Medicurio

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Pulmonary resection is the first line of treatment of stage I and II non-small cell lung cancer (NSCLC). It is also important as part of the management of stage IIIA. In early stages of NSCLC, the surgery focuses on diagnosis, staging and resection of the entire tumor. Pneumonectomy and lobectomy carry a mortality rate in hospital of up to 4% and 8% percent respectively.

Types of Pulmonary Resection

Different portions of the lung are removed during the diverse procedures that make up pulmonary resection, including:

Pneumonectomy refers to removal of the lung affected with cancer.

Lobectomy refers to the removal of the diseased lobe, ligation of the bronchovascular structures and removal of the lymph nodes in the hilum and mediastinum on the same side. It is the gold standard for pulmonary resection in lung cancer.

Sublobar resection refers to the removal of less than an entire lobe of a lung, within anatomical or non-anatomical boundaries. Their advantages include lower mortality rates and comparable complication rates or lung function when set against a lobectomy. Currently, these are advised when a patient is too ill or whose lung reserve is too low to tolerate lobectomy.

Wedge resections, also known as non-anatomical sublobar resections are performed in patients too ill for lobectomy, for small tumors which are peripherally located and cross anatomical boundaries, or those with multiple primary NSCLC tumors. Wide margins of excision should be provided to ensure tumor-negative margins and lymph node removal is mandatory.

Segmentectomy refers to the removal of a lung segment beginning with bronchovascular ligation and anatomical dissection, followed by a mediastinal lymph node sampling as for lobectomy. Anatomical segmentectomy has comparable survival and recurrence rates to lobectomy, when performed for tumors smaller than 3 cm. For larger tumors, it is associated with higher recurrence rates.

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Cardiopulmonary bypass (CPB) provides a bloodless field for cardiac surgery. It incorporates an extracorporeal circuit to provide physiological support in which venous blood is drained to a reservoir, oxygenated and sent back to the body using a pump. Team effort between surgeon, perfusionist and anaesthesiologist is paramount for the successful use of CPB. However, it also has its share of complications and strategies to reduce these complications are the area of the current research.

Advances in cardiac surgery have been possible due to the development of cardiopulmonary bypass (CPB). CPB is a form of extracorporeal circulation whose function is circulatory and respiratory support along with temperature management to facilitate surgery on the heart and great vessels. The first successful human cardiac surgery using CPB was performed by John Gibbon in 1952[1] for repair of the atrial septal defect. The safe conduct of CPB requires a team effort between the surgeon, perfusionist, and anaesthesiologist.

This article gives an overview of CPB, its components, setup, complications and anaesthesia management during CPB.

There are many types of congenital heart defects. If the defect lowers the amount of oxygen in the body, it is called cyanotic. If the defect doesn’t affect oxygen in the body, it is called acyanotic.

What are cyanotic heart defects?

Cyanotic heart defects are defects that allow oxygen-rich blood and oxygen-poor blood to mix.

In cyanotic heart defects, less oxygen-rich blood reaches the tissues of the body. This results in the development of a bluish tint (cyanosis) to the skin, lips, and nail beds.

Cyanotic heart defects include:

• Tetralogy of Fallot.
• Transposition of the great vessels.
• Pulmonary atresia.
• Total anomalous pulmonary venous return.
• Truncus arteriosus.
• Hypoplastic left heart syndrome.
• Tricuspid valve abnormalities.

What are acyanotic heart defects?

Congenital heart defects that don’t normally interfere with the amount of oxygen or blood that reaches the tissues of the body are called acyanotic heart defects. A bluish tint of the skin isn’t common in babies with acyanotic heart defects, although it may occur. If a bluish tint occurs, it often is during activities when the baby needs more oxygen, such as when crying and feeding.

Acyanotic congenital heart defects include:

• Ventricular septal defect (VSD).
• Atrial septal defect (ASD).
• Atrioventricular septal defect.
• Patent ductus arteriosus (PDA).
• Pulmonary valve stenosis.
• Aortic valve stenosis.
• Coarctation of the aorta.

Tetralogy of Fallot

Tetralogy of Fallot is a condition in which a child is born with the following four different heart defects: Overriding aorta.

