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Essentials
ofOperative
Cardiac Surgery
PrakashP.Punjabi
PanagiotisG.Kyriazis
Editors
SecondEdition
123
Essentials of Operative Cardiac Surgery
Prakash P. Punjabi
Panagiotis G. Kyriazis
Editors
Essentials of Operative
Cardiac Surgery
Second Edition
Editors
Prakash P. Punjabi
National Heart and Lung Institute
Faculty of Medicine, Imperial College
London
London, England, UK
Department of Cardiothoracic
Surgery
Hammersmith Hospital
Imperial College Healthcare NHS Trust
London, UK
Panagiotis G. Kyriazis
National Heart and Lung Institute
Faculty of Medicine, Imperial College
London
London, England, UK
Department of Cardiothoracic
Surgery
Hammersmith Hospital
Imperial College Healthcare NHS Trust
London, UK
ISBN 978-3-031-14556-8 ISBN 978-3-031-14557-5 (eBook)
https://doi.org/10.1007/978-3-031-14557-5
© Springer Nature Switzerland AG 2015, 2022
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specically the rights of translation, reprinting, reuse of
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and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specic statement, that such names are
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The publisher, the authors, and the editors are safe to assume that the advice and information in
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the authors or the editors give a warranty, expressed or implied, with respect to the material
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neutral with regard to jurisdictional claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Preface
“The life so short, the craft so long to learn.”—Hippocrates of Kos (460–370 BC)
aka Father of Medicine was a Greek physician, one of the most outstanding gures
in the history of Medicine
According to the World Health Organization, around 7.2 million men and
women die every year from coronary heart disease (CHD), which is the leading cause of cardiovascular death worldwide [1, 2]. In Europe, CHD accounts
to approximately 1.95 million deaths yearly of which over 66,000 are in the
UK and over 53,000 of those are in England alone [1–3]. It has also been
estimated that 2.3 million people live with CHD in the UK of which 1.9 million people are in England [1, 3]. Considering the UK has a population of
approximately 67 million, it has been deduced that 3.7% of the UK population is suffering from CHD.
The number of heart disease cases accelerated in early 2000, thereafter
recent advances in primary prevention coupled with percutaneous intervention for acute myocardial infarction which stabilised and gradually declined
the morbidity rate [3]. Associated with this decline, a rise in valvular heart
disease has compensated in maintaining the total number of cardiac surgery
procedures in adults. Multiple studies and guidelines have recommended
ongoing improvement of techniques minimising risks to maintain and
enhance safety. Currently, it is estimated that more than one million cardiac
operations are performed each year worldwide with the use of the heart-lung
machine, more specically in the UK 35,158 cardiac surgeries were performed in 2015 [4]. In most cases, the operative mortality is quite low,
approaching 1% for some operations [5].
Inspired by cardiac surgery and driven to simplify the charm of surgical
principles, the goal of this book is to provide surgeons the necessary tools
with review of techniques along with tips and tricks to netune and excel
their skills in an ever-expanding eld of adult cardiac surgery. The second
edition offers the readership an opportunity to widen their repertoire by reading each chapter and introductory literature review, major technical essentials
and conclude with the results and long-term outcomes. The Philosophy of
Essentials of Operative Cardiac Surgery remains the same ‘keep simple cases
simple and turn complex cases into simple cases’.
“The important thing in science is not so much to obtain new facts as to discover
new ways of thinking about them.’’—Sir William Bragg (1862–1942), Physics
Nobel Laureate 1915, was a British physicist, chemist, and mathematician
v
vi
References
1. British Heart Foundation. England factsheet; April 2019.
2. Mackay J, Mensah G, eds. The atlas of heart disease and stroke. World
Health Organization, Geneva; 2004.
3. British Heart Foundation. UK Factsheet; April 2019.
4. The Society for Cardiothoracic Surgery in Great Britain & Ireland, Blue
Book Online.
5. Punjabi PP, Taylor KM. The science and practice of cardiopulmonary
bypass: from cross circulation to ECMO and SIRS.Global Cardiol Sci
Pract. 2013:32.
