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Cardiac surgery is a specialized field of medicine focused on the surgical treatment of heart and thoracic aorta pathologies, and it has progressively evolved since the late 19th century. Cardiac surgery has advanced through the efforts of many dedicated surgeons, leading to the development of more sophisticated treatments for various cardiac pathologies. Notably, the invention of cardiopulmonary bypass was crucial, allowing surgeons to access the heart and perform more complex surgical procedures. Modern cardiac surgery encompasses a broad spectrum of interventions, including coronary artery bypass grafting, surgical revascularization for ischemic heart disease, valve repair and replacement for valvulopathies, heart transplantation, and the treatment of congenital heart defects and arrhythmias. Techniques have evolved significantly—from early methods such as closed mitral commissurotomy to advanced approaches such as transcatheter aortic valve replacement and minimally invasive surgeries. Cardiovascular surgery relies on skilled healthcare professionals and cutting-edge equipment despite its high operative and perioperative risks. With the increasing prevalence of cardiovascular diseases, the demand for cardiac procedures and specialists in cardiology continues to rise. This activity reviews the importance of cardiac surgery and explores techniques for implementing an effective interprofessional management approach to enhance patient outcomes. This activity also addresses the growing demand for cardiac surgery and interprofessional collaboration among healthcare providers as cardiovascular disease prevalence increases, thereby highlighting the crucial roles of imaging and consensus-based decision-making in optimizing patient care. Objectives: Identify the various surgical techniques and interventions available for treating different cardiac pathologies, including coronary artery bypass grafting, valve repair, and heart transplantation. Assess the effectiveness of various imaging modalities and diagnostic tools in planning and executing cardiac surgical interventions. Apply knowledge of advanced surgical techniques and technologies, such as transcatheter aortic valve replacement and extracorporeal membrane oxygenation, to improve patient care.

Identify the various surgical techniques and interventions available for treating different cardiac pathologies, including coronary artery bypass grafting, valve repair, and heart transplantation. Assess the effectiveness of various imaging modalities and diagnostic tools in planning and executing cardiac surgical interventions. Apply knowledge of advanced surgical techniques and technologies, such as transcatheter aortic valve replacement and extracorporeal membrane oxygenation, to improve patient care. Collaborate with an interprofessional healthcare team, including cardiologists, anesthesiologists, and nurses, to develop and implement comprehensive patient care plans. Access free multiple choice questions on this topic.

Cardiac surgery is a medical specialty focused on the surgical treatment of heart and thoracic aorta pathologies. This surgery has become a routine practice for many heart conditions, with the median sternotomy approach remaining the gold standard for most open-heart procedures. Since the 19th century, the field has seen significant advancements, including the development of cardiopulmonary bypass (CPB), coronary artery bypass grafting (CABG), valve repairs, and minimally invasive techniques.[1][2] Despite innovations, traditional methods remain crucial, especially in complex cases. Modern cardiac surgery addresses a wide range of conditions, from congenital heart defects to advanced coronary artery disease, necessitating interprofessional decision-making and careful patient selection to optimize outcomes. These advancements in cardiac surgery continue to evolve (see Image. Coronary Artery Bypass Surgery).[3][4] Evolution of Cardiac Surgery Billroth performed the first pericardiectomy in 1882. The first successful treatment of cardiac trauma was achieved by Ludwig Rehn in 1896 when he operated on a cardiac stab wound, challenging the then-prevailing belief that the heart was not an organ suitable for surgery. The development of CPB became essential for accessing critical cardiac structures, driven by the high mortality rates of early cardiac operations, such as the first embolectomy performed by Trendelenburg.[5] Surgical revascularization is an option for relieving ischemic heart disease complicated by atherosclerosis.[6] Vineberg implanted the left internal mammary artery (LIMA) into the anterior free wall without forming direct anastomoses to the coronary vessels.[7] In earlier experiments, Vineberg observed that collaterals develop when ischemia is present. During the 1960s, several surgeons in different locations pioneered the first CABG operations.[8] The era of reversing coronary artery disease started with the invention of cardiac catheterization by Forssman in 1929 and the injection of contrast media by Shirey in 1962 to visualize coronary vessels and locate stenosis. Bypass grafting and interventional revascularization are now the 2 primary options for treating ischemic heart disease, alongside drug therapy.

