cuffs and great
vessels. With this, he made good progress in the laboratory. However, he realised that immunosuppression was not yet t for purpose.
Enter the charismatic South African surgeon Christiaan Barnard and his brother Marius.
Barnard had spent time with Lillehei in Minneapolis and performed well leaving a good
impression. On his return to Groote Schuur in Cape Town, his position was secured, and he
returned for a period with Shumway picking up their technology. Without announcing his
intentions, he returned to South Africa, precipitously gathered a team around him and performed the world’s rst successful heart transplantation on Louis Washkansky, a diabetic with
terminal heart failure. The news circled the globe, and Barnard became a surgical superstar
overnight, featuring on the cover of Time magazine as well as almost every other respectable
publication in every country.
The inevitable happened, and suddenly every “self-respecting” cardiac surgeon “had a go”
with catastrophic results. The rst in the UK was by Donald Ross at the National Heart
Hospital. Some early successes were reported, but most patients succumbed to rejection from
days to weeks after surgery. The result of this was a moratorium on further attempts in the UK
in the early 1970s. There was one small but most important shining light of persistence in
California. Norman Shumway and his team continued to work steadily with improving results.
During the decade of the 1970s, much was learnt to the extent that a relaunch of the procedure
became viable in 1979. In January of that year, Sir Terence English and his team at Papworth
Hospital in Cambridge began his programme, which despite the lack of adequate funding but
with detailed and determined efforts began to yield good results. Others followed. Then another
breakthrough came with the introduction of the new and game-changing immunosuppressant
cyclosporin A.
This was followed quite quickly by the transplantation of the heart-lung block for patients
with cystic brosis and end-stage pulmonary hypertension by Shumway’s team once again.
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Contemporary results are excellent with 98% one year and 92% 5 years with a median survival
of 10 years. This once outlawed procedure had become mainstream.
As can be seen from this brief review, the early development of this important speciality
frequently revolved around personal household experience and happenstance. As things have
progressed, more science and engineered technology have been used to the point of sophistication that we know today.
More recently, the mechanical articial heart as a bridge to transplantation and a permanent
replacement has made slow but steady progress. The percutaneous insertion of replacement
heart valves moves ahead at a fast pace, and the treatment of coronary artery disease has
become truly hybrid with evidence-based integration of transcatheter techniques of angioplasty and stenting with the judicious use of coronary bypass surgery.
The story will not end here, and the next 70 years of development of cardiac disease treatment promises to be just as exciting as the rst.
References
1. Harken D.Foreign bodies in and in relation to the thoracic blood vessels and the heart. Surg
Gynaecol Obstet. 1946; 83:117–25.
2. Arora R, Nair M, Kalra GS, Nigam M, Khalilullah. Immediate and long-term results of
balloon and surgical closed mitral valvotomy: a randomised study. Am Heart J.
1993;125(4):1091–4.
3. Gott V. Cross-circulation: a milestone in cardiac surgery. J Thorac Cardiovasc Surg.
2004;127(3):617.
Preface
Suggested Reading
• Forrester J.The Heart healers. Mists, Mavericks and rebels who created the greatest medi-
cal breakthrough of our lives. St Martin’s Press; 2015. ISBN 978-1-250-05839-3.
• Morris T. A history of the heart in eleven operations. Penguin Random House. ISBN
9781847923912.
