How is the heart treated? An expert on the types of diagnostics and operations on the vessels. Surgery and invasive cardiac examinations

The treatment of heart diseases using surgery is the field of surgery and cardiology, which is called cardiac surgery. To date, cardiac surgery is the most effective method of treating certain types of heart defects, coronary heart disease and helps prevent the development of myocardial infarction, as well as eliminate its consequences - aneurysms.
Surgical intervention is used only in cases where conservative methods of treatment cease to help and the patient's condition worsens. The untimely appeal of the patient to the doctor can also lead to heart surgery, when only surgical intervention remains the only way to help.

Today, cardiac surgery is one of the most actively developing and technically equipped branches of medicine. Every year, 700 patients undergo open heart surgery. The bulk of operations are in the United States. In Europe, the number of operations is 4 times less. In Asian countries, cardiac surgery is practically absent. In Russia, the number of heart surgeries is below the required minimum. This statistic is due to the fact that heart surgeries are expensive. In addition to open heart surgery, surgical intervention is also carried out without opening parts of the heart (for example, implantation of pacemakers, angioplasty).

Surgery is required for diseases such as:

1. Ischemic heart disease and its consequences (myocardial infarction);
2. Heart defects.
3. Violation of the heart rhythm.

Cardiac ischemia

Ischemic heart disease occurs as a result of insufficient blood supply to the working myocardium. The main cause of coronary heart disease is atherosclerosis (plaque formation on the walls of blood vessels). A slight narrowing of the lumen of the vessel leads to angina pectoris (a person feels pain only when the heart's need for oxygen is increased, for example, during exercise). A strong narrowing of the lumen of the vessel causes pain even at rest, and the duration of pain attacks can also become more frequent and increase - unstable angina. With a strong violation of the coronary blood flow, the death of the muscle fibers of the heart occurs - this is a myocardial infarction.

One of the severe complications of myocardial infarction is the formation of a post-infarction aneurysm of the left ventricle. An aneurysm is a bubble-like bulge. It is formed due to the fact that dead tissue is replaced by scar tissue, which in turn is not able to contract. Under the pressure of healthy contracting fibers, the scar tissue swells, part of the blood is retained in the ventricle in the area of ​​aneurysmal expansion. With each contraction, organs and tissues receive less blood in an amount equal to the volume of the aneurysm. This is its main negative meaning. Very often, blood clots form in the aneurysm area, which can break off and be transferred with the blood flow to any organs, causing their heart attack (death of part or all of the organ). When a blood clot enters the brain, a stroke occurs.

Surgical intervention (heart surgery) for coronary heart disease is aimed at restoring the normal nutrition of all parts of the heart. The degree of damage to the coronary arteries will depend on what kind of operation should be done. An analysis of the state of the vessels is carried out using coronary angiography - this is an X-ray contrast research method that allows you to determine the location, nature and degree of narrowing of the coronary artery. Most often, stenting of the coronary artery, which causes pain, is done. In the case of severe atherosclerotic lesions of the coronary vessels, the patient needs coronary artery bypass grafting.

Types of surgery for coronary heart disease

Angioplasty and stenting of the coronary arteries

Angioplasty and stenosis is aimed at removing obstructions to blood flow by expanding the artery from the inside.
The operation is carried out as follows: with the help of special equipment, a catheter is inserted through a puncture in the thigh area under the control of a fluorographic preparation into the artery that feeds the heart. It must reach the site of narrowing of the artery, where a special balloon is inflated with a stent - a device that does not allow the artery to subside. The stent remains in the artery, and the catheter is brought out through the same hole in the thigh.

Coronary artery bypass grafting (ACS)

Coronary artery bypass grafting - restoring the blood supply to the heart muscle by creating a new blood flow path around the affected area of ​​the coronary vessel using shunts - pieces of arteries or veins taken from the patient himself (for example, in the limb area). This operation is aimed at preventing myocardial infarction. To date, CABG operations are performed both with the use of a heart-lung machine and on a beating heart (cardiac immobility is only in the operated area).
One of the types of coronary artery bypass surgery is mammary coronary artery bypass grafting (MCB). The internal mammary artery is used as a shunt. The use of this vessel is beneficial, since in this case no additional incisions are needed due to the close location of the thoracic artery and the heart, and also because atherosclerotic plaques do not form in the artery, and therefore, the service life of such a shunt is quite long.

Plastic surgery of postinfarction aneurysm of the left ventricle

The essence of the intervention is to reduce the volume of the left ventricle by delimiting the area of ​​aneurysmal expansion and the healthy part of the left ventricle. The surgeon removes the blood clots that have arisen in the area of ​​the aneurysm, then sews a septum made of dense elastic human tissue across the cavity of the left ventricle. Two cavities are formed: one with normal, actively contracting walls, the other - from scar tissue that is not able to contract, but does not interfere with the normal functioning of the heart. Thus, blood circulation is restored and the risk of a blood clot breaking off is eliminated.

Heart defects

Heart disease is called defects in the structure of the heart, which lead to disruption of normal blood circulation, there is stagnation of blood in the pulmonary or systemic circulation.
The following violations are distinguished:

- stenosis (narrowing) of the valvular apparatus;
With valve stenosis, it stops passing the required volume of blood through the reduced opening.
- insufficiency of the valvular apparatus;
The valve leaflets cannot close tightly and allow blood to pass in the direction opposite to normal blood flow.