Normally the large blood vessel that carries blood to the body (aorta) receives only oxygen-rich blood from the left side of the heart. With an overriding aorta, the aorta gets blood from both lower chambers of the heart. This lets oxygen-poor blood mix with oxygen-rich blood, allowing oxygen-poor blood to flow to the body. Ventricular septal defect (VSD).

A ventricular septal defect is an opening in the heart wall (septum). In tetralogy of Fallot, there is a very large opening in the wall between the lower heart chambers (ventricles). This lets oxygen-poor blood mix with oxygen-rich blood, allowing oxygen-poor blood to flow to the body. Pulmonary stenosis.

In tetralogy of Fallot, there is also a narrowing (stenosis) of the pulmonary valve between the lower right heart chamber and the pulmonary artery, which carries blood to the lungs. The narrow valve lets less blood flow through the pulmonary artery to the lungs. Thickened right lower chamber of the heart.

Because the pulmonary valve is narrowed, it is more difficult for blood to be pumped out of the lower right chamber of the heart. This makes the heart chamber thicker.

A baby who has tetralogy of Fallot needs surgery to repair the defects.

People who have had tetralogy of Fallot surgically repaired can usually do most normal activities. But competitive sports and strenuous exercise may need to be restricted. The person needs to be closely monitored by a doctor to detect and treat any problems right away.

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Transposition of the great vessels

in transposition of the great vessels, the major blood vessels attached to the heart—the aorta and the pulmonary artery—are reversed. This reversal results in the blood going to the wrong places. This leads to low oxygen levels in the body.

The aorta, which normally carries oxygen-rich blood from the left side of the heart to the body, instead receives oxygen-poor blood from the right side of the heart. The pulmonary artery, which normally carries oxygen-poor blood from the right side of the heart to the lungs, instead receives oxygen-rich blood from the left side of the heart.

In transposition of the great vessels, the right lower chamber of the heart (rather than the left lower chamber) pumps blood to the body. But the right side of the heart normally is not strong enough to pump blood effectively to the whole body. This increased workload on the right side of the heart can lead to a weakened heart.

There are several types of transposition of the great vessels. Each has slightly different placement of the vessels and openings that result in mixing of blood between the two sides of the heart. The most common form of transposition of the great vessels results in oxygen-poor blood being pumped to the body.

Certain other heart defects must be present to allow a child with transposition of the great vessels to live. Other defects ultimately compensate for the transposition of the great vessels by allowing oxygen-rich blood to mix with oxygen-poor blood so that some oxygen can get to the tissues of the body. Surgery is usually needed for long-term survival

Pulmonary atresia

Pulmonary atresia is a type of congenital heart defect in which the opening between the pulmonary artery and the right ventricle is blocked. This can result in an enlarged heart, reduced blood vessel function in the lungs, and problems with the right ventricle.

Pulmonary atresia is usually linked with heart abnormalities such as tetralogy of Fallot.

Treatment for pulmonary atresia includes medicine or a catheter procedure. Or surgery may be used to provide another way for blood to get to the lungs. Depending upon the heart’s condition, surgical repair may remove or bypass the blockage.

Total anomalous pulmonary venous return

Total anomalous pulmonary venous return is a structural problem with the heart that causes oxygen-poor blood. It is a type of congenital heart defect, which means it develops before a baby is born.

With this defect, all the pulmonary veins from the lungs do not connect with the left side of the heart as they should. Instead, they connect to veins or structures that drain into the right side of the heart. This results in oxygen-rich blood flowing back into the right side of the heart.

The left side of the heart and the body get some oxygen-rich blood because of other defects that are usually present, including:

• Atrial septal defect, which is an opening in the wall (septum) between the upper chambers (atria) of the heart.
• Foramen ovale, which is an opening between the two upper chambers (atria) of the heart. This opening (which is present in the fetus but normally closes at birth) remains open in total anomalous pulmonary venous return.

Surgery is needed to correct the defect.

Ventricular septal defect

Ventricular septal defect (VSD), the most common heart problem that develops before birth (congenital), is an opening in the wall that separates the lower chambers of the heart. Most ventricular septal defects are small and do not cause a problem.

