Kalp Cerrahisinin Prensipleri

Kalp Cerrahisinin Prensipleri
Dr. Rıza TÜRKÖZ
Başkent İstanbul Hastanesi

Kalbin Anatomisi
MANAR ELKHOLY

Kalbin Anatomisi
Anatomic relationship between the aortic
valve and surrounding structures.

 Figure 5-18 Calcific aortic stenosis. (A) Calcification of an anatomically normal tricuspid aortic valve in an
elderly patient, characterized by mineral deposits localized to the basal aspect of the cusps; cuspal free
edges and commissures are not involved. (B) Congenitally bicuspid aortic valve, characterized by two equal
cusps with basal mineralization. (C) Congenitally bicuspid aortic valve having two unequal cusps, the larger
with a central raphe (arrow). (D and E) Photomicrographs of calcific deposits in calcific aortic stenosis;
deposits are rimmed by arrows. Hematoxylin and eosin 15x. (D) Shows deposits with the underlying cusp
largely intact; transmural calcific deposits are shown in (E). (A and B: Reproduced with permission from
Schoen FJ, St. John Sutton M: Contemporary issues in the pathology of valvular heart disease. Hum Pathol
1987; 18:568. C: Reproduced with permission from Schoen FJ: Interventional and Surgical Cardiovascular
Pathology: Clinical Correlations and Basic Principles. Philadelphia, WB Saunders, 1989.)

 Figure 5-19 Major etiologies of mitral valvular disease. (A) Atrial view, and (B) subvalvular and aortic aspect of a valve
from a patient with rheumatic mitral stenosis. There are severe valvular changes, including diffuse leaflet fibrosis and
commissural fusion and ulceration of the free edges of the valve, as well as prominent subvalvular involvement with
distortion (arrow in [B]). (C and D) Myxomatous degeneration of the mitral valve. In (C) (left atrial view), there is
prolapse of a redundant posterior leaflet (p), whereas in (D) from another case, the opened annulus reveals a
redundant posterior mitral leaflet (arrows), with thin elongated chordae tendineae. The patient with the valve shown in
(D) had chronic mitral regurgitation with prolapse noted clinically, and Marfan syndrome. (Reproduced with permission
from Schoen FJ: Interventional and Surgical Cardiovascular Pathology: Clinical Correlations and Basic Principles.
Philadelphia, WB Saunders, 1989.)

 Surgical reconstructive procedures for mitral valve disease. (A) Open mitral commissurotomy for
mitral stenosis. Incised commissures are indicated by arrows. (B) Mitral valve repair with partial
leaflet excision. (C) Mitral valve repair with annuloplasty ring. (D) ePTFE suture replacement (arrow)
of ruptured cord in myxomatous mitral valve. (A: Reproduced with permission from Schoen FJ, St.
John Sutton M: Contemporary issues in the pathology of valvular heart disease. Hum Pathol 1987;
18:568. D: Reproduced with permission from Schoen and Edwards.185 D: Courtesy of William A.
Muller, MD, PhD, Cornell Medical School, New York.)

 Reconstructive procedures for aortic stenosis. (A) Aortic valve balloon valvuloplasty for
degenerative calcific aortic stenosis, demonstrating fractures of nodular deposits of
calcifications highlighted by tapes. (B and C) Catheter balloon valvuloplasty–induced
fracture of large calcific nodule of noncoronary cusp of aortic valve with calcific stenosis.
This patient died during the procedure, owing to wide-open aortic insufficiency with
inability of the cusp to close because of slight malposition of the edges of the calcific
nodule with impingement of its fracture fascicles. (B) Gross photograph; (C) Specimen
radiograph. Fracture site of nodular calcific deposit is demonstrated by arrows in (B) and
(C). (D and E) Operative decalcification of the aortic valve. (D) Aortic valve after operative
mechanical decalcification demonstrating perforated cusp. (E) Histologic cross section of
aortic valve cusp after decalcification with lithotripter. Weigert elastic stain. Ca = calcium.
(A, D, and E: Reproduced with permission from Schoen and Edwards.185 B and C:
Reproduced with permission from Schoen FJ: Interventional and Surgical Cardiovascular
Pathology: Clinical Correlations and Basic Principles. Philadelphia, WB Saunders, 1989.)

