SURGICAL

INTERVENTIONS,MONITORING
AND SUPPORT
Dr Ramish Saleem, PT
DPT(SMC)
MS-OMPT(RIU)
CARDIOTHORACIC SURGICAL
APPROACHES
• VIDEO-ASSISTED THORACOSCOPIC SURGERY (VATS) : is a type
of thoracic surgery performed using a small videocamera that is introduced into the
patient's chest via small incisions. The surgeon is able to view the instruments that are
being used along with the anatomy on which the surgeon is operating.
• POSTEROLATERAL THORACOTOMY : The incision extends from the spine
of fourth thoracic vertebra and tip of scapula in a gently curving arch to the 5 th or 6th
intercostal space at the anterior axillary line.
• MEDIAN STERNOTOMY : in which a vertical inline incision is made along the
sternum, after which the sternum itself is divided.
• ANTEROLATERAL THORACOTOMY : in which entry to the chest is made with
an incision below the breast but above the costal margins. The incision involves the
pectoralis, serratus anterior, and intercostal muscles.
 SURGICAL INCISIONS
POSTEROLATERAL STERNOTOMY
 SURGICAL INCISIONS
ANTEROLATERAL CLAMSHELL
PERCUTANEOUS TRANSLUMINAL
CORONARY ANGIOPLASTY ( PTCA)
• Angioplasty is a method of treating the localized
coronary artery narrowing by dilating the blockage
using a special double lumen balloon catheter.
• A balloon angioplasty procedure in which a small
balloon at the tip of the catheter is inserted near
the blocked or narrowed area of the coronary
artery.
 PTCA
• When the balloon is inflated, the fatty plaque or blockage is
compressed against the artery walls and the diameter of the blood
vessel is widened (dilated) to increase blood flow to the heart. This
procedure is sometimes complicated by vessel recoil and
restenosis.
 PTCA & STENT
• Coronary stent insertion is an intervention that is
used in association with balloon angioplasty to
open up a blocked coronary artery.
• A stent is a small, metal mesh tube that acts as a
scaffold to provide support inside the coronary
artery.
• A balloon catheter, placed over a guide wire, is
used to insert the stent into the narrowed artery.
 PTCA & STENT
• Once in place, the balloon is inflated and the stent
expands to the size of the artery and holds it open.
• The balloon is deflated and removed, and the
stent stays in place permanently.
• During a period of several weeks, the artery heals
around the stent. In this way, restenosis is
somewhat diminished.
CORONARY REVASCULARIZATION CONT.
PERCUTANEOUS TRANSLUMINAL CORONARY
ANGIOPLASTY AND STENT
CORONARY ARTERY BYPASS
GRAFTING(CABG)
• It is still major intervention in the treatment of
patients with coronary heart disease. Current
CABG is a surgical procedure in which a
blood vessel from another part of the body is
grafted to the occluded blood vessel so that
blood can flow around the occlusion .
 CORONARY ARTERY BYPASS
GRAFTING(CABG)
• Indications
Chronic angina
Unstable angina
Acute myocardial infarction
Acute failure of percutaneous transluminal coronary
angioplasty (PTCA)
Severe coronary artery disease
CORONARY ARTERY BYPASS
GRAFTING(CABG)
Most common
arteries bypassed:
◦ Right coronary artery
◦ Left anterior
descending coronary
artery
◦ Circumflex coronary
artery
CORONARY ARTERY BYPASS
GRAFTING(CABG)
• Saphenous vein used for bypassing right coronary
artery and circumflex coronary artery
CORONARY ARTERY BYPASS
GRAFTING(CABG)
Internal mammary artery (IMA) used for
bypassing left anterior descending coronary
artery.
◦ Patency rate over 90% after 10 years.
If more veins are needed, alternative sites
such as upper extremity veins can be used
◦ Patency rate as low as 47% after 4.6 years.
CORONARY ARTERY BYPASS
GRAFTING(CABG)
 VALVULAR SURGERY
• In adult, valvular surgery is mostly used for the aortic
valve and mitral valve.
Aortic valve
– Aortic valve replacement: most cases
– Valvuloplasty: some cases
Mitral valve
– Valvuloplasty: most cases
– Mitral valve replacement if valvuloplasty is impossible.
CHEST TUBE PLACEMENT
• A chest tube is a hollow,
flexible tube placed into chest . It acts
as a drain.
•  Chest tubes drain blood, fluid, or air
from around your lungs, heart, or
esophagus.
 TRANSPLANTATION
• Treatment for patients with end stage heart and lung disease.
• It aims to improve
- Quality of life
- Survival
• Physiotherapists are key members of the transplant team,
providing expertise in the physical and functional
assessment, respiratory management and rehabilitation of
patient.
 PHYSIOTHERAPY ASSESSMENT
• Recipients are assessed by an experienced multidisciplinary
team at transplant centre.
• Evaluate the severity of cardiac/ pulmonary dysfunction.
• Physiotherapy assessment focuses on the impact of cardiac,
respiratory and musculoskeletal limitations on exercise,
functional capacity & social performance.
• Medical history & results of relevant investigations (imaging,
arterial blood gases, angiography) should be reviewed.
 SUBJECTIVE ASSESSMENT
• It gives detail of.
- Clinical course (e.g duration of illness, rate of decline, hospital
admissions).
- Symptoms experienced.
- Main limitations to activities.
- Ability to perform activities of daily living.
- Current /previous exercise and rehabilitation.
- Social supports.
- Patient goals and expectation of transplant.