The opening of a ventricular septal defect can be as small as a pinhole, or the wall between the heart chambers may be completely missing. This defect is usually found when a baby is 1 to 4 weeks old.

A large, untreated ventricular septal defect may result in the lower left heart chamber’s inability to pump enough blood to the body and too much blood going to the lungs. Large ventricular septal defects usually cause heart problems and symptoms by the time a baby is 3 to 6 months old.

Treatment is not needed in cases where a ventricular septal defect is small or closes on its own. Some children and adults need surgery or a catheter procedure to close the defect, especially if it is large.

Atrial septal defect

An atrial septal defect is an opening in the wall that separates the upper chambers of the heart. It is one of the most common congenital heart defects, which are structural problems that develop before a baby is born or at birth.

When an atrial septal defect is present, some oxygen-rich blood that should have been pumped to the body flows from one side of the heart to the other. This blood is then pumped to the lungs. This creates extra work for one side of the heart.

If an atrial septal defect is large, heart failure may occur, although this is not common in children. Many children have no symptoms. So this defect may not be found until a child is older or becomes an adult.

A heart catheterization can typically be used to close the opening. This prevents blood from flowing between chambers.

Atrioventricular septal defect

Atrioventricular septal defect is an opening between all four chambers of the heart that is present at birth (congenital heart defect). The opening is caused by a failure of heart tissue to come together during the growth of the fetus.

Atrioventricular septal defect results in a large opening in the center of the heart, with a hole between the 2 lower chambers (ventricular septal defect) and between the 2 upper chambers (atrial septal defect).

Atrioventricular septal defect requires surgery to correct.

Patent ductus arteriosus

The ductus arteriosus is a blood vessel in a fetus that connects the pulmonary artery, which carries blood to the lungs, and the aorta, which carries blood to the body, so that blood flow bypasses the lungs. Normally, this blood vessel closes at birth as the baby starts breathing. But if the vessel does not close, it is known as a patent (open) ductus arteriosus (PDA).

A patent ductus arteriosus allows some oxygen-rich blood to flow from the aorta back into the pulmonary artery and to the lungs instead of to the rest of the body. Because some of the blood intended for the body returns to the lungs, the left side of the heart has to pump harder to get enough blood to the body. This can enlarge and weaken the heart.

Some babies do not have symptoms from a patent ductus arteriosus. But this abnormality often causes symptoms, such as poor feeding and shortness of breath. An older child may develop heart failure or an infection of the heart’s inner lining (infective endocarditis). How bad the symptoms get and whether complications develop depend on how much blood flows through the ductus.

Treatment for a patent ductus arteriosus might be medicine that helps close the blood vessel. Or a doctor will insert a small closure device into the heart during a heart catheterization. This prevents blood from flowing into the lungs. If a heart catheterization can’t be done, a surgeon might operate to close the PDA.

Coarctation of the aorta

Coarctation of the aorta is a common heart defect present at birth.

With this defect, a portion of the large blood vessel that carries blood from the heart to the rest of the body (aorta) is abnormally narrowed or pinched. Coarctation of the aorta makes it harder for the heart to pump blood to the body. Over time, this can lead to high blood pressure, heart failure, or other complications.

This condition is usually detected in newborns during normal blood pressure checks and by listening to the heart. Further tests, such as echocardiography, may be done to confirm the diagnosis.

Coarctation of the aorta requires repair by surgery or heart catheterization.

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Cardiopulmonary bypass (CPB) provides a bloodless field for cardiac surgery. It incorporates an extracorporeal circuit to provide physiological support in which venous blood is drained to a reservoir, oxygenated and sent back to the body using a pump. Team effort between surgeon, perfusionist and anaesthesiologist is paramount for the successful use of CPB. However, it also has its share of complications and strategies to reduce these complications are the area of the current research.

Advances in cardiac surgery have been possible due to the development of cardiopulmonary bypass (CPB). CPB is a form of extracorporeal circulation whose function is circulatory and respiratory support along with temperature management to facilitate surgery on the heart and great vessels. The first successful human cardiac surgery using CPB was performed by John Gibbon in 1952 for repair of the atrial septal defect. The safe conduct of CPB requires a team effort between the surgeon, perfusionist, and anaesthesiologist.

