Kalp Cerrahisinin Prensipleri

Kalp Cerrahisinin Prensipleri

Dr. Rıza TÜRKÖZBaşkent İstanbul Hastanesi

Kalbin Anatomisi

Kalbin Anatomisi

Kalbin Anatomisi

MANAR ELKHOLY

Kalbin Anatomisi

Anatomic relationship between the aortic valve and surrounding structures.

Figure 5-18 Calcific aortic stenosis. (A) Calcification of an anatomically normal tricuspid aortic valve in an elderly patient, characterized by mineral deposits localized to the basal aspect of the cusps; cuspal free edges and commissures are not involved. (B) Congenitally bicuspid aortic valve, characterized by two equal cusps with basal mineralization. (C) Congenitally bicuspid aortic valve having two unequal cusps, the larger with a central raphe (arrow). (D and E) Photomicrographs of calcific deposits in calcific aortic stenosis; deposits are rimmed by arrows. Hematoxylin and eosin 15x. (D) Shows deposits with the underlying cusp largely intact; transmural calcific deposits are shown in (E). (A and B: Reproduced with permission from Schoen FJ, St. John Sutton M: Contemporary issues in the pathology of valvular heart disease. Hum Pathol 1987; 18:568. C: Reproduced with permission from Schoen FJ: Interventional and Surgical Cardiovascular Pathology: Clinical Correlations and Basic Principles. Philadelphia, WB Saunders, 1989.)

Figure 5-19 Major etiologies of mitral valvular disease. (A) Atrial view, and (B) subvalvular and aortic aspect of a valve from a patient with rheumatic mitral stenosis. There are severe valvular changes, including diffuse leaflet fibrosis and commissural fusion and ulceration of the free edges of the valve, as well as prominent subvalvular involvement with distortion (arrow in [B]). (C and D) Myxomatous degeneration of the mitral valve. In (C) (left atrial view), there is prolapse of a redundant posterior leaflet (p), whereas in (D) from another case, the opened annulus reveals a redundant posterior mitral leaflet (arrows), with thin elongated chordae tendineae. The patient with the valve shown in (D) had chronic mitral regurgitation with prolapse noted clinically, and Marfan syndrome. (Reproduced with permission from Schoen FJ: Interventional and Surgical Cardiovascular Pathology: Clinical Correlations and Basic Principles. Philadelphia, WB Saunders, 1989.)

Surgical reconstructive procedures for mitral valve disease. (A) Open mitral commissurotomy for mitral stenosis. Incised commissures are indicated by arrows. (B) Mitral valve repair with partial leaflet excision. (C) Mitral valve repair with annuloplasty ring. (D) ePTFE suture replacement (arrow) of ruptured cord in myxomatous mitral valve. (A: Reproduced with permission from Schoen FJ, St. John Sutton M: Contemporary issues in the pathology of valvular heart disease. Hum Pathol 1987; 18:568. D: Reproduced with permission from Schoen and Edwards.185 D: Courtesy of William A. Muller, MD, PhD, Cornell Medical School, New York.)

Reconstructive procedures for aortic stenosis. (A) Aortic valve balloon valvuloplasty for degenerative calcific aortic stenosis, demonstrating fractures of nodular deposits of calcifications highlighted by tapes. (B and C) Catheter balloon valvuloplasty–induced fracture of large calcific nodule of noncoronary cusp of aortic valve with calcific stenosis. This patient died during the procedure, owing to wide-open aortic insufficiency with inability of the cusp to close because of slight malposition of the edges of the calcific nodule with impingement of its fracture fascicles. (B) Gross photograph; (C) Specimen radiograph. Fracture site of nodular calcific deposit is demonstrated by arrows in (B) and (C). (D and E) Operative decalcification of the aortic valve. (D) Aortic valve after operative mechanical decalcification demonstrating perforated cusp. (E) Histologic cross section of aortic valve cusp after decalcification with lithotripter. Weigert elastic stain. Ca = calcium. (A, D, and E: Reproduced with permission from Schoen and Edwards.185 B and C: Reproduced with permission from Schoen FJ: Interventional and Surgical Cardiovascular Pathology: Clinical Correlations and Basic Principles. Philadelphia, WB Saunders, 1989.)