-defects of the interventricular and interatrial septum;
With defects in these partitions, blood enters from a cavity with high pressure into a cavity with less pressure, and venous blood, poor in oxygen, mixes with oxygenated arterial blood, which leads to oxygen starvation of tissues.
Heart defects can be congenital or acquired. Most of them do not require surgery. Sometimes the disease proceeds unnoticed by the patient. Congenital heart disease can disappear with age, but if this does not happen and signs of heart failure increase, then surgery is required.

Treatment of heart defects is aimed at correcting the existing mechanical defect in the functioning of the heart.

There are the following types of surgical intervention:

Prosthetics and plastic heart valves

Operations to install prostheses are performed on the open heart, using a heart-lung machine.
Valve prostheses are mechanical and biological.

Mechanical valves

Mechanical valves are made of metal and plastic. The validity period of such prostheses is about 80 years. However, when using them, a person has to take anticoagulants daily, since blood clots are easily formed on the prostheses, which contribute to the formation of blood clots. In rare cases, a breakdown of a mechanical prosthesis is possible, which most often leads to the death of the patient. Mechanical valve prostheses can be in the form
- rotating disc
The disc completely covers the hole, but is fixed at one end only. Blood moving in the right direction presses on the disc, turns it on the hinge and opens the hole; when the blood moves back, the disc completely covers the hole.
- built on the principle of a ball in a grid
The blood flow in the right direction pushes the ball out of the hole, pressing it to the bottom of the mesh and thereby creating the possibility of further passage of blood; the reverse flow pushes the ball into the hole, which is thus closed and does not allow blood to pass through.

biological valves

Biological prostheses, usually made from animal heart tissue, are considered more efficient. After their installation, treatment with anticoagulants, which have many contraindications, is not necessary. Such a prosthesis works from 10 to 20 years, its aging occurs gradually and you can prepare in advance for its replacement in a planned manner. Of course, in this case, a second operation is needed.
Biological valves do not require mandatory anticoagulation (although it is often recommended), but wear out faster than mechanical valves.

Plastic defects of the interatrial and interventricular septum

If the structure of the septum is violated, with a small defect (the size of the hole is not more than 3 cm), it is sutured, and with a significant size, a plastic patch is performed (using synthetic tissues or autopericardium)

Heart rhythm disorder

Cardiac arrhythmias are violations of the sequence, rhythm and frequency of contractions of the heart. Arrhythmias can occur as a result of metabolic disorders, for example, endocrine and autonomic, or the effects of certain drugs. They are also often caused by heart disease, and sometimes - intoxication.
The danger of arrhythmia is that it can lead to ventricular fibrillation (scattered contraction of fibers).
For the treatment of arrhythmias, drugs, catheter ablation, or a pacemaker (pacemaker) are implanted.

Surgical methods for the treatment of arrhythmias:

RF ablation

This is a minimally invasive surgical method that is used for:
- high heart rate with a pronounced pulse deficit;
- atrial fibrillation;
- progressive heart failure;
- supraventricular tachycardia.

The method of radiofrequency ablation consists in passing a special catheter to the area of ​​the heart that causes an abnormal pathological rhythm. An electrical impulse is applied to this department, which destroys the tissue site that sets the wrong rhythm.
Ablation restores normal heart rhythm.

Pacemaker implantation

The operation is done in patients with heart rhythm disturbances that threaten life. The pacemaker aims to control and restore the normal contraction of the heart.
Doctors implant a special device under the skin or under the pectoral muscle. Two or three electrodes depart from the pacemaker, which are connected to the chambers of the heart to transmit an electrical impulse to them.

Defibrillator implantation

The principle of operation of a defibrillator is similar to a pacemaker. Its distinctive feature is the elimination of too fast and too slow heart rate. The heart rate is assessed using electrodes. Installing a defibrillator is similar to installing a pacemaker.

Installing a defibrillator is indicated for ventricular tachycardia.

Heart transplant

In critical cases, when the heart cannot perform its function and does not respond to any treatment, they resort to a heart transplant. Thanks to this operation, doctors prolong the life of the patient for a period of about 5 years. Research is currently underway to extend the life of people who have undergone heart transplants.

Postoperative recovery period

An important stage of recovery after surgery is the period of postoperative recovery. Strict monitoring of human health is required. This period is different and individual for each patient. Patients are prescribed special cardio training, diets. Emotional calm is needed.

Heart surgeries are dangerous due to their complications. The main signs of complications are fever, pain in the operated area, tachycardia, drop in blood pressure, shortness of breath. The ECG shows characteristic changes. The recovery period lasts six months - a year.

An example of monitoring the health of postoperative patients is the work of the doctor of medical sciences, professor, arrhythmologist Andrey Vyacheslavovich Ardashev. He does over 200 surgeries a year. Postoperative monitoring of patients began in 2011 with the help of the project. The doctor controls both the conclusion of the cardiovisor and the ECG itself in postoperative patients. Using the site service helps to monitor the recovery of the health of operated people via the Internet. This is a huge plus, since a large number of patients come to Moscow from all over Russia in order to have heart surgery. They pass the postoperative period already at home. Using the Cardiovisor allows you to take ECG readings at home and send them to the doctor using the site.

