Key Questions in Cardiac Surgery

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Key Questions in CARDIAC SURGERY

tfm Publishing Limited, Castle Hill Barns, Harley, Nr Shrewsbury, SY5 6LX,
UK. Tel: +44 (0)1952 510061; Fax: +44 (0)1952 510192
E-mail: [email protected]; Web site: www.tfmpublishing.com

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First Edition: © March 2011
Reprinted: December 2011

Paperback ISBN: 978-1-903378-69-4

E-book editions: 2013

ePub ISBN: 978-1-908986-51-1
Mobi ISBN: 978-1-908986-52-8
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ii
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Contents
Preface
page
v

Foreword vii

Acknowledgements ix

Abbreviations x

Recommendations and evidence xvii

Chapter 1 Cardiac anatomy 1

iii
Chapter 2 Cardiac physiology 33

Chapter 3 Cardiac pharmacology 67

Chapter 4 Electrocardiography 83

Chapter 5 Echocardiography 119

Chapter 6 Cardiac catheterisation 155

Chapter 7 Radiological imaging 173

Chapter 8 Cardiopulmonary bypass 199

Chapter 9 Cardiopulmonary bypass scenarios 219

Chapter 10 Adjuncts to cardiopulmonary bypass 229

Chapter 11 Myocardial protection 243

Chapter 12 Aortic valve disease 255

Chapter 13 Mitral valve disease 283

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Key Questions in CARDIAC SURGERY

Chapter 14 Tricuspid valve disease 305

Chapter 15 Infective endocarditis 313

Chapter 16 Thoracic aortic disease 321

Chapter 17 Coronary artery disease 349

Chapter 18 Heart failure 383

Chapter 19 Arrhythmia surgery 411

Chapter 20 Pericardial disease, cardiac 423

tumours and cardiac trauma

Chapter 21 Cardiac anaesthesia and 441

intensive care management
iv
Chapter 22 Postoperative management 461

Appendix I Transoesophageal echocardiographic views 469

Appendix II Transthoracic echocardiographic views 470

Appendix III Normal echocardiographic values 471

Appendix IV Standard coronary angiographic views 472

Appendix V Normal arterial blood gas values 474

Appendix VI Normal cardiac physiological values 475

Appendix VII AHA guidelines for quantifying the severity 476

of valvular disease

Appendix VIII EuroSCORE 477

Index 479
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Preface
Cardiac surgery is a continually expanding field with the development of
novel techniques and operations as well as the refinement of well-
established surgical procedures. These developments fuel the demand for
knowledge regarding cardiac surgical disease processes and the optimal
therapeutic strategies currently available. Although several large volume
texts exist, there are very few which aim to deliver this knowledge base in
one concise book. Key Questions in Cardiac Surgery systematically covers
all the main topics involved in the contemporary practice of an adult cardiac
surgeon using numerous illustrations to enhance the reader's
understanding.

In keeping with modern practice, the data and body of knowledge

presented is strictly evidence-based. The book incorporates the current v

guidelines for practice from the American Heart Association and European
Society of Cardiology, with up-to-date information based on current
scientific literature. Each chapter contains important references for further
reading and greater in-depth study. All the chapters have been written by a
cardiac surgeon who has recently undertaken cardiothoracic examinations
and reviewed by a cardiothoracic surgery examiner. Uniquely, the images
have been drawn by a cardiac surgeon from an operative perspective.

This book is relevant to all cardiac surgical trainees and residents, at any
stage of their training programme, as it provides them with the necessary
knowledge base to carry out their daily duties. Adult cardiologists,
cardiothoracic intensive care unit specialists, nursing staff,
physiotherapists and other allied professionals working with adult cardiac
patients, either pre-operatively or postoperatively, will also find this book
key to facilitating their understanding of the principles surrounding adult
cardiac surgical disease management. Importantly, the book is also an ideal
revision aid for trainees and residents undertaking their cardiothoracic
surgery board examinations around the world. Its concise yet complete
coverage of the important topics make it the perfect guide to answer the
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Key Questions in CARDIAC SURGERY

Key Questions in Cardiac Surgery that are often asked within the confines
of an examination. The style and content of the book allow the reader to
obtain information in an easily accessible format.