C. Walton Lillehei (left), the father of open-heart surgery, and Richard Varco

Lillehei CW, Cohen M, Warden HE, et al: The results of direct vision closure of ventricular septal defects in eight patients by means of controlled cross circulation. Surg Gynecol Obstet 1955; 101:446.

Lillehei CW, Cohen M, Warden HE, et al: The direct vision intracardiac correction of congenital anomalies by controlled cross circulation.

Surgery 1955; 38:11

  Cardiopulmonary bypass circuit 

Venöz Kanülasyon

Placement of venous cannulas. (A) Cannulation of both cavae from incisions in the right atrium. (B) Cannulation using the "two-stage cannula." Blood in the right atrium is captured by vents in the expanded shoulder several inches from the narrower IVC catheter tip. IVC = inferior vena cava; PA = pulmonary artery; RA = right atrium; RV = right ventricle; SVC = superior vena cava.

Cardiopulmonary bypass circuit 

Diagram of a typical cardiopulmonary bypass circuit with vent, field suction, aortic root suction, and cardioplegic system. Blood is drained from a single "two-stage"catheter into the venous reservoir, which is part of the membrane oxygenator/heat exchanger unit. Venous blood exits the unit and is pumped through the heat exchanger and then the oxygenator. Arterialized blood exits the oxygenator and passes through a filter/bubble trap to the aortic cannula, which is usually placed in the ascending aorta. Blood aspirated from vents and suction systems enters a separate cardiotomy reservoir, which contains a microfilter, before entering the venous reservoir. The cardioplegic system is fed by a spur from the arterial line to which the cardioplegic solution is added and is pumped through a separate heat exchanger into the antegrade or retrograde catheters. Oxygenator gases and water for the heat exchanger are supplied by independent sources.

Disk Oksijenatör

Bubble Oksijenatör

Design of bubble oxygenator

Membran Oksijenatör

Carmeda® AFFINITY® NT Oxygenator

Kalp Kapakları

Mekanik protezler (Coumadin, tromboemboli, kanama)

Xenogreft Bioprotezler (Dejenerasyon ve reoperasyon)

StentliStentsiz

Allogreftler (Homogreftler)

Otogreftler

Prototype model of a ball and cage valve, an early Starr-Edwards model.

Mekanik protezler

The Medtronic Hall valve

Mekanik protezler

Mekanik protezler

The original Kalke-Lillehei bileaflet valve as compared to the St. Jude Medical valve introduced nearly a decade later.

CarboMedics Top Hat valve.

Mekanik protezler

Mekanik protezler

ATS Medical valve. Note the open pivot design maintaining leaflet insertion.

On-X valve. Note the flange of the inflow portion of the valve housing which seats in the left ventricular outflow tract.

Mekanik protezler

St. Jude Medical Regent valve.

Mekanik protezler

Mekanik protezler

All sutures have been passed through the sewing ring and the valve is lowered to the aortic annulus and seated appropriately by placing gentle leverage on the valve sewing ring and traction on the suture bundles.

(A) Tricuspid valve replacement is performed with a St. Jude Medical valve. The native leaflets are left in situ, and the pledgeted 2-0 Ethibond sutures are passed through the annulus and the edges of the leaflets. (B) The valve is seated, and the sutures are tied. The subvalvular apparatus is visualized to ensure that there is no impingement of the prosthetic valve leaflets. The valve can be rotated if necessary to prevent leaflet contact with tissue.

FDA-approved mechanical mitral valves. A. Starr-Edwards ball-and-cage. B. Medtronic-Hall tilting-disk. C. Omnicarbon tilting-disk. D. St. Jude Medical bifleaflet. E. Carbomedics bileaflet. F. ATS bileaflet. G. On-X bileaflet.

