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SandhyaK.Balaram
LeviBassin
Cardiac Surgical
Complications
Strategic Analysis and Clinical Review
Cardiac Surgical Complications
SandhyaK.Balaram • LeviBassin
Cardiac Surgical
Complications
Strategic Analysis andClinical Review
SandhyaK.Balaram
Department of Cardiothoracic Surgery
New York-Presbyterian
Brooklyn Methodist Hospital
Weill Cornell Medicine
New York, NY, USA
LeviBassin
Royal North Shore Hospital
St. Leonards, NSW, Australia
ISBN 978-3-030-71562-5 ISBN 978-3-030-71563-2 (eBook)
https://doi.org/10.1007/978-3-030-71563-2
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or
part of the material is concerned, specically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microlms or in any other physical way, 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 exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed
to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty,
expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been
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This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Dedicated to those who trust us with their lives -
our families
our patients
vii
Countless amounts of vital information and advice are transmitted between experienced car-
diac surgeons and their residents during the thousands of hours they spend together in the
training environment. Given the importance of surgical outcomes, many of these conversations
revolve around complications. Pointed discussions of both potential and actual complications
are shared in the operating room, on the ward, and in the clinics. However, it is often the inten-
sity of discussion, exchanged during scheduled Morbidity and Mortality conferences, that is
ultimately remembered and internalized. This education, of course, does not end with the com-
pletion of residency and subsequent board certication.
It is well understood that decreased external distractions, balanced decision-making, and good
communication help in the prevention of medical errors. Human factors play a key role in surgi-
cal outcomes, and a deeper understanding of prevention and treatment strategies helps avoid
future catastrophes. It is frequently said that if a surgeon operates on a large number of patients
throughout his or her career, nearly every complication will be experienced rsthand. This is an
overwhelming thought for a young surgeon, particularly as decreased case volume and work
hours act in tandem to diminish overall operative experience in training programs. In addition,
not all cardiac surgery occurs in large academic centers, where options for 24-h a day intensive
care specialists and immediate mechanical ventricular support are available. Prevention, particu-
larly in these environments with few bailout options, is mandatory for good outcomes.
The purpose of this book is to provide structured knowledge regarding recognized dangers
and pitfalls in the eld of cardiac surgery. A sharp and prepared mind must accompany techni-
cal skill. The book takes a “premortem” approach: a focus on complications in cardiac surgery
as a method of surgical preparation. Detailed, relevant, and memorable narratives provide sce-
narios that may perhaps replace experienced events, particularly for those just starting a career
in cardiac surgery. Dramatic crises, survival checklists, technical pearls, basic science funda-
mentals, and strategic algorithms help rmly establish key surgical concepts. It is likely that
young surgeons working with experienced colleagues have already heard some variation of
these scenarios.
Cardiac surgery requires constant strategic thinking in a mentally and physically challenging
environment. Reviewing complications to understand their prevention and treatment is a method
of harnessing the experience of others. In addition to the technical and nontechnical elements of
actual surgical procedures, human factors and time-sensitive decision-making play a signicant
role in outcomes. This is a specialty that strives for perfection with data-driven focus. However,
there remain certain elements over which there is little control. Crisis scenarios in cardiac sur-
gery have benetted from the development of checklists and algorithms to create systematic
treatment of several possible events. For a surgeon, crisis prevention with similar models is
helpful, particularly in settings where limited backup assistance is available.
Published data tells us up to one-third of deaths after coronary surgery are potentially pre-
ventable. More importantly, the majority of events that occur during an operation may often be
repaired without any noticeable effect on the patient. This critical information suggests that a
resilient surgeon who is knowledgeable and exible could carry on with a successful operation
even after an initial unexpected event. A classic tenet of heart surgery, of which there are many,
is that it is not the rst unexpected event that harms the patient. Rather, harm often lies in the
Preface
viii
repair of injury, or the result of that repair, or even a further, more far-reaching result that
occurs in the postoperative period. This cause-consequence is a key part of failure analysis.
The rebalancing of the boat in a critical surgical situation is either lifesaving or devastating.
Careful decision-making after early recognition of an error results in improved outcomes;
every decision thereafter must be aimed at increasing this chance. Cardiac surgical decisions
are made under strict time constraints and with serious consequences, both immediate and long
term. It is essential to keep unexpected events in perspective.
High risk, coupled with life-protecting high stress, have led to comparisons between cardiac
surgery and the airline industry. Both are elds in which unpredictable human error occur.
Another similarity to high-consequence elds is that the familiarity of the same team working
repetitively towards the same goal improves outcomes by both reducing teamwork failure and
technical errors. Multiple complex factors contribute to the work itself, and analysis has led to
the creation of models to improve patient safety. Furthermore, in the modern era, extensive
data collection has been used to identify both surgeons and systems at risk.
Cardiac surgery has traditionally been compared to chess with its need for planned stepwise
strategy, calm reactivity, constant reassessment, and time-sensitive decision-making. Similar
to chess, all the information or rules are theoretically known prior to proceeding with an opera-
tion. Every move should yield a certain result. Sometimes subtle information about the patient,
their hemodynamics, and the environment are being processed while the surgeon is deciding
on the next move. These mental gymnastics occur whether a procedure is 30min or 12 h long,
and certainly account for the more mental than physical fortitude that is required. Given this
variability, it is helpful to invoke the dictum of “playing a bad hand well.” This concept exem-
plies much of modern cardiac surgery, in which an intrinsically complex patient population
with multiple comorbidities undergoes treatment in a complex environment. It is imperative to
focus energy on careful preparation and smooth execution of operations, all the while prepar-
ing for unexpected issues that occur in real time.
