Preoperative Evaluation for Cardiac Surgery..Simple Notes

Preoperative Evaluation for Cardiac Surgery

improved risk-adjusted mortality for CABG of less than 2% for the general population

particular attention should be paid to the patient's risk for 
   -endocarditis, 
    -the presence of aortic insufficiency, 
    -the presence of vascular disease, and 
    -the neurologic status.
    -conduit ..vein/arteial.. Ima for mastectomy

    -contraindications to the use of an intra-aortic balloon pump, which include aortic insufficiency, severe peripheral vascular insufficiency, abdominal aortic aneurysm, or significant atherosclerosis

 
Examination of the head, eyes, ears, throat, and teeth for infection is helpful in the assessment of an individual's risk of endocarditis in valvular surgery. Inspection of the patient's skin is helpful in detecting and preventing infection (e.g., the presence of tinea pedis on the lower extremities increases the risk of lower extremity cellulitis). Identifying the presence of an aortic regurgitation murmur is important because regurgitation can worsen during cardiopulmonary bypass and acute left ventricular distention may develop.

Basic laboratory testing prior to cardiac surgery should include 
    -a complete blood count, anemia tdk blh, ec hemodilusi intraop 
    -coagulation screen,   
    -chemistry profile, f hepar/renal u obat anest
    -electrolitr, ... U risk arythmia 
    -stool hematest, 
    -evaluation of ventricular function, and 
    -assessment of coronary anatomy via cardiac catheterization
    -nutrisi, albumin <2.5...dikoreksi skt 1wk, ec risk sepsis/resp failure Myocard consumtion naik .     -chf     -as     -lm disease Kl plu transfusi preop... Individuals with mitral regurgitation and heart failure should receive preoperative afterload reduction with angiotensin-converting enzyme (ACE) inhibitors or intravenous sodium nitroprusside to maintain systolic blood pressures in the 90 to 100 mm Hg range.   While patients with aortic stenosis and hemodynamically significant cerebral or renovascular disease should not receive the latter therapies, intra-aortic balloon counterpulsation (IABP) may be useful in such subgroups. Intra-aortic balloon support can also be used in the setting of acute mitral regurgitation due to papillary muscle rupture as well as in infarct-related ventricular septal defect. Preoperative IABP use in high-risk patients decreases mortality and shortens ICU stay due to enhanced hemodynamic performance Right ventricular dysfunction caused by increased pulmonary vascular resistance should be treated with inotropes that have vasodilator properties such as dobutamine (5 µg/kg/min) and milronone (5 µg/kg/min). Intravenous nitrates, prostacyclin (0.5–2.0 ng/kg/min), and nitric oxide (10–20 ppm) are also effective agents for lowering pulmonary vascular resistance with resultant improvement in right ventricular function (COPD), -prolonged weaning from mechanical ventilation postoperatively is common if FEV1 is less than 65% of VC or if FEV1 is less than 1.5 L. CABG patients with severe COPD are more likely to develop ventilatory failure and have higher mortality rates than those with mild-to-moderate or no COPD (death: 19% vs. 4% vs. 2%, p = .02). -Preoperative screening of arterial oxygen concentration on room air can provide guidance in respiratory management postoperatively.  -preoperative spirometry and perioperative bronchodilators remains unclear in stable patients and cannot be recommended on a routine basis The postoperative hypermetabolic state requires increased nutrition in order to facilitate wound healing and to meet corporal metabolic demands.  -patients who are malnourished preoperatively should receive at least 2 to 4 weeks of intensive nutritional bolstering prior to elective surgery, and all patients should resume an oral diet within 24 hours after uncomplicated surgery. Since perioperative stroke may limit the ability of some patients to protect their airway, a swallowing evaluation is mandatory in this subset of patients.  -Early enteral feeding is warranted in those individuals who have no contraindications to feeding. Low body mass index (<20 kg/m2) and hypoalbuminemia (<2.5 g/dL) are independently associated with increased risk of morbidity and mortality after cardiac surgery. -Patients with decreased albumin levels are at increased risk for bleeding, renal failure, prolonged ventilatory support, and reoperation.  -obesity is not associated with increased mortality, patients with high percent body fat and poor aerobic capacity are at higher risk for sternal wound infection (OR = 2.3; p<.001), saphenous vein harvest site infection, and atrial arrhythmias -Preoperative temporary transvenous pacemaker wire insertion is recommended in patients with hemodynamic instability and high-grade heart block (third degree or Mobitz II).  -Permanent epicardial pacing lead implantation should be done intraoperatively for patients undergoing tricuspid valve replacement with a mechanical prosthesis, due to the contraindication of passing a transvenous lead through the latter. HIt ..white clot syndrm... Immune... Vein arterial pulmonal trombois...Hit igG -penurunan tc >50%, at >30% bl ada gjl pdarahan/trombosis
-pd pts dg heparin (ufh/lmwh), min 5d-14d
-risk ; heparinisasi in 3bln
-if stopped.. Tc naik within days n pdarahan/tromosis within 1bln
Treathment
-delay 3bln
-warfarin initiation should be done in the presence of lepirudin or argatroban due to warfarin's association with limb gangrene

In the PURSUIT trial, patients who received the glycoprotein IIb/IIIa inhibitor eptifibatide within 30 days of CABG did not experience higher rates of bleeding, probably due to the short half-life of the drug. 
However, the CURE trial showed that the antiplatelet agent clopidogrel was beneficial in patients with acute coronary syndromes undergoing PCI but was associated with a concomitant increased risk of major bleeding.34 Though clopidogrel can decrease mortality, it may potentially pose serious problems with major perioperative bleeding (clopidogrel vs. placebo .The median time between discontinuation of clopidogrel and CABG was 5d
Limited data are available regarding the use of fibrinolytic agents prior to CABG. However, in a subgroup analysis of the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries trial (GUSTO I), patients who underwent PCI or CABG after receiving fibrinolytics had a lower rate (0%) of intracranial hemorrhage than those treated with repeat fibrinolysis (1.3%) or medical therapy (0.5%) (p = .046)

Hypercoaguable Disorders
In general, warfarin therapy can be switched to LMWH 3 to 5 days prior to cardiac surgery. 
Anticoagulation using UFH as a bridge should be resumed as soon as the bleeding risks associated with cardiac surgery have been stabilized, usually within 2 to 3 days postoperatively. 
The patients at highest risk for venous thrombosis are those within 3 months of an episode of thrombosis and those with conditions that predispose to the highest risk of thrombosis, such as antithrombin deficiency

Atrial Fibrilasi
10% to 40% of patients after CABG and in up to 65% of patients undergoing combined CABG and valve surgery.42–45
24 to 48 hours after surgery, considered benign and self-limited, 
associated with prolonged hospitalization, hemodynamic instability, and thromboembolization. 
the risk of stroke increases 3-fold 
(25% to 80%) spontaneously convert to sinus rhythm within 24 hours.