• Westaby S, Bosher C.Landmarks in cardiac surgery. Oxford UK: Isis Medical Ltd. ISBN 1
899066 54 3. 1997
Cambridge, UK FrancisC.Wells
Contents
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Part I Ischaemic Heart Disease
1 Coronary Artery Bypass Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Samer A. M. Nashef
2 Off Pump Coronary Artery Bypass Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Rizwan Q. Attia and Ravi J. de Silva
3 Surgical Treatment of Complications of Acute Myocardial Infarction:
Postinfarction Ventricular Septal Defect and Free Wall Rupture . . . . . . . . . . . . . 13
Choo Ng
4 Complications of Myocardial Infarction: Papillary Muscle Rupture . . . . . . . . . . 19
Francis C. Wells
Part II Valve Surgery: Aortic Valve Surgery
5 Timing of Heart Valve Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Madalina Garbi
6 Surgery for Aortic Valve Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Ismail Vokshi and Steven Tsui
7 Aortic Root Enlargement Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Rizwan Q. Attia, Shakil Farid, and Steven Tsui
8 Valve Sparing Aortic Root Replacement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Rizwan Q. Attia and Ravi J. de Silva
9 Minimally Invasive Aortic Valve Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Rizwan Q. Attia and Shakil Farid
Part III Valve Surgery: Mitral Valve Surgery
10 Surgical Access to the Mitral Valve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Francis C. Wells and Narain Moorjani
11 Surgical Correction of Degenerative Mitral Valve Disease . . . . . . . . . . . . . . . . . . . 63
Francis C. Wells
12 Surgery of Rheumatic Mitral Valve Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Francis C. Wells
13 Mitral Valve Infective Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Narain Moorjani
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Part IV Valve Surgery: Tricuspid Valve Surgery
14 Tricuspid Valve Disease Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Narain Moorjani, Francis C. Wells, and Samer A. M. Nashef
15 Tricuspid Valve Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Narain Moorjani
Part V Surgery of the Aorta
16 Aortic Arch and Ascending Aorta Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Ravi J. de Silva
Part VI Surgery of the Failing Heart
17 Cardiopulmonary Transplantation: An Overview . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Marius Berman
18 Lung Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Pradeep Kaul, Lu Wang, and Mohamed Osman
19 Orthotopic Heart Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Ahmed Al-Adhami and Steven Tsui
Contents
20 Heart-Lung Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Muhammad U. Raq and Steven Tsui
21 Mechanical Circulatory Support and DCDD Heart Transplantation . . . . . . . . . . 155
Stephen Large and John Onsy Louca
Part VII Pulmonary Thromboendarterectomy
22 Pulmonary Endarterectomy Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
David P. Jenkins
Part VIII Pericardial Disease
23 Pericardiectomy for Constrictive Pericarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Jason Ali
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Contributors
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AhmedAl-Adhami, MBChB (Hons) MRCSEd Department of Cardiothoracic Surgery and
Transplantation, Royal Papworth Hospital, Cambridge, UK
Jason Ali, MA (MedEd), PhDm, FRCS Department of Cardiothoracic Surgery, Royal
Papworth Hospital, Cambridge, UK
RizwanQ.Attia, MS, MD, PhD, FRCS(C-Th) Department of Cardiothoracic Surgery and
Transplantation, Royal Papworth Hospital, Cambridge, UK
Marius Berman, MD, FRCS (CTh) Royal Papworth Hospital NHS Foundation Trust,
Cambridge, UK
ShakilFarid, FCPS (Surgery), FRCS (C-Th), MBA Department of Cardiothoracic Surgery
and Transplantation, Royal Papworth Hospital, Cambridge, UK
Madalina Garbi, MD, MA, FRCP Department of Cardiology, Royal Papworth Hospital,
Cambridge, UK
DavidP. Jenkins, FRCS, MS (Lond), FRCS (CTh) Department Cardiothoracic Surgery,
Royal Papworth Hospital, Cambridge, UK
PradeepKaul, FRCS (CTh) Royal Papworth Hospital, Cambridge, UK
