Cardiothoracic Procedures Vocabulary

Thoracic Surgery

Primary focus is the lungs, including treatment of chest wall deformities and identification of lesions within the mediastinum.

Surgical procedures include:

• Bronchoscopy

• Mediastinoscopy

• Thoracoscopy

• Thoracotomy

• Lobectomy

• Decortication of the lung

• Lung transplant

• Pectus excavatum repair

• Pulmonary embolectomy

Instrumentation for Thoracic Procedures

Instruments needed to remove a rib (e.g., Bethune rib shears and Matson rib stripper/elevator) and expose and repair the organs of the thorax.

Thoracotomy requires a vascular instrument set and thoracotomy instrument set.

• Atraumatic Clamps: Facilitate surgery within the thoracic cavity, including the heart, lungs, and chest.

• Retractors: Actively separate the edges of a surgical incision or wound in the thoracic area.

• Rib Shears: For opening the chest wall during thoracic surgery.

• Rib Cutters: For cutting through the ribs prior to lifting off the chest plate.

Equipment Required

• ESU

• Cell saver

• Suction system

• Fiberoptic headlight

• Fiberoptic light source

• Defibrillation unit

• May need Prefusion

Anesthesia Monitoring Equipment

• Swan-Ganz and arterial catheters

• Arterial blood gases (ABG’s)

• Electrocardiography equipment

• Oxygen saturation equipment

• Temperature/blood pressure equipment

• Double-lumen endotracheal tube

Thoracic Surgical Procedures

Mediastinoscopy

A procedure used to examine the mediastinum, the space behind the breastbone (sternum) in the middle of the chest, between the 2 lungs, using a lighted, tube-like instrument called a mediastinoscope which may also have a lens for viewing and a cutting tool.

• Diagnostic tissue sampling

• Mediastinal lymph node biopsy

• Staging of tissue, nodes, and metastasis

Pulmonary Thromboendarterectomy

an operation that removes organized clotted blood from the pulmonary arteries, which supply blood to the lungs.

Video-Assisted Thoracic Surgery (VATS)

A type of surgery for diagnosing and treating a variety of conditions involving the chest area (thorax) using small incisions in the chest and inserting a small tube called a thoracoscope through one of the incisions.

Variety of conditions, including lung: cancer, cysts, blebs, biopsies and effusions and heart conditions: cancer, blood clots, and biopsies

Complications: air leaks, collapsed lungs, and bleeding

Bronchoscopy

A technique used to look at your air passages with a small camera that is located at the end of a flexible tube used to diagnose and treat lung problems such as tumors, airway blockages, inflammation, and infections.

Pneumonectomy

Surgical removal of an entire lung to remove lung masses and growths, such as non-small cell lung cancer, COPD, Tuberculosis (TB), Traumatic lung injury, and Congenital lung disease

Nuss Pectus Excavatum Repair by VATS

Makes a sunken chest, called pectus excavatum- malformation of the chest wall in which several ribs and the sternum (breastbone), grow abnormally, resulting in a caved-in, or sunken appearance.

• congenital deformity and occurs more often in males than in females

• present at birth, the condition may also develop during puberty and can range from mild to severe

• not completely understood, the condition is believed to arise from excessive growth of the cartilage connecting the ribs to the breastbone, which pulls the sternum inward

• compromise lung and heart capacity

• bar pushes your breastbone forward to flatten your chest. While the bar is in place, it helps your breastbone grow in the right way.

Lobectomy

A surgery to remove one or more lobes of the lungs that can be used to treat benign and malignant lung diseases such as Lung cancer, Infection, COPD, Benign tumors, Tuberculosis (TB), Lung abscess, and Emphysema.

Decortication of the Lung

A type of surgical procedure performed to remove a fibrous tissue that has abnormally formed on the surface of the lung, chest wall or diaphragm.