Rostislav Zhadeiko, especially for the project .

View all articles

Let's try to lift the veil of the mystery of their work and find out what types of heart surgeries exist and are carried out today. Is it also possible to perform heart surgery without opening the chest?

1 When the heart is in the palm of your hand or open surgery

Open heart surgery is so called because the cardiac surgeon "opens" the patient's chest, cuts through the sternum and all soft tissues, and makes an opening of the chest. Such interventions, as a rule, are performed with the connection of a heart-lung machine (hereinafter referred to as AIC), which is a temporary replacement for the heart and lungs of the operated person. This apparatus is a complex device of rather impressive dimensions, which continues to pump blood through the body when the patient's heart is artificially stopped.

Thanks to AIC, open-heart surgery can be extended for many hours if necessary. Open surgeries are used for valve replacement, coronary artery bypass grafting can also be performed in this way, many heart defects are eliminated by open interventions. It should be noted that AIC is not always used during their implementation.

The body can not always tolerate the intervention of a foreign heart substitute: the use of AIC is fraught with complications such as renal failure, impaired cerebral blood flow, inflammatory processes, and impaired blood rheology. Therefore, some operations on the open heart are carried out in the conditions of his work, without the connection of the AIC.

Such interventions on a beating heart include coronary artery bypass grafting, during this operation on a beating heart, the area of ​​\u200b\u200bthe heart that the surgeon needs is temporarily switched off from work, and the rest of the heart continues to work. Such manipulations require high qualifications and skills of the surgeon, and also have a much lower risk of complications, they are perfect for people over 75 years old, patients with a large arsenal of chronic diseases, patients with diabetes mellitus than operations on an organ that is turned off from the blood circulation.

But all the pros and cons, of course, are determined by the cardiac surgeon. Only the doctor decides to keep the heart working, or stop it for a while. Open surgeries are the most traumatic, having a higher percentage of complications; after surgery, a scar remains on the patient's chest. But sometimes only such an operation can save a person's life, improve his health, return him to a full, happy life.

2 Intact heart or closed surgeries

If the sternum, heart chambers and the heart muscle itself were not opened during surgery, then these are closed heart surgeries. During such operations, the surgical scalpel does not affect the heart, and the surgeon's work consists in the surgical treatment of large vessels, cardiac arteries and aorta, the chest is also not opened, only a small incision is made on the chest.

Thus, a pacemaker can be installed, heart valve correction, balloon angioplasty, shunting, vascular stenting can be performed. Closed operations are less traumatic, have a lower percentage of complications, unlike open ones. Closed vascular surgery can often be the first step before subsequent heart surgery.

Indications for their conduct is always determined by the doctor.

3 Achievements of modern cardiac surgery or minimally invasive operations

Cardiac surgery is steadily moving forward, and an indicator of this is the increasing percentage of low-traumatic, high-tech manipulations that allow you to get rid of the pathology of the heart and blood vessels with minimal intervention and impact on the human body. What are minimally invasive interventions? These are surgical operations performed by introducing instruments or special devices, through mini-accesses - 3-4 cm incisions, or without incisions at all: during endoscopic operations, incisions are replaced by punctures.

When performing minimally invasive manipulations, the path to the heart and blood vessels can lie through the femoral vessels, for example - these operations are called endovascular, they are performed under X-ray control. Elimination of congenital malformations, prosthetic heart valves, all operations on vessels (from removal of a blood clot to expansion of the lumen) - all these interventions can be performed using minimally invasive technologies. Emphasis is placed on them in modern cardiac surgery, since a low risk of complications, minimal impact on the body are those huge advantages that patients can appreciate literally on the operating table.

Anesthesia during endoscopic procedures is not required, it is enough just to anesthetize the puncture site. Recovery after heart surgery performed using a minimally invasive technique is ten times faster. Such methods are also indispensable in diagnostics - coronary angiography, a method for examining the vessels of the heart by introducing contrast and subsequent x-ray control. In parallel with the diagnosis according to the indications, the cardiac surgeon can also perform therapeutic manipulations on the vessels - the installation of a stent, balloon dilation in a narrowed vessel.

And diagnosis and treatment by puncture on the femoral artery? Isn't this a miracle? Such miracles for cardiac surgeons are becoming routine. The contribution of endovascular methods of treatment is also invaluable in cases where the threat to the life of the patient is especially acute and minutes count. These are situations of acute coronary syndrome, thromboembolism, aneurysm. In many cases, the availability of the necessary equipment and qualified personnel can save the lives of patients.

4 When is surgery indicated?

It is up to an experienced cardiac surgeon or a council of doctors to decide whether an operation is indicated, as well as to determine the type of surgical intervention on the heart and blood vessels. The doctor can make a conclusion after a thorough examination, familiarization with the history of the development of the disease, monitoring the patient. The doctor should know the ins and outs of the disease very well: how long the patient has been suffering from cardiac pathology, what medications he takes, what chronic diseases he has, when he felt worse ... After evaluating all the pros and cons, the doctor makes his verdict: whether to have surgery or not. If the situation develops according to the above scheme, then we are dealing with a planned cardiac surgery.