StephenLarge, FRCS (CTH), MRCP, MBA, PAE (RCP) Department of Cardiac Surgery,
Royal Papworth Hospital, Cambridge, UK
JohnOnsyLouca, FRCOG, MSc Gonville & Caius College, Cambridge, UK
NarainMoorjani, MB ChB, MRCS, MD, FRCS (CTh), MA Department of Cardiothoracic
Surgery, Royal Papworth Hospital, Cambridge, UK
Samer A. M. Nashef, MB, ChB, FRCS, PhD Department of Surgery, Royal Papworth
Hospital, Cambridge, UK
ChooNg, MB BCh FRCS (CTh) Department of Cardiothoracic Surgery, Royal Papworth
Hospital NHS Foundation Trust, Cambridge, UK
MohamedOsman, MD, PhD Transplant Surgery, Royal Papworth Hospital, Cambridge, UK
Muhammad U. Raq, FRCS C-Tha Department of Cardiothoracic Surgery and
Transplantation, Royal Papworth Hospital, Cambridge, UK
RaviJ. de Silva, MBBS, MRCS (Ed), MS, FRCS (CTh) Department of Surgery, Royal
Papworth Hospital NHS Foundation Trust, Cambridge, UK
StevenTsui, MD, FRCS (Eng), FRCS(C-Th) Department of Cardiothoracic Surgery and
Transplantation, Royal Papworth Hospital, Cambridge, UK
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IsmailVokshi Department of Cardiothoracic Surgery and Transplantation, Royal Papworth
Hospital NHS Foundation Trust, Cambridge, UK
LuWang Transplant Surgery, Royal Papworth Hospital, Cambridge, UK
FrancisC.Wells Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
Royal Papworth Hospital, Cambridge University Group of Hospitals, Cambridge, UK
Contributors
Part I
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Ischaemic Heart Disease
Coronary Artery Bypass Grafting
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SamerA.M.Nashef
1
In 1964, Vasilii Kolesov carried out the rst coronary artery
bypass grafting (CABG) operation using the left internal
mammary artery (LIMA) to graft the left anterior descending
(LAD) in St Petersburg. Three years later, René Favaloro
performed a similar operation at the Cleveland Clinic using a
saphenous vein graft. Half a century after this pioneering
work, CABG is now one of the most frequently performed
surgical operations in the world. Despite increasing competition from percutaneous intervention, CABG remains a phenomenal success story, unparalleled in its remarkable dual
ability to eliminate symptoms and extend life, both of which
are achieved at a very low risk of mortality which should be
less than 1% overall.
The standard version of CABG, and the one that features
in the overwhelming majority of operations, consists of
grafting the LAD with the LIMA and using saphenous vein
grafts for other coronary arteries, with the operation being
performed on cardiopulmonary bypass, a cross-clamped
aorta and cold blood cardioplegia. Myriad alternatives to this
have been proposed, such as total arterial revascularisation,
minimal access approaches, video-assisted and robotic surgery, hybrid revascularisation, and off-pump CABG, with a
variety of claims to better short-term and long-term outcomes. These approaches are performed successfully in
many centres, but have not yet supplanted the standard operation which will be the central theme of this chapter. I shall
describe the steps taken to bypass the three major coronary
arteries (the left anterior descending (LAD), the right or posterior descending coronary artery (PD), and the major obtuse
marginal (OM) branch of the circumex).
Procedure
Preparation
After sternotomy, the LIMA is taken down. Using a retractor
that elevates the left hemisternum, the LIMA is harvested as
a pedicle, with surrounding veins and soft tissue, taking care
not to injure it or even touch it. This can usually be achieved
using only diathermy and blunt dissection, but occasionally
metal clips may need to be used for large side branches. It is
important that the entire length of the artery is taken down,
especially proximally, so that the graft lies posterior to the
left lung for the most direct route to the LAD.The LIMA is
then left attached to the circulation at both ends while preparations are made for cardiopulmonary bypass. During the
LIMA harvest, the long saphenous vein is taken from the
lower leg, starting at the ankle and going up to just above the
knee to secure sufcient length for two grafts, or further if
additional grafts are contemplated.
