Heart Valve Repair

Severe valve damage means that the valve will need to be replaced. Valve replacement is most often used to treat aortic valves and severely damaged mitral valves. It is also used to treat any valve disease that is life-threatening. Sometimes, more than one valve may be damaged in the heart, so patients may need more than one repair or replacement.

There are 2 kinds of valves used for valve replacement:

• Mechanical valves, which are usually made from materials such as plastic, carbon, or metal. Mechanical valves are strong, and they last a long time. Because blood tends to stick to mechanical valves and create blood clots, patients with these valves will need to take blood-thinning medicines (called anticoagulants) for the rest of their lives.
• Biological valves, which are made from animal tissue (called a xenograft) or taken from the human tissue of a donated heart (called an allograft or homograft). Sometimes, a patient’s own tissue can be used for valve replacement (called an autograft). Patients with biological valves usually do not need to take blood-thinning medicines. These valves are not as strong as mechanical valves, though, and they may need to be replaced every 10 years or so. Biological valves break down even faster in children and young adults, so these valves are used most often in elderly patients.

You and your doctor will decide which type of valve is best for you

During valve repair or replacement surgery, the breastbone is divided, the heart is stopped, and blood is sent through a heart-lung machine. Because the heart or the aorta must be opened, heart valve surgery is open heart surgery.

What to Expect

The operation will usually be scheduled at a time that is best for you and your surgeon, except in urgent cases. As the date of your surgery gets closer, be sure to tell your surgeon and cardiologist about any changes in your health. If you have a cold or the flu, this can lead to infections that may affect your recovery. Be aware of fever, chills, coughing, or a runny nose. Tell the doctor if you have any of these symptoms.

Also, remind your cardiologist and surgeon about all of the medicines you are taking, especially any over-the-counter medicines such as aspirin or those that might contain aspirin. You should make a list of the medicines and bring it with you to the hospital.

It is always best to get complete instructions from your cardiologist and surgeon about the procedure, but here are some basics you can expect when you have valve repair or replacement surgery.

Before the Hospital Stay

Most patients are admitted to the hospital the day before surgery or, in some cases, on the morning of surgery.

The night before surgery, you will be asked to bathe to reduce the amount of germs on your skin. After you are admitted to the hospital, the area to be operated on will be washed, scrubbed with antiseptic, and, if needed, shaved.

A medicine (anesthetic) will make you sleep during the operation. This is called “anesthesia.” Because anesthesia is safest on an empty stomach, you will be asked not to eat or drink after midnight the night before surgery. If you do eat or drink anything after midnight, it is important that you tell your anesthesiologist and surgeon.

If you smoke, you should stop at least 2 weeks before your surgery. Smoking before surgery can lead to problems with blood clotting and breathing.

Day of Surgery

Before surgery, you may have an electrocardiogram (ECG or EKG), blood tests, urine tests, and a chest x-ray to give your surgeon the latest information about your health. You will be given something to help you relax (a mild tranquilizer) before you are taken into the operating room.

Small metal disks called electrodes will be attached to your chest. These electrodes are connected to an electrocardiogram machine, which will monitor your heart’s rhythm and electrical activity. You will receive a local anesthetic to numb the area where a plastic tube (called a line) will be inserted in an artery in your wrist. An intravenous (IV) line will be inserted in a vein. The IV line will be used to give you the anesthesia before and during the operation.

After you are completely asleep, a tube will be inserted down your windpipe and connected to a machine called a respirator, which will take over your breathing. Another tube will be inserted through your nose and down your throat, into your stomach. This tube will stop liquid and air from collecting in your stomach, so you will not feel sick and bloated when you wake up. A thin tube called a catheter will be inserted into your bladder to collect any urine produced during the operation.

A heart-lung machine is used for all valve repair or replacement surgeries. This will keep oxygen-rich blood flowing through your body while your heart is stopped. A perfusion technologist or blood-flow specialist operates the heart-lung machine. Before you are hooked up to this machine, a blood-thinning medicine called an anticoagulant will be given to prevent your blood from clotting. The surgical team is led by the cardiovascular surgeon and includes other assisting surgeons, an anesthesiologist, and surgical nurses.