C. Walton Lillehei (left), the father of open-heart surgery, and Richard Varco

Lillehei CW, Cohen M, Warden HE, et al: The results of direct vision closure of
ventricular septal defects in eight patients by means of controlled cross
circulation. Surg Gynecol Obstet 1955; 101:446.
Lillehei CW, Cohen M, Warden HE, et al: The direct vision intracardiac correction of
congenital anomalies by controlled cross circulation. Surgery 1955; 38:11

Cardiopulmonary bypass circuit

Venöz Kanülasyon
 Placement of venous cannulas. (A) Cannulation of both cavae
from incisions in the right atrium. (B) Cannulation using the "two-
stage cannula." Blood in the right atrium is captured by vents in
the expanded shoulder several inches from the narrower IVC
catheter tip. IVC = inferior vena cava; PA = pulmonary artery; RA
= right atrium; RV = right ventricle; SVC = superior vena cava.

Cardiopulmonary bypass circuit
 Diagram of a typical cardiopulmonary bypass circuit with vent, field suction, aortic root suction, and
cardioplegic system. Blood is drained from a single "two-stage"catheter into the venous reservoir,
which is part of the membrane oxygenator/heat exchanger unit. Venous blood exits the unit and is
pumped through the heat exchanger and then the oxygenator. Arterialized blood exits the
oxygenator and passes through a filter/bubble trap to the aortic cannula, which is usually placed in
the ascending aorta. Blood aspirated from vents and suction systems enters a separate cardiotomy
reservoir, which contains a microfilter, before entering the venous reservoir. The cardioplegic
system is fed by a spur from the arterial line to which the cardioplegic solution is added and is
pumped through a separate heat exchanger into the antegrade or retrograde catheters. Oxygenator
gases and water for the heat exchanger are supplied by independent sources.

Bubble
Oksijenatör
Design of bubble oxygenator

Membran Oksijenatör
 Carmeda® AFFINITY® NT Oxygenator

Kalp Kapakları
Mekanik protezler (Coumadin, tromboemboli, kanama)
Xenogreft Bioprotezler (Dejenerasyon ve reoperasyon)
Stentli
Stentsiz
Allogreftler (Homogreftler)
Otogreftler

 Prototype model of a ball and cage valve, an early Starr-Edwards model.
Mekanik protezler

 The Medtronic Hall valve
Mekanik protezler

Mekanik protezler
 The original Kalke-Lillehei bileaflet valve as compared
to the St. Jude Medical valve introduced nearly a
decade later.

CarboMedics Top Hat valve.
Mekanik protezler

Mekanik protezler
 ATS Medical valve. Note the open pivot design maintaining leaflet insertion.

On-X valve. Note the flange of the inflow portion of the valve
housing which seats in the left ventricular outflow tract.
Mekanik protezler

St. Jude Medical Regent valve.
Mekanik protezler

All sutures have been passed through the sewing ring and the
valve is lowered to the aortic annulus and seated appropriately by
placing gentle leverage on the valve sewing ring and traction on the
suture bundles.

 (A) Tricuspid valve replacement is performed with a St. Jude Medical valve. The
native leaflets are left in situ, and the pledgeted 2-0 Ethibond sutures are passed
through the annulus and the edges of the leaflets. (B) The valve is seated, and
the sutures are tied. The subvalvular apparatus is visualized to ensure that there
is no impingement of the prosthetic valve leaflets. The valve can be rotated if
necessary to prevent leaflet contact with tissue.