Once heparin has been given and the bypass cannulae are
in place, the LIMA is divided distally and checked for good
ow before applying a bulldog clamp. The vein is checked
for leaks, calibre and overall suitability as a conduit. Bypass
is then instituted, and the next few minutes are spent in planning the operation by identifying and preparing the target
coronary arteries, so that there are no surprises once the aorta
is clamped. A 15 blade is used to divide any epicardial fat
over each target. Inspection and palpation ensure that there is
no atheroma or calcium at the planned anastomotic site. The
aorta is then clamped, and cardioplegic solution is infused
into the aortic root. With the heart stopped, the cardioplegic
cannula is attached to a pump sucker, but this should be
switched off before any coronary is opened, to prevent damage to the back wall of the artery on arteriotomy.
S. A. M. Nashef (*)
Department of Surgery, Royal Papworth Hospital, Cambridge, UK
e-mail: sam.nashef@nhs.net
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
F. C. Wells (ed.), Atlas of Cardiac Surgery, Springer Surgery Atlas Series, https://doi.org/10.1007/978-3-031-43195-1_1
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Distal Anastomoses
Usually, the right coronary or its PD branch is done rst.
Access is made easier by dropping any left-sided pericardial
stay sutures and rotating the heart away from the surgeon
with a couple of moist swabs tucked in behind the right pulmonary veins. The already prepared anastomotic site is
entered with a sharp, pointed blade, or diamond knife. The
aortic root suction can now begin. The arteriotomy is
extended with ne Potts scissors or similar. An arteriotomy
of around 5–7mm is usually sufcient.
The technique I shall describe for the distal anastomosis
is my own, but has the distinction of having been invariably
adopted by every trainee who has been through Papworth in
the last 30years, so that it is now in very widespread use. It
is also time-efcient and, on a good day, with favourable
access and no snags, a distal anastomosis can be completed
in less than 7min.
Once the heart has been correctly positioned and the arteriotomy has been made, the surgeon holds the end of the vein
with the adventitia pinched between thumb and forenger.
The scrub nurse passes the surgeon a 7/0 double-ended polypropylene suture mounted on a ratchetless Castro-type needle holder with a small rubber-shod mosquito forceps
clamped on the other end of the suture and held by the nurse.
(Note: ratcheted needle holders can also be used, but the
ratchet slows the procedure down, jerks the needle while in
the tissues and prevents the use of the SEXI techniques [1].)
The rst suture is through the vein, outside-to-in, 1mm from
the heel on the surgeon’s side.
The surgeon then withdraws the suture and while pulling
it through, the nurse brings the other end held by the mosquito to lie on the chest wall just lateral to the right sternal
retractor blade (Fig.1.1). A fold in the surgical drape helps
prevent the mosquito falling to the side.
The surgeon then takes the coronary 1mm from the heel,
inside-to-out, picks up the needle, and takes the heel of the
vein outside-to-in (Fig.1.2), then the heel of the artery, then
the vein 1mm beyond the heel, and similarly the artery. We
now have three loops of suture joining the heels of vein and
artery (Fig.1.3). Pulling only on the active suture end, the
vein is brought down until it touches the artery. Then pulling
on the suture is stopped, and the vein is drawn away to take
up any slack in the loops. This is repeated till the vein and
the artery are together (this method prevents sutures from
slicing through either the coronary or the conduit: one
should never pull simultaneously on suture and conduit). At
this point, the fold in the surgical drape is straightened out
and the mosquito clip allowed to fall gently under gravity so
as to keep the artery open with its opposing walls away from
each other.
S. A. M. Nashef
Fig. 1.1 The start of a distal anastomosis: the rst pass takes the conduit one stitch from the heel, outside-to-in. As your hand is holding the
conduit, be sure to pick up the needle ready for the next stitch in the
coronary artery and avoid having to remount
Fig. 1.2 The second suture in a distal anastomosis: take the coronary
artery one stitch from the heal, inside-to-out. Similarly, pick up the
needle in situ ready for the next stitch in the conduit
Fig. 1.3 The three heel sutures are in, and the conduit should be ‘parachuted’ down onto the coronary artery in stages. Pull only on the active
end of the suture, and never pull on conduit and suture simultaneously,
to avoid the suture cutting through either vessel
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