Narain Moorjani MB ChB, MRCS, MD, FRCS (C-Th)

Department of Cardiothoracic Surgery
Hahnemann University Hospital
Drexel University College of Medicine
Philadelphia, USA
Nicola Viola MD
The Hospital for Sick Children
University of Toronto
Toronto, Ontario
Canada
Sunil K. Ohri MD, FRCS (Eng, Ed & CTh), FESC
Department of Cardiothoracic Surgery
vi Wessex Cardiothoracic Centre
Southampton University Hospital
Southampton, UK
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Foreword
There are many ways to learn a subject. A traditional method is to read
and review a large body of visual material and, having performed that
exercise, to be subjected to testing to see what has been learned.
Unfortunately, when the body of knowledge is large, it is sometimes unclear
as to the relevance of individual items as they are perused. The
consequence may be inordinate amounts of time spent on inconsequential
bits of knowledge at the expense of the most critical components of the
subject matter.

In his textbook, Key Questions in Cardiac Surgery, Narain Moorjani,

writing from the vantage point of one who has recently undertaken specialty
exams following completion of his cardiac surgery training, provides a most
interesting alternative. Specifically, the work of determining the most critical vii

aspects of the body of knowledge has been thoroughly reviewed and

questions are asked as a teaching tool without the antecedent didactics. In
this system, there is no uncertainty as to the elements that are regarded as
important for the student. The text in this book is accompanied by very
useful illustrations and photographs. Once again these visual tools are
pointedly related to the question surrounding the anatomic or disease
process. I have found this a rather fun way to test my own knowledge, even
though I have been practicing cardiac surgery for thirty-five years and
teaching residents during most of that time. The danger of a question and
answer approach to learning or knowledge testing is the presence of
ambiguity in either the questions or the answers. Reassuringly, such
instances are remarkably rare in this book and it is clear that important
forethought was given to the formulation of the test items. Moreover, there
is a strong didactic component to the text because the answers to the
question are brief, to the point and authoritative.

The strength of this book lies in one of the important words in the title,
that being ‘key’: it focuses on the essential information that every cardiac
surgeon should have at their fingertips. For this reason, I believe the book
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Key Questions in CARDIAC SURGERY

is particularly appropriate for those in the late stages of their training or the
early stages of their practicing career.

Andrew S. Wechsler, M.D.

Stanley K. Brockman Professor and Chairman
Department of Cardiothoracic Surgery
Hahnemann University Hospital
Drexel University College of Medicine
Philadelphia, USA
Editor Emeritus, The Journal of Thoracic and Cardiovascular Surgery

viii
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Acknowledgements
We would like to thank and acknowledge the consultant surgeons at
Southampton General Hospital, Southampton, UK (Mr Steven Livesey, Mr
Marcus Haw, Mr Geoffrey Tsang and Mr Clifford Barlow) and the attending
surgeons at Hahnemann University Hospital, Drexel College of Medicine,
Philadelphia, USA (Professor Andrew Wechsler, Dr John Entwistle, Dr
Percy Boateng) for imparting the knowledge described in this book and
also for the opportunity to take the operative photographs.

As regards some of the individual chapters, we are grateful to Professor

John Morgan, Dr Alison Calver, Dr Steven Harden, Dr Ivan Brown, Dr
Arthur Yue, Dr Michael Rubens and Dr James Shambrook for their images.
In particular, we would like to thank Dr Tom Pierce for access to his
collection of electrocardiograms. We are grateful to Edwards Lifesciences ix

and Eurosets Medical Devices for permission to reprint their copyrighted

images.