London, UK PrakashP.Punjabi
London, UK PanagiotisG.Kyriazis
Preface
Contents
1 Echocardiography in Adult Cardiac Surgery . . . . . . . . . . . . . . . 1
Rasa Ordiene, Karan P. Punjabi, and Egle Ereminiene
2 Cardiac Magnetic Resonance Imaging in Cardiothoracic
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Nikita P. Punjabi, Zahra Raisi-Estabragh,
and Gajen Sunthar Kanaganayagam
3 Systemic Inflammatory Response and Cardiopulmonary
Bypass. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Ahmet Rüçhan Akar, Bahadır İnan, Karan P. Punjabi,
and Sadettin Dernek
4 Basic Setup in Adult Cardiac Surgery . . . . . . . . . . . . . . . . . . . . . 69
Panagiotis G. Kyriazis, Guiqing Liu, Nikhil Sahdev,
and Prakash P. Punjabi
5 Coronary Artery Bypass Graft with Cardiopulmonary
Bypass. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Panagiotis G. Kyriazis, Habib Khan, Guiqing Liu,
and Prakash P. Punjabi
6 Off Pump Coronary Artery Bypass Grafting . . . . . . . . . . . . . . . . 89
Nikhil Sahdev, Osama Hamid, Panagiotis G. Kyriazis,
and Prakash P. Punjabi
7 Aortic Valve Repair/Replacement . . . . . . . . . . . . . . . . . . . . . . . . . 97
Panagiotis G. Kyriazis, Nikita P. Punjabi,
and Prakash P. Punjabi
8 Surgery for Mitral Valve Disease: Degenerative Repair . . . . . . . 107
Philip Hartley, Panagiotis G. Kyriazis, and Prakash P. Punjabi
9 Surgery for Mitral Valve Disease: Degenerative
Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Philip Hartley, Panagiotis G. Kyriazis, and Prakash P. Punjabi
10 Post Ischemic Mitral Regurgitation . . . . . . . . . . . . . . . . . . . . . . . 121
Alessio Giuseppe Vite, Panagiotis G. Kyriazis,
and Marco Moscarelli
vii
viii
11 Minimally Invasive Mitral Valve Repair/Replacement . . . . . . . . 133
Daniel Grinberg, Benoît Cosset, Matteo Pozzi,
and Jean François Obadia
12 Tricuspid Valve Repair/Replacement . . . . . . . . . . . . . . . . . . . . . . 145
Panagiotis G. Kyriazis, Antanas Macys,
and Prakash P. Punjabi
13 Cannulation Strategies for Aortic Root Surgery . . . . . . . . . . . . . 157
Ourania Preventza and Darrell Wu
14 Ascending Aortic Aneurysm Surgery . . . . . . . . . . . . . . . . . . . . . . 163
Edgar Aranda-Michel, Ibrahim Sultan, and Joseph E. Bavaria
15 Ascending Aortic Dissection Surgery . . . . . . . . . . . . . . . . . . . . . . 171
Ourania Preventza and Darrell Wu
16 Valve Sparing Aortic Root Procedure: Yacoub’s Procedure . . . . 177
Gopal Soppa, Rajdeep Bilkhu, Marjan Jahangiri,
and Magdi Yacoub
17 Valve-Sparing Aortic Root Surgery by the Reimplantation
Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Maral Ouzounian, Malak Elbatarny, and Tirone David
Contents
18 Coronary Artery Bypass Graft vs. Percutaneous
Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Donna Kimmaliardjuk and David Glineur
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Echocardiography inAdult Cardiac
Surgery
RasaOrdiene, KaranP.Punjabi,
andEgleEreminiene
1
Learning Objectives
• Understand the principles of echocardiogra-
phy in cardiac surgery as an essential guiding
tool
• Understand the role of each different technique
based on its sophistication and sensitivity
• Understand the process of assessing the infor-
mation gathered from each technique
• Understand how each technology can assist
and support the decision making process of a
surgeon
• Understand its necessity as a diagnostic tool in
adult cardiac surgery
R. Ordiene (*) · K. P. Punjabi
Department of Cardiology, Medical Academy,
Lithuanian University of Health Sciences,
Kaunas, Lithuania
e-mail: rasa.ordiene@lsmuni.lt
K. P. Punjabi
School of Medicine, St. George’s University of
London, London, UK
E. Ereminiene
Department of Cardiology, Medical Academy,
Lithuanian University of Health Sciences,
Kaunas, Lithuania
Institute of Cardiology, Lithuanian University of
Health Sciences, Kaunas, Lithuania
Introduction
Echocardiography has become the major imaging and diagnostic modality of cardiac diseases,
so all cardiac specialists, cardiologists and cardiac surgeons, need to know basic principles of
this investigation in order to make the right decisions in the management of the patients.
A complete transthoracic echocardiogram
(TTE) is routinely performed before any cardiac
surgical procedure. It consists of two- dimensional
(2D) anatomic imaging, M-mode, and three
Doppler techniques: pulsed-wave (PW),
continuous- wave (CW), and color-ow imaging
and provides a surgeon with information on the
dimensions, areas, and volumes of cardiac chambers, biventricular function, cardiac valve anatomy
and function, and pericardium. Currently available
new techniques—Doppler tissue imaging and
speckle-tracking echocardiography add very
important data about early changes of regional and
global myocardial dysfunction in surgery patients.