After you are hooked up to the heart-lung machine, your heart is stopped and cooled. Next, a cut is made into the heart or aorta, depending on which valve is being repaired or replaced. Once the surgeon has finished the repair or replacement, the heart is then started again, and you are disconnected from the heart-lung machine.

The surgery can take anywhere from 2 to 4 hours or more, depending on the number of valves that need to be repaired or replaced.

Recovery Time

You can expect to stay in the hospital for about a week, including at least 1 to 3 days in the Intensive Care Unit (ICU).

Recovery after valve surgery may take a long time, depending on how healthy you were before the operation. You will have to rest and limit your activities. Your doctor may want you to begin an exercise program or to join a cardiac rehabilitation program.

If you have an office job, you can usually go back to work in 4 to 6 weeks. Those who have more physically demanding jobs may need to wait longer.

Life After Valve Replacement

Most valve repair and replacement operations are successful. In some rare cases, a valve repair may fail and another operation may be needed.

Patients with a biological valve may need to have the valve replaced in 10 to 15 years. Mechanical valves may also fail, so patients should alert their doctor if they are having any symptoms of valve failure.

Patients with a mechanical valve will need to take a blood-thinning medicine for the rest of their lives. Because these medicines increase the risk of bleeding within the body, you should always wear a medical alert bracelet and tell your doctor or dentist that you are taking a blood-thinning medicine.

Even if you are not taking a blood-thinning medicine, you must always tell your doctor and dentist that you have had valve surgery. If you are having a surgical or dental procedure, you should take an antibiotic before the procedure. Bacteria can enter the bloodstream during these procedures. If bacteria get into a repaired or artificial valve, it can lead to a serious condition called bacterial endocarditis. Antibiotics can prevent bacterial endocarditis.

Patients with mechanical valves say they sometimes hear a quiet clicking sound in their chest. This is just the sound of the new valve opening and closing, and it is nothing to be worried about. In fact, it is a sign that the new valve is working the way it should.

Heart Valve Replacement

What is heart valve replacement surgery?

heart valve replacement surgery is an ‘open’ heart surgery procedure to replace heart valves that have become susceptible to heart valve disease, or are abnormal in some way. Valves are replaced with either biological (animal or human tissue) or man-made valves.

Who can benefit from heart valve replacement surgery?

Individuals who have heart valve disease or endocarditis can hugely benefit from heart valve replacement as the surgery can improve symptoms or completely eradicate damage resulting in greater quality of life. Birth defects that have not been immediately addressed may get worse and aging can weaken the valves. Both of these may also be reasons for undergoing heart valve replacement surgery.

Procedure

There are four valves surrounding the heart, and the length of operation will depend on how many need to be replaced.

• Traditional heart valve replacement - An incision will be made down the length of the breastbone in order to reach the heart. The heart is then stopped using medication, and the blood diverted to a heart-lung bypass machine to maintain circulation. The affected valve is then replaced and the heart re-started using electrical shocks. The sternum is closed using wires and the incision sewn up.
• Minimally invasive surgery - Minimally invasive surgery (also known as ‘keyhole’ surgery) is a less common procedure. This type of surgery avoids the need for an incision down the sternum and instead uses small incisions between the ribs that instruments can be passed through. The surgeon then uses a TV monitor in order to replace the affected valve.

Recovery period

You will need to stay in hospital for around one week. On returning home you can take painkillers to alleviate the pain, which you be present around the wound. The breastbone (sternum) will take around six weeks to heal, and you should avoid driving and strenuous activities during this time. You will also need to take several weeks off work.

Risks

Any surgical procedure carries risk; specific to heart valve replacement, complications can include blood clotting (which may lead to a stroke or heart attack), infection, damage to the new valve and an irregular heart beat (usually temporary). There is also the risk of death during and after the operation, but this is very small. Your surgeon will go through all of the risks with you before undertaking any procedure.

Implantable Cardiac Defibrillators (ICDs)

For those who are at high risk of the deadliest forms of arrhythmias – ventricular tachycardia and ventricular fibrillation – an internal “shocking” device may provide the best defense against sudden cardiac arrest. Such a device, known as an implantable cardioverter defibrillator (ICD), is considered effective in fighting cardiac arrest over 90 percent of the time, an astounding success for a condition that few survived as recently as 15 years ago.