Surgical revascularization is an option for relieving ischemic heart disease complicated by atherosclerosis.[6] Vineberg implanted the left internal mammary artery (LIMA) into the anterior free wall without forming direct anastomoses to the coronary vessels.[7] In earlier experiments, Vineberg observed that collaterals develop when ischemia is present. During the 1960s, several surgeons in different locations pioneered the first CABG operations.[8] The era of reversing coronary artery disease started with the invention of cardiac catheterization by Forssman in 1929 and the injection of contrast media by Shirey in 1962 to visualize coronary vessels and locate stenosis. Bypass grafting and interventional revascularization are now the 2 primary options for treating ischemic heart disease, alongside drug therapy. Surgical treatment of valvulopathies began with closed mitral commissurotomy, where a finger or instrument was passed through the narrow orifice of the mitral stenosis to dilate or cut it, a procedure first performed by Cutler in 1923. The first artificial valve, the Hufnagel cage-and-ball valve, was introduced in 1952 and was placed in the descending thoracic aorta to prevent blood flow reversal in aortic regurgitation. In 1967, a similarly structured valve, the Starr-Edwards cage-and-ball valve, was implanted 1000 times for mitral valve disease.[9] Surgical techniques improved from early single-valve procedures to 4-valve replacement in 1992. Specialized techniques, such as the Ross procedure, were also introduced, which involved replacing the aortic valve with a pulmonic valve autograft. To treat proximal aortic dissection or aneurysm, Bentall developed a procedure that combines the implantation of an artificial aortic valve with an ascending aortic vessel prosthesis.

Surgical treatment of valvulopathies began with closed mitral commissurotomy, where a finger or instrument was passed through the narrow orifice of the mitral stenosis to dilate or cut it, a procedure first performed by Cutler in 1923. The first artificial valve, the Hufnagel cage-and-ball valve, was introduced in 1952 and was placed in the descending thoracic aorta to prevent blood flow reversal in aortic regurgitation. In 1967, a similarly structured valve, the Starr-Edwards cage-and-ball valve, was implanted 1000 times for mitral valve disease.[9] Surgical techniques improved from early single-valve procedures to 4-valve replacement in 1992. Specialized techniques, such as the Ross procedure, were also introduced, which involved replacing the aortic valve with a pulmonic valve autograft. To treat proximal aortic dissection or aneurysm, Bentall developed a procedure that combines the implantation of an artificial aortic valve with an ascending aortic vessel prosthesis. In 1944, cardiac surgeons Blalock, Taussig, and Thomas made their first venture into the field of congenital heart lesions by operating on a patient with tetralogy of Fallot—a cyanotic heart defect.[10] Pulmonary stenosis is another cyanotic heart lesion.[11] For cardiac arrhythmias, the Cox-Maze procedure provides a surgical treatment for atrial fibrillation. The development of cardiac pacemakers began with the application of external electrodes to stimulate the heart. Lillehei advanced this by placing electrodes directly into the heart during open-heart surgery. The first implanted pacemaker, however, lasted only 8 hours. Modern aggregates offer long-lasting solutions to diverse rhythm abnormalities.[12]