Suboptimal outcomes affect more than just the patient and their families, as cardiac sur-
geons who have sat through decades of arduous morbidity and mortality conferences will
attest. The truth is, many of these conferences are not about which needle to use, the size of
stitch to place and where, or other mundane technical aspects of surgery. Rather, it is often
judgment and decision-making that comprise the forefront of the discussion. Medical errors
may be due to misinterpretation of information, poorly structured planning, or improper
choices. Knowledge or system failures in the medical environment are not always individual
issues, but team based. These challenging surgical situations, which are composed of constant
anxiety and stress, are aided by an intuitive knowledge that promotes reasoning and minimal
emotion with every decision made.
As a profession constantly striving towards perfection, cardiac surgery requires experience
accompanied by maturity. To that end, crafting calm responses to events in the operating room
is a critical skill. Given the high stakes involved, this can be very difcult at times. There is
much to be learned; the simple act of thorough case review by an individual or group builds
experience, knowledge, and intuition, even for completed successful cases. Formal thinking
through each step of an operation leads to constant renement and improvement.
Surgery is a focused exercise at its core, the goal of which is the right operation at the right
time and in the right manner. Solid thought processes, repetitive safe actions, standardized
reactions, and constant information gathering, all require attention to detail. The surgeon’s life
revolves around prevention, prompt detection, and management of recovery of unexpected
crises. All of these may occur normally during a single operation. The creation of a habit of
considering and preparing for complications will ultimately improve both decision-making
and outcomes.
New York, NY, USA SandhyaK.Balaram
St. Leonards, NSW, Australia LeviBassin
Preface
ix
We would like to express our gratitude and acknowledgment to Dr. Paul Cullen, an advanced
cardiac surgery fellow at Royal North Shore Hospital in Australia, who kindly assisted with the
writing and preparation of the minimally invasive cardiac surgery chapters
Acknowledgment
xi
The ancient Stoic idea of premeditatio malorum, clearly visualizing what can go wrong in
order to prevent that particular outcome, is an effective technique in preparing for cardiac sur-
gery. There are an endless number of harmful events that have the potential occur in these
settings, at virtually any large or small step of the operation. Even the initial skin incision can
result in harm to a patient. Negative visualization of potential intraoperative problems prior to
a specic procedure helps ensure that each step is safe and carefully considered. Sound
decision- making and anticipation of outcomes are vital concepts in surgery.
Unexpected critical events disrupt the ow of an operation and cost time, sometimes vital
time, during ischemic arrest. Psychological preparation for rare events such as air embolism or
postoperative myocardial infarction is lifesaving in cardiac surgery. Education and experience
allow for preparation and help avoid reactive decision-making in these situations.
This book is divided into chapters which emphasize the multifaceted nature of this spe-
cialty, as well as the impact of cardiac surgery on all organ systems. Some of these complica-
tions are extremely rare, and others are more common. The narrated sequence of case events
presented are not actual but are realistic. The scenarios are written in a manner to help focus
the surgery team of when to be aware, when to be cautious, and when to be substantially pre-
pared for problems. The formal reviews of each complication also describe possible prevention
and treatment. Included in each section are basic science, useful strategies, structured plans,
and immediate actions. This book is not just a list of potential complications, it is an alternative
way of thinking about cardiac surgical procedures that will help to improve outcomes.
This text is neither bedside manual nor formal textbook; it is based on the idea that the
anticipation of a bad outcome can lead to a good outcome.
The scenarios and format are inspired by Near Misses in Cardiac Surgery, published in
1992 by Myles Edwin Lee (Butterworth-Heinemann, Newton MA). Although the narrative
surgical scenarios are not similarly written in second person (nor with the same dramatic air),
it is our goal that they are current, relevant, meaningful, and memorable in expanding the
reader’s experience. This is a simple guide to prepare for war in times of peace, aim for excel-
lence, and create connections and conclusions that are critical in cardiac surgery. We consider
the book as a starting point in the development of technical and mental patterns that promote
successful surgery in a complex environment.
About this Book
xiii
1 Cardiac Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Introduction to Median Sternotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Paramedian Sternotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.3 Tracheal Laceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.3.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.4 Carotid Artery Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.4.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.5 Introduction to Minimal Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.6 Mini-Sternotomy: Bleeding and Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.6.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.7 Right Anterior Mini-Thoracotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.7.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.8 Lung Herniation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.8.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.9 Reoperative Cardiac Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.9.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2 Cardiopulmonary Bypass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.1 Introduction to Cardiopulmonary Bypass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.2 Heparin Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.2.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.3 Cold Agglutinin Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.3.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.4 Coronary Sinus Rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.4.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.5 Persistent Left Superior Vena Cava . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.5.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.6 Air Embolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.6.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.7 Surgical Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.7.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.8 Inferior Vena Cava Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.8.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.9 Protamine Reaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.9.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.10 Right Ventricular Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2.10.1 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Contents
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