It is shown to the following people:

• lack of effect from adequate drug therapy;
• rapidly progressive deterioration of well-being against the background of ongoing treatment with pills and injections;
• severe arrhythmias, angina pectoris, cardiomyopathy, congenital and acquired heart defects requiring correction.

But there are situations when there is no time for reflection, questioning and analysis of the medical history. We are talking about life-threatening conditions - a blood clot broke off, an aneurysm exfoliated, a heart attack occurred. When the time goes by for minutes, emergency cardiac surgery is performed. Stenting, coronary artery bypass grafting, thrombectomy of the coronary arteries, radiofrequency ablation can be performed urgently.

5 Consider the most common types of heart surgery

1. CABG - coronary artery bypass grafting "on hearing" in many, probably because it is performed for coronary heart disease, which is extremely common among the population. CABG can be performed both open and closed, and combined techniques with endoscopic inclusions are also performed. The essence of the operation is to create bypass routes of blood flow through the vessels of the heart, restoring normal blood supply to the myocardium, which leads to a better supply of oxygen to the heart muscle.
2. RFA - radiofrequency ablation. This type of surgical intervention is used to eliminate persistent arrhythmias, when drug therapy is powerless in the fight against arrhythmias. This is a minimally invasive intervention, which is performed under local anesthesia, a special conductor is inserted through the femoral or subclavian vein, which supplies an electrode to the focus of pathological impulses in the heart, the current flowing through the electrode to the pathological focus destroys it. And the absence of a focus of pathological impulses means the absence of arrhythmia. 12 hours after the manipulation, the patient is already allowed to get up.
3. Prosthetic or plastic heart valves. Prosthetics means complete valve replacement, the prosthesis can be mechanical or biological. And plastic implies the elimination of defects in the "native" valve or valve apparatus. There are certain indications for these interventions, which are clearly known to cardiac surgeons.
4. Installing a pacemaker. Cardiac arrhythmias, severe bradycardia may be indications for installation, which, thanks to modern technology, can also be performed endoscopically.

Our expert is Viktor Demin, MD, Honored Doctor of the Russian Federation, Head of the Department of X-ray Surgical Methods of Diagnosis and Treatment of the Orenburg Regional Clinical Hospital.

Maya Milic, AiF.ru: What is the essence of the treatment of heart diseases today?

Viktor Demin: Modern treatment of heart diseases involves accurate diagnosis, that is, today it is far from always enough to take an electrocardiogram and do an ultrasound examination of the heart. If the patient is diagnosed with coronary heart disease - and this is still the main pathology that leads to mortality - then the patient in the vast majority of cases needs to perform coronary angiography.

After that, a unique treatment scenario is developed for each patient. Thanks to the study, we see what kind of lesions themselves, and, accordingly, we choose several ways of treatment. This may be a conservative treatment if the patient does not have major vasoconstriction and a likely pathology that stimulates heart damage. Or if there are prerequisites for pathology, but they have not yet reached such values ​​that require surgical treatment. Sometimes a patient is prescribed endovascular treatment, that is, stenting of the coronary arteries, and the percentage of this type of treatment is increasing. If the disease has already gone very far, then it is performed.

It happens that the operation is impossible to do due to diffuse damage to the arteries, when no surgical treatment is indicated.

The relationship between types of treatment varies greatly. On average around the world, the ratio of coronary artery stenting to bypass surgery is five to one, in Russia it is about two and a half to one, and in the most developed countries, for example, in Japan, ten to one.

Every year there is a growing trend towards endovascular operations, because they are less traumatic and allow intervention in some cases in patients with more extensive pathology, when not only the vessels of the heart, but also other organs are involved.

— Many patients are very afraid to lie down on the operating table. What are the risks and complications of heart surgery?

We cannot know in advance what the patient will encounter. The patient may have a vascular lesion that can lead to complications even at the first injection. But this is an extremely rare case. Also, the patient may have an allergic reaction to medications.

Now the intervention is performed on modern equipment, with the help of miniature instruments and so gently that trauma is minimized. At the same time, modern types of monitoring are carried out, and most endovascular operations are performed under local anesthesia, which also removes one of the risk factors.

It is impossible to completely remove all risks, but today, thanks to technology, they are minimized. This applies to both endovascular and cardiac surgeries. The so-called "open" operations are considered more difficult, more traumatic, but they are also very technologically developed.

If you look at thirty years ago, then, in fact, the operations have changed little, but the content itself and the way they are carried out technologically, of course, have gone far ahead, and security has increased significantly.

Time factor

- How quickly does the patient get to the surgeon's table if necessary?

— Here it is necessary to divide the patients into two groups. There are patients of the so-called "chronic coronary artery disease", who have signs of coronary heart disease, have angina pectoris, pain in the heart, who once suffered a myocardial infarction. These are scheduled patients. And there are patients who come to the hospital or clinic with myocardial infarction. These are fundamentally different situations.

As for myocardial infarction, over the past five years, a lot of work has been done in our country, a special program of vascular centers has been created, which received special funding, there is a program dedicated to the fight against myocardial infarction and stroke. This allowed in all regions, even where there were no operating rooms for myocardial infarction at all, to create such operating rooms. All regions are included in this program.

