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Hello, good afternoon everyone. Thank you for joining us today uh on a Saturday and giving up your um an hour of your time. My name is Rashad. I'm the founder of teaching Frontier. Um We're essentially a group of resident doctors with various grades and various specialties who've come together to provide a wide range of teaching topics covering medical and surgical. Um and aim to prep you for UK MLA and also foundation slash specialty training overall. Also, um we frequently offer specialized lectures delivered by experienced registrars and consultants within the field. Um We have few lined up and today is an example of that. So without further ado, um we are delighted to have Mister A Abbas with us today who is going, going to give us a talk about cardiac surgery operations and emergencies. Uh Mr Abbas is a seasoned cardiac surgery registrar at Trend Cardiac Center with 10 years plus experience in the field. He has a wealth of clinical knowledge and expertise in managing complex cardiac surgical cases and this extensive background provides invaluable insight into various aspects of cardiovascular care. So, thank you again, Mister Abbas for giving us your time on a Saturday to join us and giving a lecture today and I'll leave the floor to you. Um I think you're muted. Um So uh still IUT um No, I still muted. Yeah. Working now. Eating now. Good. Finally. Sorry about that. OK. Uh It's OK. You hearing me right now? Yeah. All good. So thank you guys. Good afternoon. My name is uh Sharifa Pass. I'm one of the uh senior fellows in Nottingham uh City Hospital. I been in cardiac surgery. To be honest, I am Egyptian. So in Egypt for a few years and then come back to uh UK for five years now. So uh I know that most of you guys are medical students and uh junior doctors. So I'm trying to um do as much as I can uh in the basics, uh uh basic ideas about the operations and how we deal with patients. I will not go in deep details, but just giving you an idea about uh cardiac surgeries uh that uh most of the centers in, in uh in your case doing. And I'll give you uh some hints about uh new techniques that's going on uh nowadays as well. So uh before we start, we have to agree on some things that surgery means anatomy. So you can't start any uh surgical procedure even if you are a consultant. So knowing this anatomy of these uh lesions that you are dealing with and you have to see all the scans and make sure that you are oriented with everything because there is always anatomical variations and there is always something may uh a uh you have to know about before going to open the patient. So basic is very important uh in cardiac surgery. And to be honest, cardiac surgery also you deal with most of the body systems. So this is, is one of the things that uh different in cardiac surgeries and other uh surgeries. Because if you are orthopedics or general surgery, you're only dealing with your organ only with cardiac surgery because you are dealing with the motor of the body, which is the heart. So, uh you can affect the brain, kidneys. All organs can be affected from the perfusion, the effects that you can cause in cardiac surgery starting with uh uh with anatomy. And uh if you don't mind, we can do this session as interactive session. So if I can uh ask a few questions, simple questions and if anybody knows the answer, feel free to answer. So anybody knows where is the uh the heart located in the area? Where is the heart located in, what is it called? Not the chest. For sure. He knows about something called megestin. Fine. So the heart is uh uh pump of blood. It's a muscle that supply blood to the whole body organs and to the lungs as well. So, uh it's a hollow muscular organ, it's located in the chest in a compartment called me mediastinum. And its function, it's, it actually, it's there are two separated pumps inside the heart, the right side and left side, right side, uh pump, deoxygenated blood to the lungs and left side pump, oxygenated blood to the rest of the body. Uh These two pumps are separated by in interatrial and interventricular septum and they shouldn't connect uh connected together unless there is a a hole in the septum, which is called atrial septal defect or ventricular septal defect. This is the shape of the mediastinum from the side view. So as you can see, it is uh as you can see, it is anteriorly, you have the sternum bone and on the back, you have the vertebral column and on both sides. If we go back to the previous slide, on both sides, you can see both lungs right and left lung. And when you retract disease, lungs, you will find the heart in the middle right here. Ok. So as we all know, so the heart consists of four chambers, four compartments, uh right and left atrium and right and left ventricle. Each compart, each atrium ISD from the ventricle by a valve. And the ventricle pump blood across a big artery. So the right ventricle pump blood against across the pulmonary artery to the lungs. And the right ventricle pump blood uh across the aorta to the whole body organs, including brain, kidneys, liver, abdomen, legs, arms. So we have to know something that each uh and there is uh each compartment is separate from the other one by a valve. So from the right atrium, the right ventricle valve, from the right ventricle to the pulmonary artery, it's pulmonary valve from left atrium to left ventricle. It's mi right valve and from left ventricle to left to the aorta. It's aortic valve. All the valves are unidirectional valve. So this should allow the blood to pass from one side to the other side and not in the opposite direction. Because if there is any uh if the blood runs in the opposite direction, this is one of the lesions that we deal with, which called leaky valve or regur. And if this valve is uh tight or we call it stenosis, it is another uh as well another lesion that we uh should interfere with if the patient is symptomatic as a key fact, mitra uh sorry uh valve stenosis is a chronic procedure is a chronic process, sorry, which normally takes long time to affect the patient and become symptomatic, but it can be acute or chronic. So you can hear acute