Mitral Valve Replacement

First-Generation Prostheses First-generation bioprostheses were preserved with high-pressure fixation Medtronic Hancock Standard and Modified Orifice (Medtronic, Minneapolis,

MN) Carpentier-Edwards Standard porcine prostheses (Edwards Life Sciences,

Irvine, CA).

Second-Generation Prostheses Second-generation prostheses are treated with low- or zero-pressure fixation. Porcine second-generation prostheses

Medtronic Hancock II valve (Medtronic, Minneapolis, MN) Medtronic Intact porcine valve (Medtronic, Minneapolis, MN) Carpentier-Edwards Supraannular valve (SAV) (Edwards Life Sciences, Irvine,

CA). Pericardial prostheses

Carpentier-Edwards Perimount (Edwards Life Sciences, Irvine, CA) Pericarbon (Sorin Biomedica, Saluggia, Italy) prostheses.

Third-Generation Prostheses Newer-generation prostheses incorporate zero- or low-pressure fixation with anti-mineralization processes that are designed to reduce material fatigue and calcification. Stents have become progressively thinner, have a lower profile, and are more flexible The Medtronic Mosaic porcine valve (Medtronic, Minneapolis, MN) St. Jude Medical Epic valve (St. Jude Medical Inc., Minneapolis, MN) is a porcine The Carpentier-Edwards Magna valve (Edwards Life Sciences, Irvine, CA) The Mitroflow Pericardial aortic prosthesis (Carbomedics, Austin, TX)

Antimineralization

XenoLogiX (Edwards Lifesciences, Irvine, CA), No-React (Shelhigh, Inc., Union, NJ), AOA (two-alpha-amino oleic acid) (Biomedical

Design, Inc., Atlanta, GA), BiLinx (St. Jude Medical, Inc., St. Paul, MN)

FDA-approved bioprosthetic mitral valves. A. Hancock II porcine heterograft. B. Carpentier-Edwards standard porcine heterograft. C. Mosaic porcine heterograft. D. Carpentier-Edwards pericardial bovine heterograft. E. St. Jude Biocor porcine heterograft.

Stentless bioprosthetic heart valves.

The Toronto SPV fully scalloped glutaraldehyde-fixed porcine valve with the entire external aspect covered with cloth

Stentless bioprosthetic heart valves.

The Toronto Root. This can be used as a full root, inclusion root, or either subcoronary implant. (Used with permission of St. Jude Medical, Inc., St. Paul, MN.) anticalcification methods (BiLinx)

Stentless bioprosthetic heart valves.

The Edwards Prima Plus. The dashed line is a marking suture delineating the safe extent of sinus excision so this can be used as a full root, inclusion root, or either subcoronary implant. (Used with permission of Edwards Lifesciences LCC, Irvine, CA.) porcine root The Prima Plus is a low-pressure fixed valve with proprietary XenoLogiX treatment for calcium mitigation.

Stentless bioprosthetic heart valves.

The Medtronic Freestyle Aortic Root Bioprosthesis. The longitudinal view shows the fabric covering of the porcine septal muscle and the associated higher position of the right coronary stump. porcine root The device is fixed with physiologic (40 mm Hg) pressure applied to the aortic wall but a net zero pressure across the leaflets. It is treated with alpha-amino-oleic acid as a calcium mitigant.

Stentless bioprosthetic heart valves.

The CryoLife-O’Brien valve. This device has no cloth covering and no muscle because of its composite design. Sutures joining the three segments are obvious at each commissure. tissue is fixed in glutaraldehyde but there is no specific antimineralization treatment of this valve.

Stentless bioprosthetic heart valves.

The Sorin Pericarbon Freedom Valve. This is a completely pericardial construction designed for subcoronary implantation with a double suture line, but it can also be trimmed to allow a single suture line technique. bovine pericardium

Stentless bioprosthetic heart valves.