The mechanism 
-multiple wavelet reentry in the atria, 
-rapid firing of an atrial focus, and less likely 
-atrial ischemia.Preoper

predictors 
- age, history of hypertension, male sex, and a previous history of atrial fibrillation and congestive heart 
- aortic cross-clamp time, pulmonary vein venting, respiratory disease, and prolonged ventilation

-The prophylactic use of beta-blocker therapy decreases the incidence of post–CABG atrial fibrillation by as much as 70% to 80%.
-amiodarone in decreasing the incidence of postoperative atrial fibrillation when started one week prior to surgery and continued until hospital discharge.
-Sotalol, a class III antiarrhythmic 
-prophylactic continuous atrial overdrive pacing via temporary epicardial wires or from the right atrium

Carotid Artery Diseases
 -Approximately 1% to 6% of persons develop neurologic complications after cardiac surgery.
-Cerebral microembolization from the arterial tree during CABG is likely the most common culprit. 
-atherosclerosis of the ascending aorta is an independent predictor of long-term neurologic insult and mortality.
-patients undergoing CABG, the incidence of carotid artery disease can be as high as 22% (3% in unselected populations), depending on multiple factors including screening method, age, diabetic status, the presence of left main disease or left ventricular dysfunction, female sex, and a history of smoking or prior cerebrovascular attacks
-perioperative stroke risk is believed to be highest (>5%) in patients with more than 80% unilateral stenosis, bilateral stenoses of at least 50%, and unilateral occlusion with at least a 50% carotid artery lesion on the contralateral side.
Consequently, all patients who fall into one of these categories should be considered for combined carotid endarterectomy (CEA) and CABG. 
-Several authors report operative mortalities between 0% and 5%, and perioperative neurologic and myocardial events of approximately 3%.89–93 At 5 years, over 85% of these patients are stroke free 
-combined CABG/CEA is recommended in symptomatic patients with carotid artery stenosis. 
-Although perioperative myocardial infarction and mortality are generally higher with combined CABG/CEA than with CABG alone, the former is still preferred in this group. 
-no demonstrated difference in mortality or morbidity whether CEA is done before or during CABG.
-Carotid artery stenting can also be. performed in close proximity to CABG. Potential advantages of carotid artery stenting include minimizing the need for systemic heparinization prior to CABG. At present, stenting can be safely performed 4 weeks prior to CABG. Thus carotid artery stenting might be advantageous in patients with stable carotid and coronary disease, in elderly patients who are at high risk for thoracotomy, and in patients who have concomitant carotid artery disease and single-vessel left anterior descending artery disease for which minimally invasive surgery is planned. .

Perioperative Myocardial Protection

Key points

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Myocardial protection refers to all strategies that increase the heart's ability to withstand an ischaemic insult.

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Stunning is potentially life-threatening post-ischaemic myocardial impairment after blood flow is fully restored.

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Hibernation is a prolonged state of reduced myocardial contractility in response to arterial insufficiency such that oxygen demand matches oxygen supply.

*

Volatile anaesthetic agents possess cardioprotective properties independent of their beneficial effect on myocardial oxygen balance.

*

There is good evidence that perioperative use of β-blockers, statins, and α2-agonists reduce perioperative myocardial mortality

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Myocardial protection refers to all strategies that increase the heart's ability to withstand ischaemic insult, which together with reperfusion injury are principally responsible for cardiac morbidity and mortality after high-risk surgery. The bloodless and motionless operating conditions required for cardiac surgery is an environment diametrically opposed to the metabolic demands of the heart.

Pathophysiology of myocardial reperfusion

Ischaemia of sufficient duration results in cell death. However, should the ischaemic insult be interrupted at an appropriate point, a patient will be left with viable myocardium while experiencing a spectrum of detrimental sequelae including arrhythmias and a low cardiac output state. This is directly consequent to the reperfusion injury. Should outright cell death be averted, there are two possible alternatives, that is, stunning and a state of hibernation.

In 1975, it was demonstrated that 15 min of coronary occlusion resulted in 6 h of left ventricular depression, leading Braunwald and Kloner to state that ‘transient ischaemia may interfere with normal myocardial function, biochemical processes, and ultra-structure for prolonged periods’. Stunning is a commonly encountered phenomenon characterized by potentially life-threatening post-ischaemic myocardial impairment after coronary blood flow has been fully restored. It can be overcome by inotrope therapy or calcium infusions without negative consequences and has a duration of hours to days. Examples of stunning would be unstable angina or after aortic cross-clamping during cardiac surgery.

The mechanism underlying stunning is thought to be a combination of cytosolic calcium overload which, if prevented, abolishes this phenomenon and the development of oxygen free radicals. Severe cellular damage has been demonstrated when an anoxic heart preparation is re-exposed to oxygen. Calcium overload may damage the myocyte contractile apparatus in ways that impair its normal response to calcium. Suggested sources of calcium include entry through voltage-sensitive calcium channels, decreased uptake into the sarcoplasmic reticulum, impaired sodium–calcium exchange due to decreased cytosolic pH, and activation of the calcium release channel of the ryanodine receptors. During a hypoxaemic episode, electrons form damaging free radicals instead of passing down the energy gradient of the electron transport chain. The hydroxyl group in particular is thought to play a significant role in the lipid peroxidation of cell membranes leading to increased permeability to calcium.

Hibernation was first described by Rahimtoola as ‘a state of persistently impaired myocardial and left ventricular function at rest due to reduced coronary blood flow that can be partially or completely restored to normal if the myocardial oxygen supply/demand relationship is favourably altered, either by improving blood flow and/or by reducing demand’. The ‘smart heart’ has down-regulated mechanical activity to a level at which aerobic metabolism functions normally. Current theories suggest that hibernation is the consequence of serial episodes of ischaemia, possibly silent, causing repeated stunning. Tumour necrosis factor-α signals structural changes that in part parallel disuse atrophy and include loss of myofibrils, accumulation of collagen and fibroblasts, and loss of mitochondria.

Hibernation is reversed by revascularization and the scope for potential improvement in ventricular function can be examined by a number of means including positron emission tomography (PET) and dobutamine stress echocardiography. Mismatch of myocyte utilization of labelled deoxyglucose relative to blood flow indicates hibernating tissue on PET scanning whereas a positive echocardiographic response to inotropy suggests viability with dobutamine stress examination.