valve mitral or yes, you can uh or you can hear uh chronic as well. It's one of the most important slides because what uh because it will help you to uh nausea or you can even predict the symptoms uh from any valvular lesion. Uh either a stenosis or a. So we, we all know should know the cardiac cycle and we all should know what's happening in cysto and diastole because the benzone says uh you will uh you can know what, what kind of symptoms the patient would have. So as we said, it has two separate pumps, right pump and left pump or right compartment and left compartment. Ok. So the right compartment, the right atrium receive the whole venous blood from the whole body organs. So two big arteries which is uh sper vena cava and aerial vena cava. And this deoxygenated blood has been to the right, right, pump it up on the pulmonary artery to the lungs to get oxygen. Oh, sorry. And after getting the oxygen, it returned back to the left atrium through four pulmonary veins, through the mitral valve to the left ventricle, then through the aortic valve to the aorta and to the whole body organs. So this is only directional flow of blood. So this is the cardiac cycle. So let's uh see if this mitral valve is getting tight and stenotic. So this means that the left atrium is not emptying fully in the left ventricle. So the blood will get congested here and means that the blood will get congested here as a back backflow. So the patient will get congested lungs. So this means that the patient will be estic and complain of shortness of breath and if this process is chronic again, so it will be back flow here to the right atrium to the right ventricle and then the right atrium and then he will get from the pressure back pressure, let's say, and then he will get back pressure to his body organs. So this patient, if he got as a complication for moderate stenosis, he will get ascitis and lower limb edema. And the same if it's a or you can make it like this, you can just uh predict what's happening if this valve is leaky or if this valve is stenotic by following these arrows. So it's very important picture and it will make your life easy to predict what kind of symptoms that the patient will have if he has any v lesion. Also, we have to know that this is our heart. So the heart is not uh separate compare uh two separate compared to the right or left. So the heart is like this. When we open the chest, we find the right atrium and right ventricle like this. And behind it is the left ventricle and behind it is the left atrium and the heart valves are close to each other. So this is a pulmonary valve is the anterior of the body and this is the posterior. So this is a pulmonary valve, this is aortic valve, this is a mitral valve and this is a trach big valve. So when we are doing uh operations to replace or repair in, let's say a mitral valve, if the surgeon take deep stitch in this area. This stitch may affect his aortic valve. And if he is doing tricuspid valve operation and take a deep stitch, it may affect the aortic valve. And if doing aortic valve and deep stitch here can cause mitral problem. So it's not each uh valve is not totally away from the other one. So if you cut the heart coronal section or transverse section like this, you will find the valves uh beside each other. So it's not right eye, left and left. Like most of the de administration diagrams showing it mostly slides us and anybody knows uh uh the name of the uh our house are hard to get blood supply like coronary arteries, names, how many coronary arteries do we have? But do you know an answer? Ok. So we have two coronary arteries supplying uh blood to the heart which you can see here which run in the top of the uh um on the surface of the heart, you have the left coronary artery and you have right coronary artery. And they will go in details later on. Yes, morbid you to describe the cardiac cycle as that I have just said. Ok, then uh just a brief, I know that after a couple of weeks, there is uh another talk about uh uh heart lung machine, but just a brief talk about heart lung machine. It's our best friend. So it's used in more than 95% even of the heart operations, uh its main function, its act like heart and lungs. So we take, and we adjust or we attach uh a plastic tubes to the big veins of the heart, like vena cava and vena cava. Or even you can use peripheral veins like femoral vein or internal jugular vein to take all the venous blood of the body and pump it in this machine. We stop the heart and we stop the lung. Then this machine uh supplies this blue blood or the blood with oxygen. And then we attach another plastic annular here to the aorta or femoral artery to supply to the body with oxygenated blood. So we can bypass the heart and lung or take them out of the CCU uh circulation. And then we can do any kind of operations on heart and lung in a bloodless field without any problem. Also, one of the other uh functions of the heart and lung machine is we use one of these pumps to supply his heart with cardioplegic solution, which is a solution used to stop his heart. The solution is very high or rich in potassium to uh stop the heart in the, to decrease the oxygen demand and relax the heart uh during the operation. And also uh attached to this bypass machine is another machine which is a temperature machine used to control the temperature of the body to keep the blood or or cold as we wish. Depends on the time of the operation. The traditional incisions that we use for most of the open heart operation is the median sternotomy, which is a midline incision here. So we open the sternum by a sole and then we can get access to any organ in the. These are the new techniques that uh where some surgeons are doing it. Now, it's not spread uh in all cardiac surgery units uh in the UK, but it's coming. Uh I think in the next few years, it will be spread across the most of the units because uh each unit that is starting to be honest. So sometimes we do uh one operations through a small incision on the left side and some other operations can be done by a small incision on the right side just below and it will exist and you can do any kind of operations. We want, sometimes