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Heart surgery

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A doctor performing open heart surgery

Heart surgery, also known as cardiac surgery, is any surgery performed on the heart or surrounding blood vessels. Because the heart is so delicate and complex surgeons were unable to operate on the heart for centuries. Early surgeons knew the risks of opening the heart and allowing the patient to die from blood loss because there were no other organs that could do the job of the heart. It wasn't until July 10, 1893, that Dr. Daniel Hale Williams performed the very first heart surgery. Dr. Williams did what many thought to be impossible and by doing so he paved the way for future surgeons who would perform open heart surgery years later. Today, surgeons are able to perform open heart surgery, heart bypass surgery, valve repair or replacement, minimally invasive heart surgery, heart transplant and other heart surgeries.

Types

Different types of heart surgery are performed depending on what's wrong with the heart. Heart surgeries are performed to:

  • Repair or replace heart valves
  • Bypass blocked and narrowed arteries to the heart
  • Implant devices that help control the heart's rhythm
  • Make channels in the heart muscle which allow blood from the heart chamber to flow into the heart muscle
  • Repair aneurysms in the heart
  • Replace a damaged heart with another heart from a donor

[1]

Open Heart

Heart Surgery that involves cutting the chest open, whether the heart is opened or not, is called Open Heart Surgery. The surgery may focus on the heart muscle, valves, or arteries depending on what specific type of surgery is being performed. Doctors use a heart-lung machine to help give the brain and other organs blood. The machine also gives oxygen, takes the carbon dioxide out of the blood, and gives the patient an anesthetic that keeps them asleep during surgery. [2]

Heart Bypass

Main Article: Coronary artery bypass surgery
Heart Bypass Surgery, also known as Coronary Artery Bypass Grafting, makes new paths around narrowing or blocked arteries. This allows a sufficient amount of blood, carrying nutrients and oxygen, to the heart. When heart arteries begin to get blocked its called coronary artery disease, and it is caused when atherosclerotic plaque builds up on the walls of the arteries. The main causes of the build up are smoking, high blood pressure, high cholesterol, and diabetes. The arteries are shrinking therefore they are unable to pump a sufficient amount of blood and oxygen to the heart muscles. The patients with plaque build up are at a greater risk for a heart attack, because blood clots can form and become stuck in the plaque causing a heart attack. [3]
This diagram shows the inside of the heart

Valve Repair or Replacement

Heart Valve repair is a specific type of open-heart surgery. The sternum is cut, divided and the heart is stopped, and the blood is pumped through the body with the heart-lung machine. Replaced heart valves are either biological or artificial.[4] In the heart there are four valves: tricuspid valve, pulmonary valve, mitral valve, and aortic valve. The mitral and aortic valves work the hardest because they pump oxygen-rich blood from the lungs into different parts of the body. Most valve repair and replacement surgeries are done on these two valves. Valve replacement is mainly used to treat aortic valves and damaged mitral valves, but can also be used to treat any valve condition. [5]

Heart Transplant

During a Heart Transplant the patient is anesthetized. The doctor cuts open the chest saws the sternum and uses chest retractors to gain access to the heart. Then they cut open the pericardium which is a double layer sac that helps hold the heart in place (after the surgery is complete the pericardium is left open). Then they clamp the aorta, inferior vena cava, and the superior vena cava blood vessels. This isolates the heart leaving the heart/lung machine to pump blood to the rest of the body. Then they cut away the rest of the heart leaving behind the left atrium. Using sutures they attach the left atrium of the patients heart to the donors heart. After removing the clamp from the aorta artery then the heart should start beating, and if the heart beats uncontrollably then the doctors shock it with the defibrillator. Around 800 people a year die because they are unable to get a heart transplant in time. [6]

Minimally Invasive Heart Surgery

Minimally Invasive Heart Surgery avoids using the heart/lung machine. It is an alternative surgery to the coronary artery bypass graft surgery. Both surgeries reroute the blood around the coronary arteries that have been clogged by plaque which results in a better supply of blood and oxygen to the heart. This surgery is used when only one or two arteries need to be bypassed. The surgeons make small holes in the chest and one small incision over the coronary artery which will be bypassed. They detach an artery from the chest wall and re-attach the artery to the coronary artery that is clogged. [7]