Temperature and haemodynamic modulation

In addition to being the primary mode of cerebral protection, hypothermia also offers myocardial protection. It achieves this by promoting electromechanical inactivity, impeding the process that results in apoptosis, and perhaps most importantly by reducing oxygen consumption. The lowest oxygen demands occur when the heart is arrested and decompressed. At 22°C, myocardial oxygen consumption is reduced from 80 to 0.3 ml 100 g−1 min−1.1 Increases in wall tension, contractility, and heart rate all serve to increase myocardial oxygen demand. Laplace's law for a sphere states that the wall tension (σ) is proportional to the internal pressure (P) and internal radius (r), and inversely proportional to the wall thickness (η)

Thus, we see a direct relationship between radius and wall tension that provides the rationale behind several haemodynamic interventions available to the surgical team all aimed at reducing ventricular wall tension. Venting of the left side of the heart via a catheter is an effective technique for cardiac decompression and air removal and has the added advantage of providing a dry operative field. The left ventricular vent catheter can be inserted during the surgical procedure via various routes such as the ascending aorta, a right-sided pulmonary vein, or the left ventricular apex. The aim is to maintain a low ventricular wall tension. Separation from cardiopulmonary bypass while the heart is relatively empty offers the same advantage but requires careful observation and incremental filling to maintain an adequate preload.

Cardioplegic techniques

Cardioplegic diastolic arrest and hypothermia currently form the foundation of protective practice for on-pump cardiac surgery. Other interventions such as anaesthetic preconditioning (APC) and several novel strategies are worthy of discussion. Widespread in use, cardioplegia was introduced as a concept by Lamb in 1958. Cardioplegia may be blood or crystalloid, warm or cold, and continuous or intermittent. The main component of cardioplegic solutions responsible for inducing diastolic cardiac arrest is potassium, and concentrations in the order of 20 mmol litre are required. Blood is superior at preserving myocyte and endothelial function resulting in reduced incidence of mortality, myocardial infarction, and left ventricular failure in high-risk patients.2 A recent meta-analysis demonstrated reduced incidence of low cardiac output syndrome in the blood cardioplegia arm.3 Compared with crystalloid cardioplegia, blood offers several attributes that may contribute to the above clinical findings. In addition to the potential oxygen carrying ability, blood offers delivery of other nutrients, and also an inherent buffering ability and scavenging of oxygen free radicals. Note that the haemoglobin content of blood used for cardioplegia is diluted to around 5 g dl−1 and its p50 on the oxygen haemoglobin dissociation curve is displaced to the left. This will decrease potential oxygen delivery to the myocardium significantly.

Cardioplegia can be delivered in antegrade or retrograde fashion. The former provides quick arrest and good left ventricular protection and is undertaken by infusing the solution into the aortic root proximal to the aortic cross-clamp. A competent aortic valve is required in order for the cardioplegia to perfuse the coronary arteries and to prevent detrimental left ventricular dilation. Retrograde cardioplegia is applied through a specific cannula into the coronary sinus and requires venting of the aortic root. This may reach parts of the myocardium inadequately perfused by the coronary arteries but may be insufficient for right ventricular protection as a sole technique.

The optimal composition for cardioplegia is a subject of continued research. It should be slightly hyperosmolar to limit oedema, alkalotic to attenuate subsequent pH changes, and have a low calcium concentration. The basic recipe can be complemented by a variety of substances aiming to provide metabolic substrates and enhanced cellular protection. Addition of aspartate and glutamate improves left ventricular stroke work index, increases myocardial oxygen consumption, and improves metabolic recovery. Metabolic enhancement with insulin and glucose has recently demonstrated trends towards improved functional recovery in patients undergoing coronary artery bypass grafting (CABG). Adding the vasodilator and metabolic precursor adenosine has also demonstrated promising trends in a variety of clinically relevant endpoints. Other possible additives include magnesium, the nitric oxide precursor l-arginine, N-acetylcysteine, nicorandil, and bupivacaine.

The temperature at which cardioplegia is administered can be divided into cold (5–10°C), tepid (27–30°C), and warm (37–38°C). Low temperatures may be conducive to ischaemic protection but may accentuate the reperfusion injury. Evidence exists to suggest that warm cardioplegia is associated with reduced postoperative CK-MB increase (12.3% vs 17.7%) and a reduced hospital stay (6 vs 9 days). The authors of this study did, however, warn that interruption to the continuous administration of warm cardioplegia renders the myocardium susceptible to warm ischaemic injury. Surgeons who prefer intermittent administration of cardioplegia might adopt a regimen consisting of inducing arrest with warm cardioplegia and then providing maintenance with cold. Alternatively, an infusion of warm cardioplegia or warm blood only, via the cardioplegia cannula towards the end of the procedure (hot shot), has its advocates. Evidence to date suggests that, on balance, tepid cardioplegia provides the best overall protection and recovery.

Ischaemic preconditioning

Preconditioning describes the remarkable phenomenon whereby exposure to a physical or pharmacological stimulus reduces subsequent injury from ischaemia. This is analogous to the reduced infarct size seen in a myocardial infarct after frequent angina. Postconditioning is similar, but the stimulus occurs at the end of the insult. Remote ischaemic preconditioning (RIPC) happens after reperfusion of a limb or organ, distant from the myocardium, which underwent a period of ischaemia. The concept of preconditioning can be broadly divided into ischaemic preconditioning (IPC) and APC.

IPC was first described in dog hearts in 1986. In these experiments, hearts were subjected to four short episodes of ischaemia separated by 5 min of perfusion before being subjected to a 40 min ischaemic insult. Preconditioning reduced the size of the resultant infarct from 30% to 7%.4 IPC is divided into early (classical) and late, with differing mechanisms that explain the different chronology. Early preconditioning starts within 15 min and lasts for several hours. It protects against myocardial infarction but not stunning. The speculative mitochondrial hypothesis for preconditioning proposes adenosine as one of several possible triggering agents that activates phospholipase C leading to increased expression of protein kinase C. This subsequently phosphorylates and hence activates the final target, that is, mitochondrial ATP-sensitive potassium channels (KATP). Drugs such as the sulphonylureas, which act by blocking KATP channels, may inhibit the preconditioning effect. Recent evidence suggests that patients with non-insulin-dependent diabetes mellitus and coronary heart disease may benefit from changing their treatment perioperatively to insulin.5 Thyrosin kinase and mitogen-activated protein kinases are also involved. Other potential triggers include acetylcholine, opioids, and bradykinin. Opening of these channels protects the mitochondria from calcium overload.

