Cardiac Surgery and Complications Overview

Pacemaker Implantation

• A cardiac permanent pacemaker (PPM) is an electronic pulse generator creating an artificial action potential to control cardiac arrhythmias, most often bradycardia.
• Pacemakers can be temporary or permanent.
• They're used to control transient arrhythmias during a heart attack (MI) or after surgery when vagal tone (parasympathetic stimulation) is elevated.
• Chronic arrhythmias (e.g., heart blocks, recurrent tachyarrhythmias) might need permanent pacemaker implantation.

Combating Postoperative Complications

• Postoperative issues like arrhythmias (e.g., atrial fibrillation), respiratory failure, and venous thromboembolism are significant after revascularization surgery.
• Advances in perioperative care (early mobility, pulmonary hygiene, continuous vital sign monitoring) have reduced these risks.
• Enhanced Recovery After Surgery (ERAS) protocols speed recovery and lower complications.

Peripheral Vascular Surgery

• Peripheral Vascular Surgery (PVS) treats various vascular disorders, including Peripheral Arterial Disease (PAD).
• PAD can lead to critical limb ischemia, mobility loss, and even amputation if untreated.
• This lecture focuses on surgical techniques, risks, and postoperative care for peripheral vascular interventions.

Peripheral Vascular Surgery (cont.)

• Surgical bypass and arterial reconstruction can be performed on peripheral arteries (e.g., femoral-popliteal, aortofemoral, infrapopliteal, axillobifemoral).
• Candidates for surgery include those with long lesions (≥0.5 cm), multiple stenoses, critical single stenosis, or occlusion.
• A strong predictor for successful intervention is symptomatic claudication.
• Patients with claudication pain have better long-term outcomes and fewer amputations than patients with limb-threatening ischemia.

Peripheral Vascular Surgery (cont.)

• Stents and atherectomies are sometimes used with angioplasty to optimize outcomes better than angioplasty alone.
• For severe peripheral ischemia, bypass is better than angioplasty in the long term, but angioplasty is preferred when PAD is mild proximally.

Pacemaker Indications

• The American College of Cardiology has guidelines for pacemaker implantation based on electrocardiographic findings.
• General indications include sinoatrial nodal disorders (bradyarrhythmias), atrioventricular nodal disorders, and tachyarrhythmias (supraventricular tachycardia, frequent ventricular ectopy) causing hemodynamic compromise symptoms (lightheadedness, fainting, etc.).

Reconstruction

• Surgical procedures like bypass can be performed on different parts of the body like:
  • Femoral-Popliteal Bypass
  • Aortofemoral Bypass
  • Infrapopliteal Bypass.

Surgical Approaches (cont.)

• Endarterectomy: Removing plaque from arterial walls to restore blood flow, typically for short, localized blockages. Can be combined with bypass or stenting.
• Bypass Grafting: Rerouting blood around blocked arteries using veins or synthetic grafts (often femoral-popliteal or aortofemoral). A new pathway is created to improve circulation in affected areas.
• Angioplasty and Stenting: First line treatment for shorter, less complex blockages. A balloon expands the artery, and a stent maintains the widening.

Endovascular Aneurysm Repair (EVAR)

• EVAR uses stent grafts for minimally invasive abdominal aortic aneurysm repair.
• Preferred in high-risk patients.

Risks and Complications

• Risks include infection (groin incisions, diabetes, poor circulation), bleeding/hematoma formation (particularly at graft insertion sites), thrombosis/occlusion, aneurysm/pseudoaneurysm formation, and limb loss (severe ischemia)

Postoperative Care and Recovery

• Early mobilization (1-2 days post-surgery) reduces DVT risk and improves circulation.
• Continuous monitoring of vital signs, wound healing, and response to exercise is crucial.

Postoperative Care (cont.)

• Gait and exercise therapy helps with pain and promotes blood flow, crucial for long-term success and preventing future occlusions.

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This quiz covers key concepts related to pacemaker implantation, postoperative complications, and advances in peripheral vascular surgery. Explore how both temporary and permanent pacemakers are used to manage cardiac arrhythmias, and learn about strategies for minimizing postoperative risks. Perfect for medical students and professionals alike.