In 1944, cardiac surgeons Blalock, Taussig, and Thomas made their first venture into the field of congenital heart lesions by operating on a patient with tetralogy of Fallot—a cyanotic heart defect.[10] Pulmonary stenosis is another cyanotic heart lesion.[11] For cardiac arrhythmias, the Cox-Maze procedure provides a surgical treatment for atrial fibrillation. The development of cardiac pacemakers began with the application of external electrodes to stimulate the heart. Lillehei advanced this by placing electrodes directly into the heart during open-heart surgery. The first implanted pacemaker, however, lasted only 8 hours. Modern aggregates offer long-lasting solutions to diverse rhythm abnormalities.[12] In 1967, several surgical teams worldwide performed the first heart transplants—Barnard in South Africa; Shumway at Stanford, who improved posttransplant survival with the addition of immunosuppressive treatment; and Kantrowitz, who pioneered pediatric heart transplantation in New York.[13] Some devices can supply mechanical circulatory support. Since 1963, the intra-aortic balloon pump has enhanced left ventricular function through counterpulsation. Open-heart surgery requires CPB to temporarily replace the function of the heart and lungs with an external circuit composed of pumps and an oxygenation membrane. Artificial hearts were first used extracorporeally in 1982, with subsequent devices enabling implantation. Cardiac surgery carries high operative and perioperative risk, requiring professional staff and advanced equipment. Besides the diseases that require cardiac surgery, perioperative period often involves a range of complications, including systemic inflammatory response following CPB, myocardial stunning, low cardiac output syndrome, arrhythmias, massive transfusion needs, and multiorgan issues such as kidney injury, stroke, and respiratory distress.

Cardiac surgery carries high operative and perioperative risk, requiring professional staff and advanced equipment. Besides the diseases that require cardiac surgery, perioperative period often involves a range of complications, including systemic inflammatory response following CPB, myocardial stunning, low cardiac output syndrome, arrhythmias, massive transfusion needs, and multiorgan issues such as kidney injury, stroke, and respiratory distress. With the rise of interventional and minimally invasive techniques for treating cardiac pathologies, both cardiology and cardiac surgery must adapt to these advancements.[14] As Lytle and Mack described in their 2005 editorial, "The times they are changing," the field of cardiac surgery is undergoing a fundamental transformation. In his presidential address, Guyton stated, "If we do not embrace innovation, we will become its victims." Recent developments include the establishment of cardiac arrest centers, broader and more accessible use of extracorporeal membrane oxygenation (ECMO), system process improvements, fast-track hospital stay, collaborative decision-making by interprofessional cardiovascular teams, and challenges posed by an aging patient population.[15][16][17][18]

The overall mortality rate in cardiac surgery ranges from 2% to 3%. Significant complications include postoperative bleeding, stroke,[72][73] renal failure,[74] mesenteric ischemia, atrial fibrillation,[75] cardiogenic shock,[76] and respiratory distress. Postoperative bleeding and hemorrhagic shock, along with coagulation disorders like heparin-induced thrombocytopenia, contribute to 10% to 20% of national blood product usage in cardiac surgery. Acute kidney injury affects up to 18% of patients undergoing cardiac procedures, with approximately 2% requiring renal replacement therapy. The incidence of these complications can serve as a quality indicator and impact both reimbursement and patient decision-making. A nationally representative study has shown an increase in the incidence of postoperative stroke complications following CABG, corresponding with a rise in overall baseline patient risks. Among 2,569,597 CABG procedures, ischemic stroke occurred in 47,279 patients (1.8%), with the incidence rising from 1.2% in 2004 to 2.3% in 2015 (P < .001). Patient risk profiles have worsened over time, with stroke patients exhibiting higher Charlson comorbidity scores. Stroke was independently associated with a 3-fold increase in in-hospital mortality, an extended hospital stay of approximately 6 days, and an increase in total hospitalization costs by about $80,000. The strongest predictors of stroke were age 60 years or older and female sex (both P < .001).[77]

