Specialized Anesthesia Services

Specialized Anesthesia Services

Cardiovascular Surgery

Any surgery where the chest is opened and surgery is performed on the heart is called open heart surgery. The term "open" refers to the chest, not the heart itself (which may or may not be opened, depending on the type of surgery).

Open heart surgery includes surgery on the heart muscle, valves, arteries, or other structures. The definition becomes confusing in light of new procedures being performed on the hearth through smaller incisions. Minimally invasive surgery and robotic-assisted heart surgery are still referred to as open heart surgery.

A heart-lung machine (also called cardiopulmonary bypass) is usually used to help provide oxygen-rich blood to the brain and other vital organs. It supplies oxygen to, and removes carbon dioxide from the blood and also provides anesthesia to keep the patient asleep during surgery.

There are some new surgical procedures being performed that are done with the heart still beating. These procedures are referred to as minimally invasive heart surgery, off-pump coronary artery bypass or limited access coronary artery surgery. These procedures are being evaluated in several medical centers as an alternative to the standard methods using the heart-lung machine.

Anatomy of the Heart

The heart is a four-chambered muscle about the size of your fist. It pumps blood and oxygen to the rest of the body. Each side has two chambers, the atria and the ventricles; the valves lie between the chambers and act as one-way doors to control the flow of blood. The blood travels to the right side of the heart through the vena cava -- the largest vein in the body and then on to the lungs. After returning from the lungs, the blood on the left side of the heart travels to the rest of the body through the aorta -- the largest artery in the body.

The heart muscle itself is supplied with blood by two main coronary arteries. These arteries lie on the surface of the heart and divide into smaller branches that send oxygenated blood to every portion of the heart.

Coronary Artery Bypass Grafting Surgery (CABG)

The goal of coronary artery bypass grafting surgery is to increase blood flow around a blocked coronary artery. A piece of vein or artery is used as a graft to go past the blocked coronary artery. This creates a new route for blood to reach the heart. These bypasses improve the oxygen supply to the heart, and help relieve chest pains and other symptoms. There are several vessels which can be used for this surgery. The saphenous veins from the legs are commonly used for bypass grafts. Frequently, an artery that runs along the chest wall (internal mammary artery) is used to bypass a blockage. The radial artery from the forearm can also be used. Your surgeon will determine the number and type of bypasses needed based on your own special needs.

During bypass surgery, the breastbone (sternum) is divided, the heart is stopped, and blood is sent through a heart-lung machine. Unlike other kinds of heart surgery, the chambers of the heart are not opened during bypass surgery.

When you hear the words single bypass, double bypass, triple bypass, or quadruple bypass, it refers to the number of arteries that are bypassed. The number of bypasses does not necessarily indicate how severe the heart condition is.

VALVULAR HEART DISEASE

Your heart has four valves, which act as the doors in your heart. They make sure the blood that enters your heart flows in the correct direction. The four valves are:

  • Tricuspid – blood flows from the right atria through this valve into the right ventricle.
  • Pulmonic – blood flows through this valve as it leaves the right ventricle, and goes to the lungs.
  • Mitral – blood flows from the left atria through this valve into the left ventricle.
  • Aortic – blood is pumped from the left ventricle, through this valve, out to the rest of the body.

Valvular heart disease occurs when one or more of the heart valves function abnormally. Heart valves can be damaged by infection, rheumatic/scarlet fever, the aging process, or birth defects. Valvular disease can involve a valve that is narrowed (stenosis) or one that does not close properly (insufficiency). The end result of a valve that doesn’t work properly is a decrease in the heart’s pumping ability. The overworked heart may fail, causing symptoms such as dizziness, chest pain, shortness of breath, fatigue, fluid retention. As these symptoms worsen, a decision needs to be made as to whether the heart valve needs to be repaired or replaced.

Valve Repair or Replacement

Blood is pumped through your heart in only one direction. Heart valves play key roles in this one-way blood flow, opening and closing with each heartbeat. Pressure changes behind and in front of the valves allow them to open their flap-like "doors" (called cusps or leaflets) at just the right time, then close them tightly to prevent a backflow of blood.

Two of the most common kinds of valve problems that require surgery are

  • Stenosis, which means the leaflets do not open wide enough and only a small amount of blood can flow through the valve. Stenosis occurs when the leaflets thicken, stiffen, or fuse together. Surgery is needed to either open the valve that is there or replace it with a new one.
  • Regurgitation, which is also called insufficiency or incompetence, means that the valve does not close properly and blood leaks backward instead of moving in the proper forward direction. Surgery is needed to either tighten or replace the valve.