Why Is Cardiopulmonary Bypass Used?

To stop the heart without harming the patient, oxygenated blood must continue to circulate through the body during surgery without stopping. The cardiopulmonary bypass pump does the work of the heart, pumping blood through the body, and making sure that the tissues of the body get the oxygen they need.2 The machine also adds oxygen to the blood while taking over the pumping action of the heart, replacing the function of the lungs.

The CBM is used for two primary reasons. The most common reason is so the heart can be stopped for surgery.3 Some cardiac surgeries would be impossible to perform with the heart beating, as surgery would be performed on a “moving target” or there would be significant blood loss. A great example of this is a heart transplant procedure – the patient’s heart must be removed from the body so the donated heart can be put in.4 Without a pump to replace the action of the heart, the heart transplant would be impossible.

The same is true of some lung surgeries; there must be a way to oxygenate the blood when the lungs cannot. A lung transplant procedure requires an alternative way to oxygenate blood when the lungs cannot, but the heart may continue to beat during the procedure.5

For other patients, the pump is used not for surgery, but to help keep a patient alive when they are experiencing heart failure that would be life-ending. In some rare cases, a heart failure patient may be placed on the pump to support the patient until a heart transplant becomes available.

How Does Cardiopulmonary Bypass Work?

The surgeon attaches special tubing to a large blood vessel (like starting a very large IV) that allows oxygen-depleted blood to leave the body and travel to the bypass machine. There, the machine oxygenates the blood and returns it to the body through the second set of tubing, also attached to the body.3 The constant pumping of the machine pushes the oxygenated blood through the body, much like the heart does.

The placement of the tubes is determined by the preference of the surgeon. The tubes must be placed away from the surgical site so they do not interfere with the surgeon’s work, but placed in a blood vessel large enough to accommodate the tubing and the pressure of the pump. The two tubes ensure that blood leaves the body before reaching the heart and returns to the body after the heart, giving the surgeon a still and mostly bloodless area to work.6

A third tube is also inserted very near or directly into the heart, but not connected to the CPM. It is used to flush the heart with cardioplegia, a potassium solution which stops the heart.7

Once the cardioplegia takes effect, the CBM is initiated and takes over the heart and lung function.

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Who Runs the Cardiopulmonary Bypass Machine?

The person who runs a cardiopulmonary bypass pump is called a perfusionist. Perfusionists typically have a bachelor’s degree in a health-related field, then pursue an additional two years of education training as a perfusionist. Some perfusionists take an exam to become a certified clinical perfusionist, which is similar to a physician being board certified in a specialty.

The Risks of Cardiopulmonary Bypass

The risks of being on heart and lung bypass include blood clots, bleeding after surgery, surgical injury to the phrenic nerve, acute kidney injury, and decreased lung and/or heart function. These risks are decreased with shorter times on the pump and increased with longer pump times. 

A Word From Verywell

Any procedure that requires the use of the cardiopulmonary bypass machine is major surgery and should be taken extremely seriously. While the risks associated with these procedures can be significant, these surgeries can also be life-saving or life-enhancing. ​

When possible, it is important to take the time to discuss the risks and rewards of the procedure as well as alternatives to surgery before you make a decision.

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Valvular heart disease is a form of heart disease that occurs when one or more of the heart’s four valves don’t function properly. Valve replacement surgery may be an option if the valves of your heart are too fragile, scarred, or otherwise damaged to repair.

Aortic valve repair and aortic valve replacement are procedures that treat diseases affecting the aortic valve, one of four valves that control blood flow through the heart.

The aortic valve helps keep blood flowing in the correct direction through the heart. It separates the heart’s main pumping chamber (left ventricle) and the main artery that supplies oxygen-rich blood to your body (aorta).

With each contraction of the ventricle, the aortic valve opens and allows blood to flow from the left ventricle into the aorta. When the ventricle relaxes, the aortic valve closes to prevent blood from flowing backward into the ventricle.