FDA-approved mechanical mitral
valves. A. Starr-Edwards ball-and-
cage. B. Medtronic-Hall tilting-disk. C.
Omnicarbon tilting-disk. D. St. Jude
Medical bifleaflet. E. Carbomedics
bileaflet. F. ATS bileaflet. G. On-X
bileaflet.
Mitral Valve
Replacement

First-Generation Prostheses First-generation bioprostheses
were preserved with high-pressure fixation
 Medtronic Hancock Standard and Modified Orifice (Medtronic, Minneapolis, MN)
 Carpentier-Edwards Standard porcine prostheses (Edwards Life Sciences, Irvine,
CA).
Second-Generation Prostheses Second-generation
prostheses are treated with low- or zero-pressure fixation.
 Porcine second-generation prostheses
 Medtronic Hancock II valve (Medtronic, Minneapolis, MN)
 Medtronic Intact porcine valve (Medtronic, Minneapolis, MN)
 Carpentier-Edwards Supraannular valve (SAV) (Edwards Life Sciences, Irvine, CA).
 Pericardial prostheses
 Carpentier-Edwards Perimount (Edwards Life Sciences, Irvine, CA)
 Pericarbon (Sorin Biomedica, Saluggia, Italy) prostheses.
Third-Generation Prostheses Newer-generation prostheses
incorporate zero- or low-pressure fixation with anti-mineralization processes that
are designed to reduce material fatigue and calcification. Stents have become
progressively thinner, have a lower profile, and are more flexible
 The Medtronic Mosaic porcine valve (Medtronic, Minneapolis, MN)
 St. Jude Medical Epic valve (St. Jude Medical Inc., Minneapolis, MN) is a porcine
 The Carpentier-Edwards Magna valve (Edwards Life Sciences, Irvine, CA)
 The Mitroflow Pericardial aortic prosthesis (Carbomedics, Austin, TX)

Antimineralization
XenoLogiX (Edwards Lifesciences, Irvine, CA),
No-React (Shelhigh, Inc., Union, NJ),
AOA (two-alpha-amino oleic acid) (Biomedical
Design, Inc., Atlanta, GA),
BiLinx (St. Jude Medical, Inc., St. Paul, MN)

FDA-approved
bioprosthetic mitral valves.
A. Hancock II porcine
heterograft. B. Carpentier-
Edwards standard porcine
heterograft. C. Mosaic
porcine heterograft. D.
Carpentier-Edwards
pericardial bovine
heterograft. E. St. Jude
Biocor porcine heterograft.

Stentless bioprosthetic heart
valves.
 The Toronto SPV fully scalloped glutaraldehyde-fixed porcine
valve with the entire external aspect covered with cloth

valves.
The Toronto Root. This can be used as a full root,
inclusion root, or either subcoronary implant. (Used with
permission of St. Jude Medical, Inc., St. Paul, MN.)
anticalcification methods (BiLinx)

valves.
 The Edwards Prima Plus. The dashed line is a marking suture delineating the safe extent of
sinus excision so this can be used as a full root, inclusion root, or either subcoronary implant.
(Used with permission of Edwards Lifesciences LCC, Irvine, CA.) porcine root The Prima
Plus is a low-pressure fixed valve with proprietary XenoLogiX treatment for calcium
mitigation.

valves.
The Medtronic Freestyle Aortic Root Bioprosthesis. The
longitudinal view shows the fabric covering of the
porcine septal muscle and the associated higher position
of the right coronary stump. porcine root The device is
fixed with physiologic (40 mm Hg) pressure applied to
the aortic wall but a net zero pressure across the
leaflets. It is treated with alpha-amino-oleic acid as a
calcium mitigant.

valves.
The CryoLife-O’Brien valve. This device has no cloth
covering and no muscle because of its composite design.
Sutures joining the three segments are obvious at each
commissure. tissue is fixed in glutaraldehyde but there is no
specific antimineralization treatment of this valve.

valves.
The Sorin Pericarbon Freedom Valve. This is a completely
pericardial construction designed for subcoronary implantation
with a double suture line, but it can also be trimmed to allow a
single suture line technique. bovine pericardium

valves.
The Shelhigh Superstentless valve is a porcine aortic
valve treated with the No-React (Shelhigh Inc., Union, NJ)
process. isolated porcine aortic valve

Freestyle stentless porcine aortic valve
Freestyle stentless porcine aortic valve