Late preconditioning reflects a second delayed window of protection, which starts at around 12 h and lasts up to 4 days. It protects against both myocardial infarction and stunning. This phenomenon involves the development of an altered myocardial cell structure which is dependent on stress responsive gene transcription leading to the synthesis of cardioprotective proteins, including most importantly cyclooxygenase-2 and inducible nitric oxide synthase. Less important examples are superoxide dismutase and heat-shock proteins that are able to stabilize the cytoskeleton. The collective activity of these proteins results in reduced apoptosis.6

Anaesthetic preconditioning

Over a quarter of a century ago, reduced ST segment elevation was demonstrated in dog hearts exposed to brief ischaemic episodes in the presence of halothane. Unfortunately, subsequent concerns regarding the risk of ‘coronary steal’ with isoflurane anaesthesia took precedence. Coronary steal is postulated to occur in the presence of coronary vasodilators acting on normal vasculature and depriving tissue supplied by atherosclerotic vessels of blood, as these are less able to dilate. It was thought to be a particular risk in ‘steal-prone’ anatomy, defined as being the complete occlusion of one coronary artery that is supplied distally by collateral flow from another coronary artery with >50% occlusion. In clinically relevant concentrations, this has been shown not to be the case. It is now appreciated that all currently used volatile agents are cardioprotective and that this property extends to ischaemic tissue. In addition to the indirect cardioprotective properties of negative inotropy and chronotropy that result in a beneficial effect on myocardial oxygen balance, volatile anaesthetic agents have a direct cardioprotective effect that strongly resembles IPC

APC involves exposure of the myocardium to halogenated inhalation anaesthetics in order to attenuate the subsequent injury due to ischaemia and reperfusion. As low as 0.25 minimum alveolar concentration (MAC) may be protective, but the maximum effect is achieved at 1.5–2 MAC. It is also associated with an early and a late or memory effect. This technique avoids the risk and practical difficulty of exposing diseased myocardium to transient ischaemia. Evidence now exists suggesting that volatile agents also exert a renal, cerebral, and hepatic preconditioning effect. The extracellular signalling pathways responsible for this effect are very similar to those seen in IPC and involve signalling substances binding to inhibitory G-protein-coupled receptors to trigger several intracellular pathways. Intracellular protein kinase C plays a central role in the mechanism leading to opening of mitochondrial KATP channels. Production of mitochondrial reactive oxygen species (ROS) is increased via partial inhibition of complex III of the electron transport chain, which activates signalling pathways for preconditioning resulting in less ROS production on reperfusion. Mitogen-activated protein kinase and adenosine receptor activation are also involved. In a recent meta-analysis involving slightly <3000 patients undergoing CABG surgery, APC significantly lowered troponin I concentrations, reduced inotrope requirement, reduced duration of hospital stay, and was associated with 20% greater cardiac indices. However, it did not reduce the incidence of perioperative myocardial infarction or mortality.

Halogenated volatile agents are not the only pharmacological agents capable of eliciting pharmacological preconditioning. Xenon, adenosine, nicorandil, and norepinepherine among others also have preconditioning properties. Morphine is a preconditioning agent, which in addition has synergistic activity with volatiles. As this effect is mediated via the delta receptor, other opioids used in anaesthesia do not demonstrate this property. Ageing, diabetes, and hypercholesterolemia all attenuate APC.

Postconditioning and remote ischaemic preconditioning

Ischaemic postconditioning is the interruptive reperfusion at completion of cardiac surgery. This might consist of repeated sequences of perfusion for 30 s followed by re-occlusion for 30 s. It has been found to significantly reduce infarct size in patients undergoing angioplasty for complete coronary artery occlusion. Volatile agents also have a postconditioning effect possibly mediated by inhibition of the neutrophil-mediated ROS generation responsible for reperfusion injury.

RIPC involves inducing ischaemia distant to the myocardium in tissues such as the mesentery, kidney, or lower limb in order to obtain a myocardial protective effect after reperfusion of the remote tissue. An example is 5 min of renal artery occlusion before coronary artery reperfusion; this also has demonstrated reduction in the extent of infarct. A recent study of RIPC in patients undergoing elective abdominal aortic aneurysm repair found a 27% reduction in myocardial injury, a 22% reduction in myocardial infarction, and a 23% reduced incidence of renal impairment.7 Both remote conditioning and postconditioning are mediated by adenosine which reduces inotrope requirement, ICU stay, and significant reductions in troponin I release. Volatile anaesthetic agents also possess postconditioning properties which, as in preconditioning, results in the opening of ATP-sensitive potassium channels preventing mitochondrial calcium overload.

Pharmacotherapy

Postoperative myocardial infarction has a mortality of ∼10%. It is often silent, non-Q-wave, and preceded by ST depression. It normally occurs within a few hours of completion of surgery and is associated with tachycardia and hypertension, which, as previously discussed, are factors contributing to increased myocardial oxygen demand. β-blockade reduces mortality after myocardial infarction in proportion to the reduction in heart rate. The influential Mangano and colleagues, and Poldermans and colleagues trials have demonstrated reduced myocardial infarction and mortality after major non-cardiac surgery in β-blocked patients. However, for a variety of reasons, these trials have courted criticism. A meta-analysis of six randomized controlled trials found that β-blockade was associated with a 75% reduction in the risk of perioperative cardiac death. The benefits of β-blockers are not confined to non-cardiac surgery as their use has also been shown to reduce 30 day mortality after CABG.8 The benefits of perioperative β-blockade may be more pronounced in patients with risk factors for ischaemic events.

The α2-agonists clonidine and mivazerol have demonstrated perioperative myocardial protective properties. In patients with known coronary artery disease, mivazerol reduces the incidence of myocardial infarction and overall mortality rate in general surgical and vascular patients. Clonidine after operation significantly reduces myocardial ischaemia in vascular patients.

The statin family of drugs offers both lipid lowering and a complex collection of unrelated or ‘pleotropic’ benefits, including increased plaque stability, decreased platelet activity, decreased inflammatory markers, and improved arterial blood flow. Patients receiving statins at the time of surgery enjoy a reduction in all-cause mortality, myocardial infarction, and cardiovascular mortality.9 The reduced mortality has been shown to extend up to 5 yr after operation. Like β-blockers, the benefit may be greater in higher risk patients.

Other strategies

Meta-analysis has demonstrated that despite the sound theoretical reasoning of improved analgesia and reduced stress response to surgery, thoracic epidural analgesia and intrathecal analgesia do not reduce the incidence of mortality or myocardial infarction.10 It has recently been shown that a glucose–insulin–potassium infusion in non-diabetics reduces myocardial damage and inotrope requirements. The potential antioxidant properties of propofol remain controversial with a recent study comparing large-dose propofol (100 µg kg−1 min−1) with isoflurane and finding a reduced inotrope requirement and myocardial injury. Antibody therapy to prevent P-selectin and intercellular adhesion molecule-1 activation may attenuate leucocyte-mediated reperfusion injury and is associated with reduced infarct size in animal models.

Conclusion

The ageing and more expectant population with increasing morbidity provides continued impetus to develop the practice of a myocardial preservation management system. The role of hypothermia is increasingly controversial in the light of the fact that diastolic arrest provides the majority of protection derived from reduced oxygen demand. An increased understanding of the mechanisms involved in myocardial injury will lead to an increased application of pharmacotherapy to prevent them. Volatile anaesthetic agents and morphine posses direct and synergistic cardioprotective effects, independent of their beneficial effects on myocardial oxygen balance. The American College of Cardiology and American Heart Association recommend that patients with a requirement for β-blockers to manage angina or hypertension and patients at risk for ischaemic heart disease should be titrated to a heart rate of 50–60 beats min−1. This may protect against ischaemic events. It also suggests that the α2-agonists may offer similar protection.