Finally, we are deeply indebted to Nikki Bramhill of TFM Publishing,

whose enthusiasm, endless patience and hard work has resulted in the
production of this cardiac text.
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Abbreviations
AC assist control
ACC American College of Cardiology
ACEI angiotensin-converting enzyme inhibitor
ACS acute coronary syndrome
ACT activated clotting time
ADH anti-diuretic hormone
ADP adenosine diphosphate
AF atrial fibrillation
AHA American Heart Association
AL anterior leaflet of the tricuspid valve
ALT alanine transaminase
AMVL anterior mitral valve leaflet
ANP atrial natriuretic peptide

x
AoV aortic valve
AP anteroposterior
APTTR activated partial thromboplastin time ratio
AR aortic regurgitation
ARB angiotensin II receptor blocker
ARDS adult respiratory distress syndrome
ART Arterial Revascularisation Trial
ARTS Arterial Revascularisation Therapies Study
AS aortic stenosis
ASA American Society of Anesthesiologists
ASH asymmetrical septal hypertrophy
AST aspartate aminotransferase
AT acceleration time
ATG anti-thymocyte globulin
ATLS® Advanced Trauma Life Support
ATP adenosine triphosphate
AVA aortic valve area
AVN atrioventricular node
AVR aortic valve replacement
BARI Bypass Angioplasty Revascularisation Investigation
BNP brain natriuretic peptide
BP blood pressure
BSA body surface area
Ca calcium
CABG coronary artery bypass grafting
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Abbreviations

cAMP cyclic adenosine monophosphate

CAPRIE Clopidogrel versus Aspirin in Patients at Risk of Ischaemic
Events
CASS Coronary Artery Surgery Study
CBF coronary blood flow
CHARM Candesartan in Heart Failure Assessment of Reduction in
Mortality and Morbidity
CI cardiac index
Cl chloride
CK creatinine kinase
CK-MB creatinine kinase MB isoenzyme
CMV cytomegalovirus
CO cardiac output
CO2 carbon dioxide
COCPIT Comparative Outcome and Clinical Profiles in
Transplantation
CONSENSUS Cooperative North Scandinavian Enalapril Survival Study
COPD chronic obstructive pulmonary disease
xi
COPERNICUS Carvedilol Prospective Randomised Cumulative Survival
CP constrictive pericarditis
CPAP continuous positive airway pressure
CPB cardiopulmonary bypass
Cr creatinine
CS coronary sinus
CSA cross-sectional area
C-SMART Cardiomyoplasty-Skeletal Muscle Assist Randomised Trial
CT computed tomography
CURE Clopidogrel in Unstable Angina to Prevent Recurrent
Events
CVA cerebrovascular accident
CVP central venous pressure
Cx circumflex artery
CXR chest X-ray
DBP diastolic blood pressure
DC direct current
DES drug-eluting stent
DFP diastolic filling period
DHCA deep hypothermic circulatory arrest
ECG electrocardiogram
ECSS European Coronary Surgery Study
EEG electroencephalogram
EF ejection fraction
EOAI effective orifice area index
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Key Questions in CARDIAC SURGERY

EROA effective regurgitant orifice area

ESC European Society of Cardiology
ETCO2 end-tidal carbon dioxide
ETT exercise tolerance test
FDG fluorodeoxyglucose
FEV1 forced expiratory volume in 1 second
FFP fresh frozen plasma
FFR fractional flow reserve
FiO2 inspired oxygen concentration
FRISC Fragmin in Unstable Coronary Artery Disease Study
FS fractional shortening
GTN glyceryl trinitrate
Hb haemoglobin
Hct haematocrit
HFSS heart failure survival score
HLA human leucocyte antigen
HMG 3-hydroxy-3-methylglutaryl
HOCM hypertrophic obstructive cardiomyopathy
xii
HR heart rate
HS heart sound
HU Houndsfield units
IABP intra-aortic balloon pump
I:E inspiration: expiration ratio
IL interleukin
IMAGE International Multicenter Aprotinin Graft Patency
Experience
IMV intermittent mandatory ventilation
INR international normalized ratio
ISHLT International Society for Heart and Lung Transplantation
ITU intensive therapy unit
IV intravenous
IVC inferior vena cava
IVS interventricular septum
IVUS intravascular ultrasound
JVP jugular venous pulse; jugular venous pressure
K potassium
LA left atrium
LAA left atrial appendage
LAD left anterior descending (coronary artery)
LAHB left anterior hemiblock
LAO left anterior oblique
LAP left atrial pressure
LBBB left bundle branch block
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Abbreviations