Surgical repair of a valve involves the surgeon rebuilding the valve so that it will work properly. Valve replacement means that the valve is replaced with a biological valve (made of animal or human tissue) or a mechanical valve (made from materials such as plastic, carbon, or metal).

Arrhythmia Surgery

Any irregularity in your heart's natural rhythm is called an arrhythmia. Arrhythmias are usually treated first with medicines. Other treatments may include

  • Electrical cardioversion, where the cardiologist or surgeon uses paddles to "shock" the heart back into a normal rhythm.
  • Catheter ablation, where the cardiologist uses a special tool to destroy (ablate) the cells that are causing the arrhythmia. This is done in the cardiac catheterization laboratory (the cath lab).
  • Pacing and rhythm-control devices, including pacemakers and implantable cardioverter defibrillators (ICD’s). Patients can have these devices implanted while in the operating room or the cath lab.

When these treatments do not work, surgery may be needed. One type of surgery is called Maze surgery. In Maze surgery, surgeons create a "maze" of new electrical pathways to let electrical impulses travel easily through the heart. Maze surgery is used most often to treat a type of arrhythmia called atrial fibrillation. Atrial fibrillation is the most common type of arrhythmia.

Aneurysm Repair

An aneurysm is a balloon-like bulge in a blood vessel or in the wall of the heart. An aneurysm occurs when the wall of a blood vessel or the heart becomes weakened. Pressure from the blood forces it to bulge outward, forming what you might think of as a blister. An aneurysm can often be repaired before it bursts.

Surgery involves replacing the weakened section of blood vessel or heart with a patch or artificial tube (called a graft).

Aneurysms in the wall of the heart occur most often in the lower-left chamber (called the left ventricle). These aneurysms are called left ventricular aneurysms, and they may develop after a heart attack. (A heart attack can weaken the wall of the left ventricle.) If a left ventricular aneurysm leads to an irregular heartbeat or to heart failure, the surgeon may perform open heart surgery to remove the damaged part of the wall.
Transmyocardial Laser Revascularization (TMLR)

Angina is the pain you feel when a diseased vessel in your heart (called a coronary artery) can no longer deliver enough blood to a part of the heart to meet its need for oxygen. The heart's lack of oxygen-rich blood is called ischemia. Angina usually occurs when your heart has an extra need for oxygen-rich blood, such as during exercise. Angina is nearly always caused by coronary artery disease (CAD).

Transmyocardial laser revascularization (TMLR) is a procedure that uses lasers to make channels in the heart muscle, in an attempt to allow blood to flow from a heart chamber directly into the heart muscle. If the blood flow is increased, more oxygen can reach the heart. This procedure is only done as a last resort. For example, TMLR may be done in patients who have had many coronary artery bypass operations and cannot have another bypass operation.

PREPARING FOR SURGERY

Pre-Surgical Screening

The Preanesthesia Evaluation Program (PEP) Department at CCHS will contact you by phone to set up a pre-surgery appointment. For this appointment you will need to come to the hospital for testing so your surgeon can review the results before surgery. Your appointment may take four to five hours and could include all or part of the following:

  • Blood work
  • Urine sample
  • Chest X-ray
  • Leg vein mapping
  • Carotid artery ultrasound studies
  • Nursing interview in which you will be asked about your past medical and surgical history
  • History and physical by a physician, Physician’s Assistant, or Nurse Practitioner
  • Anesthesia interview
  • Signing the consent forms for heart surgery, blood, and admission to the hospital

During your appointment, the nurse will tell you what time to come to the hospital for your surgery and will discuss any needs you may have if you live alone or have questions about your discharge. The Cardiovascular Liason nurse will review pain control methods and will teach you some important exercises. You also may watch a video on open-heart surgery. If you are already in the hospital as a patient, these will be done in the hospital before surgery or before you go home to wait for surgery.

You will need a dental check-up if you are having surgery on a heart valve, a congenital heart defect or a procedure on your aorta. This is very important so that any dental infection you might have can be treated before you are admitted to the hospital. If you are having only coronary bypass surgery (CABG) and no other procedure on your heart or you do not have any of your own teeth left you do not need a dental check up. If you have any questions about whether or not you need to have a dental check up, please check with your surgeon's office.

Cardiac surgery often requires the use of blood and/or blood products. If you have any questions about the use of blood and blood products during surgery, or if you are unwilling to receive blood or blood products, please let your surgeon know.

Medications

It is important that you do not take Aspirin, or any medication that contains Aspirin for three days before your surgery. Aspirin is a blood thinner and can keep your blood from being able to clot. Aspirin can be found in many medications such as Alka-Seltzer, Anacin, Ascriptin, Bufferin, and Vanquish. Be sure to read the label of any medication that you take to be sure it does not have Aspirin in it. You may take Tylenol instead of Aspirin as needed. Plavix, another type of blood thinner, should be stopped five days before surgery.