About ICDs

Implantable cardioverter defibrillators (ICDs) are small devices, about the size of a pager, that are placed below the collarbone. Via wires, or leads, these devices continuously monitor the heart’s rhythm. If the heart beats too quickly, the ventricles will not have enough time to fill with blood and will not effectively pump blood to the rest of the body. Left unchecked, the rapid heartbeat could cause death. To intervene, the ICD issues a lifesaving jolt of electricity to restore the heart’s normal rhythm and prevent sudden cardiac death.

ICDs also can act as pacemakers when a heart beat that is too slow (bradycardia) is detected.

Most ICDs keep a record of the heart's activity when an abnormal heart rhythm occurs. With this information, the electrophysiologist, nurse practitioner or electrophysiology nurse who is a specialist in arrhythmias, can study the heart's activity and ask about other symptoms that may have occurred. Sometimes the ICD can be programmed to “pace” the heart to restore its natural rhythm and avoid the need for a shock from the ICD. Pacing impulse from the ICD are not felt by the patient; shocks are felt, and have been described as a kick in the chest.

When is ICD Therapy the Right Choice?

In the simplest terms, anyone who has had or is at a high risk of having ventricular tachycardia, fibrillation or sudden cardiac arrest is a candidate for an ICD.

A cardiac arrhythmia specialist (electrophysiologist) should evaluate cardiac patients if they have experienced any of the following:

• A prior cardiac arrest
• Ventricular tachycardia (VT) which is an episode of rapid heartbeat originating from the lower chambers of the heart.
• Ventricular fibrillation (VF), which is similar to VT but is characterized by a heartbeat that is too rapid and is irregular or chaotic.
• Ejection fractions of less than 35 percent. An ejection fraction (EF) is the proportion, fraction, or percentage of blood pumped by the heart with each beat. A normal heart pumps out a little more than half the heart's volume of blood with each beat, making a normal EF 55 percent or higher.
• Patients at a high risk for sudden cardiac death (SCD) because of an inherited heart abnormality.

How Effective Are ICDs?

Studies of ICDs show they are 99 percent effective in detecting and stopping deadly heart rhythm disorders. In clinical trials, ICDs have been shown to be the most successful therapy to prevent sudden cardiac death in certain groups of high-risk patients.

Common Questions About ICDs

Can I use a cellular phone?

Yes, with these general guidelines:

• Hold the phone to the ear on the side of the body opposite of the implanted device.
• Do not carry the phone in the ON position in a breast pocket over or within 6 inches of the ICD.
• Maintain a minimum of 6 inches between the ICD and the phone.

Are security systems and airports a problem?

Walk normally through theft detector systems. Carry your ID card with you at all times. Show the airport security people the card, and ask to be hand searched.

Can an ICD patient drive a car?

Many physicians recommend no driving for 6 months after implantation of an ICD, or after a shock. Commercial drivers may be restricted from driving. Discuss this issue with your physician to maintain your safety as well as that of others.

How does it feel?

Fast pacing therapy may feel like a flutter or palpitation in the chest, or nothing at all. The shocks may feel like a sudden painful kick in the chest. It occurs in an instant and then is gone. If a blackout occurs, the shock may not be felt. Someone touching the patient may feel a small muscle jerk. It will not harm them.

How and when is the battery replaced?

The battery check at each visit will determine when the ICD should be replaced. The electronic circuitry as well as the battery are sealed inside the ICD. When replacement time arrives the lead(s) will be tested and then a new ICD is attached to the lead(s). Usually the original lead(s) are reused.

Mitral Valve Repair

What is Mitral Valve Repair?

Mitral valve repair is an open heart procedure performed by cardiothoracic surgeons to treat stenosis (narrowing) or regurgitation (leakage) of the mitral valve. The mitral valve is the "inflow valve" for the left side of the heart. Blood flows from the lungs, where it picks up oxygen, and into the heart through the mitral valve. When it opens, the mitral valve allows blood to flow into the heart's main pumping chamber called the left ventricle. It then closes to keep blood from leaking back into the lungs when the ventricle contracts (squeezes) to push blood out to the body. It has two flaps, or leaflets.