LCC left coronary cusp of the aortic valve

LCCA left common carotid artery
LCS left coronary sinus
LED light emitting diode
LGL Lown-Ganong-Levine
LICA left internal carotid artery
LiDCO lithium indicator dilution cardiac output
LIMA left internal mammary artery
LIMV left internal mammary vein
LIPV left inferior pulmonary vein
LMCA left main coronary artery
LMS left main stem
LMWH low-molecular-weight heparin
LPHB left posterior hemiblock
LSPV left superior pulmonary vein
LV left ventricle
LVAD left ventricular assist device
LVEDP left ventricular end-diastolic pressure
xiii
LVEDV left ventricular end-diastolic volume
LVEF left ventricular ejection fraction
LVESV left ventricular end-systolic volume
LVH left ventricular hypertrophy
LVIDd left ventricular internal diameter in diastole
LVIDs left ventricular internal diameter in systole
LVM left ventricular mass
LVMI left ventricular mass index
LVOT left ventricular outflow tract
LVOTO left ventricular outflow tract obstruction
LVPW left ventricular posterior wall
MACS maximal aortic cusp separation
MADIT Multicenter Automatic Defibrillator Implantation Trial
MAGIC Myoblast Autologous Grafting in Ischaemic Cardiomyopathy
MAP mean arterial pressure
MECC minimal extracorporeal circulation
MI myocardial infarction
MMF mycophenolate mofetil
MPAP mean pulmonary artery pressure
MR mitral regurgitation
MRI magnetic resonance imaging
MRSA methicillin-resistant Staphylococcus aureus
MS mitral stenosis
MUGA multi-gated acquisition
MUSTIC Multisite Stimulation in Cardiomyopathies
MV mitral valve
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Key Questions in CARDIAC SURGERY

MVA mitral valve area

MVR mitral valve replacement
Na sodium
NCC non-coronary cusp of the aortic valve
NICE National Institute for Health and Clinical Excellence
NSTEMI non-ST elevation myocardial infarction
NYHA New York Heart Association
O2 oxygen
OM obtuse marginal artery
OPCAB off-pump coronary artery bypass grafting
PA pulmonary artery; posteroanterior
PaCO2 partial pressure of carbon dioxide
PADP pulmonary artery diastolic pressure
PaO2 partial pressure of oxygen
PAP pulmonary artery pressure
PASP pulmonary artery systolic pressure
PAU penetrating aortic ulcer
PAWP pulmonary artery wedge pressure
xiv
PCI percutaneous coronary intervention
PCV pressure controlled ventilation
PDA posterior descending (coronary) artery
PEA pulseless electrical activity
PEEP positive end expiratory pressure
PET positron emission tomography
PHT pressure half-time
PISA proximal isovelocity surface area
PL posterior leaflet of the tricuspid valve
PLSVC persistent left superior vena cava
PMBV percutaneous mitral balloon valvuloplasty
PMVL posterior mitral valve leaflet
PPM patient prosthesis mismatch
PS pressure support (ventilation)
PTCA percutaneous transluminal coronary (balloon) angioplasty
PV pulmonary vein; pulmonary valve
PVC polyvinyl chloride
PVR pulmonary vascular resistance
PVRI pulmonary vascular resistance index
PWT posterior wall thickness
RA right atrium
RAA right atrial appendage
RALES Randomized Aldactone Evaluation Study
RAO right anterior oblique
RAP right atrial pressure
RAPCO Radial Artery Patency and Clinical Outcome
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Abbreviations