we do post incisions actually, if we need to do uh certain operations, what is the benefit of these incisions is to avoid this sternotomy wound because this is very painful wound. And there is uh loads of complications like infection and sis and these things which can happen, it's not common to happen, but it can happen from this wound and it's very painful and limit the patient's recovery after the operation. But with this kind of incision, so he, he uh he can uh back to his normal life faster and decrease his hospital stay, which for sure, affect the finance uh in the hospital. Ok. So this was a brief introduction about uh anatomy and physiology of uh the heart, which we all should know about. And then what are the basic uh heart disease that uh that most of the cardiac uh surgery uh uh units and uh cardiology deal with? So, we have the atherosclerotic disease which affects the coronary arteries, causing ischemic heart disease and can also affect the aorta sending aorta and causing aneurysm or dissection, which uh in which hypertension is the main cause of it, you have cardiac arrhythmias which can be atrioventricular. We have heart valve disease as we said, can be stenotic or, or tight or leaky. We have heart infections, cardiac surgery don't deal much with heart infections apart from infective endocarditis for sure. So that can affect any kind of bugs. And this is uh the main uh heart infections of the U. But if any myocarditis or anything like this is mainly con and heart failure. Also, the uh contribution of uh cardiac surgery is not much in heart failure, but mostly it's medical management or uh cardiology deal. But sometimes in difficult situations that they can't manage by uh medications. Sometimes they need surgery to uh help with this patient to recover. So let's start with the skin heart disease. And the important skin heart is that you will uh see these patients mostly when you start, uh or if you're uh already started uh your medical career in a uh and in cardio ward and even in the medical ward patient who the chest pain. So uh this patient present with chest pain, which we call it angina. Sometimes he present with shortness of breath. Sometimes we pre he present with uh heart attack or MRI or we call it acute coronary syndrome, which uh some there is different types like Stimmy or uns non ST or unstable angina. And sometimes he present with out of hospital arrest from ventricular arrhythmia. Oh, but as I mentioned earlier, so there are two main arteries are supplying blood to the heart. So the first artery is called left, main coronary artery and right coronary artery. So the left coronary artery, both of them come from the ascending aorta. And actually, these are the only branches coming from the ascending aorta. So the left uh may divide into two big arteries, which is the first one is left and through descending artery going down to the apex of the heart. And this supplies nearly 70% of the heart of the myocardial uh muscle. And there's also left circumflex artery, which is the second branch coming from the left coronary artery, right coronary artery also are uh coming from the ascending and run in this direction and supply two big arteries which is still descending, called the artery and posterolateral or posterior left artery. And I put this picture because this is a map that uh we can as a cardiologist use to uh uh mark uh lesions or the obstructions so they can guide the management uh later on. So you can like a mark here like a mark here. So I know later on that is the obstructions here and the obstruction is here. This is the coronary angiogram. So how we diagnose the obstruction in the arteries? So we put a cannula in a uh in the artery in the radial artery or the femoral artery. And we pass a wire until we reach the coronary arteries. And we inject a dye this Dione in the same uh flow of the blood. And then we can take an X ray picture. So we can see that this is tightness and there is tightness here. So this is uh left main coronary artery and this is the left anterior descending artery and this is uh left or complex artery and the C shaped artery is the right coronary artery. And you can see his obstruction is here or diagnosis here. This is another picture. So you can see the, the left main or left coronary artery and this is the left anterior descending and this is the left circumflex and you can see the obstruction here and here this is after putting a stent into obstruction by the cardiology. So, management of is heart disease, there are three ways of management. So first thing is medical management, which is by tablets and this uh way of management is uh just conservative management. So you don't uh increase the blood flow to the heart muscle, but you just keep it stable to avoid any extension of this obstruction to be total obstruction. Then we have our uh participation in the management, which is a coronary artery bypass grafting. And this is a cardiology uh participation, which is percutaneous coronary intervention where they can put a stent. So the coronary artery to keep it open and not closed again. And after all of this, the patient should have uh or guided about secondary prevention, which is mainly medical uh management and uh healthy lifestyle to avoid smoking, controlled diabetes, control BP. The idea of bypass operation, it's a ping operation or we can call it plumbing operation as you wish. So, uh it's mainly uh doing a bridge from before the obstruction to after the obstruction to bypass the obstruction and supply the heart muscle with uh more blood or enough blood to act properly uh to avoid uh ischemia affecting this heart muscle because if this muscle is tired, it can to regenerate again as we all know. So it's not like the kidney, uh not like the liver uh cells which can regenerate the heart muscle, it's dead, it's dead. So the idea is to try to save as much as we can from the heart muscle to allow her to pump uh effectively after. So, this is the coronary arteries here. OK. And this is a cross section across artery. You can see this area of this, OK. And the idea is to do preg. So preg means we need a, a vessel to take from somebody and to use it as a