A nationally representative study has shown an increase in the incidence of postoperative stroke complications following CABG, corresponding with a rise in overall baseline patient risks. Among 2,569,597 CABG procedures, ischemic stroke occurred in 47,279 patients (1.8%), with the incidence rising from 1.2% in 2004 to 2.3% in 2015 (P < .001). Patient risk profiles have worsened over time, with stroke patients exhibiting higher Charlson comorbidity scores. Stroke was independently associated with a 3-fold increase in in-hospital mortality, an extended hospital stay of approximately 6 days, and an increase in total hospitalization costs by about $80,000. The strongest predictors of stroke were age 60 years or older and female sex (both P < .001).[77] Myocardial infarction following cardiac surgery is classified as type 5 myocardial infarction according to the universal classification. The incidence ranges from 5% to 10%. Diagnosing postoperative myocardial infarction can be challenging due to routinely elevated cardiac enzyme levels from surgical manipulation and symptoms influenced by the postoperative status. Therefore, alternative diagnostic modalities, such as ECG, echocardiography, and coronary angiography, are crucial for assessing bypass patency. Echocardiography may reveal septal wall motion abnormalities that are not necessarily related to myocardial ischemia. Refractory shock and arrhythmias are highly suggestive of myocardial infarction. Myocardial infarction following CABG can be classified into graft-related and non-graft–related categories. Early graft dysfunction occurs in up to 3% of cases. Non-graft-related causes include inadequate myocardial protection and embolization. Treatment strategies for type 5 myocardial infarction include conservative medical treatment, PCI, and redo CABG.[78][79][80]

Myocardial infarction following cardiac surgery is classified as type 5 myocardial infarction according to the universal classification. The incidence ranges from 5% to 10%. Diagnosing postoperative myocardial infarction can be challenging due to routinely elevated cardiac enzyme levels from surgical manipulation and symptoms influenced by the postoperative status. Therefore, alternative diagnostic modalities, such as ECG, echocardiography, and coronary angiography, are crucial for assessing bypass patency. Echocardiography may reveal septal wall motion abnormalities that are not necessarily related to myocardial ischemia. Refractory shock and arrhythmias are highly suggestive of myocardial infarction. Myocardial infarction following CABG can be classified into graft-related and non-graft–related categories. Early graft dysfunction occurs in up to 3% of cases. Non-graft-related causes include inadequate myocardial protection and embolization. Treatment strategies for type 5 myocardial infarction include conservative medical treatment, PCI, and redo CABG.[78][79][80] Following mitral valve replacement, left ventricular outflow tract obstruction can occur, characterized by systolic anterior motion of the anterior mitral leaflet. Treatment is approached in a stepwise manner, beginning with beta-blockers, increasing afterload with fluids, allowing hypertension, and, if necessary, proceeding to reoperation. Surgical techniques for reoperation include edge-to-edge repair, posterior leaflet shortening, short neochord, sliding plasty, and ellipsoid excision of the anterior leaflet.[81] Preoperative risk factors for this complication include a thick basal interventricular septum, a small left ventricle, a short distance between the interventricular septum and the mitral leaflet coaptation point, a tall posterior leaflet, and an aorta-mitral angle of less than 120 degrees.[82][83]

Following mitral valve replacement, left ventricular outflow tract obstruction can occur, characterized by systolic anterior motion of the anterior mitral leaflet. Treatment is approached in a stepwise manner, beginning with beta-blockers, increasing afterload with fluids, allowing hypertension, and, if necessary, proceeding to reoperation. Surgical techniques for reoperation include edge-to-edge repair, posterior leaflet shortening, short neochord, sliding plasty, and ellipsoid excision of the anterior leaflet.[81] Preoperative risk factors for this complication include a thick basal interventricular septum, a small left ventricle, a short distance between the interventricular septum and the mitral leaflet coaptation point, a tall posterior leaflet, and an aorta-mitral angle of less than 120 degrees.[82][83] Postoperative pain management is crucial in cardiac surgery due to the intense stress and discomfort associated with these procedures. Ensuring patient comfort and calmness is vital for overall well-being, as it supports the immune response to the new graft and ensures the proper functioning of the heart, which in turn impacts the health of all other organs in the body. Effective postoperative pain management in cardiac patients is crucial for both medical professionals and patients, as it can significantly impact recovery and survival. Research shows that cardiac patients often experience their most intense postoperative pain about an hour after extubation. During this period, the highest doses of analgesics are typically administered to manage pain effectively. Pain intensity generally decreases over time, reaching its lowest point approximately an hour after the patient is transferred from the ICU to the ward.[84]