MUSCULOSKELETAL
ASSESSMENT
• Screening include
- Posture
- Joint ROM
- Muscle length
- Muscle strength
- Muscle bulk
- Shoulder pathologies (Rotator cuff impingement syndrome)
EXERCISE CAPACITY
• Six minute walk test (6MWT)
- Distance walked, response to exercise, HR, BP or any other
symptom.
- General guidelines: in adults a 6MWT < 300-400m is
suggested as appropriate for listing for both heart and lung
transplantation.
• Maximal exercise testing
- VO2 peak < 14ml per kg per min is an indication for listing for
cardiac transplant.
RESPIRATORY ASSESSMENT
• Breathing pattern
- Extent and use of accessory muscles.
• Auscultation
• Effectiveness of huff and cough
• Ventilatory support
• Airway clearance
- Evaluation of effectiveness of current techniques
PHYSIOTHERAPIST SHOULD…
• Give advice regarding exercise and the importance of
maintaining physical fitness preoperatively.
• Provide education regarding the commitment required
for rehabilitation post transplant with long term
maintenance.
• Inform other members of team about previous/current
exercise and airway clearance regimens.
 DONORS
• Organ donation is performed in the setting of brain death
(Caused by severe head injury or haemorrhage).
• Consent of family member is also required.
• Timing of retrieval and implantation is important.
• Organ is kept in preservation in solution till implanted in the
selected recipient.
• Cardiac teams aim for an ischaemic time of less than 4 hours.
• Lung team aims for less than 8 hours.
HEART TRANSPLANTATION
PROCEDURE
• Orthotopic Heart Transplantation
- Preparation is anesthesia, median sternotomy.
- Recipient heart is removed by incising the atria, pulmonary
artery and aorta.
- The donor heart is sutured in place.
- The anastomoses join the recipient and donor atria, plmonary
arteries and the aortas .
HEART TRANSPLANTATION
• Heterotopic Heart Transplantation:
- Indicated in patients with cardiac dysfunction resulting in
severe pulmonary hypertension.
- In this “piggyback” procedure the recipient hearts is left in
place and the donor’s heart is placed in the right chest.
- Anastomoses is made between two hearts at the atria, aorta
and pulmonary artery.
- Both hearts share the work required to overcome the increased
pulmonary pressure.
LUNG TRANSPLANTATION
PROCEDURE
• Single Lung Transplantation:
• Lung with poor pulmonary function is excised.
• If both lung have similar function then right side is preferred for surgery
because cardio pulmonary bypass is easier.
• Posterolateral thoracotomy is done through 4 th or 5th intercostal space.
• The recipient’s lung is removed and the donor lung is positioned in the
chest.
LUNG TRANSPLANTATION
• Double lung/ bilateral sequential lung transplantation
• It involves the implantation of ‘en bloc’ of both lungs via
median sternotomy.
• Bilateral anterolateral thoracotomies through the 4 th or 5th
intercostal space connected with a transverse sternotomy or
“clamshell incision” is now preferred.
• Pneumonectomy of native lung and implantation of donor’s
lung are conducted in same way as single lung
transplantation.
OTHER LUNG TECHNIQUES
Split-Lung Technique:
• Utilizes individual lobes from the donor.
• It may be indicated if there is localized pathology in
one lobe.
Living donor Lobar lung transplantation:
• Involves two donors each donating single lobe (usually
lower lobe) for bilateral lung transplantation.
IMMUNOSUPPRESSION AND REJECTION
• Rejection immune response to the donor tissue.
• Response can occur by humoral (B lymphocytes) or cell
mediated (T lymphocytes) immune mechanism.
• Immunosupression is required to manage rejection.
• Two to three life long maintenance immunosupressive
agents are used by majority.
• Excessive immunosupression increase the risk of
infection.
 REJECTION
1.Hyper Acute Rejection:
• Occurs within the first 72 hours postoperatively.
• Primary graft failure generally results from ischemia –reperfusion injury.
• The presenting features of heart transplant recipient similar to cardiogenic
shock.
• Both require total mechanical support in the form of extracorporeal
membrane oxygenation (ECMO).
 REJECTION
2. Acute Rejection:
• Characterized by a host T-cell response towards the transplanted organ.
• Common complication in the first week to month following transplant.
• In lung transplant recipient , rejection mimics the symptoms of upper
respiratory tract infection or bronchitis i.e dyspnoea, fever, non-
productive cough etc.
• Chest radiographs show new pleural effusion.
• Drop in lung function.
 REJECTION
• Bronchoscopy with brochoalveolar lavage (BAL) and
transbronchial biopsy are often required.
• Mild rejection is usually not treated but moderate
rejection is treated with immunosuppressive agents.
• Heart transplant recipients present with arrhythmias,
hypotension, fever, fluid retention, malaise or dyspnea.
 REJECTION
3. Chronic Graft Impairment:
• Chronic rejection manifests as airway disease in lung transplant
recipients and cardiac allograft vasculopathy in cardiac recipients.
• Likely to be a result of scarring following acute rejection, infection
combined with chronic inflammation.
• In lung, chronic graft dysfunction is characterized histologically by
bronchiolitis obliterans
(untreatable & irreversible fall in lung function)) and
physiologically by airflow limitation.
MONITORING AND SUPPORT
NON-INVASIVE MONITORING:
• ECG
• Pulse Oximetry
• Blood pressure monitoring
• Respiratory rate
• Level of conciousness
MONITORING AND SUPPORT
INVASIVE TECHNIQUES :
• Arterial Line
• Central Line
• Cardiac Output