bridge to bypass the obstruction. So here we have the ascending aorta and we, here we have the subclavian artery and we know uh we should know that the internal mammary artery, which has, which is our uh playmaker, let's say in the cage operation because uh the, the left internal mammary or left internal uh the the artery, we use it to bypass the left an descending artery, which is the main artery, as I said, supplying blood to the heart. So we harvest this artery and then stitch it to the left descending after the obstruction, not before the obstruction to bypass the obstruction and supply more to the heart. And this another conduit, we call it conduits. It's a, it's a vessels that we use for the operation, we call it conduits. Uh And this is another conduit we use to bypass uh obstruction, which is a radial artery, softeners vein. So uh we stitch it here in the, get the plug and we stitch it here in the pulmonary artery after the obstruction to supply this area with oxygenated blood uh to protect the heart. As I said, these are the uh four main conduits uh that we use in bypass operation. So we have the internal mammary artery which is behind the breast bone. We have right and left. And we can use mainly, we use the left internal mammary artery, but we can use both sides. Not a problem. We have the radial artery which we take from the arm and we take it. Normally, we take it from an Abdomin hand under. Here, we have the long softeners vein, which uh is uh the second most common use of the salary artery. And the benefit of the su means that it can be easily uh harvested in no time. So it can save lots of time or can be used in emergency operations techniques of gavage. As I said, our best friend is the heart and lung machine. So we uh when we use the uh heart and lung machine, we call it on pump technique using card heart machine. But we can use the uh there is another technique of doing cage operation, which we call it off pump where we don't use uh off pump. We we don't use a heart and lung machine, but we use this uh machine which is called, we call it octopus. So this machine actually, it's not a machine, it's just a sucker. So we have this, we call the cause is uh arm, looks like an octopus arms. So we attach it around the vessel that we need to stitch around and this tube is attached to the suction. So it's not here. So it fix this area. So the rest of the heart is pumping properly, but we fix this area and uh we start doing the stitches here where we do the uh the idea of stitches. So if this is a was up and this is uh uh conduit that we, we, we use, let's say it's so vein. So we do a tiny hole in the stuff. We start stitching circle to a circle and it should be at the end like this two, be regarding of pump machine. So we can see one of them. Hopefully the voice will start. Yes, sir. This is uh how uh actual operation and how we opened the left anterior descending and this is the left anterior dis uh the left anterior mammary artery. Ok. And this is when we uh start stitching the uh internal mammary artery to the left descending artery and then your thighs are stitch and, and these ones and the smoothest one has been done. Ok. Ok. Now, any questions regarding the bypass, anyone has any Wistrom. So we should carry on for the sake of the time. Ok. Let's move on. So, speaking about mitral valve. So as we said before, mitral valve is a valve uh between the left atrium and left ventricle. It's bili valve. Ok. And it's a external valve as all valves to allow blood to flow from the or oxygen blood to be specific from the left atrium to the left ventricle in. So here I put this picture just to uh make you oriented that uh the heart uh structures are all around each other. So if you all this view from the left atrium, on top, left atrium, so it finds a lateral gland like this. And on the top of it, it's part of the gland. And here you can find is a coronary sinus, which is the main venous drainage of uh uh of the valve and uno it is uh this is uh uh a complex artery uh around it. Ok. Uh So I've seen, I have seen a question uh here by cat before moving to the uh mitral valve. So cat is asking how often do you use a pump and why would you use it over bypass? Ok. So, uh how often it's not quite often, it depends on the surgical preference. Ok. But some surgeons are not used to do it uh regarding what, what would makes the off. I'm not saying better, but what makes it indicated on top of the uh pump. So, in the heart and lung machine, and you will notice this in the uh section of heart lung machine uh after a couple of weeks as I mentioned. So the heart and lung machine is not like normal heart and lungs. So it affects the whole body organs in a bad way, not in a good way, but it cause something called c response which can cause uh some disturbance in the kidney functions and the liver functions, all of these things. So if you have already a patient who has kidney failure or liver failure, and you want to vo to avoid bypass machine, you can use off pump technique. Also one of the most common indications to use of uh of pump technique that I said that uh we do the approximal or the top anastomosis of the any conduits apart from the internal mammary artery of the ascending aorta. So if there is loads of calcium here and they can show it can show you even from Google, uh some aorta has uh calcification in the ascending aorta. So, and in this situation, if we manipulate with the aorta, the patient will be at a very high risk of uh getting the strokes. So, in this situation, sometimes we use uh off pump technique and instead to avoid any claming or any manipulation to ascending aorta. And instead of doing the top and here in the aorta, we put it in the left internal mammary artery. So we avoid touching this part at all and we can do the cage and do the top end on the internal mammary artery. Still do our OK. Uh OK. Back to the mitral valve. So, yeah. So uh mitral valve, as I said, it uh so uh this is the idea that all the heart structure in each other. So if you are doing operation, you should know anatomy because as I said, you are stitching a heart operation. At the end of the story, it's just stitching operation. But