Postoperative pain management is crucial in cardiac surgery due to the intense stress and discomfort associated with these procedures. Ensuring patient comfort and calmness is vital for overall well-being, as it supports the immune response to the new graft and ensures the proper functioning of the heart, which in turn impacts the health of all other organs in the body. Effective postoperative pain management in cardiac patients is crucial for both medical professionals and patients, as it can significantly impact recovery and survival. Research shows that cardiac patients often experience their most intense postoperative pain about an hour after extubation. During this period, the highest doses of analgesics are typically administered to manage pain effectively. Pain intensity generally decreases over time, reaching its lowest point approximately an hour after the patient is transferred from the ICU to the ward.[84] A range of early mobilization strategies is available for post-surgery patients, and while many have proven effective in enhancing recovery, optimal protocols are still under investigation. Early mobilization is crucial for improving outcomes after cardiac surgery and is now standard practice in many hospitals. This approach has been shown to safely and effectively enhance tissue perfusion, preserve muscle strength and mass, reduce the risk of pulmonary complications, shorten hospital stays, improve quality of life, and decrease mortality rates. Additionally, early mobilization has been found to reduce the incidence of delirium, a significant contributor to cognitive impairment associated with ICU stays.[85]

A range of early mobilization strategies is available for post-surgery patients, and while many have proven effective in enhancing recovery, optimal protocols are still under investigation. Early mobilization is crucial for improving outcomes after cardiac surgery and is now standard practice in many hospitals. This approach has been shown to safely and effectively enhance tissue perfusion, preserve muscle strength and mass, reduce the risk of pulmonary complications, shorten hospital stays, improve quality of life, and decrease mortality rates. Additionally, early mobilization has been found to reduce the incidence of delirium, a significant contributor to cognitive impairment associated with ICU stays.[85] After a sternotomy, patients are typically advised to restrict certain activities to allow the sternum sufficient time to heal and prevent complications from physical exertion. These guidelines, often referred to as "sternal precautions," generally include avoiding lifting, pushing, or pulling objects weighing more than 5 to 10 pounds, driving, or using the arms to assist with sitting or standing. Patients are also encouraged to protect their chest by crossing their arms over it when moving or coughing. These precautions are usually recommended for up to 12 weeks post-surgery until the sternum fully recovers. However, some experts have raised concerns that these restrictions may be overly limiting, potentially leading to issues such as muscle atrophy and difficulty resuming daily activities.

After a sternotomy, patients are typically advised to restrict certain activities to allow the sternum sufficient time to heal and prevent complications from physical exertion. These guidelines, often referred to as "sternal precautions," generally include avoiding lifting, pushing, or pulling objects weighing more than 5 to 10 pounds, driving, or using the arms to assist with sitting or standing. Patients are also encouraged to protect their chest by crossing their arms over it when moving or coughing. These precautions are usually recommended for up to 12 weeks post-surgery until the sternum fully recovers. However, some experts have raised concerns that these restrictions may be overly limiting, potentially leading to issues such as muscle atrophy and difficulty resuming daily activities. A new movement protocol, "Keep Your Move in the Tube," is designed for patients recovering from sternotomy. This focuses on limiting arm extension to reduce strain on the healing sternum. The protocol emphasizes minimizing humeral movement to avoid tension on the surgical site. This approach is rooted in ergonomics and emphasizes patient education rather than strict directives. This encourages patients to keep their upper arms close to their body, as if modifying their movements within an imaginary tube around the torso. This helps avoid placing excessive stress on the sternum while allowing for functional movement.[86] Fever, edema, and increased inflammatory markers are commonly observed in postoperative patients, making it challenging to differentiate between confirmed infections and evolving sepsis.[87] The time course can give additional information. If signs and symptoms of infection appear after the second or third postoperative day, further investigation for infection should be initiated.[88]