RBBB right bundle branch block

RCA right coronary artery
RCC right coronary cusp of the aortic valve
RCCA right common carotid artery
RCM restrictive cardiomyopathy
RCS right coronary sinus
RECA right external carotid artery
REMATCH Randomised Evaluation of Mechanical Assistance for the
Treatment of Congestive Heart Failure
RESTORE Reconstructive Endoventricular Surgery Returning Torsion
Original Radius Elliptical Shape to the Left Ventricle
RICA right internal carotid artery
RIMA right internal mammary artery
RIPV right inferior pulmonary vein
RITA Randomised Intervention Treatment of Angina trial
ROOBY Randomized On/Off Bypass Study
RPA right pulmonary artery
RPV right pulmonary vein
xv
RR respiratory rate
RSCA right subclavian artery
RSPV right superior pulmonary vein
RV right ventricle
RVOT right ventricular outflow tract
RVSP right ventricular systolic pressure
SAM systolic anterior motion (of the mitral valve)
SAN sino-atrial node
SaO2 arterial oxygen saturation
SAVER Surgical Anterior Ventricular Endocardial Restoration
SBP systolic blood pressure
SEP systolic ejection period
SIADH syndrome of inappropriate anti-diuretic hormone
SIMV synchronised intermittent mandatory ventilation
SIRS systemic inflammatory response syndrome
SL septal leaflet of the tricuspid valve
SNP sodium nitroprusside
SOLVD Studies of Left Ventricular Dysfunction
SoS Stent or Surgery
SPECT single photon emission computed tomography
SR sinus rhythm
STEMI ST elevation myocardial infarction
STICH Surgical Treatment for Ischaemic Heart Failure
SV stroke volume
SVC superior vena cava
SVD structural valve deterioration
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Key Questions in CARDIAC SURGERY

SVG saphenous vein graft

SvO2 mixed venous saturation
SVR systemic vascular resistance; surgical ventricular restoration
SVRI systemic vascular resistance index
SYNTAX Synergy between PCI with TAXUS and Cardiac Surgery
SZA solitary zone of apposition
TEG thrombo-elastogram
TIMI Thrombolysis in Myocardial Infarction
TM tropomyosin
TMR transmyocardial revascularisation
TOE transoesophageal echocardiography
Tp troponin
TR tricuspid regurgitation
TS tricuspid stenosis
TTE transthoracic echocardiography
TV tricuspid valve; tidal volume
TVA tricuspid valve area
UA unstable angina
xvi
UNOS United Network for Organ Sharing
VA Veterans Administration
VAC vacuum-assisted closure
Val-HeFT Valsartan in Heart Failure Trial
VSR ventricular septal rupture
VTI velocity time integral
WL window level
WPW Wolff-Parkinson-White
WW window width
YAG yttrium aluminium garnet
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Recommendations
and evidence
The classification of recommendations and the levels of evidence used in
this book are taken from the American Heart Association guidelines:

Class I: Conditions for which there is evidence or general

agreement that a given procedure or treatment is
beneficial, useful, and effective.
Class II: Conditions for which there is conflicting evidence
or a divergence of opinion about the usefulness/
efficacy of a procedure or treatment.
Class IIa: Weight of evidence/opinion is in favour of
usefulness/efficacy.

xvii
Class IIb: Usefulness/efficacy is less well established by
evidence/opinion.
Class III: Conditions for which there is evidence or general
agreement that a procedure/treatment is not useful/
effective and in some cases may be harmful.

Level of Evidence A: Data derived from multiple randomised clinical trials

or meta-analyses.
Level of Evidence B: Data derived from a single randomised trial or non-
randomised studies.
Level of Evidence C: Only consensus opinion of experts, case studies,
or standard-of-care.
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Key Questions in CARDIAC SURGERY

xviii
chapter 1_chapter 1.qxd 10-05-2013 00:08 Page 1

Chapter 1
Cardiac anatomy

1 Describe the anatomy of the coronary artery system

(Figure 1)

1
Aorta

Pulmonary artery
SVC
LMCA

LAA
LCS
RAA
RCS

Cx
RCA

LAD

IVC

Figure 1. Coronary artery system. SVC = superior vena cava; RAA =

right atrial appendage; IVC = inferior vena cava; RCS = right coronary
sinus; RCA = right coronary artery; LCS = left coronary sinus; LMCA = left
main coronary artery; LAA = left atrial appendage; Cx = circumflex
artery; LAD = left anterior descending artery.
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Key Questions in CARDIAC SURGERY