The Shelhigh Superstentless valve is a porcine aortic valve treated with the No-React (Shelhigh Inc., Union, NJ) process. isolated porcine aortic valve

Freestyle stentless porcine aortic valve

Freestyle stentless porcine aortic valve

Thrombus

Figure 5-25 Thrombotic occlusion of substitute heart valves. (A) Tilting disk prosthesis. Thrombus was likely initiated in the region of stasis immediately distal to the smaller of the two orifices through which blood flows (arrow), causing near-total occluder immobility. (B) Porcine bioprosthesis, with thrombus filling the bioprosthetic sinuses of Valsalva. (A: Reproduced with permission from Anderson and Schoen.54 B: Reproduced with permission from Schoen and Hobson.199)

Endocarditis

Figure 5-26 Prosthetic valve endocarditis. (A) Endocarditis with large ring abscess (arrows) observed from ventricular surface of aortic Bjork-Shiley tilting disk prosthesis in a patient who died suddenly. The ring abscess impinges on the proximal atrioventricular conduction system. (B) Bioprosthetic valve endocarditis with cuspal perforation by organism-induced necrosis (arrow). (A: Reproduced with permission from Schoen FJ: Cardiac valve prostheses: pathological and bioengineering considerations. J Cardiac Surg 1987; 2:65. B: Reproduced with permission from Schoen FJ, et al: Long-term failure rate and morphologic correlations in porcine bioprosthetic heart valves. Am J Cardiol 1983; 51:957.)

Structural valve dysfunction

Figure 5-27 Structural valve dysfunction. (A) Disk escape owing to a fractured lesser strut of a Bjork-Shiley heart valve prosthesis. This model had the strut welded to the metal frame. Both the fractured strut and the disk embolized; the strut was not found at autopsy. The fracture sites are indicated by arrows. (B) and (C) Porcine valve primary tissue failure owing to calcification with secondary cuspal tear leading to severe regurgitation. (B) Gross photograph; (C) specimen radiograph. Dense calcific deposits are apparent in the commissures. (D) Clinical Ionescu-Shiley mitral bovine pericardial bioprosthesis with extensive tear of one cusp (arrow) and resultant incompetence. (A: Reproduced with permission from Schoen FJ, et al: Pathological considerations in substitute heart valves. Cardiovasc Pathol 1992; 1:29. B and C: Reproduced with permission from Schoen and Hobson.199 D: Reproduced with permission from Schoen FJ: Cardiac valve prostheses: pathological and bioengineering considerations. J Cardiovasc Surg 1987; 2:65.)

Structural valve dysfunction

Figure 5-28 Dehiscence of commissural region of Hancock Standard porcine bioprosthetic valve. (A) Gross photograph. (B) Schematic diagram (arrow denotes loss of attachment of commissural support). Removed for regurgitation, this valve had prolapse of one cusp, minimal calcification, and no cuspal tears.

Nonstructural dysfunction of prosthetic heart valves.

Figure 5-29 Nonstructural dysfunction of prosthetic heart valves. (A) Late paravalvular leak adjacent to mitral valve prosthesis (arrow). (B) Tissue overgrowth compromising inflow orifice of porcine bioprosthesis. (C) Immobility of tilting disk leaflet by impingement of retained component of submitral apparatus (arrow) that had moved through the orifice late following mitral valve replacement surgery. (D) Suture with long end inhibiting free disk movement (arrow) of Lillehei-Kaster tilting disk valve. (A and C: Reproduced with permission from Schoen FJ: Histologic considerations in replacement heart valves and other cardiovascular prosthetic devices, in Schoen FJ, Gimbrone MA [eds]: Cardiovascular Pathology: Clinicopathologic Correlations and Pathogenetic Mechanisms. Philadelphia, Williams & Wilkins, 1995; p 194. B: Reproduced with permission from Schoen FJ, et al: Pathologic considerations in substitute heart valves. Cardiovasc Pathol 1992; 1:29. D: Reproduced with permission from Schoen FJ: Pathology of cardiac valve replacement, in Morse D, Steiner RM, Fernandez J [eds]: Guide to Prosthetic Cardiac Valves. New York, Springer-Verlag, 1985; p 209.) Nonstructural dysfunction of prosthetic heart valves. (E) Suture looped around central strut of a Hall-Medtronic tilting disk valve causing disk immobility. (F) Suture looped around stent post of bovine pericardial bioprosthesis causing stenosis (arrow). (E: Photo courtesy of Office of the Chief Medical Examiner, New York City. F: Reproduced with permission from Schoen FJ: Cardiac valve prostheses: pathologic and bioengineering considerations. J Cardiac Surg 1987; 2:65.)