Recovery

The recovery time after heart surgery is 6-8 weeks. During this time doctors recommend increasing activity levels slowly as not to reopen the incision or cause further damage to the heart through stress or strain. Doctors tell the patients that they should not stand in place for longer than 15 minutes, lift objects heavier than 10lbs, or push and pull heavy objects. Activities such as climbing the stairs should be avoided for the first couple days. Doctors do advise going for walks daily to keep moving but to keep them under 15 minutes.Recovery time varies depending on the surgery. [8]

It is important that the incision stays clean and dry. Soap and water are the only two substances that should be used to clean the wound. Patients should maintain a healthy diet to help the body heal up properly. A doctor should be notified if any of the following signs of infection appear:

  • Increased amount of fluid or oozing coming from the incision
  • Incision begins to open more
  • The area around the incision becomes red or warm to the touch
  • Body temperature rises about 101 degrees Fahrenheit
  • The patient has diabetes and their blood sugar begins to vary abnormally

After the surgery the patient may experience aches in the muscle or incision area during activities. It is normal for the area around the incision to itch as well as become tight or numb. The pain however won't be as severe as it was before the surgery. The doctors prescribe pain medication, depending on what kind of heart surgery was performed, before the patient leaves the hospital. A doctor should be notified if the patient's sternum feels like it is moving around, or if it cracks when they move. Typically patients that have bypass surgery have more pain in their legs if vein grafts were used. The ache and discomfort diminishes with walking, daily activities, and time. [9]

Heart Surgeon

Heart surgeons are not only very well trained and passionate surgeons but also skilled technicians. The education required for this career path can take 12-16 years to complete. They must earn a Bachelor of Science degree or a Bachelor of the Arts degree. After which they must get accepted into medical school where they will study for four years. Followed by five years of training in general surgery. Then they must complete a two or three year cardiothoracic training program. Lastly, they must pass the qualifying licensing examinations which is required to practice medicine. Heart Surgeons must not only have the knowledge obtained over years of study but also and the stamina required to work long hours. They must have good communication skills and be able to make those around them comfortable by having confidence in what they are doing. They must also be emotionally strong. Heart Surgeons should be able to solve problems easily and enjoy leading and directing others. They must have the ability to stay calm under stress and push through fatigue and stay focused. Heart Surgeons work in hospitals, universities, intensive care units, private clinics and also in other research offices. The typical task that they perform are:

Heart Surgeons typically work 50 to 60 hours each week. They manage their time by seeing patients, performing surgery, doing administrative work and conducting research.

[10]

History

Anesthetics such as ether and chloroform were not created until mid 19th century. After the discovery of these agents, major operations such as heart surgery began to be studied more. Doctors in Europe began to do studies in the animal laboratory on how to repair heart wounds. The first heart surgery took place on July 10, 1893, when Dr. Daniel Hale Williams operated on a 24 year old man. The man had been stabbed in the heart with a knife during a fight. Dr. Williams opened the chest and tied off a vein and artery that had been hurt and was most likely causing the blood loss. He also saw a cut in the pericardium, and a puncture wound in the heart. Williams didn't stitch through the heart itself because he didn't think it was needed instead he stitched closed the pericardium. A few years later in Germany Dr. Ludwig Rehn also performed a successful heart surgery. On September 9, 1896, a 22 year old man who had been stabbed in the heart 2 days earlier went in for heart surgery. Dr. Rehn placed 3 sutures in the man's heart which closed up the 1.5 cm wound and stopped the bleeding. The patient's heart beat returned to normal and his pulse improved steadily.[11] These cases paved the way for other doctors to perform similar surgeries each time discovering new and better methods for heart surgery.