Post CABG arrythmias/AF

Following a CABG there are usually two peak times in the incidence of arrhythmia's. The first in the operating room and the second usually is between the second and fifth post-op days. The underlying problems of why there is usually arrhythmia's is still unclear. But many describe them due to the effects of circulating catecholamines, changes in the autonomic nervous system tone, changes in the electrolyte imbalance, myocardial ischemia or just irritation of the heart.

Other several factors may include flux changes of the electrolytes within in K+, MG+, CA+, and maybe Dig tox effects.

Atrial Fibrillation is the most common arrhythmia following cardiac surgery, the best management strategies is yet to be defined. Even if the patient has been on prophylactic Dig, beta blockers, transient A-Fib occurs in at least 25%-30%of patients after CABG.

New methods have been now utilized as FedMedic described. If the patient is hemodynamically stable some use of Verapamil (5mg SIVP) q every 5 minutes upt to 3-4 doses. Newer in the past 5-10 yrs is Dilitizem (Cardizem 0.25mg-0.35mg/kg bolus over 2 minutes). Esmolol (Brevibloc ) is Beta1 blocker, a newer med primarily used for SVT as well. The problem is sudden discontinuation can lead to increase . The dose is dysrhythmias usually 50 mcg/kg to 200 mcg/kg and one has to perform a "loading dose: first with a maintenance drip followed. Dosage needs to be recalculated if they are already on Beta blocker up to 50%. Some of the cardiologist I am in rotation with loves the stuff, and the other despises it.. so I have seen mix results, personally I have seen it abolish SVT in lieu of cardioversion. Professionally, have not seen it used that much for A-fib with RVR, but understand it is an alternative.

The pacemaker is newer device that has brought an alternative way for those with chronic A-fib, that is resistant to other therapy. One of the physicians father is one of the inventor of the bi-chamber pacer and as well experimental cutaneous plasty ablation that re-routes the pathway.

SVT, is also another post CABG side effect, as well as ventricular arrhythmias. Although new conduction defects may develop up to 45% of patients following cardiac surgery, the majority are usually transient and related to the use of cold cardioplegia, hypothermia, and electrolytes shifting.

Of course other dangers include P.E.'s , arterial spasms, myocardial ischemia. Almost all patients have a pericardial effusion. These effusions may develop into cardiac tamponade post-op and has to be considered in patients that of course have JVD, muffled heart tones, pulse paradoxus ( (Beck's Triad) and or hypotension.

The other problem that I did not realize was so prominent was mediastinitis, which occurs about within 2 weeks. the usually represent fever and purulent discharge from sternal wound.

Risk factors from this is usually from prolong cardiopulmonary bypass time, excessive bleeding, and poor cardiac output. Usually, the incidence of mediastinitis is increased with both the internal mammary arteries are used bilaterally for use of conduits. Many Doc's prefer to use only to use the left internal mammary artery, especially in geriatric, and diabetics, who may already have a wound healing problem.

Usually, one obtains wound cultures as well as blood cultures and seek specific growth. Staphylococcus aureus (Staph) is the usual culprit.

The most common medication are usually as described from airway goddess described. More common are angiotensin-converting enzyme (ACE) inhibitors
and anticoagulants such as Coumadin, or Plavix. The problem with ACE is they can cause problems on the glomerular capillary pressure as well the patient has already been through nephrotoxic drugs, radiocontrast med's (they glow in the dark) and cholesterol plaque med.'s this can screw up the kidneys and cause renal failure.

Even though these procedures are considered "routine" and occur daily nationwide, and over all most do not have "drastic" effects, Surgeon and EMS needs to be cautious aware of potential patients

CPB 101 : General Bypass Setup

General Bypass setup

The bypass machine needs to be set up for circulatory arrest. 

Two arterial lines are needed: 

Option 1 - one for central  perfusion and one with a second branch in it for selective cerebral perfusion. During the period of selective cerebral perfusion the central perfusion line is inserted into the proximal descending aorta via the open arch for distal body perfusion.

Option 2 - one for femoral perfusion and one with a second branch in it for selective cerebral perfusion.

Venous return is usually via a two stage cannula.  Venous Cannulation and Drainage

Venting of the right superior pulmonary vein (RSPV) is the commonest method of venting the heart, however other routes exist.

Diagram shows locations used to vent (decompress the heart). 

(A) Aortic root vent, which can also be used to administer cardioplegic solution after the ascending aorta is clamped. 

(B) A catheter placed in the right superior pulmonary vein/left atrial junction can be passed through the mitral valve into the left ventricle. 

(C) Direct venting of the left ventricle at the apex. 

(D) Venting the main pulmonary artery, which decompresses the left atrium because pulmonary veins lack valves.

Cardioplegia line with a branch for anterograde and retrograde cardioplegia.

One or Two pump suckers.

CPB Setup

During cardiopulmonary bypass (CPB) for clinical cardiac surgery, blood is typically drained by gravity into the venous reservoir of the heart-lung machine via cannulas placed in the superior and inferior vena cavae or a single cannula placed in the right atrium. Blood from this reservoir is pumped through a membrane oxygenator into the systemic arterial system, usually through a cannula placed in the distal ascending aorta. This basic extracorporeal perfusion system can be adapted to provide partial or total circulatory and respiratory support or partial support for the left or right heart or for the lungs separately.

Basic CPB set up

Basic cardiopulmonary bypass circuit with membrane oxygenator and centrifugal pump.

The complete heart-lung machine includes many additional components. Most manufacturers consolidate a membrane oxygenator, venous reservoir, and heat exchanger into one unit. A microfilter-bubble trap is added to the arterial line. Depending on the operation various suction systems are used to return blood from the surgical field, cardiac chambers, and/or the aorta. Aspirated blood passes through a cardiotomy reservoir and microfilter before returning to the venous reservoir. Optionally, but increasingly recommended, field blood is washed in a cell saver system and returned to the perfusate as packed red cells. In addition to adjusting pump flow, partial and occluding clamps on venous and arterial lines are used to direct and regulate flow. Sites for obtaining blood samples and sensors for monitoring pressures, temperatures, oxygen saturation, blood gases, and pH are included, as are various safety devices.

Actual typical CPB setup

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

A separate circuit for administering cardioplegic solutions at controlled composition, rate, and temperature is usually included in the system. Less often a hemoconcentrator (for removal of water and small molecules) is added to the primary circuit.

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Arterial Perfusion Setups

The following are some of the many perfusion scenarios in aortic surgery

Bilateral antegrade cerebral perfusion obtained by selective cannulation of the innominate and left common carotid artery. 

Upper right: retrograde cerebral perfusion via the superior vena cava. 