Aortic valve allograft after harvesting from the donor. The block includes a variable amount of ventricular muscle and the anterior leaflet of the mitral valve. Additional trimming for replacement is performed at the time of implantation.

Allogreftler (Homogreftler)

The Cribier-Edwards valve consists of three pericardial leaflets sewn to a stainless-steel stent. The valve is stored in the open position to avoid damage to the leaflets (left panel) and must be hand-crimped to the delivery balloon (right panel) immediately prior to implantation.

BALLOON-EXPANDABLE VALVES

Fluoroscopic appearance of Cribier-Edwards valve placement. Stent is expanded by balloon at the level of the native aortic valve using calcification as a guide (left panel). Rapid ventricular pacing at 220 beats per minute transiently inhibits cardiac output to allow accurate valve placement. Aortic root injection after successful placement of the valve (right panel). Note nonobstructed flow to the coronary arteries and the presence of aortic insufficiency, suggesting perivalvular leak.

BALLOON-EXPANDABLE VALVES

Percutaneous valve devices and concepts. (A) The Cribier-Edwards valve consists of three equine pericardial leaflets fixed to a balloon-expandable steel stent. It is hand-crimped over a delivery balloon prior to deployment. (B) The Corevalve system is a self-expanding nitinol cage housing three porcine pericardial leaflets. Devices in preclinical development include (C) the Sadra self-expanding Lotus valve (D), the Aortx valve (E), the Bonhoeffer valve (F), and the eNitinol thin membrane PercValve. (Reproduced with permission from Davidson et al.180)

BALLOON-EXPANDABLE VALVES

SELF-EXPANDING VALVES

The Corevalve system consists of pericardial leaflets attached to a self-expanding nitinol frame. In the deployed state. The flared distal end assists in anchoring in the ascending aorta. The stent covers the coronary ostia, but cell size is designed to allow later coronary catheterization.

Mitral Valve Repair

The Carpentier-Edwards ring annuloplasty is shown. A sizer measuring the intertrigonal distance was used to determine the ring size. Multiple interrupted, pledgeted 2-0 Ethibond sutures are placed at the atrioannular junction. All sutures are inserted prior to seating the ring. (B) The valve is seated, and the sutures are tied.

Myocardial Revascularization with Percutaneous Devices

The coronary stent is a metallic "meshwork" that increases its rigidity when coldworked by balloon expansion. Buttressing of the vascular wall, propagation of dissection, and early vascular recoil are reduced significantly.

Myocardial Revascularization with Percutaneous Devices

Myocardial Revascularization Myocardial

Revascularization with Cardiopulmonary Bypass

Cannulation. After full systemic heparinization, cannulation of the distal ascending aorta is performed with an appropriately sized curved or straight tip aortic cannula. A two-stage venous cannula is used for access to the right atrium, usually through the right atrial appendage. An aortic root cardioplegia/vent is placed. A retrograde cardioplegia cannula may be placed at the discretion of the surgeon. Patients with aortic regurgitation benefit from placement of a right superior pulmonary vent to avoid distention of the left ventricle from infusion of cardioplegia into the aortic root.

Myocardial Revascularization with Cardiopulmonary Bypass

Composite Y graft. (A) Y-graft anastomotic technique: A coronary artery bypass graft (CABG) is used as a donor site for the proximal anastomosis of another conduit. An incision is created in the donor conduit. The proximal end of the recipient conduit is then anastomosed to the donor site in an end-to-side fashion as previously described for a distal anastomosis. The recipient conduit is then gently parachuted down onto the donor conduit. (B) Total arterial revascularization: As shown, arterial revascularization can be performed using the right internal thoracic artery (RITA) off the left internal thoracic artery (LITA) as a Y graft and liberal use of sequential grafting.