In this case, emergency coronary angiography and, if necessary, emergency intervention are immediately performed. Moreover, in this case, the operation is usually performed on a single vessel. Several arteries supply blood to the heart, and plaques can be in all arteries, but when a patient has an acute attack of pain, this is most often due to the fact that a blood clot has formed in any one vessel. Moreover, the original plaque could also cause a relatively slight narrowing, which had not previously provoked pain in the heart (angina pectoris), but the plaque disintegrated, which led to a heart attack.

In these cases, the time factor is extremely important - the faster the patient arrives, the better the results of the operation. With myocardial infarction, if the patient arrives in the first hours, immediate surgery is indicated immediately. If, for some reason, the patient cannot be delivered within the first six hours, then we can slightly delay this time by using "thrombolytic therapy". The patient is given special preparations that dissolve the thrombus, and in this case we can increase the time of delivery of the patient to the operating room by up to a day.

If the patient lives far from the interventional laboratory or for some reason could not get there in the first hours, for example, he called an ambulance late, then this method helps us to successfully operate on him. A delayed operation is in progress.

But the earlier the operation is done, the less changes will remain in the heart, the affected area will be smaller.

What about chronic heart disease?

In a number of regions, leading institutions have entered this system of assistance, but still this assistance cannot cover all those in need. Therefore, the availability is still different. Moreover, in each region there are different health insurance rates for diagnostic tests. The assistance system is aimed at operations, but the patient also needs to be examined. This should be covered by insurance companies. As a result, patients are in unequal conditions, and this is perhaps the weak point of the program.

But nevertheless, every year we have an increase in the number of studies, coronary angiography from 10 to 20%. This is a very decent growth. And even at such rates, we still need about seven or eight years to reach the average European level.

Operation types

What types of heart surgeries are there?

– Coronary artery bypass surgery is the first operation that was developed for the treatment of heart vessels, it remains extremely relevant, especially when the disease has gone very far. This operation is carried out in different versions. Requires a chest incision, general anesthesia and cardiopulmonary bypass.

But there are situations where open surgery can be done with a small incision on the beating heart, with less invasiveness. The vessel is fixed with special devices and one or two shunts are applied.

Endovascular operations involve minimal intervention, any vessel can be operated through a small puncture, not only the heart, but also the carotid arteries, and the intracerebral and renal arteries, the vessels of the upper and lower extremities, and the intestinal vessels. That is, there is no vessel that could not be operated on. Most often, two accesses are used for such operations - a puncture is made either in the groin or in the radial artery, near the wrist. There is no need for general anesthesia, no incisions, no stitches. The advantage of these operations is that we restore those vessels that a person has, or expand the vessel, or free it from plaque. During shunting, a fragment is superimposed around the affected area, replacing the human vessel. This is the fundamental difference between the two operations.

But it's still an operation, because surgeons intervene and fix something. Unlike conventional surgery, where something superfluous is removed, cardiovascular surgery is a reconstructive surgery, where we must restore and return the normal flow of blood.

Recovery after operations

What is the recovery period after heart surgery?

Another thing is when the same operation is performed, but several vessels are already affected and heart attacks have already been transferred before. After the operation and after the restoration of blood flow in the heart, the affected areas still remain, and it will no longer be the same as before. Therefore, a longer rehabilitation will be required, and sanatorium treatment is often recommended.

But more often, long-term rehabilitation is required after bypass surgery, since this operation is more traumatic, it is necessary for the postoperative wound to heal, for the blood flow in the heart to be rebuilt, for strength to be restored. Therefore, after shunting, the patient usually stays in the hospital for an average of two weeks, and a month is a recovery period that needs to be spent at home on sick leave or in a sanatorium.

Heart disease is very rejuvenated

What role does the age of the patient play?

Of course, age matters a lot. The problem is that heart disease is very young. If earlier patients under the age of 40 were extremely rare, now we are no longer surprised by patients who are 23 or 22 years old. On the other hand, earlier, for example, 20 years ago, if a patient had damage to the vessels of the heart, vessels of the lower extremities or kidneys at the same time, then it was considered that the patient was already inoperable. And now - you just need to smoothly build a treatment scenario, the patient is successfully operated on and recovers. That is, what was previously impossible is now possible.

Previously, 70 years old was the age limit for operations, but today we operate on patients over 80 years old, and this is also, most likely, not the limit. Today, medicine does not look at the calendar age of a person, but at the degree of deterioration of the body and all its systems - biological age, which may not correspond to the years lived.

Therefore, it is very important that both patients and all people are very attentive to themselves and their health, to taking the necessary and prescribed medications, to avoid such factors as smoking, obesity, hormonal imbalance and others.

Cardiac surgeons are contacted in cases where medical conservative treatment of diseases of the cardiovascular system is impossible or leads to the progression of the disease.

Cardiac surgery (otherwise - cardiothoracic surgery) belongs to the field of cardiology and surgery and today is considered one of the most effective ways to treat coronary heart disease, which helps prevent the development of myocardial infarction.

Cardiac surgeons work, as a rule, in large multidisciplinary hospitals with appropriate departments or in centers of cardiology and cardiovascular surgery, which is associated with the need to have specialized equipment and an intensive care unit equipped with modern medical equipment.