Minimally invasive mitral valve repair and its benefits

Minimally invasive mitral valve repair is performed through a two-inch keyhole incision on the side of the chest. The port access technique is a step ahead in that the incision is even smaller and the whole operation is video-directed, whereas in non-port access minimally invasive mitral valve surgery, the operation is done by direct vision. The minimally invasive approaches avoid an incision in the breastbone (sternotomy) and have several benefits like:

• Less pain
• Shorter stay in hospital. Hence, patients return to work and everyday activity sooner after surgery.
• Less bleeding
• Fewer chances of infection as the incision is smaller
• Cosmetic benefits

What could go wrong with the Mitral Valve?

• Mitral valve stenosis: The mitral valve thickens and narrows. Hence, the valve cannot open completely, causing an obstruction in the flow of blood.
• Mitral regurgitation: The valve does not shut tight and hence blood flows back into the left atrium when the left ventricle contracts to push the blood out.
• Mitral valve prolapse: The two halves or leaflets of the mitral valve are bulging and they do not close properly. They flop backwards and cause a clicking or murmuring sound (heart murmur). This also causes the mitral valve to leak and blood flows back into the left atrium. Mitral valve prolapse can be a congenital defect or develop later on. In either case, the cause is not known.

All three conditions will affect the functioning of the heart and its capacity to pump blood through the body. This will force the heart to work harder. Symptoms of mitral valve malfunction range from fatigue and breathlessness to even vomiting blood. Mitral valve prolapse is a fairly common condition, and most people with this condition live with no discomfort or symptoms. But in some cases, stress on the flopping valve halves can cause other problems that need to be treated.

Pacemaker Surgery

What is a pacemaker?

An artificial pacemaker is a small device that is fitted inside the chest to help regulate the heartbeat.

Who can benefit from having a pacemaker fitted?

We all have a natural pacemaker – the sinoatrial node – that regulates the heartbeat by sending an electrical signal through the heart. Sometimes individuals may have an irregular heart rhythm or one that beats to slow or fast (referred to as arrhythmias). In this case, an artificial pacemaker will need to be fitted to regulate the heartbeat. A patient may also need a pacemaker if there is a block in the heart’s electrical pathway. An artificial pacemaker can help promote a more active lifestyle for those who suffer from arrhythmias.

Procedure

The pacemaker will be fitted while you are under a local anesthetic. A needle is placed into a vein close to your shoulder, and is used to thread wires through the vein and into the heart. Once the wires have been placed in the heart, a small cut is made into the chest and the pacemaker is fitted under the skin and attached to the wires. The incision is then closed using sutures. This procedure is called the endocardial approach; however sometimes a more surgical procedure called the epicardial approach can be used, but is less common in adults.

Recovery period

Recovery from the pacemaker will involve an overnight stay in hospital so that your heartbeat can be monitored. You will need to arrange for someone to pick you up, as you are not allowed to drive for around a week following the pacemaker being fitted. Painkillers can be taken to alleviate any pain, and you may be aware of some bruising and swelling. You may need to avoid doing any strenuous exercise and coming into contact with certain electrical devices, but your doctor will advise you on this.

Risks

Infection, discharge from the wound, nerve damage, movement of pacemaker leads, collapsed lung, bleeding, blood vessel damage, reaction to anesthetic.

Patent Ductus Artery (PDA)

What is Patent Ductus Artery (PDA)

Patent ductus arteriosus (PDA) describes a preservation of the connection between the pulmonary artery and the aorta that exists in the fetus (see Figure 8). Since aortic diastolic pressure is higher than pulmonary artery systolic pressure, there is continuous flow into the pulmonary circulation, creating the characteristic continuous ("machinery") murmur, heard best just below the left clavicle. In hemodynamically insignificant lesions (>50% of cases), patients are asymptomatic. Patients with bigger shunts develop cardiac failure at an age that depends on the severity of the lesion. Eisenmenger syndrome can occur with PDA. Treatment is surgical closure of the duct; this can be carried out percutaneously.

What are the signs and symptoms of patent ductus arteriosus?

A heart murmur may be the only sign that a baby has patent ductus arteriosus (PDA). A heart murmur is an extra or unusual sound heard during the heartbeat.

Some infants may develop signs or symptoms of volume overload on the heart and excess blood flow in the lungs. Signs and symptoms may include:

• Fast breathing, working hard to breathe, or shortness of breath, or in the case of a premature infant, need for increased oxygen or ventilatory support
• Poor feeding and poor weight gain
• Tiring easily
• Sweating with exertion (such as while feeding)

How is patent ductus arteriosus diagnosed?