deep stitching here, deep stitching here affecting here affecting here, you have to know the surgery and you have to know the anatomy surrounding your stitching because if a complication happen, you have to know what's happening to depends on the anatomy that you are affecting. Ok. Uh So as I said, any valve can be leaky valve or the valve or any valve can be stenotic valve. So uh causes of mi sclerosis, stromatic heart disease, which is common in developing countries in the Middle East and the Gulf area. Degenerative calcific uh disease which is more common European country. And also there is congenital stenosis for er or fever can cause regurge as well. Degenerative can cause regurge as well. Infective endocarditis, which is an infection to the heart endocardium can cause heart attacks can cause regur atrial fibrillation can cause mitral regur. Ok. Can you of disease of mitral valve disease, stenosis or the girls? So it would be disea shortness of breath with it. Ok? Would be fatigue and weakness and tiredness and patient will tell you that activity is not the same while walking distance is not the same. I have to stop after uh a few years before uh you need to catch your breath and to rest a little bit and then continue walking, lower limb and the edema is not a secondary and secondary after mitral disease as a consequence of disease. Ok. Ok. Before proceeding, uh diagnosis of any valve, uh disease is clinically diagnosed and echo diagnosis. So we have to do echo to identify the val disease. Why? Because each val disease, stenosis regards as great mild, moderate, severe and surgical intervention is on severe disease, not on mild or moderate, so mild or moderate are under surveillance, treated by cardiology, surgical management until they reach a stage of severe uh disease and then surgical inter uh intervention can help. So any patient who is well, disease will be referred for cardio management or intervention can be uh through cardiology or so surgery. So for uh for mitral stenosis, cardiology can do balloon dilatation, surgery can do replacement for 30 years. Cardio can do something called mitral clip, which I'll show you a picture about surgery can do a repair of the valve or replacement of the valve. Ok. So general rule, there is no repair or any valve stenosis. The repair is mainly for repair. Why is this because of this shape? So this is a shape of mitral valve stenosis because of rheumatic fever. So how can I repair this or how cardio can repair this? So this is the only way to treat this picture is to take it out, chop it out and put another ring. Ok. But for reg, so reg is because of redundancy of tissues. So we can repair this valve by cutting, cutting a piece, putting getting I'm sorry. So there is two types of heart valves in the market. So there is a mechanical valve which is made of carbon and there is a tissue valve. So the main difference between these 21 is the longevity and zing it of blood thinners. So mechanic can run loss for life, but patients should take Warfarin which is a blood thinner for life and keep the checking. Not because if you stop taking Warfarin, this uh is an or um is uh can act as a nucleus on top of it. Uh some uh thrombus can happen and then this thrombus can reach the plate and cause a stroke or any organ and cause infarction in any organ. So that's why as a patient should take Warfarin for life. But if he take off and the kid is in range, this one should be, should be uh live until his no like this bar is a tissue bar which is made of cow or big bs, ok. Uh In this valve, this patient don't need, the patient doesn't need to take Warfarin, but this valve uh can get destroyed or wear, wear and tear up into this val after 10 to 15 years and he may need another operation. So that's why we recommend a mechanical valve for young people and we recommend a tissue valve for old people. So less than 65 more than 65. Sometimes uh sometimes young people become uh want tissue valve because if you're athletic, if they don't want to take Warfarin or if she is a young female uh who wants to uh give birth and to complete her family. But we or we will, we tell her that after a few years, you will need another operation to replace this one because it would not uh last long. These are two types of mitral ring. So we have incomplete ring and we have complete ring which are used in uh repair. These are two pictures of uh mitral operations. So this is a surgical retractors that you can see here. And this is an opening in the left atrium. And these pipes are a part um it's a plastic pipes. I told you about uh heart or lung machine uh that we use uh to attach as a patient to the heart and lung machine. And this is a mechanical bump. But in after stopping the old valve, these are the surgical stitches that we about the mi by the stitches. OK? And if I take the deep stitch here, I may catch up that working well. If I take a deep stitch here, I may catch the left C or the coronary sinus. So that's why I told you you have to be oriented about the anatomy of this. And this is a picture of the mitral valve repair. So as you can see there is a redundancy in the leaflet. And we, so what he did here, he got a tiny piece here and then stitched it back together and then put the ring. The idea of the ring is to protect your repair and support the migraine to avoid any uh dilatation. Again, these are the access to Sumatra valve. So this is our best friend, medium soy and this is uh the right soy or mini incision for doing the minimal access mitral valve procedure. And as you can see here, when we do the mini access or minimal procedure, you can see that the heart and lung machine is attached through the femoral artery and femoral vein because we can reach out from here. So attaches a machine through femoral art and femoral vein. And sometimes we put a an adult cannula here inside the no vein. So I have two venous cannula attached together to uh uh uh will attract most of the venous blood from. Mhm. This is a cardiology intervention which is the mitral clip. So the idea of the MitraClip, if you have the mili is only for leaky valve, not for stenotic valve, as we said. So it's uh some sort of repair. So