History of the development of cardiology

Back in the late 19th century, heart surgery was not performed. Compared to traditional surgery, the foundations of which were laid by Hippocrates and the Arab scientist Avicenna, the development of cardiac surgery became possible thanks to the discovery of anesthesia and the development of medical technologies. Open heart surgery was first performed in the 1950s, and since that time, cardiac surgery has begun its rapid development.

The impetus for the development of such a medical specialty as a cardiac surgeon was not only the development of medicine, but also the high demand for cardiac operations.

The statistics on heart disease are getting worse all the time. And this is due not only to the number of people suffering from these diseases, but also to the high mortality rate - according to the available data, more than half of all deaths occur in diseases of the cardiovascular system.

Types of cardiac surgery

Cardiac surgeons are most in demand for coronary heart disease. It is possible to single out the main types of operations that are quite successfully carried out now by cardiac surgeons all over the world. Among them:

• Coronary artery bypass grafting, which is recognized as the most effective method for coronary heart disease. The method of minimally invasive coronary bypass grafting is the most progressive and safe for the patient method of such surgical intervention. This implies that a cardiac surgeon performs an operation on a beating heart without stopping it. The main factor in the success of bypass surgery is the high qualification of the cardiac surgeon, who must have experience in successfully performing a large number of such operations;
• Operations on the aortic valve, which are indicated for aortic malformations and include both repair and replacement of the aortic valve. The replacement of heart valves by cardiac surgeons is now widely and universally worked out. The new valve is either made from biological material (porcine or horse heart tissue) or metal, which is more practical, but requires anticoagulants (drugs to prevent blood clotting) after insertion;
• Bentall operation, which is performed by cardiac surgeons in case of ascending aortic aneurysm with aortic insufficiency;
• A heart transplant used in end-stage heart failure in cases where the condition cannot be improved with traditional heart surgery or conservative therapy.

Pediatric cardiac surgeon

Pediatric cardiac surgeons are in-demand specialists in the elimination of congenital pathologies of the heart and blood vessels, which are a fairly common pathology (about 8 sick children for every thousand newborns). Modern cardiac surgery is especially effective in the first six months of life. The most successful are the operations of pediatric cardiac surgeons to create new heart ducts equipped with valves.

An important factor determining the professionalism of a cardiac surgeon is the place of his internship after graduation. So, for a pediatric cardiac surgeon, the best clinics for practice and training are specialized medical institutions in Germany, the USA and Israel, whose doctors have accumulated vast experience in this field.

The center's cardiac surgeons specialize in the surgical treatment of children with hypoplastic left heart syndrome (a critical heart defect), which causes 95 percent of children to die within the first year of life. Pediatric cardiac surgeons of this center have achieved not only success in its treatment, but also in postoperative nursing of children.

Stably successful today can be called operations performed by pediatric cardiac surgeons with the wrong location of the arteries in infants.

How to become a cardiac surgeon

In order to work as a cardiac surgeon, you need to get a higher medical education in the specialty "General Medicine", after which you need to complete an internship and residency in the specialty "Cardiac Surgery".

With all its advantages, heart surgery is a complex and very risky treatment. And this is primarily due to the professionalism of the cardiac surgeon, who, in addition to surgical skills, needs to have analytical skills in order to weigh all the possible risks and benefits of the operation.

Also, the success of operations also depends on the knowledge of a cardiac surgeon in many related medical specialties - functional diagnostics, anesthesiology, topographic anatomy.

The need for great endurance of a cardiac surgeon and his ability to work in a team is associated with the duration of the operations (6-12 hours), as well as the fact that they require the work of an entire medical team, usually consisting of at least four people.

High demands are usually placed on the personal qualities of a cardiac surgeon, including:

• Inclination towards natural sciences;
• Stress tolerance;
• Good health;
• A responsibility;
• Desire to help people;
• Readiness for justified risk;
• Accuracy of movement coordination.

Depending on the need for security can be divided into several groups.

1. Operations in conditions of natural circulation on a beating heart.
2. Operations performed on a "dry" heart under conditions of general hypothermia - when the patient's body is cooled to 30-32 °. With a decrease in body temperature, all metabolic processes are slowed down. Under conditions of hypothermia, it is possible to stop the access of blood to the brain for up to 10 minutes without the development of ischemic manifestations, turn off the heart from the blood circulation for this period, and perform surgery. When conducting deep hypothermia, the shutdown time of the heart can be extended.
3. Operations performed on a switched-off heart with cardiopulmonary bypass, with additional coronary perfusion, cardioplegia and hypothermia.
4. Operations under cardiopulmonary bypass, general hypothermia in combination with hyperbaric oxygenation.

Access to the heart

Transpleural. Anterior-lateral, lateral intercostal thoracotomy, often left-sided. The choice of intercostal space is determined by the department of the heart, where the surgical intervention is supposed to be performed. Transpleural approaches are used when performing operations on the heart with natural circulation and in emergency surgery.

Direct access to the heart (extrapleural)- often median sternotomy. Universal access that provides access to all chambers of the heart, vessels entering and exiting the heart. It is used when performed on an open heart with cardiopulmonary bypass.