• The coronary artery system originates from the aortic root and
consists of the left and right coronary arteries and their individual
branches.
• The left coronary artery originates from the left coronary ostium as
the left main stem and divides early into the left anterior descending
artery (also known as the anterior interventricular artery) and
circumflex artery (see below).
• The right coronary artery originates from the right coronary ostium
and eventually terminates as the posterior descending artery (also
known as the posterior interventricular artery) and posterior left
ventricular artery (see below).

2 Describe the anatomy of the left main coronary artery

(Figure 2)
• The left main coronary artery (left main stem) courses from the left
coronary sinus of the aorta in an anterior and inferior direction
between the pulmonary trunk and the left atrial appendage.
2 • It then divides into two major arteries of nearly equal diameter, the left
anterior descending artery and the circumflex artery. Typically, no
branches are seen before this bifurcation.

Left main coronary artery

Circumflex branch

Circumflex branch
Intermediate
branch

Left anterior descending artery Left anterior descending artery

Figure 2. Bifurcation and trifurcation of the left main coronary artery.

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1 Cardiac anatomy

• In some patients, the left main coronary artery trifurcates into the
intermediate coronary artery (ramus intermedius), left anterior
descending artery and circumflex artery.
• The left main coronary artery is typically 10-40mm in length but may
be absent in patients with separate circumflex and left anterior
descending coronary ostia.

3 Describe the anatomy of the left anterior descending

(LAD) artery (Figure 3)
• The LAD artery courses anteriorly and inferiorly in the anterior inter-
ventricular groove towards the apex of the heart.

3
Left main coronary artery

Diagonal branches

Left coronary sinus or sinus #2

First septal perforator branch

Septal perforator branches

Left anterior descending or

anterior interventricular artery

Figure 3. Left anterior descending (LAD) artery and its branches.

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Key Questions in CARDIAC SURGERY

• Occasionally, the LAD continues around the apex to supply part of

the posterior interventricular groove and rarely even replaces the
posterior descending artery.
• In 4% of patients, the LAD bifurcates proximally and continues as two
equal sized parallel vessels down the anterior interventricular groove.
• The main branches of the LAD include:

a) diagonal arteries (usually 2-6 in number) which course along

and supply the anterolateral wall of the left ventricle;
b) septal perforator arteries (usually 3-5 in number) which branch
perpendicularly into and supply the anterior two thirds of the
ventricular septum. The first septal artery is the largest and
runs perpendicularly towards the medial papillary muscle of the
tricuspid valve. It is at risk during the Ross procedure as it lies
immediately beneath the right ventricular outflow tract and
pulmonary valve;
c) right ventricular branches, which supply blood to the anterior
surface of the right ventricle but are not always present.

Proximal LAD

Mid LAD

First septal perforator branch

Last diagonal branch

Distal LAD

Figure 4. Segments of the left anterior descending (LAD) artery.

chapter 1_chapter 1.qxd 10-05-2013 00:08 Page 5

1 Cardiac anatomy

• The LAD is divided into (Figure 4):

a) a proximal third, which runs from the origin of the LAD to the
origin of the first septal artery;
b) a middle third, which runs from the first septal artery to the
origin of the last diagonal artery;
c) a distal third, which runs from the last diagonal artery to the
termination of the LAD.

4 Describe the course of the circumflex coronary artery

(Figure 5)
• The circumflex coronary artery courses along the left atrioventricular
groove and in 85-90% of patients terminates before reaching the
posterior interventricular groove. In 10-15% of patients, the circumflex
coronary artery continues as the posterior descending artery.

Left main coronary artery

LAA

PA

Left coronary sinus or sinus #2

Circumflex artery
Obtuse marginal branches

Figure 5. Circumflex artery and its branches. LAA = left atrial

appendage; PA = pulmonary artery.