if you have an 80 plus years old patient who is three years has loads of comorbidities, diabetics, frail patient, which can tolerate an open heart procedure. So this is if you have just to put a clip here to a to approximate the two together. So in uh instead of having a leaky big opening, uh you have two small openings. So uh you reduce the leak a little bit to help the patient to improve his symptoms and improve his lifestyle. Uh still uh not all you using it. And there is no long term outcomes about the microclip. But it's to be honest, it saves loads of uh big operations for fragile patients and they couldn't pass through or stay in the hospital after the operation for a long time for recovery. But this is a less invasive just uh in uh for an hour or so. And the patient, if you pass successfully, you can go home and set next day without any problem. Is there another valve? Uh another valve that we can operate on is a tricuspid valve. So it's a trili valve, which is the right form the right ventricle, allowing urine blood flow in the same uh form direct to the ventricle. And this is the opening of the right atrium. You can see the tricuspid valve consists of three lipids and three lipid, three lipid and lipid. And here are the structures surrounding it. So here you have the opening of the coronary sinus, which is the main view of the image of the heart. Here you have the anode hands up on the which the the lift and here which is very important structure. You have to know the location properly and here you have the what they call it. So the same if you want to lose a clinical picture of think this way. So if you have or you have BP to the rest of the body, so you have liver congestion, patients will get jaundice, you will have abdominal congestion. So patient will have abdominal pain and and also you have a heart because of the air, the patient will get short of breath, sorry. And you have a low and edema as well. Patients can get shortness of breath and fatigued, not because of age, but sometimes with associated mitral uh uh disease as well. That can happen because the patient has rheumatic fever. So he he may have mitral disease management of trachelia valve is either surgery or medical management. So for, as you said, for stenosis, which is not common, but it would be surgical. And for stenosis, we don't repair. So it's a replacement or uh rega it's mainly medical. Unless medical management fail, then we can intervene uh surgically or we can intervene surgically. There is a patient room for a for another heart operation like the patient is going for C let's say, and the CVS has been, we do it in the same uh procedure or if he's going for mi operation has been, we do it in the same procedure. But uh for isolated has been, it's also effect on the heart like this, which is mostly managed medically as well or give a medical measurement uh fail, then we can interfere surgically. So, surgical management, as I said, for any repairs, it's also it's mainly repair or replacement for stenosis, it's replacement. So uh first replacement valve, the main valve, most is a tissue valve, not a mechanical valve, but sometimes you can use me valve for young people, but white tissue valve because the right side of the heart is uh a low pressure uh compartment. So the risk of uh thrombus is other than the left on the left side. Sorry. So that's why uh tissue val is for if I put mechanical valve, I will need very hard in r uh level to avoid thrombus. So most things we will put tissue valve if replacement needed. But most of the operations to tricosa or leaky tri is TRM repair, which is an incomplete drink like what you can see to support the. Uh I used to put this slide to be honest. Uh because this is a different track as the drinks from different companies, ok? But as I mentioned, all of them are incomplete drinks. You can see here why to avoid injury to this structure? Which is a no, because if we injure this structure, the patient will be in complete heart block and he will need a permanent pacemaker. So uh for the companies to avoid any surgery, to avoid any stitch because we know are brilliant. So they just make it incomplete ring. So to tell us, don't put any stitches here because there is no space in the ring anyway, to put stitch for jumping to the aortic valve. Uh so the aortic valve, but mostly what I said, mostly because 1 to 2% of the population has bicuspid aortic valve, which means that two liss are joined together. So we could consider that bis valve, why it's important the car valve, those people with white valve are prone to have uh valve lesions sooner than normal people at young age, let's say, and they are uh woman to have aortic uh aortic disease, not aortic. These are all a disease like atherosclerosis, ation ays and these things which are more prone. Ok. So aortic valve is an inter allow blood to flow from the to the aorta as any valve and it as uh rest of the valves can be stenotic or is the same fatigue, chest pain syncope. So you have a triad of aortic valve stenosis which is syncope, chest pain dyspnea. This is a triad symptoms of uh uh severe aortic stenosis. The worst one is dyspnea and uh benign one is the chest pain syncope is in the middle. Ok. Management for aortic valve stenosis, we have pero dilatation or TV. So, cardiology or surgical by replacement or aortic, it's mainly mainly, mainly replacement, but there is a new set now and in specific patients, they can do some sort of aortic repair, but most of the uh centers and most of the surgeons are doing the replacement of the aortic valve. OK. So, uh this is a picture of the aorta or a which is open and this is uh aortic valve, aortic valve stitch it to the aorta. And this is uh the, the uh that, that's a control you use to put, so that you, they put a cannula in the femoral artery and the impact to the aorta. And they, they uh inflate a balloon uh to destroy the old one. And then they uh deploy this one uh which is a tissue B as well. OK. When we use this, when you use this. So the idea of that we came from the same frail patient, old age of severe aortic stenosis and uh very high surgical arrest. So, f from this stage, the idea of having