Lower right: regional cerebral perfusion (unilateral antegrade perfusion) via cannulation of the right subclavian artery.

Sequential bilateral antegrade perfusion of the brain. The branch of a multiple-arms graft is initially connected to the left common carotid artery allowing rapid establishment of a bilateral perfusion of the brain. The other anastomoses are performed thereafter. Perfusion of the right subclavian artery through a graft allows monitoring of the perfusion pressure via the right radial artery.

Ascending aortic aneurysm extending into the underside of the aortic arch. (B) Bentall reconstruction of the aortic root with open resection of the hemiarch. Perfusion via the right axillary artery. (C) Completed repair and full systemic perfusion.

(A) Acute type A aortic dissection with the entry point located in the aortic arch. 

(B) Cardiopulmonary bypass via the right axillary artery. 

(C) Separate graft anastomosis to the brachiocephalic vessels. 

(D) Selective cerebral perfusion and elephant trunk construction.

(E) Arch reconstruction with graft-to-graft anastomosis. 

(F) Completed repair.

(A) Atherosclerotic ascending and arch aneurysm. 

(B) Fabrication of the trifurcated graft. 

(C) Selective cerebral perfusion and construction of the elephant trunk. 

(D) Completed repair.

(A) Recurrent arch proximal descending aneurysm. 

(B) Selective cerebral perfusion and arch reconstruction. 

(C) Completed repair.

(A) Distal arch descending thoracic aortic aneurysm with femoral artery perfusion. 

(B) HCA and anastomosis to the distal arch. 

(C) Selective cerebral perfusion. 

(D) Reattachment of the left subclavian artery and completed repair.

(A) Technique for extensive thoracoabdominal aortic aneurysm repair utilizing proximal aortic isolation with distal aortic perfusion employing left atrial to left common femoral artery bypass with a centrifugal pump. 

(B) Following completion of the proximal anastomosis, visceral and renal arteries are perfused using 9 F Pruitt catheters with oxygenated blood from the bypass circuit during intercostal arterial reattachment. 

(C) Prior to completion of distal reconstruction, visceral and renal perfusion are continued during reattachment of the aortic graft. Sequential clamping provides intercostal perfusion.

Crawford extent IV thoracoabdominal aortic aneurysm with visceral and renal oxygenated blood perfusion from left atrium during the ischemic period of aortic reconstruction.

(A) Crawford extent I thoracoabdominal aortic aneurysm using atrio-femoral bypass, with beveled distal anastomosis, includes visceral and renal arterial reattachment that is carried out first. 

(B) Sequential clamping of graft provides renal and visceral perfusion during reattachment of a patch of intercostal arteries. 

(C) Sequential placement of the clamp allows distal perfusion of reattached intercostal arteries during the proximal aortic anastomosis.

Diagram showing a typical setup for partial left heart bypass in a patient with aortic disruption at the isthmus.

Iliac artery exposure

This is sometimes necessary when the femoral arteries are too diseased to cannulate or are too small for stent insertion.

Iliac Artery Exposure

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Anterograde, Retrograde and Integrated Cerebral Perfusion

Antegrade Cerebral Perfusion

Antegrade perfusion of the brain through cannulae inserted in the innominate (or more distally in the right common carotid artery) and left common carotid artery provides the most physiologic and efficient perfusion of the brain. Perfusate temperature is usually set at 18°C and flow is set between 10 and 20 mL/kg/min or adjusted to maintain a pressure between 40 and 50 mm Hg in the right radial artery. Clinical results, especially regarding swift recovery of cerebral function, have been outstanding with this method of perfusion. The necessity to cannulate relatively small and often diseased arch arteries and the presence of additional cannulae in the operating field constitute the main drawbacks of the technique. Cannulation of the common carotid arteries can result in dissection of the arterial wall and embolism of atheromatous plaque material or air. Furthermore, the flow in the artery is dependent on proper positioning of the tip of the cannula within the vessel. For these reasons, many surgeons rely on a unilateral perfusion of the brain, with the sole cannulation and perfusion of the right subclavian artery. The right vertebral and right common carotid artery territories are perfused in an antegrade fashion. The blood reaches the left cerebral hemisphere through the circle of Willis and, to a lesser extent, through cervicofacial connections. It is, therefore, important that the left common carotid and left subclavian arteries be occluded to avoid a steal of blood down these arteries. Occlusion (usually with an inflatable balloon) of the descending aorta is also a useful maneuver to improve overall body perfusion. Effective somatic perfusion (including the abdominal organs, spinal cord, and lower limb musculature) has been documented with this maneuver.

The presence of an aberrant right subclavian artery (also called arteria lusoria) is obviously a contraindication to the use of this perfusion method. The aberrant origin of the artery is usually readily identified by computed tomography or magnetic resonance. The burst of blood from the descending aorta during the opening of the aortic arch should alert the surgeon to this anatomic variation, and prompt a direct cannulation of the ostium of the right and left common carotid arteries.

Sequential perfusion of the cerebral arteries provides additional safety to unilateral cerebral perfusion, and avoids cannulation of small or diseased arch arteries. The right subclavian artery remains perfused during the whole procedure. A vascular graft is immediately sewn on a common patch of aortic wall including all the arch vessels, or the second branch of a multiple-arm prosthesis is anastomosed to the left common carotid artery. Perfusion is then instituted through this additional graft and enhances, after a short period of time, cerebral perfusion.

 

Retrograde Cerebral Perfusion

The value of retrograde cerebral perfusion in protecting the human brain has still not been clearly elucidated. No animal model truly replicates the complex anatomy and physiology of the human brain, and none allows a fine neuropsychologic evaluation. Conflicting results and conclusions in clinical and experimental studies have, therefore, been reported. Accepted facts include a deep and homogenous cooling of the brain hemispheres (the cooling scalp effect) and the expulsion of solid particles or gaseous bubbles from the arch arteries. Controversies surround the possible nutritive value of retrograde perfusion. The nutritive value has been demonstrated in rabbits but not in dogs, pigs, or baboons. In humans, signs of cerebral perfusion and oxygen uptake have been documented, but the amount of perfusate providing cerebral nutrition is low, corresponding to about 5% of total retrograde flow. The blood delivered in the superior vena cava flows preferentially in the low-pressure inferior vena cava, via the azygos system, the perivertebral venous plexus, and the thoracic wall veins. Even within the brain, the distribution of retrograde flow is uneven, with a preferential distribution in the sagittal sinus and hemispheric veins. The large steal of blood to the inferior venous territory is corroborated by the clinical finding of an extremely small proportion of perfused blood flowing out of the arch arteries. Occlusion of the inferior vena cava to decrease the pressure gradient between the two venous territories effectively reduces the amount of stolen blood, but increases the sequestration of fluid in the interstitial tissue. Interstitial edema is another potential problem of retrograde perfusion, which can lead to cerebral edema and hypertension, particularly when the perfusion pressure exceeds 25 mm Hg. Finally, the finding that the human jugular system may contain competent valves casts definitive doubts regarding the reliability of retrograde cerebral perfusion.