Two painless tests are used to diagnose a PDA.

Echocardiogram. This test, which is harmless and painless, uses sound waves to create a moving picture of your baby's heart. During an echocardiogram, reflected sound waves outline the heart's structure completely. The test allows the doctor to clearly see any problem with the way the heart is formed or the way it's working. An echocardiogram is the most important test available to your baby's cardiologist to both diagnose a heart problem and follow the problem over time. In babies with PDA, the echocardiogram shows how big the ductus is and how well the heart is responding to it. When medical treatments are used to try to close a ductus in premature babies, echocardiograms are used to see how well the treatment is working.

EKG (electrocardiogram). This test records the electrical activity in the heart. In the case of a PDA, it can show:

• Enlargement of the heart chambers
• Other subtle changes that can suggest the presence of a PDA

How is patent ductus arteriosus treated?

The goal of treatment is to close the patent ductus arteriosus (PDA) to prevent complications and reverse the effects of increased blood volume.

Surgery for PDA may be performed when:

• A premature or full-term infant develops health problems from the PDA and is too small to have a catheter-based procedure
• A PDA is not successfully closed by a catheter-based procedure
• Surgery is planned for treatment of related congenital heart defects

Surgery often is not performed until after 6 months of age in infants who do not have health problems from the PDA. Doctors sometime perform surgery on small PDAs to prevent the risk of bacterial endocarditis.

The operation is done under general anesthesia. The surgeon will:

• Make a small cut between your child's ribs to reach the PDA
• Close the PDA with stitches or clips

Complications of the surgery are rare and usually short term. They can include hoarseness, a paralyzed diaphragm, infection, bleeding, or fluid buildup around the lungs.

After surgery. After surgery, you will spend a few days in the hospital. Most people go home 2 days after surgery. While in the hospital, you will be given medicines to reduce pain or anxiety. The doctors and nurses at the hospital will teach you how to care at home. They will talk to you about:

• Limits on activity while you recovers
• Followup appointments with your doctors
• How to give medicines at home, if needed

When you go home after surgery, you will feel fairly comfortable, although there may be some pain temporarily.

Then you will begin to eat better and gain weight quickly. Within a few weeks, you should be fully recovered and able to participate in normal activities.

Long-term complications from surgical treatment are rare. They can include narrowing of the aorta, incomplete closure of the ductus arteriosus, and reopening of the ductus arteriosus.

PDA Occlusion

What is PDA Occlusion?

PDA coil closure is done during a heart catheterization or "heart cath". A heart cath is a procedure in which catheters (long, thin, bendable tubes) are gently threaded (guided) into the heart. Your caregivers push 1 or more tiny metal coils through a catheter and plug them into the PDA. If the PDA coil closes your PDA, you may not need surgery. You may go home the same day or may stay in the hospital after the PDA is closed.

During Your PDA Closure

You will change into a hospital gown. Your will get medicine to make him relaxed and drowsy. He will be taken on a stretcher to the room where the PDA closure will be done. Your will get an IV and may get more medicine to make him go to sleep. Once you are asleep, catheters will be put into the blood vessels in your groin, neck, or arm. The catheters are gently threaded (pushed) through the blood vessels and heart.

Caregivers will repair your PDA. Your caregivers may use dye and x-rays during the procedure. Caregivers may use these before and after the PDA closure to look at your PDA. During the procedure, caregivers will use 1 or more tiny coils to plug your PDA closed. The catheters will be removed after the PDA is closed. Caregivers will put pressure on the area where the catheters came out. This is to stop the bleeding. A pressure bag or bandage may be put in place for 2 or more hours. You may have stitches to stop the bleeding. It is very important for you to lie flat and to keep the leg or place that had the catheter very still. This is to prevent bleeding.

