Afroecho 2011, Joint PASCAR/AHS Echo Workshop & 8th African Heart Seminar (AHS)
Cardiac Surgery- A Team Work
Charles Yankah*, Willie Koen**, Carlos Mestres***, Francis Smit****
German Heart Institute Berlin, Germany*, Christiaan Barnard Memorial Hospital, Cape Town, South Africa**, University of Barcelona, Spain, ***, University of Free State, Bloemfontein, South Africa****
It’s never just one person or one physician that determines the patient’s outcome. With cardiac surgery, it is truly the team.
Cardiothoracic surgeons today are confronted with operating on neonates, infants and patients of advanced age, many of whom have more than one associated diseases. Thanks to advancements in preoperative laboratory evaluation of organ functions and their metabolism, imaging of cardiovascular diseases and associated organ involvement, anesthesia, cardiovascular perfusion, myocardial protection, surgical techniques and intensive care support staff, few patients are turned away regardless of age or co-morbidities.
In addition to coronary artery disease and valvular heart disease, congestive heart failure has become prevalent in young and in aging population. Fully five percent of the adult population over the age of 65 has been diagnosed with congestive heart failure. Five percent of these patients will not respond to medical therapy and may be candidates for newer techniques in the surgical treatment of heart failure such as catheter-based and hybrid interventions.
Despite the advancements that have been made in cardiovascular surgery, including the use of transcatheter endovascular stents, minimally invasive catheter-based transfemoral and transapical valve implantation, robotics, mechanical circulatory devices, most important advancements in cardiac care have to do with the medical team that supports the cardiac surgeon.
This highly trained and experienced team makes it possible to treat patients with complicated cardiac diseases. Just four decades ago, a fraction of these patients would have likely died of heart disease.
“The major change in cardiac surgery in the last fourty years is that we are now able to operate on neonates and infants, older and sicker patients. “Many of our patients have multiple medical conditions, including high blood pressure, diabetes mellitus and peripheral vascular disease. Many have had previous cardiac procedures, stroke or other morbidity.
Cardiac surgery team’s roles
The survival of the patient may be determined in the operating room and may depend on the quality of myocardial protection, experience in surgical techniques and training of the cardiac surgeon.
The anesthesiologist is an important team player, as being critical to the success of any cardiac surgical procedure. Patients with heart disease could have cardiovascular complications from general anesthesia and surgery more often and more severely than patients without heart disease. The specialty of cardiac anesthesia has developed and grown in the past three decades in particular in the field of intraoperative echocardiographic imaging to detect possible causes of postcardiotomy heart failure. Intraoperatively transesophageal or epicardial echocardiographic assessment of cardiac function has improved significantly the quality control and patients’ outcome after intracardiac and coronary bypass surgery. All hospitals with cardiac surgery program have specialists in cardiac anesthesia that are vital to patient survival.
The role of the clinical perfusionist as an example of a part of the surgical team who has taken on a much greater role in the last four decades. Perfusionists operate the heart/lung machine that supports the patient’s circulation when the heart is arrested during cardiac operations. They monitor circulatory, physiologic and metabolic processes during surgery and take action if problems arise. They are also involved in blood conservation. Many perfusionists have Master’s degrees in biomedical engineering.
“These men and women are real thinkers and team players in the operating room. With heart surgery, you don’t just do the surgery and send the patient home”.
Intensive care unit
Cardiovascular nursing is another prominent advancement in the care of cardiovascular surgical patients. The experience of the cardiovascular surgical nurse is critical to the surgical procedures in the operating room and to the ultimate recovery of the patient in the intensive care unit and the general ward. The survival of the patient with a postoperative complication may be determined in the intensive care unit and may depend on the experience and training of the cardiac surgical nurse and the intensivists.
In the past, the intensive care unit was dedicated for all patients with different kinds of complexed diseases. Consequently, the outcome of cardiovascular patients was not optimal. In the last three decades, most large hospitals have an intensive care unit dedicated to cardiovascular surgery patients. Ever since the specialty of cardiovascular nursing has developed, advanced and improved the care of cardiovascular patients after the operation. Because nurses in the cardiac intensive care units work exclusively with heart patients, they are familiar with all types of complications from cardiovascular surgery which are detected and confirmed by the intensivist for early intervention. With these improvements in the team surrounding the cardiac surgeon, older, sicker patients have a better chance of survival through cardiac surgery.
In conclusion, “It’s never just the cardiac surgeon or one physician that determines the cardiovascular patient’s outcome”.
Prof. Charles Yankah,
German Heart Institute Berlin,