There are other medications that can keep your blood from being able to clot. They include Advil, Anturane, Atromid-S, Butazolidin, Clinoril, Warfarin (coumadin), Indocin, Motrin, Persantine, and Valium. Please check with your doctor about taking any of these medications before your surgery. Call your doctor or pharmacist if you have questions about any medications you are unsure about. You will be instructed what medicine to take the morning of surgery. Remember to bring a list of the medications and the dosages you are taking.

Breathing Exercises

You will be instructed in how to deep breathe using an incentive spirometer (IS). Practice using this device before surgery because your lungs will need to be exercised frequently after surgery. Coughing is also necessary to help clear the lungs of secretions and excess fluid.

Bring your card or information if you have a permanent pacemaker or implantable cardiac defibrillator device (AICD).

Preparing for Your Hospital Stay

In the days leading up to your surgery:

  • Eat nutritiously but lose weight if recommended
  • Stop smoking and drinking alcohol, at least 24 hours before surgery. It is mandatory that you stop smoking before your operation. Smoking irritates your lungs and as a result, the body may not receive the amount of oxygen it needs to work well. When your lungs are not in top shape, it may take longer for you to recover from your surgery
  • Cut down on your caffeine intake
  • Get plenty of rest

The day before you come into the hospital:

  • Trim nails and remove polish
  • Remove all rings and jewelry; leave all money at home

Let your doctor know as soon as possible if you start to have any new health problems. This could include a fever, sore throat, draining sores, a cold , the flu or if you have been started on an antibiotic. It is important for you to be in the best shape possible at the time of your surgery. Your doctor may want to examine you and treat any problems early so your surgery is not delayed. You should try to stay away from people who are sick as you get closer to your surgery date.

The Night Before Surgery

  • You may be given sleeping medication to help you get a good night’s rest.
  • You will be instructed not to eat or drink anything after midnight the day before surgery. It is okay to brush your teeth as long as you do not swallow the water. You may be instructed to take medication with sips of water only.
  • You will need to take a shower with a liquid antibacterial soap the night before surgery and the morning of surgery before coming to the hospital.

The Morning of Surgery

If coming from home, the Pre-Surgical Screening Department will tell you what time to arrive at the hospital; usually it is 6:00 AM. If you are in the hospital, someone will wake you early enough to shower, shave, and brush your teeth. You will have an EKG done on the morning of surgery.

Your family may visit you before you go to surgery. They will need to come at least two hours before your surgery is scheduled. Please give your valuables, dentures, and eyeglasses to them to take home. When you are taken to surgery, your family can wait for you in the HVIS (Heart and Vascular Interventional Services) waiting area. They should register with the receptionist once they arrive in the lounge. Your surgeon will talk with your family in detail after the operation.

Before leaving your room, you will be given tranquilizer to help you relax and begin to make you feel drowsy prior to coming to the operating room. A surgical staff member will clip the hair on your chest, abdomen, and legs. You will be taken to the operating room approximately a half hour before your surgery is scheduled.

Your heart surgery may take from three to six hours depending on its complexity. Please understand that the surgery schedule sometimes has to change at short notice. If this happens, the date or time of your surgery may have to be postponed. We will let you know as soon as possible if any changes have to be made.

Upon arrival in the operating room, you will meet the anesthesiologist, nurse anesthetist, and some of the operating room staff. They will attach electrodes to an ECG monitor to you to allow constant monitoring of the heart rate and heart rhythm during the operation.

The anesthesiologist will put an intravenous (IV) line into a vein in the hand or arm and give you some more sedative medication. The IV line allows the anesthesia team to administer medication or fluid directly into the bloodstream. Another catheter called an arterial line (a-line) is inserted while you are sedated but prior to being put under general anesthesia. This catheter, similar to an IV, is placed into the radial artery at the wrist, where you can feel your pulse. The a-line allows continuous monitoring of your blood pressure and is used to draw a blood sample for lab tests both during the operation and afterwards in the intensive care unit.

At this point general anesthesia will be induced by the administration of anesthetic agents via the IV. These drugs have multiple functions; they cause sedation and amnesia, relieve pain, and induce muscle relaxation. After you are put to sleep, an endotracheal tube (breathing tube) is put into your mouth and down into your windpipe. The tube is then connected to a ventilator (breathing machine). The ventilator does the work of breathing for you while you are asleep.