After Your PDA Closure

Aftercare: Your will be taken to a recovery area. Then, your may be taken to a hospital unit or room, or he may go home. Caregivers will watch you closely for any problems. Caregivers will check your vital signs (pulse, blood pressure, and breathing) every 15 minutes for 1 to 2 hours. The pulses in your feet or wrists will also be checked often. Your toes and fingers will be checked to see if they are warm. Tell your caregiver if your has any of the following:

• Chest pain or discomfort.
• Change in color or temperature of your arm or leg.
• Swelling or bleeding from the area where the catheter was.
• Pain, numbness, or tingling in your arm or leg.
• Pain in your back, thigh, or groin.
• Nausea (your feels sick to your stomach).
• Sweating a lot.

RISKS of PDA Occlusion

There are risks in putting catheters in the blood vessels. This could cause bleeding, a bruise, and soreness around the place where a catheter went in. You could bleed and need a blood transfusion (trans-FEW-shun) or surgery to repair the hole. You could get air bubbles or a blood clot from the heart cath or device. Air bubbles could give you a stroke. Blood clots may go to your lungs or brain and cause a stroke. The clots may go to your arm or leg and stop the blood flow. Fluid could build up in your lungs and cause trouble breathing.

You could get a collapsed lung or an infection. You could have an allergic reaction or kidney problems from the dye used during the procedure. A blood clot may form on the coil that was used to close the PDA. The coil could move out of place. Then you may need surgery to remove the coil and repair the PDA. Caregivers will watch you closely for these problems.

If your does not have your PDA closed, your health condition could get worse. Your heart could fail (wear out), your lungs could be damaged, and you could die. Call your caregiver if you are worried or have questions about your PDA, medicine, or care.

Angiogram

What is an angiogram?
An angiogram is an X-ray test to detect any enlargement, narrowing or blockages in the blood vessels. The lungs, heart, brain, neck, legs and arms are common areas of concentration during an angiogram.

Who can benefit from having an angiogram?
An angiogram can be used to detect and diagnose certain medical conditions including coronary heart disease, angina, myocardial infarction and portal hypertension - among others. If your doctor or physician suspects any of these, they may request that you have an angiogram.

Procedure
You will be asked to lie on a table and a radiologist will administer a local anesthetic - usually into the groin (but sometimes through the arm). A catheter (small tube) is then pushed into a blood vessel in the groin, and passed through your body up to the suspected blood vessel(s); you will not be able to feel this. A special dye is then injected into the catheter so that specific blood vessels can be easily seen on the X-ray pictures, which are taken following the injection. The catheter is then removed and the wound bandaged. During the angiogram you will be continually observed on a heart monitor.

Angioplasty

What is coronary angioplasty?
Coronary angioplasty is a procedure to open up narrow or blocked arteries to improve blood flow to the heart.

Who can benefit from coronary angioplasty?
Coronary arteries can sometimes become narrowed or blocked by the formation of blood clots, cholesterol or cell build-up. There are many circumstances where patients may need to undergo coronary angioplasty, for example:
Acute coronary syndrome (a heart attack or angina for example)
Atheroma
Atherosclerosis

Procedure
Coronary angioplasty is not an invasive surgical procedure and takes around 30 minutes to complete under local anesthetic. Having determined how severe the problem is through an angiogram, your surgeon will numb a sport on your groin or arm and insert a small tube into an affected artery. The tube is threaded through the artery until a coronary artery is located. Using an X-ray machine, a wire is then threaded into the coronary artery followed by a catheter with an expandable balloon. The balloon is then inflated which pushes the blockage to the sides and stretches the artery, allowing the blood to flow. For some patients a stent (a collapsed wire mesh) that is mounted on the balloon is moved over the wire and into the blocked area. As the balloon inflates, the stent is opened and pushed against the walls of the artery, and is locked into position, keeping the artery permanently open. The stent is then left in, while the balloon and catheters are taken out, allowing continual blood flow through the artery and to the heart. A dressing will then be applied to the entry point.

Angioplasty With Stent Implantation

What is a angioplasty with stent implantation?
A angioplasty with stent implantation is a type of heart surgery, otherwise known as a coronary artery bypass graft (CABG). The procedure diverts blood around clogged or narrowed arteries via new or ‘grafted’ arteries to improve the flow of blood and oxygen to the heart.

Who can benefit from a angioplasty with stent implantation?
Coronary arteries can sometimes become narrowed or blocked by the formation of blood clots, cholesterol or cell build-up. There are many circumstances where patients may need to undergo coronary angioplasty, for example:A angioplasty with stent implantation can be a life-saving surgical procedure to help those who suffer from coronary heart disease, which may have blocked or narrowed the coronary arteries. If the problem remains untreated, individuals may suffer a heart attack. Other patients may include those whose heart’s major pump is not functioning properly.