Thrombus
 Figure 5-25 Thrombotic occlusion of substitute heart valves. (A) Tilting disk
prosthesis. Thrombus was likely initiated in the region of stasis immediately distal to
the smaller of the two orifices through which blood flows (arrow), causing near-total
occluder immobility. (B) Porcine bioprosthesis, with thrombus filling the
bioprosthetic sinuses of Valsalva. (A: Reproduced with permission from Anderson
and Schoen.54 B: Reproduced with permission from Schoen and Hobson.199)

Endocarditis
 Figure 5-26 Prosthetic valve endocarditis. (A) Endocarditis with large ring abscess
(arrows) observed from ventricular surface of aortic Bjork-Shiley tilting disk prosthesis in
a patient who died suddenly. The ring abscess impinges on the proximal atrioventricular
conduction system. (B) Bioprosthetic valve endocarditis with cuspal perforation by
organism-induced necrosis (arrow). (A: Reproduced with permission from Schoen FJ:
Cardiac valve prostheses: pathological and bioengineering considerations. J Cardiac
Surg 1987; 2:65. B: Reproduced with permission from Schoen FJ, et al: Long-term
failure rate and morphologic correlations in porcine bioprosthetic heart valves. Am J
Cardiol 1983; 51:957.)

Structural valve dysfunction
 Figure 5-27 Structural valve dysfunction. (A) Disk escape owing to a
fractured lesser strut of a Bjork-Shiley heart valve prosthesis. This model
had the strut welded to the metal frame. Both the fractured strut and the
disk embolized; the strut was not found at autopsy. The fracture sites are
indicated by arrows. (B) and (C) Porcine valve primary tissue failure
owing to calcification with secondary cuspal tear leading to severe
regurgitation. (B) Gross photograph; (C) specimen radiograph. Dense
calcific deposits are apparent in the commissures. (D) Clinical Ionescu-
Shiley mitral bovine pericardial bioprosthesis with extensive tear of one
cusp (arrow) and resultant incompetence. (A: Reproduced with
permission from Schoen FJ, et al: Pathological considerations in
substitute heart valves. Cardiovasc Pathol 1992; 1:29. B and C:
Reproduced with permission from Schoen and Hobson.199 D:
Reproduced with permission from Schoen FJ: Cardiac valve prostheses:
pathological and bioengineering considerations. J Cardiovasc Surg 1987;
2:65.)

Structural valve dysfunction
 Figure 5-28 Dehiscence of commissural region of Hancock
Standard porcine bioprosthetic valve. (A) Gross photograph.
(B) Schematic diagram (arrow denotes loss of attachment of
commissural support). Removed for regurgitation, this valve
had prolapse of one cusp, minimal calcification, and no cuspal
tears.

Nonstructural dysfunction
of prosthetic heart valves. Figure 5-29 Nonstructural dysfunction of prosthetic heart
valves. (A) Late paravalvular leak adjacent to mitral valve
prosthesis (arrow). (B) Tissue overgrowth compromising
inflow orifice of porcine bioprosthesis. (C) Immobility of
tilting disk leaflet by impingement of retained component
of submitral apparatus (arrow) that had moved through
the orifice late following mitral valve replacement surgery.
(D) Suture with long end inhibiting free disk movement
(arrow) of Lillehei-Kaster tilting disk valve. (A and C:
Reproduced with permission from Schoen FJ: Histologic
considerations in replacement heart valves and other
cardiovascular prosthetic devices, in Schoen FJ,
Gimbrone MA [eds]: Cardiovascular Pathology:
Clinicopathologic Correlations and Pathogenetic
Mechanisms. Philadelphia, Williams & Wilkins, 1995; p
194. B: Reproduced with permission from Schoen FJ, et
al: Pathologic considerations in substitute heart valves.
Cardiovasc Pathol 1992; 1:29. D: Reproduced with
permission from Schoen FJ: Pathology of cardiac valve
replacement, in Morse D, Steiner RM, Fernandez J [eds]:
Guide to Prosthetic Cardiac Valves. New York, Springer-
Verlag, 1985; p 209.) Nonstructural dysfunction of
prosthetic heart valves. (E) Suture looped around central
strut of a Hall-Medtronic tilting disk valve causing disk
immobility. (F) Suture looped around stent post of bovine
pericardial bioprosthesis causing stenosis (arrow). (E:
Photo courtesy of Office of the Chief Medical Examiner,
New York City. F: Reproduced with permission from
Schoen FJ: Cardiac valve prostheses: pathologic and
bioengineering considerations. J Cardiac Surg 1987;
2:65.)