2D and 3D transesophageal echocardiography
(TOE) examination provides additional information in patients who are not optimally imaged by
the transthoracic approach. In addition, structures
that are not well visualized by TTE (left atrial
appendage, thoracic aorta, prosthetic valves) can
be assessed by the transesophageal approach. A
third indication is to guide intraoperative management during cardiac surgery. Class I indications for perioperative TOE are listed in Table1.1.
© Springer Nature Switzerland AG 2022
P. P. Punjabi, P. G. Kyriazis (eds.), Essentials of Operative Cardiac Surgery,
https://doi.org/10.1007/978-3-031-14557-5_1
1
2
R. Ordiene et al.
Table 1.1
• Acute and life-threatening hemodynamic instability
• Valve repair or complex valve replacements
• Hypertrophic obstructive cardiomyopathy
• Aortic dissection with possible aortic valve
• Endocarditis (perivalvular involvement)
• Congenital heart surgery
• Pericardial windows (posterior or located effusions)
• Placement of intracardiac devices
Class I Indications for perioperative TEE
involvement
TOE also may be useful in surgical procedures in
patients at risk of myocardial ischemia or hemodynamic instability, minimally invasive surgery,
or intracardiac mass resection, detecting intracardiac air or aortic atheromatous disease. According
to the guidelines, TOE should be used in all open
heart and thoracic aortic surgical procedures to
conrm the preoperative diagnosis, detect new or
unsuspected pathology, and to assess the results
of surgical intervention [1, 2].
In this chapter, we will highlight the applications of echocardiography on the following
topics, most relevant for cardiac surgeons: assessment of biventricular geometry and function,
mitral, tricuspidal, and aortic valve morphology
and function, evaluation of aorta, valve repair and
replacement results.
Assessment ofBiventricular
Geometry andFunction
LV Geometry, Global andRegional
Function
Evaluation of LV dimensions and function is essential for the preoperative assessment of the patient.
LV dilatation and systolic dysfunction, as well as
increased LV end-systolic dimension and volume
are important parameters in valvular surgery timing.
Internal dimensions can be obtained with a 2DE
guided M-mode approach, although linear measurements obtained from 2D echocardiographic images
are preferred. LV volumes are measured using 2DE
or 3DE.One of the advantages of 3D echocardiographic volume measurements is that they do not
rely on geometric assumptions, are accurate and
reproducible, closer to those obtained by cardiac
magnetic resonance (CMR) and should therefore be
used when available and feasible. LV size and volume measurements should be indexed to BSA. 2D
echocardiographic LV end diastolic volume index of
74ml/m2 for men and 61ml/m2 for women and LV
end systolic volume index of 31ml/m2 for men and
24ml/m2 for women are used as the upper limits of
the corresponding normal range. LV systolic function is assessed using 2DE or 3DE by calculating
ejection fraction (EF). LV EF of <52% for men
and<54% for women are markers of abnormal LV
systolic function [3]. Detailed assessment of LV systolic function is of great importance in patients with
severe valve regurgitation for surgery timing and
prediction of cardiac events. Surgery in patients with
asymptomatic severe MR is recommended when LV
dysfunction occurs (LVEF≤60% and/or LV
ESD≥40 mm). However, assessment of LV dysfunction by LVEF is often overestimated in MR
patients. New 2DE modalities, such as speckle
tracking echocardiography enables calculation of
global longitudinal LV strain (GLS). Reduced GLS
with > − 18.1% showed higher risk of composite
events in asymptomatic severe MR patients, and
diagnostic value in predicting a reduction in LVEF
of >10% with a resulting postoperative LVEF of
<50% (area under the curve, 0.93; P< .001 [4–6]
and patients with GLS>−19.5% were more likely
to have a shorter survival in asymptomatic patients
with aortic regurgitation patients who did not
undergo aortic valve replacement [7]. This indicates
the important value of myocardial longitudinal
deformation indices for surgery timing in severe aortic and mitral regurgitation patients (Fig.1.1).
Determination of regional and global LV systolic function is one of the most common indications of perioperative TOE examination. Quick
‘eyeballing’ of the overall LV systolic function
by an experienced observer in the operating room
correlate to quantitative measurements of LV
ejection fraction. Assessment of LV regional wall
motion abnormalities (RWMA) allows detection
of areas of myocardial asynergy and identies
coronary territories in compromise. Regional
wall motion analysis can be performed using the
ME four and two chamber and ME LAX views.
However, the TG midpapillary SAX view is of
great importance, as the myocardium in these
segments is supplied by the LAD, LCX and RCA
coronary arteries simultaneously (Fig.1.2). New
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