At this point, a pulmonary artery catheter (PA line) is placed via a vein in the neck. This is a specialized catheter used to monitor the pressure inside the chambers of your heart and also let’s us know how well your heart is pumping. A urinary catheter (Foley catheter) is inserted by the OR nurse after you are asleep. It is a small soft tube that is put through the urethra into your bladder. The catheter is then attached to plastic tubing and connected to a drainage bag. The purpose of the catheter is to collect urine. While the catheter is in place you may feel like you have to urinate. Once the patient has been prepared, the surgery begins.

During heart surgery, a highly trained group works as a team. Here is a list of people who will be in the operating room during surgery.

  • The cardiovascular surgeon, who heads up the surgery team and performs the key parts of the surgery.
  • The assisting surgeons, who follow the direction of the cardiovascular surgeon.
  • The cardiovascular anesthesiologist and nurse anesthetist, who give you the medicines that keep you asleep during the surgery. The anesthesiologist makes sure that you get the right amount of medicines throughout the surgery and monitors the ventilator, which breathes for you during surgery.
  • The perfusion technologist, who runs the heart-lung machine.
  • The cardiovascular nurses, who are specially trained to assist in heart surgery.

After the surgery on the heart has been performed, but before the chest is closed, chest tubes and temporary pacemaker wires are placed by the surgeon. A chest tube is a plastic tube that is placed into your chest cavity. The chest tube is then connected to a plastic container or drainage system. The chest tube is used for draining blood and other fluids from your chest. Typically, three chest tubes are placed. Temporary pacemaker wires are slender wires that are placed onto the surface of your heart. The ends of the wires come up through the skin and can then be attached to a pacemaker, if needed. The wires are usually removed 2-3 days after surgery. At the end of surgery, while you are still asleep, an orogastric tube is inserted by the anesthesia team. This tube goes through your mouth, down the esophagus, and into your stomach; it drains your stomach fluids.

At the end of surgery, you will be transferred to the cardiovascular intensive care unit (CVICU) still asleep with the breathing tube in place.

After Surgery

When you wake up after surgery, you will be in the CVICU. The endotracheal tube will be in place when you wake up in the CVICU. You will not be able to talk while the endotracheal tube is in place but you can make your needs known. You will be able to nod when questions are asked and you can write things down on a pad of paper. Try not to talk while the endotracheal tube is still in, as this will cause a gagging sensation.

The endotracheal tube is also used to help keep your lungs free of secretions. The nurse will suction mucus from your lungs through the endotracheal tube to help you breath better.

The breathing tube will be removed as soon as you are fully awake and able to breathe without the help of the ventilator. You cannot eat or drink anything for the first few hours after the breathing tube comes out. After the tube is removed, you may have some soreness in your throat that should go away in a day or two. Once you are off the respirator we will ask you to take deep breaths and cough to keep your lungs open and free of mucus. This will help prevent any problems in the lungs like fluid build up or infection. Coughing and deep breathing exercises are an important part of your postoperative recovery. A special device called an incentive spirometer is used to help you breathe more deeply. The nurse will show you how to use this piece of equipment and have you practice several times a day. This device helps the small airways in your lungs stay open and clear of secretions to prevent a lung infection or pneumonia. Oxygen will be given to you either by nasal prongs or a mask when the endotracheal tube is removed.

Other tubes that will still be in you when you wake up include:
  • The orogastric (OG) tube. This will be removed along with the breathing tube.
  • Chest tubes. These will be removed as soon as the draining subsides, usually on the first or second day.
  • The bladder catheter. This will also be removed the first day, or as soon as you are able to get up and use a commode.
  • Monitoring lines (a-line, PA line). Both of these devices will be removed as soon as the doctor feels that your condition is stable enough, usually on the first post op day

The CVICU staff will make you as comfortable as they can. If your pain is adequately treated, you will be able to move around better and do things that will help you recover sooner. Sometimes patients are worried about taking pain medication and becoming addicted. This should not be a concern, as you will only be taking the pain medication for a short period of time. Please let the staff know as soon as you have any discomfort or if your pain medication is inadequate. To help assess your pain, the staff will ask you to rate your pain on a scale of 0 to 10. A score of 0 means you have no pain and a score of 10 means you are having the worst pain ever.

Your family will be allowed in to see you within a few hours after your arrival in the Intensive Care Unit. The nurse will come into the family lounge to find them and bring them back for a brief visit. At that time, the nurse will take the name and phone number of the family spokesperson. This is the only person we will give information to over the phone. After a brief visit, we will ask the family to go home for the night. We do ask that the family leave your slippers, glasses and dentures. The next day, your family may come in for regular visiting hours, 9:00-9:15 AM, 12:00-12:15 PM, 2:00-2:15 PM5:00-5:15 PM, and 8:00-8:15 PM.