Combined Access- transversely bipleural with a transverse intersection of the sternum.

Operations for wounds of the heart

They are non-penetrating and penetrating when the integrity of the endocardium is violated, with damage to the chambers of the heart or the intrapericardial part of the main vessels. Cardiac tamponade is a severe complication of a penetrating wound.

Tamponade is a complex syndrome, in the occurrence of which an important role belongs to the combined effect of trauma to the heart muscle, hemorrhage into the pericardium with mechanical compression of the heart, difficulty in diastolic blood filling of the ventricles, diastolic circulatory failure with the development of complex neuroreflex, humoral disorders.

Acute cardiac tamponade is an absolute indication for surgical intervention and the use of a complex of resuscitation measures. Surgery for wounds complicated by cardiac tamponade should be considered in the same group with such a well-known operation as tracheostomy. Some authors with rapidly increasing tamponade recommend percutaneous subxiphoid puncture of the pericardium as a resuscitation measure. The effect of pericardiocentesis can occur even with the removal of a small amount of blood. According to the Marfan method, pericardiocentesis is performed at a point under the xiphoid process, according to the Larrey method - at a point between the base of the xiphoid process on the left and the place of attachment to the sternum of the VII costal cartilage.

When the heart is injured, immediate surgical intervention is necessary and it is considered as the most important resuscitation measure, in critical situations even without anesthesia. In parallel with the operation, intubation, IVA, passive infusion therapy are performed. Operational access - lateral or anterolateral intercostal thoracotomy, often left-sided. The pericardium is widely opened. The wound is pressed with a finger. Wounds of the ventricles are sutured with separate interrupted sutures (preferably U-shaped). When the walls of the atria are injured, a continuous suture is applied. The pericardial cavity is flushed with saline. The pericardium is sutured with rare sutures and drained, the drainage tube is brought out. The chest cavity is sutured with drainage.

Operations for atherosclerosis of the heart vessels

In most cases, atherosclerosis affects the proximal sections of the main coronary arteries. Performing operations aimed at creating another source of blood supply to the myocardium by organocardiopexy. Thus, the epicardium was scarified in order to form adhesions between the pericardium and the epicardium. The most widespread in the same 1935 was the Thompson method - cardiopericardiopexy, in which talc was sprayed into the pericardial cavity. In 1937, O'Shaughnessy used a pedicled alnic flap for myocardial revascularization. To stimulate blood circulation in the myocardium, the Fieschi operation (1939) was performed - ligation of the internal thoracic arteries immediately below the origin of the pericardial and diaphragmatic trunks. Veek in 1948 proposed an operation to narrow the coronary sinus with incisions on the epicardium and spraying of talc into the pericardium.

Operations aimed at direct cardiac revascularization.

In 1964, DeBakey performed a successful coronary artery bypass grafting with a segment of the great saphenous vein. In 1967, cardiac surgeons performed coronary artery bypass grafting and began to actively introduce this method of treating coronary artery disease. In 1970, multiple coronary artery bypass grafting was performed. The operation of coronary artery bypass grafting (CABG) has found wide application in the work of cardiac surgery centers and departments. A lot of experience has been accumulated in the performance of these operations, numbering tens of thousands. Thus, in the United States, under the auspices of the National Institute of Health, a study was made of the effectiveness of CABG and the feasibility of its implementation according to the data of 16 (more than 25,000 patients) over 12 years. The optimistic conclusions of this study were rated as one of the highest achievements of US science.

Coronary artery bypass grafting belongs to the category of effective operations in the treatment of coronary artery disease. This operation, as noted above, is the operation of choice for threatening or myocardial infarction complicated by cardiogenic shock. The operation of coronary artery bypass grafting is performed with IR. Operative access - more often median longitudinal sternotomy. The operation begins with the isolation of the coronary artery, its ligation above the site of occlusion. Superimposed distal arterio-venous anastomosis. The next stage is the imposition of an aorto-venous proximal anastomosis by lateral squeezing of the ascending aorta, in which a hole with a diameter of 1.0 x 0.3 cm is excised and an end-to-side vascular anastomosis is applied. After the operation, rare sutures are applied to the pericardium. Sewing up the surgical wound.

With multiple arterial lesions, several shunts are performed, the average number of which is from 2.0 to 3.6. According to the RNCC RAMS, 3 vascular lesions were observed in 75% of patients out of 3300 operated. Minimally invasive surgery has now become established in the treatment of cardiac surgery patients.

Minimally invasive coronary artery bypass surgery. One of the features of this technique is the rejection of the use of cardiopulmonary bypass. Bypass surgeries are performed by cardiac surgeons on a beating heart with natural circulation. Access - longitudinal sternotomy or lateral thoracotomy. The principles of minimally invasive coronary surgery have been developed experimentally. Clinical development is associated with the activities of prof. Vasily Ivanovich Kolesov, who was the first in the world to perform direct revascularization of the heart on February 25, 1964 by anastomosis of the left intrathoracic artery with the coronary artery end-to-end on a beating heart. On February 5, 1968, 7 hours after myocardial infarction, he first imposed LKSH. By 1976, the group of V.I. Kolesov performed myocardial revascularization in 132 patients, 71.2% of whom had repeated myocardial infarctions.