Clinical series, however, have reported encouraging results. A reduction in both mortality and incidence of neurologic damage has been regularly documented with the adjunctive use of retrograde cerebral perfusion to classical hypothermia. Some studies confirmed the limited capacity of retrograde perfusion to sustain cerebral metabolism, and stressed the fact that the occurrence of neurologic damage was only delayed. Indeed, the risk rises sharply after 60 minutes of deep hypothermic circulatory arrest, perhaps at the extinction of intracellular energy substrates. If most surgeons acknowledge the capacity of retrograde cerebral perfusion to prolong the period of safe circulatory arrest, they consider the method a valuable but not an alternative adjunct to conventional methods when long periods of circulatory arrest are contemplated.

 

Integrated Perfusion

Probably the safest approach to a patient requiring a long period of circulatory arrest resides in the integration of complementary methods of perfusion and monitoring. Retrograde perfusion of the aorta through the femoral artery should be avoided in the presence of a thoracic aortic aneurysm in order to reduce the risk of particulate dislodgment with embolization in the brain and myocardium. Antegrade perfusion of the aorta is performed with cannulation of the ascending aorta or right subclavian artery. The body is cooled to 18°C. Electroencephalogram and venous jugular saturation are monitored to ensure adequate reduction of cerebral metabolism. Circulatory arrest is established only after electrocerebral silence is obtained and jugular venous saturation is superior to 95%. During the 10 to 20 minutes preceding circulatory arrest, the temperature of the perfusate can be lowered to 13°C to further reduce brain temperature and metabolism. The arch arteries are connected to a graft (either with the use of a patch of aortic wall or separately), and antegrade perfusion of the brain is resumed before more extensive resection and repair of the aorta is performed. When the risk of particle embolization to the brain is substantial (old age, severe atherosclerosis of the aorta, arch aneurysm with thrombotic material), a short period of retrograde cerebral perfusion can be performed to wash out the arch arteries before antegrade perfusion is definitively reestablished.

CPB 101. Anterograde, Retrograde and Integrated Cerebral Perfusion

Anterograde, Retrograde and Integrated Cerebral Perfusion

Antegrade Cerebral Perfusion

Antegrade perfusion of the brain through cannulae inserted in the innominate (or more distally in the right common carotid artery) and left common carotid artery provides the most physiologic and efficient perfusion of the brain. Perfusate temperature is usually set at 18°C and flow is set between 10 and 20 mL/kg/min or adjusted to maintain a pressure between 40 and 50 mm Hg in the right radial artery. Clinical results, especially regarding swift recovery of cerebral function, have been outstanding with this method of perfusion. The necessity to cannulate relatively small and often diseased arch arteries and the presence of additional cannulae in the operating field constitute the main drawbacks of the technique. Cannulation of the common carotid arteries can result in dissection of the arterial wall and embolism of atheromatous plaque material or air. Furthermore, the flow in the artery is dependent on proper positioning of the tip of the cannula within the vessel. For these reasons, many surgeons rely on a unilateral perfusion of the brain, with the sole cannulation and perfusion of the right subclavian artery. The right vertebral and right common carotid artery territories are perfused in an antegrade fashion. The blood reaches the left cerebral hemisphere through the circle of Willis and, to a lesser extent, through cervicofacial connections. It is, therefore, important that the left common carotid and left subclavian arteries be occluded to avoid a steal of blood down these arteries. Occlusion (usually with an inflatable balloon) of the descending aorta is also a useful maneuver to improve overall body perfusion. Effective somatic perfusion (including the abdominal organs, spinal cord, and lower limb musculature) has been documented with this maneuver.

The presence of an aberrant right subclavian artery (also called arteria lusoria) is obviously a contraindication to the use of this perfusion method. The aberrant origin of the artery is usually readily identified by computed tomography or magnetic resonance. The burst of blood from the descending aorta during the opening of the aortic arch should alert the surgeon to this anatomic variation, and prompt a direct cannulation of the ostium of the right and left common carotid arteries.

Sequential perfusion of the cerebral arteries provides additional safety to unilateral cerebral perfusion, and avoids cannulation of small or diseased arch arteries. The right subclavian artery remains perfused during the whole procedure. A vascular graft is immediately sewn on a common patch of aortic wall including all the arch vessels, or the second branch of a multiple-arm prosthesis is anastomosed to the left common carotid artery. Perfusion is then instituted through this additional graft and enhances, after a short period of time, cerebral perfusion. 

 
Retrograde Cerebral Perfusion

The value of retrograde cerebral perfusion in protecting the human brain has still not been clearly elucidated. No animal model truly replicates the complex anatomy and physiology of the human brain, and none allows a fine neuropsychologic evaluation. Conflicting results and conclusions in clinical and experimental studies have, therefore, been reported. Accepted facts include a deep and homogenous cooling of the brain hemispheres (the cooling scalp effect) and the expulsion of solid particles or gaseous bubbles from the arch arteries. Controversies surround the possible nutritive value of retrograde perfusion. The nutritive value has been demonstrated in rabbits but not in dogs, pigs, or baboons. In humans, signs of cerebral perfusion and oxygen uptake have been documented, but the amount of perfusate providing cerebral nutrition is low, corresponding to about 5% of total retrograde flow. The blood delivered in the superior vena cava flows preferentially in the low-pressure inferior vena cava, via the azygos system, the perivertebral venous plexus, and the thoracic wall veins. Even within the brain, the distribution of retrograde flow is uneven, with a preferential distribution in the sagittal sinus and hemispheric veins. The large steal of blood to the inferior venous territory is corroborated by the clinical finding of an extremely small proportion of perfused blood flowing out of the arch arteries. Occlusion of the inferior vena cava to decrease the pressure gradient between the two venous territories effectively reduces the amount of stolen blood, but increases the sequestration of fluid in the interstitial tissue. Interstitial edema is another potential problem of retrograde perfusion, which can lead to cerebral edema and hypertension, particularly when the perfusion pressure exceeds 25 mm Hg. Finally, the finding that the human jugular system may contain competent valves casts definitive doubts regarding the reliability of retrograde cerebral perfusion.

Clinical series, however, have reported encouraging results. A reduction in both mortality and incidence of neurologic damage has been regularly documented with the adjunctive use of retrograde cerebral perfusion to classical hypothermia. Some studies confirmed the limited capacity of retrograde perfusion to sustain cerebral metabolism, and stressed the fact that the occurrence of neurologic damage was only delayed. Indeed, the risk rises sharply after 60 minutes of deep hypothermic circulatory arrest, perhaps at the extinction of intracellular energy substrates. If most surgeons acknowledge the capacity of retrograde cerebral perfusion to prolong the period of safe circulatory arrest, they consider the method a valuable but not an alternative adjunct to conventional methods when long periods of circulatory arrest are contemplated. 