A new movement protocol, "Keep Your Move in the Tube," is designed for patients recovering from sternotomy. This focuses on limiting arm extension to reduce strain on the healing sternum. The protocol emphasizes minimizing humeral movement to avoid tension on the surgical site. This approach is rooted in ergonomics and emphasizes patient education rather than strict directives. This encourages patients to keep their upper arms close to their body, as if modifying their movements within an imaginary tube around the torso. This helps avoid placing excessive stress on the sternum while allowing for functional movement.[86] Fever, edema, and increased inflammatory markers are commonly observed in postoperative patients, making it challenging to differentiate between confirmed infections and evolving sepsis.[87] The time course can give additional information. If signs and symptoms of infection appear after the second or third postoperative day, further investigation for infection should be initiated.[88] Perioperative antibiotic prophylaxis is essential to reduce the risk of postoperative infections. Guidelines generally recommend administering cephalosporins during the 24 to 48-hour perioperative period. Fortunately, deep sternal wound infection is a rare complication of cardiac surgery, occurring in 0.4% to 4% of cases. However, if left untreated, it can progress to mediastinitis, which carries a significant mortality risk. Treatment for deep sternal wound infection involves pathogen-specific antibiotics (with common strains including Staphylococcus aureus or S epidermidis, often treated with clindamycin or according to resistance patterns), surgical exploration, and negative-pressure wound therapy.

Perioperative antibiotic prophylaxis is essential to reduce the risk of postoperative infections. Guidelines generally recommend administering cephalosporins during the 24 to 48-hour perioperative period. Fortunately, deep sternal wound infection is a rare complication of cardiac surgery, occurring in 0.4% to 4% of cases. However, if left untreated, it can progress to mediastinitis, which carries a significant mortality risk. Treatment for deep sternal wound infection involves pathogen-specific antibiotics (with common strains including Staphylococcus aureus or S epidermidis, often treated with clindamycin or according to resistance patterns), surgical exploration, and negative-pressure wound therapy. The exact cause of postoperative cognitive decline remains unclear but is believed to be related to the body's stress and inflammatory responses to surgery and anesthesia. Postoperative cognitive impairment involves a reduction in the ability to orient oneself, focus, perceive surroundings, maintain consciousness, and make decisions. Risk factors for developing this condition include advanced age, female gender, significant blood loss, and elevated creatinine levels following surgery. Cognitive impairment is a common complication after surgery, with patients undergoing CABG being particularly vulnerable. A systematic review and meta-analysis revealed that cognitive impairment was observed in over 40% of patients within the first 4 days after CABG surgery. This rate decreased to about 25% at the 1-year mark but increased again to around 40% between 1 and 5 years after surgery. In the long term, beyond 5 years post-surgery, cognitive impairment was reported in 16% of patients—a rate notably lower than other long-term estimates, likely due to patient attrition and mortality during the follow-up period.[85][89]

The exact cause of postoperative cognitive decline remains unclear but is believed to be related to the body's stress and inflammatory responses to surgery and anesthesia. Postoperative cognitive impairment involves a reduction in the ability to orient oneself, focus, perceive surroundings, maintain consciousness, and make decisions. Risk factors for developing this condition include advanced age, female gender, significant blood loss, and elevated creatinine levels following surgery. Cognitive impairment is a common complication after surgery, with patients undergoing CABG being particularly vulnerable. A systematic review and meta-analysis revealed that cognitive impairment was observed in over 40% of patients within the first 4 days after CABG surgery. This rate decreased to about 25% at the 1-year mark but increased again to around 40% between 1 and 5 years after surgery. In the long term, beyond 5 years post-surgery, cognitive impairment was reported in 16% of patients—a rate notably lower than other long-term estimates, likely due to patient attrition and mortality during the follow-up period.[85][89] Although rare, coronary obstruction is a potentially devastating complication of TAVR, most frequently occurring at the left coronary artery ostium. Detection can be challenging, as some patients may not exhibit noticeable clinical symptoms. Research indicates that a significant increase in peak diastolic flow velocity in the left main coronary artery is associated with substantial stenosis in these lesions.[90] Depending on hemodynamic stability, the patient's symptoms, and ECG findings, PCI or surgical revascularization may be indicated. If a coronary ostial iatrogenic injury occurs during surgical AVR, it is generally preferable to perform surgical revascularization rather than attempt to repair or reconstruct the coronary ostium.