 Aortic valve allograft after harvesting from the donor. The block includes a variable
amount of ventricular muscle and the anterior leaflet of the mitral valve. Additional
trimming for replacement is performed at the time of implantation.
Allogreftler (Homogreftler)

 The Cribier-Edwards valve consists of three pericardial leaflets sewn
to a stainless-steel stent. The valve is stored in the open position to
avoid damage to the leaflets (left panel) and must be hand-crimped
to the delivery balloon (right panel) immediately prior to implantation.
BALLOON-EXPANDABLE VALVES

 Fluoroscopic appearance of Cribier-Edwards valve placement. Stent is expanded by balloon at the level of
the native aortic valve using calcification as a guide (left panel). Rapid ventricular pacing at 220 beats per
minute transiently inhibits cardiac output to allow accurate valve placement. Aortic root injection after
successful placement of the valve (right panel). Note nonobstructed flow to the coronary arteries and the
presence of aortic insufficiency, suggesting perivalvular leak.

 Percutaneous valve devices and concepts. (A) The Cribier-Edwards
valve consists of three equine pericardial leaflets fixed to a balloon-
expandable steel stent. It is hand-crimped over a delivery balloon
prior to deployment. (B) The Corevalve system is a self-expanding
nitinol cage housing three porcine pericardial leaflets. Devices in
preclinical development include (C) the Sadra self-expanding Lotus
valve (D), the Aortx valve (E), the Bonhoeffer valve (F), and the
eNitinol thin membrane PercValve. (Reproduced with permission
from Davidson et al.180)

SELF-EXPANDING VALVES
 The Corevalve system consists of pericardial leaflets attached to a self-expanding
nitinol frame. In the deployed state. The flared distal end assists in anchoring in the
ascending aorta. The stent covers the coronary ostia, but cell size is designed to
allow later coronary catheterization.

 The Carpentier-Edwards ring
annuloplasty is shown. A sizer
measuring the intertrigonal
distance was used to determine
the ring size. Multiple interrupted,
pledgeted 2-0 Ethibond sutures
are placed at the atrioannular
junction. All sutures are inserted
prior to seating the ring. (B) The
valve is seated, and the sutures
are tied.

Myocardial Revascularization
with Percutaneous Devices

 The coronary stent is a metallic "meshwork" that increases its
rigidity when coldworked by balloon expansion. Buttressing of the
vascular wall, propagation of dissection, and early vascular recoil
are reduced significantly.
Myocardial Revascularization with
Percutaneous Devices

Myocardial Revascularization Myocardial
Revascularization with Cardiopulmonary Bypass
 Cannulation. After full systemic heparinization, cannulation of the distal ascending
aorta is performed with an appropriately sized curved or straight tip aortic cannula. A
two-stage venous cannula is used for access to the right atrium, usually through the
right atrial appendage. An aortic root cardioplegia/vent is placed. A retrograde
cardioplegia cannula may be placed at the discretion of the surgeon. Patients with
aortic regurgitation benefit from placement of a right superior pulmonary vent to
avoid distention of the left ventricle from infusion of cardioplegia into the aortic root.

Myocardial Revascularization with Cardiopulmonary
Bypass
 Composite Y graft. (A) Y-graft anastomotic technique: A coronary artery bypass graft (CABG) is
used as a donor site for the proximal anastomosis of another conduit. An incision is created in
the donor conduit. The proximal end of the recipient conduit is then anastomosed to the donor
site in an end-to-side fashion as previously described for a distal anastomosis. The recipient
conduit is then gently parachuted down onto the donor conduit. (B) Total arterial
revascularization: As shown, arterial revascularization can be performed using the right internal
thoracic artery (RITA) off the left internal thoracic artery (LITA) as a Y graft and liberal use of
sequential grafting.