Conditions include Chronic empyema thoracis (pyogenic or tubercular), Hemothorax, Pleural thickening, Pneumonia, Iatrogenic infection after pleural tap, Septicaemia, Pleural mesothelioma.

Lung Transplant

Is a surgical procedure to replace a diseased or failing lung with a healthy lung, usually from a deceased donor; single or double.

83–88% of patients are alive one year after a transplant, and 55–60% are alive five years after.

Anatomy and Physiology of the Heart

Role of the Heart

Essential for blood circulation, carries waste substances away from cells to excretory organs for elimination, and brings vital nutrients and oxygen from the respiratory and digestive organs to cells throughout the body.

The Heart Wall Layers

• Epicardium

• Myocardium

• Endocardium

The Heart Chambers

Two atria and two ventricles.

Blood Flow Through the Heart: Pathway

From the vena cava → right atrium → tricuspid valve → right ventricle → pulmonary arteries → lungs.

From the lungs → pulmonary veins → left atrium → mitral valve → left ventricle → aorta → to the body.

Blood Supply for the Heart

Right and left coronary arteries with supplemental branches for each.

The Heart Valves

/

• Atrioventricular valve

• Tricuspid valve

• Pulmonary semilunar valve

• Mitral valve

• Aortic semilunar valve

• Chordae tendineae

Cardiac Conduction

Cardiac conduction system coordinates the events of the cardiac cycle.

Specialized areas of tissue transmit electrical impulses throughout the myocardium for the rhythmical activity of the heart:

• SA node (pacemaker)

• AV node

• Bundle of His

• Purkinje fibers

• Sympathetic and parasympathetic division

Routine Instrumentation, Equipment, and Supplies

Most cardiac procedures require the same instrumentation, equipment, and supplies; specialty items are added that are unique to the procedure.

• Instrumentation: Cardiac instrument set

• Equipment/Supplies page 723 in Alexanders

• Refer to text for a list of routine equipment page 721 in alexanders

Technique of Cardiopulmonary Bypass

CPB: heart-lung machine is used to remove unoxygenated blood from the venous system, oxygenate it, and return it to the arterial system.

The pump generator allows the heart to be stopped so that cardiac procedure can be performed. It also allows the lungs to be deflated for better exposure of the heart and vessels.

Grafts

• Intracardiac patches- meshes, fabrics, felts, tapes, and suture

• Teflon

• Fluorocarbon fiber

• Dacron- polyester fiber – knitted and woven

• Heart valves- either synthetic materials or animal or human tissue

Mechanical Valves

Made from durable synthetic materials like graphite and pyrolytic carbon, these valves can last up to 30 years. However, patients who receive mechanical valves must take blood thinners for the rest of their lives.

Biological Valves

Made from animal or human tissue, these valves usually last 10–15 years. Biological valves made from animal tissue are often sourced from pigs or cows, but can also be made from human tissue, which are then called homograft valves. To prevent rejection, the tissue is treated before being used. Biological valves have a lower risk of blood clots than mechanical valves, but they do tend to wear out over time and may need to be replaced

Synthetic graft

Considerations for Cardiac Surgery

Cardiac surgery is typically performed in the largest room of the OR suite or in heart center.

Cardiac patient may come from the cardiac care unit on an ICU bed with monitoring lines in place.

Occasionally, the patient will be brought over from the cardiac catheterization lab (cath lab).

Patients bought from the cath lab will have a sheath still inserted in the femoral artery. This catheter will be removed by the surgeon and the site closed with suture.

An A-line (arterial line) or central line will most likely be placed.

• Arterial lines are inserted into an artery — the blood vessels that carry blood away from the heart.

• Central lines (and all IVs) are inserted into a vein — the blood vessels that carry blood back to the heart

Adult Cardiac Surgery

Coronary Artery Bypass Graft (CABG)

also known as heart bypass surgery, is a cardiac surgical procedure that improves blood flow to the heart

Valve Replacement

involves removing a faulty or damaged valve and replacing it with a new valve made from synthetic materials or animal tissue.