Integrated Perfusion

Probably the safest approach to a patient requiring a long period of circulatory arrest resides in the integration of complementary methods of perfusion and monitoring. Retrograde perfusion of the aorta through the femoral artery should be avoided in the presence of a thoracic aortic aneurysm in order to reduce the risk of particulate dislodgment with embolization in the brain and myocardium. Antegrade perfusion of the aorta is performed with cannulation of the ascending aorta or right subclavian artery. The body is cooled to 18°C. Electroencephalogram and venous jugular saturation are monitored to ensure adequate reduction of cerebral metabolism. Circulatory arrest is established only after electrocerebral silence is obtained and jugular venous saturation is superior to 95%. During the 10 to 20 minutes preceding circulatory arrest, the temperature of the perfusate can be lowered to 13°C to further reduce brain temperature and metabolism. The arch arteries are connected to a graft (either with the use of a patch of aortic wall or separately), and antegrade perfusion of the brain is resumed before more extensive resection and repair of the aorta is performed. When the risk of particle embolization to the brain is substantial (old age, severe atherosclerosis of the aorta, arch aneurysm with thrombotic material), a short period of retrograde cerebral perfusion can be performed to wash out the arch arteries before antegrade perfusion is definitively reestablished.

Residency in Cardiothoracic and Vascular Surgery: My viewpoint

Obstacles Faced by the Resident 

I have recently completed my cardiothoracic and vascular surgery (CTVS) residency. It not only taught me the techniques and art of surgery but also enriched me spiritually. There are many things which I think can make our training programmes highly successful and beneficial. We as residents should learn to take maximum benefit from our residency, as this prepares the foundation on which our future will be built. The details of an ideal resident training programme will always be debated, and it’s not always possible to achieve the ideal. Residents will continue to expect many things from their course of instruction, and the demands of residency training will continue to create obstacles.

Various hurdles and obstacles may arise in our lives; these may hinder our path of training. Most of them are either in the form of health and family related issues or at times various aspects of the hard and rigorous training which test the resident’s psychological strength. From time to time residents may develop negative thoughts about the decision to become a Cardiothoracic Surgeon.

We should learn to minimize the loss and distraction that these situations inflict on our learning and career. There are many ways of doing so. Exercise is one of the best ways to shed one’s worries and increase physical and psychological strength.





The meals should be taken in a relaxed atmosphere whenever possible, not just to push in something for the sake of filling our stomach. If we can be careful about the protection of our patients’ myocardium, why cannot we practice protection of our own stomach and myocardium?

Nothing is more relaxing than a good sound sleep. Deprivation of sleep is a big enemy for all residents, but it is the call of the duty that keeps us awake for long hours. Resting areas in the hospital should be comfortable and peaceful, so that even a short nap is refreshing. Residents should try to have a good sound sleep the night before their call day.

Almost all of us have one or another hobby, but most of us are not able to pursue it. Some time should be set aside in our busy routine for hobbies. They have a very good relaxing and refreshing effect.

Another way of relieving stress is socializing together, going out for a dinner or picnic. Departments should have their own protocol for such get-togethers at least once a month. Apart from cementing the unity between team members, these occasions also let everyone know each other in a relaxed atmosphere. Such get-togethers don’t lead to loss of working hours; rather they increase the productivity of the team members.




Music at the working place has been proven to improve the atmosphere. Lots of musical compositions which suit such places are available and should be played.

Reading popular books or magazines on technology of today such ad ipad, windows, blackberry  and many others written on related issues especiali sport (martial art is my favorit)  have a very positive impact on our thinking and behavior.

Last but not least a supportive family is of great assistance in helping us to become a Cardiothoracic surgeon. Their contribution is no less than anyone else is because they sacrifice a lot to enable us to remain busy during our training and throughout our career.



During residency which is difficult, demanding and exhausting, when the hours are long and days unpredictable, many times a negative thought comes into our mind. One might question why I chose this endeavor. But then thinking about the challenges, excitement, and rewards that lie ahead will help remind you that the choice was correct.

Rewards are immeasurable after the hard work of residency. The future is full of opportunities in our specialty, we have to recognize and seize them. Many life saving opportunities that this profession provides are very gratifying.

Cardiothoracic surgeons are frequently given special respect. They are almost uniformly considered leaders among the surgical specialties. Heading a team of skilled healthcare providers of many types is satisfying and stimulating. We should be proud that we will be trusted and called upon to treat some of the sickest patients with the most complex problems in the hospital. We will be dealing with the most vibrant and dynamic organ, i.e., the heart. It will be our privilege to touch and mend the heart, to work inside its chambers and restore the health of a gravely ill patient. 
It is an honor which few people ever get to experience. 
The joys of being a Cardiothoracic and Vascular Surgeon will certainly greatly outweigh the frustrations and irritations that lie in the path of becoming one.

Ideas about an ideal CTVS residency programme will remain different and will continue to be debated at various levels. Nevertheless, training residents with the best and latest knowledge in an environment which is cordial, friendly, disciplined and honest, is essential. We as residents should try to make our learning as productive as possible. Frustrations should not be allowed to creep in. The whole idea of residency training should be not only to produce the best of surgeons but also the best of ‘humane’ surgeons. Let us all work together to accomplish this goal.

 

I will always be extremely grateful and thankfull to all my teachers who have always taught me the art and science of this specialty and encouraged me to realize my dreams. Many thanks to my great parents, sweet and caring wife and son, wonderful friends and colleagues, family members and all the staff of  the hospital who supported and loved me all throughout my CTVS residency.

Avoiding Pitfalls: “do not stumble over the same stone, learn from the experts"

European Cardiothoracic Residents' Meeting 2010

Avoiding Pitfalls: “do not stumble over the same stone, learn from the experts"

24th EACTS Annual Meeting
Palexpo Centre Geneva, Switzerland
Monday, 13 September 2010, 15:30-16:30
Residents’ Meeting Room E

Organisers	Surgical Training and Manpower Committee
Chairmen	Dr. Peyman Sardari Nia, Nieuwegein, Netherlands Dr. J Rafael Sádaba, Pamplona, Spain
Moderators	P. Sardari Nia, Antwerp; M. Siepe, Freiburg
Program 15:30 Adult cardiac surgery Complications: from present to prevent A. Brutel de la Riviere, Amsterdam 15:45 Thoracic surgery How not to do it: mistakes I have made and that you can avoid D. Wood, Seattle 16:00 Vascular surgery Pitfalls in thoracic and thoracoabdominal aortic aneurysm surgery M. Schepens, Brugge 16:15 Congenital cardiac surgery Pitfalls in operative techniques of congenital cardiac surgery V. Tsang, London Following the meeting residents are cordially invited to a dinner. The dinner is by invitation only, which will be allocated on a first-come, first-served basis.