Now many cardiac surgical centers of the country have clinical experience in minimally invasive mammary coronary bypass grafting (MCB). MKS can be performed through a small left-sided thoracotomy without CPB. Superimposed anastomosis of the intrathoracic artery with the anterior interventricular artery. The advantage of these surgeries is the possibility of performing them in patients with high risk (diabetes, old age). At the same time, the indications for performing operations are expanded, hemostatic disorders and complications from cardiopulmonary bypass are excluded, and the cost of treatment is reduced.

Balloon angioplasty of arteries, intracoronary stenting with matrix or wire stents are widely used. There are domestic stents. According to RNPH, immediate success is observed in more than 95-96% of patients.

Surgery for heart aneurysms

Postinfarction aneurysms of the heart. Heart aneurysms, more often of the left ventricle, develop as a complication of myocardial infarction in IHD. The choice of the site of surgical treatment is determined by the type of heart aneurysm (diffuse, saccular, mushroom-shaped), the state of the coronary circulation, and the degree of heart failure. Surgical treatment methods for diffuse aneurysms are aimed at strengthening the fibrous degenerate wall of the left ventricle. This operational method includes the operation of diaphragmoplasty, developed by Petrovsky. Operational access — left-sided intercostal thoracotomy. The pericardial cavity is opened. From the diaphragm, surgeons cut out a flap 6 cm wide, 12 cm long, with the base to the apex of the heart. When cutting out the flap, the blood supply to the flap is taken into account. The epicardium and pleural cover of the diaphragmatic flap are scarified for better adhesion of the surfaces. Next, the diaphragmatic graft is fixed to the surface of the ventricle with separate sutures. The defect in the diaphragm is sutured with silk sutures. This operation is also used to improve the roundabout blood supply to the heart in IHD.

In saccular aneurysm, resection of the aneurysm is performed using a closed or open method. When resection with a closed method, anterior-lateral thoracotomy in the VI intercostal space on the left is more often used. The pericardium is dissected along the perimeter of the fusion. A needle clamp is applied to the neck of the bag and the altered wall of the left ventricle to be excised is compressed. The aneurysmal sac is opened between the handles, parietal thrombotic masses are removed. The bag is resected. The wound of the heart is sutured with a U-shaped continuous suture with a floor clamp. After removing the clamp, in order to strengthen the resection area, a second row of blanket sutures is applied and diaphragmoplasty is additionally performed.

Resection of the aneurysm by the open method is performed under EC conditions. Operative access — longitudinal median sternotomy. The pericardium is dissected along the circumference of the neck of the aneurysmal sac. The aneurysmal sac is opened, the remnants of blood and parietal thrombotic masses are removed from its cavity. Resection of the altered wall of the left ventricle, scar tissue is performed. A continuous mattress suture is applied to the wound of the heart. 11 after turning off the AIC, a second row of interrupted sutures is applied. Additionally, diaphragmoplasty is performed. Aneurysmectomy in a number of patients is combined with CABG, or CABG is supplemented with aneurysm resection. Combined operations with CABG improve blood supply in the periresection zone of the myocardium.

Surgical operations on the heart for arrhythmias

In the presence of a complete transverse block with clinical manifestations, II degree atrioventricular block of the Mobitz-P type, SSSU with Morgagni-Edems-Stokes syndrome or heart failure, Frederick's syndrome (complete AV block in combination with atrial fibrillation), carotid sinus syndrome resort to implantation pacemaker. There are several ways to stimulate the heart with a pacemaker. The first models of these devices acted on the myocardium with constant impulses that were not synchronized with the work of the heart. This effect represented a certain danger in terms of the development of ventricular fibrillation and asystole, since the simulation of the “I on T” type leads to the loss of the next heartbeat and destabilizes myocardial metabolism. An on-demand pacemaker has been proposed. He gave impulses of a fixed frequency, but turned on only when his own rhythm was disturbed. P-wave stimulators have also been proposed that excite the ventricles with amplified impulses from the sinus node. The reliability of such stimulants is low. Modern models of pacemakers provide for separate stimulation of the atria and ventricles, control of the heart rhythm depending on the energy needs of the body. Initially, a thoracotomy was used to install the pacemaker, then a lower thoracotomy. Currently, transvenous implantation of electrodes is used. A serious problem in the implantation of artificial pacemakers is the subsequent development of connective tissue around the active electrodes and the gradual deterioration of impulse conduction to the myocardium.

Syndromes of premature excitation of the ventricles (Wolf-Parkinson-White. Clark-Levy-Kritesko). These conditions are associated with the congenital presence in patients of additional pathways that shunt the conduction of an electrical impulse past the atrioventricular node, which normally slows down conduction. In this case, ventricular systole occurs earlier than normal. Changes in intracardiac hemodynamics and frequent bouts of tachyarrhythmia necessitate surgical correction of the anomaly. After mapping the electrical activity of the heart (ECG recording from many points of the anterior chest wall) and recording an ECG with an intracardiac electrode, an additional bundle is localized. Previously, its excision was possible only by an open method under EC conditions. Currently, methods of cryo- and electrical destruction, light or radiofrequency ablation of abnormal beams are used, carried out using catheters on a beating heart. Complete cure occurs in 90% of patients.