Heart valve replacement surgery can be performed using different techniques and approaches, including:

• Open heart surgery : A traditional approach that involves a 6–8 inch incision through the breastbone

• Minimally invasive surgery : A smaller incision of 3–4 inches or less, using endoscopic, keyhole, robotic, or other techniques

• Transcatheter : A catheter is inserted into a large artery, such as the femoral artery in the groin, to perform the procedure without making a chest incision

Heart Transplant

is an operation in which a failing heart is replaced with a healthier donor heart.

Orthotopic heart transplant procedure involves a median sternotomy with removal of the recipient's heart and the insertion of the donor heart in the normal anatomic position.

Performed on patients with end-stage heart failure or severe coronary artery disease when other medical or surgical treatments have failed.

Survival rates: 90% after one year and about 80% after five years for adults.

Ventricular Aneurysm Repair

an incision in the chest (sternotomy), removes the weakened area of the ventricle wall, and then sews the walls of the ventricle back together

PTCA Procedures

are performed in the cath lab with a surgical team standing by in case an emergency open heart procedure is required.

Intra-aortic balloon pump (IABP), a mechanical device that helps the heart pump more blood by controlling blood flow. It's a thin, flexible tube called a catheter with a long balloon attached to the tip that's placed in the aorta, about 2 centimeters from the left subclavian artery. The balloon inflates during diastole and deflates during LV systole, which corresponds with the middle of the T-wave and the peak of the R-wave on an ECG waveform. This indirectly increases cardiac output by reducing afterload and increasing diastolic aortic pressure, which improves diastolic blood flow and perfusion to peripheral organs

MID-CAB

Minimally invasive direct CAB (MIDCAB) surgery is typically performed when the arteries (left anterior descending (LAD)) at the front of the heart are blocked.

Off-Pump Coronary Artery Bypass (OPCAB)

also called “Beating Heart” surgery a coronary artery revascularization that is performed on a beating heart.

Intra-Aortic Balloon Pump (IABP)

a type of therapeutic device. It helps your heart pump more blood. You may need it if your heart is unable to pump enough blood for your body.

Ventricular Assist Device (VAD) Insertion

are mechanisms that help the heart pump enough blood, enabling patients with end-stage heart failure to live longer and feel better.

Pediatric Cardiac Procedures

Precautions

• Preoperative preparation

• Pediatric cardiac instruments are smaller and more delicate

• Pediatric patients are at greater risk of hypothermia, therefore, OR temperature is generally raised

• Blood loss should be closely monitored by the surgical team because of the pediatric patient’s low blood volume

Repair of ASD

to close an atrial septal defect (ASD). An ASD is a hole in the heart between the two upper chambers.

Repair of VSD

similar to ASD: repairs an abnormal hole between the left and right ventricles of the heart

Closure of Patent Ductus Arteriosus (PDA)

closed with surgery or by catheter. A PDA allows blood to flow between the aorta and the pulmonary artery, leading to an increase in flow in the lung circulation.

happens when a blood vessel called the ductus arteriosus doesn’t close as it should after birth

Repair of Coarctation of the Aorta

Coarctation of the aorta is a narrowing of the aorta.

The most common repair involves resection (removal) of the narrowed area with anastomosis (reconnection) of the two ends to each other. Sometimes the resection (removal) must be extended towards the arch if there is a longer piece of narrowing. In another method, the narrowing may be opened with a patch. Or a portion of an artery may be used as a flap to expand the area (called a subclavian flap aortoplasty).

Repair of TOF (Repair of Tetralogy of Fallot)

our related heart defects change the way blood flows to the lungs and through the heart. TOF is repaired through open -heart surgery soon after birth or later in infancy. Surgery to repair tetralogy of Fallot is done to improve blood flow to the lungs and to make sure that oxygen- rich and oxygen-poor blood flows to the right places.