Open-heart surgery being performed using hypothermia

World War II led to many advances in medicine because the military doctors facing injuries and death on a massive scale, make advances in antibiotics and blood transfusions. Dr. Dwight Harken, a U.S. Army surgeon, operated on soldiers that were from the European front lines. The soldiers came to him with shell fragments and bullets stuck inside their hearts. If he left the shrapnel in the heart then they would always be in danger, but by removing it he risked almost certain death. Harken first operated on animals; attempting to find a technique that would let him cut the wall of a beating heart, insert a finger and remove the shrapnel. At first his attempts resulted in the death for the animals but over time he developed a procedure that worked the best. He started performing surgeries on the soldiers, all of which were successful. In 1948, Harken and Dr. Charles Bailey, on two separate occasions attempted to correct mitral stenosis: a condition where the mitral valve won't open correctly because it has been narrowed. This procedure is done by cutting a small hole in the side of the heart and inserting a finger to find and carefully widen the valve. In the beginning this surgery resulted in death. Over time surgeons improved their technique and this closed heart surgery became a safe and effective method that was used around the world. [12]

Heart/Lung Machine

Those with more serious heart defects, such as a hole in their heart, had no chance at life because there was no way to do an open heart surgery. If the doctors opened the heart then their patient would die from a loss of blood. They could only stop circulation for four minutes until brain damage began to occur because of a lack of oxygen. A Canadian surgeon named Dr. Bill Bigelow found that if the patients were cold then they would have more time to operate because the patient's heart beat would be slower. On September 2, 1952, the first open heart surgery was performed on a five year old girl who was born with a hole in her heart by Dr. Walton Lillehei and Dr. John Lewis. She was placed under anaesthetize which kept her from shivering while her body temperature was brought down to 81 degrees fahrenheit by a special blanket. At this temperature she could survive for ten minutes. The two doctors cut her heart open which was still beating and then sewed the hole up. After they closed the heart up then they placed her in a warm bath which brought her body temperature back up to normal making it the first successful open heart surgery. Doctors began using this new found surgery all over the world but many times they opened the heart to find more serious problems that would take more than ten minutes to repair. In 1958 Dr. John Gibbon created a heart/lung machine that would do the job of the heart while the surgery took place. Then Dr. Dennis Melrose created an injection that would stop the heart from beating during the surgery. With these two advancements surgeons were able to work on a non beating heart that had no blood in it. This made it possible to fix the complex problems that seemed impossible before.[12]

Early attempts at heart transplants resulted in death after a short time due to infection or rejection of the new tissue. Dr. Norman Shumway continued to work on this aspect of heart surgery through out the 1970's. A fungus was discovered in Norway which contained a compound called cyclosporin. It helped control organ rejection without taking out the immune system. This discovery made it possible for those whose hearts were destroyed beyond repair to have a chance at life through a heart transplant. Today in the U.S., around 2 million people are in need of a heart transplant each year but less than 2,500 hearts are available each year. [12]

References

  1. Heart Surgery National Institutes of Health and Department of Health & Human Services
  2. Open Heart Surgery J.A. Lee, M.D., Division of Surgery, UCSF, San Francisco, CA
  3. Coronary Artery Bypass Graft Surgery (CABG) Daniel Kulick, MD, FACC, FSCAI and William C. Shiel, Jr., MD, FACP, FACR
  4. Heart valve surgery Robert A Cowles, MD, Assistant Professor of Surgery, Columbia University College of Physicians and Surgeons. VeriMed Healthcare Network. David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
  5. Valve Repair or Replacement Texas Heart Institute
  6. Operation: Heart Transplant Rick Groleau, United Network for Organ Sharing
  7. Minimally Invasive Heart Surgery American Heart Association, Inc
  8. Recovery From Heart Surgery Robert J Bryg MD. WebMD Medical
  9. Heart Surgery Recovery: Care of your incision The Cleveland Clinic
  10. Cardiovascular Surgeon EI Group, Oral Roberts University Engineering and Physics
  11. History of Cardiac Surgery Stephenson L Wi . History of Cardiac Surgery. Cohn LH, Edmunds LH Jr, eds. Cardiac Surgery in the Adult. New York: McGraw-Hill, 2003:3-29
  12. 12.0 12.1 12.2 Pioneers of Heart Surgery NOVA by PBS

Cardiovascular diseases

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