minimal or many invasive procedures to avoid uh going through open heart operation. So for so NHS, that is recommended for people above 75 people, less than 75 recommended for surgical uh operation unless there is a specific indication that makes the surgery high risk. So uh we discuss conn and we ask for time before this. So I will take that section. So this is the last topic today. Uh So I was interception. So you have uh you have to know the anatomy of the body aorta. So you have the ascending aorta which starts from the aortic valve the beginning of the arch which determined by the great results of the body. So, this is the ascending aorta and this is the aortic root, which is the proximal part of the ascending aorta. Then you have the arch of the aorta from here to here which contains the three main branches of the uh body, which is the artery, left carotid and left subclavian for grade vessels. Ok. And from after left subclavian down, you have the descending aorta until the diaphragm and diaphragm. It's abdominal aorta until it to uh common. Yeah. So you have to know this anatomy. Why? Because you, when you get, when you are in any and you have a patient where you suspect a dissection, you have to know what type of aortic dissection you are dealing with. So, a w dissection patient is uh I can say it is the only patient that you take it from A&E to the. So there's loads of uh cases which you call it emergency surgery. But imagine surgery, we transfer the patient to ICU as says, the patient, we discuss whether taken to operation today or early morning or within this week. So we can discuss, depend on the hemodynamics of the patient and the situation. But without dis diagnosed in A&E and then going to see there is no surgery in between. Why this it was with any delay, every one hour delay and 1% mortality. What is the idea of aortic dissection. So we have uh a in the aorta with aortic wall, which consists of intima media and the tissues in the artery. So when you get a, a tear in the intima in the blood, instead of going, there is a uh a main pipe, the blood will leak through this right in the wall into layers, making this and your husband it's gonna up sir causing some patient die or if it ruptures, the pericardium can cause contact component or can cause like perfusion. Because if you can imagine here, this is right and left kidney. These are the two humans of uh which by the section. So if this is a left renal artery coming from the false lumen and the blood is flowing here. So this kidney is not getting any blood because his kidney will die. So this is the idea of this is uh mild perfusion, rupture and patient die or or extension, which means sometimes the start here and stop here. But if you leave the patient do another scan tomorrow, we find the dissection down to here. So that's why we do operation for this patient. So w what's the clinical picture of this patient? So if the patient come to A&E with a pain in the chest, refer to the back, the patient uh has shortness of breath, patient, coughing blood, all of this may alarm you is that uh that there is something bad you shouldn't see it, but it's a classic symptom is severe chest pain or sometimes patient present with a stroke. Patient present with abdominal pain. If there is ischemic bowel, uh sometimes present with ischemic paralysis. What depends on the which artery is affected because sometimes dissection start here and got into the carotid artery causing a stroke. Dissection. Gone here goes through artery axillary artery and cause limb ischemia. The section start here and extend here causing limb ischemia, leg ischemia or abdominal pain because of kidney ischemia, spleen ischemia, whatever uh intestinal ischemia. But the main symptom is uh beginning of the story. You will hear sudden severe chest pain referring to the part of yourself. Hm Most common symptom is that the patient to help uh new street. I found this picture very good to be honest because it has most of the uh things. So uh this is the dissection and we'll speak about the types uh in the next slide. Don't worry. So great presentation, chest pain. As we said, few severe chest pain to the back, you will examine him. You will find unequal pulses on both on both sides. Ok. Sometimes you find a hard murmur because it was a leaky valve. I will tell you why effect which can be stroke, any limb ischemia, lysis or abdomen, ischemia or coronary ischemia, even chest pain, kidney ischemia, which because of my perfusion. Ok. Diagnosis is by uh CT scan. Ok. CT angio or by echo, which is not done. No, not normally we do in A&E but the CT uh is the main uh thing that we do and we can diagnose OK. Management. I will tell you about depends on the type. So what are the causes of uh aortic dissection? So, chronic hypertension, very high, high BP is not controlled patient. Uh stress, all of this can cause uh aortic dissection patient who has something called connective tissue disease or weakened aortic wall like Marfan Syndrome syndrome. These people have prone to have aortic aneurysm and aortic dissection and people with aneurysm already are prone to have aortic dissection. Yeah, pipes. So as I said, you have to know the anatomy of the aorta. So it ascending or descending aorta thoracic for sure if this is that we have Stanford classification, which is a simple classification. If I send the gout is involved with it, I if syna does not involved with it, stand for type B. So sta for type A is a cardiac surgery emergency. This patient should be in the within 1 to 2 hours for type B. It's not an emergency. This patient can be managed medically or managed by interventional or even if it can be by cardiac surgery, but it's not urgent unless there is am fusion, which is happening now. But apart from this, most of Stanford patient uh treated either medically or er intervention. Ge I'll tell you how now. So diagnosis, as I said, CT aorta or CT Angio, OK. Mra which nobody will do. Why it takes a long time, not available. So the easiest way to diagnose is ct aorta. OK. You have to polarize yourself with the CT chest, even if you don't know the uh the whole anatomy. But at least you have to know that this is the aorta