Çalışan kalpte bypass (off-pump bypass)

Çalışan kalpte bypass (off-pump bypass)

Çalışan kalpte bypass (off-pump bypass)

Çalışan kalpte bypass (off-pump bypass)

Aort disseksiyonu

The type A dissection extends into the proximal aortic arch. (B) The distal dissected aortic wall is reconstructed with inside and outside felt strips to replace part of the arch and ascending aorta.

Brachiocephalic vessels can be reattached to an arch graft as a unit if the inner cylinder of origin of each vessel remains intact. (A) The arch vessels are excised as a unit from the superior surface of the dissected aortic arch. (B) The separated layers of the brachiocephalic patch are reunited using inner and outer felt strips and continuous suture. (C) A corresponding hole is cut in the aortic graft and the continuous brachiocephalic unit is sutured into place.

The brachiocephalic vessels are separated from the true lumen by the dissected false lumen (left panel). If individual brachiocephalic vessels are also damaged beyond repair, short interposition grafts are added to reconnect each artery to the aortic graft (right panel).

Illustration of insertion of a composite valve-graft conduit with coronary artery reimplantation. (A) A full-thickness button of aortic wall adjacent to each coronary ostium is fashioned. The aortic valve and sinuses are then excised. (B) Pledgeted 2-0 braided polyester sutures are placed in the supra-annular position and immediately adjacent to one another to ensure a watertight closure. The sutures are placed in the upper half of the sewing ring, helping to seat the valve deep within the aortic annulus. Note that no knots or suture material are exposed to the bloodstream. (C) Ophthalmic cautery is used to create an orifice in the graft in the appropriate position for left coronary reimplantation. (D) The left coronary anastomosis is performed first with a continuous 4-0 or 5-0 polypropylene suture incorporating a thin strip of felt. The right coronary anastomosis is then performed in a similar fashion.

Aort Anevrizması

Atherosclerotic ascending and arch aneurysm. (B) Fabrication of the trifurcated graft. (C) Selective cerebral perfusion and construction of the elephant trunk. (D) Completed repair.

Replacement of the thoracoabdominal aorta. (A) A left femoral cannula perfuses the lower body and viscera while the heart continues to eject. The arch is transected near or at the left subclavian and any dissection involving the proximal cuff is repaired. (B) The clamp is moved down and a second arterial cannula is inserted into the proximal graft to perfuse the upper body and heart. The anterior wall of the dissection is incised longitudinally and bleeding intercostals of the upper six pairs are oversewn. A group of lower intercostal arteries above the celiac axis is sutured to the graft. (C) The clamp is moved down and the distal aortic clamp is moved to the left common iliac artery. A patch of aorta containing the celiac, superior mesenteric, and right renal artery is sewn into the graft. The left renal artery is sutured separately to the graft. (D) The proximal clamp is moved below the visceral anastomoses and the distal aortic anastomosis is made to the aortic bifurcation.

Mechanical Circulatory Support

(A) Balloon inflation during left ventricular (LV) diastole occludes the descending thoracic aorta, closes the aortic valve, and increases proximal coronary and cerebral perfusion. (B) Balloon deflation during LV systole decreases LV afterload and myocardial oxygen demand.

Mechanical Circulatory Support

Percutaneous ECMO support is attained via femoral vessel access. Right atrial blood is drained via a catheter inserted into the femoral vein and advanced into the right atrium. Oxygenated blood is perfused retrograde via the femoral artery. Distal femoral artery perfusion is not illustrated.

Bicaval heart transplantation

Simplified technique for heart-lung transplantation as described by Reitz and colleagues in 1981.

The Abiomed AB5000 circulatory support

system

The Heartmate left ventricular assist

device Novacor

Thoratec

Jarvikiii

AbioCor

Long-Term Mechanical Circulatory Support

SoruSoru??