Procedure
There three main angioplasty with stent implantation procedures:
Traditional angioplasty with stent implantation - There are four major coronary arteries, and this procedure may be referred to as a ‘single’, ‘double’, ‘triple’, or ‘quadruple’ bypass depending on how many arteries are affected. It is performed under general anesthetic and can take up to three hours per operation. An incision will be made down the length of your breastbone in order to reach the heart. The heart is then stopped using medication, and the blood diverted to a heart-lung bypass machine to maintain circulation. A healthy blood vessel from another part of the body is then removed and grafted onto the blocked artery, above and below the blockage, in order to allow the blood to flow freely to the heart. The heart is then re-started using electrical shocks. The sternum is closed using wires and the incision sewn up.
Off-Pump Coronary Artery Bypass surgery (OPCAB) - Some surgeons may favour the OPCAB procedure where the heart continues to beat while the bypass is completed. This method is thought to have better control over any bleeding, avoiding a need for a blood transfusion and other complications that can become present in traditional bypass surgery.
Minimally invasive surgery - Minimally invasive surgery (also known as ‘keyhole’ surgery) is a less common procedure. This type of surgery avoids the need for an incision down the sternum and instead uses small incisions between the ribs that instruments can be passed through. The surgeon then uses a video monitor in order to see the grafting process close up.

Arterial Septal Defect

What is an atrial septal defect?
An atrial septal defect (ASD) is a hole in the wall (septum) that separates the two upper chambers (atria) of the heart. The defect allows blood to flow from one atrium to the other, usually from the left side to the right side. ASDs account for 5% to 10% of all coronary heart disease , and for about 30% of the congenital heart defects diagnosed in adults.The operative mortality is < 1% in the absence of significant pulmonary hypertension. Surgical repair in young adults (< 25 years) results in long-term survival rates similar to those of matched controls. Repair in patients older than 40 years does not eliminate the risk of atrial arrhythmias and cerebrovascular accidents.

How is this problem diagnosed?
Clinical features: Most infants and children with ASD do not exhibit symptoms even if the defect is large. Occasionally, infants with large ASD develop symptoms of congestive heart failure. Some older children have shortness of breath with exercise and lower stamina than their peers.

Physical findings: The diagnosis is most often made due to the presence of a heart murmur and/or an abnormal second heart sound. Growth and development is expected to be normal although many of the children have a slender body build. Since most children are without symptoms and the physical findings are subtle, it is not uncommon for the diagnosis to be made in late childhood or adolescence.

Medical tests: In patients with a significant atrial septal defect, the electrocardiogram often shows increased right ventricular forces and may show right atrial enlargement. The chest x-ray often shows a larger than normal heart size with evidence for increased pulmonary blood flow. An echocardiogram is able to detect even small atrial septal defects with almost 100% accuracy and permits measurement of the size and description of the precise location of the defect on the atrial septum. Cardiac catheterization is rarely needed for diagnostic purposes but may be done if there is concern about pulmonary artery hypertension, the pulmonary veins, or other diagnostic questions. Closure of the defect during a heart catheterization may be done to treat the problem.

Coronary/Heart Bypass

The bypass involves using a vein taken from the surface of the leg or an artery from the inner chest wall called the internal mammary artery. The surgeon attaches one end of the vein to the aorta which is the main blood vessel leaving the heart. The other end of the vein is attached to the coronary artery beyond where it is narrowed. The artery bypass involves attaching the bottom end of the internal mammary artery to the coronary artery beyond where it is narrowed. After the bypass operation, which can take about 2 to 6 hours, you will go to the intensive care unit for a few days. Afterwards you will be brought to the regular ward and then on discharge you will be enrolled in a cardiac rehabilitation program to help you restore your health.

What’s the Effect

Numerous patients with severe angina have successfully undergone this procedure and enjoy both a longer and a better quality of life.Newer cardiothoracic techniques allow you to undergo bypass surgery without being put ona pump if your arteries are easy to get to. You may wish to discuss this option with your surgeon. The benefits however to long term neurological sequelae are not overly convincing.