and you have to know that this is the ascending aorta and this is descending aorta. This wall shape is the pulmonary artery. So as you can or you can see here, a dissection flap here, dissection flap here and the dissection flap here, the ses dissection here. So all of these are uh dissection count and dissections. So if the ascending aorta is involved, so this is done for type A. If this is also if, if we scroll down to the CT and the ascending is not involved, it done for type B. OK. Management replacement. So we have to chop this part and replace it by a graft which is made of synthetic material called. So it depends on the extension of dissection. We replace, to either replace the ascending aorta as replace the ascending aorta and the aortic root, which is approximal. And these two arteries are the coronary arteries by the way. OK? Or sometimes we are uh something or, and the three great vessels and less involvement them. OK? For the type B dissection. So this is just uh intervention, geology participation, which is uh stenting so the wire in a balloon and put a stent here to cover this area to avoid the blood from going in this false unit. But IP dissection can be managed medically by controlling BP, especially if there is no M perfusion or if the patient has no high risk uh features. Thank you very much. I'm happy for any questions and I think the next session next week is acute abdomen. Uh just at the end, you have to fill the feedback, I think to get your certificate and let's open it for any questions. Uh Thank you, Sheriff again. Uh Looks like there's not much questions. Um So like you said, if you guys can fill the feedback and get a certificate, um and then hopefully we'll be able to get this content on demand for uh future um re reviews if you wish. Um If you wish so as well. Um And also next week we'll have same time, a presentation on acute abdomen. And the week after there will be a specific presentation on cardio pulmonary bypass machine. So we are very specialized presentation presented by a clinical perfusionist. So if you're interested in cardiac surgery, I would recommend um attending. Um and if there's no other questions, um we can conclude um in terms of so a question by Connie. So the slides, we can possibly um uh distribute the slides. But um a lot of the slides, there's not much text as mostly videos. Um but we'll try to get the recording up so you can rewatch the presentation um If you wish so well, if there's no questions. Uh oh, we have a question here uh by um So it says once mini repairs come into play, uh what would be an indication to do an open rather than mini? OK. So uh so last question, to be honest. Uh Suresh, but uh doing many uh procedures, there is some uh criteria for the patient. So I can do many for a very obese patient. Let's say I can do many for a patient who require uh three things to be done. So some patients come who need mitral valve replacement, valve replacement, and repair, sorry and bypass, let's say, can do all of this through many. Uh also uh if the patient is coming for another procedure uh for a second time procedure, let's say. So if a patient has mitral valve uh repair in the past and 20 years ago and now the valve is leaky again and they need another operation. So sometimes you can do it many but sometimes because of the adhesions or because of the uh anatomy problems, you prefer to do it. Uh So sternotomy. Uh So it's not uh uh it's not, it depends mainly on the patient uh criteria and uh also uh a mini uh all the patients sometimes uh doing the incision and putting the camera, sometimes you can't see properly because of the axis due. So all the patients going for many, you have to consent them that I may need to open. Such as if, uh if uh I can't access properly or see properly or if any complication happen, like bleeding is that I can control so many, I need to uh open the sternum. So you can't, II believe you can't exclude sternotomy from open heart uh surgery. Uh, because, uh, even now there is some uh, operations can be done robotically. Ok. But it's the same if any happen. The, the first thing that you will do the toy because surgery is exposure. This is a basic, uh, quote, let's say so. Yeah. So if you have any uh problem, you have to access the stress and the easiest way to access stress is to say no to me. So we can't exclude it from the, uh, forms the forms, the consent at all. Um I have one question if that's ok. Um Maybe there is much on it but what, what would be the indication of fixation plates versus um certain wires? When would that be more advantageous or is there any role in that? So there is no indication but the plates are. So actually when, when, when the companies come, even to, to, to Nottingham or, you know, they try to convince people to do it uh instead of the wires, but it's the wires is the basic that all the surgeons used to do. But if the, we can say that the main indication if the sternum got infected and, or the patient come back after being discharged and the wires that to the sternum in and me sternum uh in like pieces, let's say. So the plates are better to get it, uh, get these pieces together and then it can attack the sternum. But anyway, you can use uh the plates to fix the sternum from the start. If, if the surgeon wants it, it's fine. No. Uh actually the, the companies tried to convince the people to use uh plates and to lose their arm. All right. Makes sense. Thank you so much again and thank you for attending. Thank you guys. I just want to uh I know it was very brief uh presentation. I was just trying to collect as much as I can regarding the basics surgeries. But if you want to uh a presentation later on in details about any specific topic like presenting on mitral valve only valve only on infective endocarditis. I didn't cover it to be honest. Uh feel free uh to tell me and we can adjust something uh at some stage. No problem at all. Yeah, you can mention it on the feedback forms. Uh Feel free to include any topics you want more in depth uh teaching on next. All right. Okey, dokey. Thank you very much guys. Enjoy your Saturday. Thank you so much for attending. Thank you. Thank you. Thank you. Cheers.