Çalışan kalpte bypass (off-pump bypass)

Aort disseksiyonu
 The type A dissection extends into the proximal aortic arch. (B) The distal dissected aortic wall is
reconstructed with inside and outside felt strips to replace part of the arch and ascending aorta.

 Brachiocephalic vessels can be reattached to an arch graft as a unit if the inner
cylinder of origin of each vessel remains intact. (A) The arch vessels are excised
as a unit from the superior surface of the dissected aortic arch. (B) The
separated layers of the brachiocephalic patch are reunited using inner and outer
felt strips and continuous suture. (C) A corresponding hole is cut in the aortic
graft and the continuous brachiocephalic unit is sutured into place.

 The brachiocephalic vessels are separated from the true lumen by the dissected
false lumen (left panel). If individual brachiocephalic vessels are also damaged
beyond repair, short interposition grafts are added to reconnect each artery to the
aortic graft (right panel).

 Illustration of insertion of a
composite valve-graft conduit
with coronary artery
reimplantation. (A) A full-
thickness button of aortic wall
adjacent to each coronary
ostium is fashioned. The aortic
valve and sinuses are then
excised. (B) Pledgeted 2-0
braided polyester sutures are
placed in the supra-annular
position and immediately
adjacent to one another to
ensure a watertight closure. The
sutures are placed in the upper
half of the sewing ring, helping
to seat the valve deep within the
aortic annulus. Note that no
knots or suture material are
exposed to the bloodstream. (C)
Ophthalmic cautery is used to
create an orifice in the graft in
the appropriate position for left
coronary reimplantation. (D) The
left coronary anastomosis is
performed first with a continuous
4-0 or 5-0 polypropylene suture
incorporating a thin strip of felt.
The right coronary anastomosis
is then performed in a similar
fashion.

Aort Anevrizması
Atherosclerotic ascending and
arch aneurysm. (B) Fabrication
of the trifurcated graft. (C)
Selective cerebral perfusion
and construction of the
elephant trunk. (D) Completed
repair.

 Replacement of the thoracoabdominal aorta. (A) A left femoral cannula perfuses the lower body and viscera while the heart
continues to eject. The arch is transected near or at the left subclavian and any dissection involving the proximal cuff is
repaired. (B) The clamp is moved down and a second arterial cannula is inserted into the proximal graft to perfuse the upper
body and heart. The anterior wall of the dissection is incised longitudinally and bleeding intercostals of the upper six pairs are
oversewn. A group of lower intercostal arteries above the celiac axis is sutured to the graft. (C) The clamp is moved down
and the distal aortic clamp is moved to the left common iliac artery. A patch of aorta containing the celiac, superior
mesenteric, and right renal artery is sewn into the graft. The left renal artery is sutured separately to the graft. (D) The
proximal clamp is moved below the visceral anastomoses and the distal aortic anastomosis is made to the aortic bifurcation.

Mechanical Circulatory Support
 (A) Balloon inflation during left ventricular (LV) diastole
occludes the descending thoracic aorta, closes the aortic valve,
and increases proximal coronary and cerebral perfusion. (B)
Balloon deflation during LV systole decreases LV afterload and
myocardial oxygen demand.

Mechanical Circulatory Support
 Percutaneous ECMO support is attained via femoral vessel
access. Right atrial blood is drained via a catheter inserted into
the femoral vein and advanced into the right atrium.
Oxygenated blood is perfused retrograde via the femoral
artery. Distal femoral artery perfusion is not illustrated.

Simplified technique for
heart-lung
transplantation as
described by Reitz and
colleagues in 1981.

The Abiomed AB5000
circulatory support system
The Heartmate
left ventricular assist device
Novacor
Thoratec
Jarvik
iii
AbioCor
Long-Term Mechanical Circulatory Support

Kalp Cerrahisinin Prensipleri

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