When the aortic valve isn’t working properly, it can interfere with blood flow and force the heart to work harder to send blood to the rest of your body.

Aortic valve repair or aortic valve replacement can treat aortic valve disease and help restore normal blood flow, reduce symptoms, prolong life and help preserve the function of your heart muscle.

Reasons for Replacement

The valves of the heart are responsible for allowing nutrient-rich blood to flow through the chambers of your heart. Each valve is supposed to close completely after ushering in blood flow. Diseased heart valves aren’t always able to perform the job as well as they should.

Stenosis, or a narrowing of the blood vessels, causes a less-than-normal amount of blood to flow to the heart. This causes the muscle to work harder. Leaky valves can also pose a problem. Instead of closing tightly, a valve may remain slightly open, letting blood flow backwards. This is called regurgitation. The signs of valvular heart disease can include:

• fatigue
• dizziness
• lightheadedness
• shortness of breath
• cyanosis
• chest pain
• fluid retention, especially in the lower limbs

Heart valve repair is also a solution for valvular heart disease. In some people, the damage is too far advanced and a total replacement of the affected valve is the only option.

Types

Mechanical and biologic valves are used to replace faulty valves. Mechanical valves are artificial components that have the same purpose as a natural heart valve. They’re created from carbon and polyester materials that the human body tolerates well. They can last between 10 and 20 years. However, one of the risks associated with mechanical valves is blood clots. If you receive a mechanical heart valve, you’ll need to take blood thinners for the rest of your life to reduce your risk of stroke.

Biologic valves, also called bioprosthetic valves, are created from human or animal tissue. There are three types of biologic heart valves:

• An Allograft or homograft is made of tissue taken from a human donor’s heart.
• A porcine valve is made from pig tissue. This valve can be implanted with or without a frame called a stent.
• A bovine valve is made from cow tissue. It connects to your heart with silicone rubber.

Biologic valves don’t increase your risk of developing blood clots. This means you most likely won’t need to commit to a lifetime of anti-clotting medication. A bioprosthetic doesn’t last as long as a mechanical valve and may require replacement at a future date.

Your doctor will recommend which type of heart valve you get based on:

• your age
• your overall health
• your ability to take anticoagulant medications
• the extent of the disease

Types of Valve Replacement Surgery

Aortic Valve Replacement

The aortic valve is on the left side of the heart and serves as an outflow valve. Its job is to allow blood to leave the left ventricle, which is the heart’s main pumping chamber. Its job is also to close so that blood doesn’t leak back into the left ventricle. You may need surgery on your aortic valve if you have a congenital defect or disease that causes stenosis or regurgitation.

The most common type of congenital abnormality is a bicuspid valve. Normally, the aortic valve has three sections of tissue, known as leaflets. This is called a tricuspid valve. A defective valve has only two leaflets, so it’s called a bicuspid valve. A recent study found that aortic valve replacement surgery has a 94 percent five-year survival rate. Survival rates depend on:

• your age
• your overall health
• other medical conditions you have
• your heart function

Mitral Valve Replacement

The mitral valve is located on the left side of the heart. It serves as an inflow valve. Its job is to allow blood from the left atrium to flow into the left ventricle. Surgery may be required if the valve doesn’t fully open or completely close. When the valve is too narrow, it can make it difficult for blood to enter. This can cause it to back up, causing pressure in the lungs. When the valve doesn’t close properly, blood can leak back into the lungs. This can be due to a congenital defect, infection, or a degenerative disease.

The defective valve will be replaced with either a metal artificial valve or a biological valve. The metal valve will last a lifetime but requires you to take blood thinners. The biological valve lasts between 15 to 20 years, and you won’t be required to take medication that thins your blood. The following also play a role in survival rate:

• your age
• your overall health
• other medical conditions you have
• your heart function

Ask your doctor to help assess your personal risks.

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Double Valve Replacement

A double valve replacement is a replacement of both the mitral and the aortic valve, or the entire left side of the heart. This type of surgery is not as common as the others and the mortality rate is slightly higher.

Pulmonary Valve Replacement

The pulmonary valve separates the pulmonary artery, which carries blood to the lungs for oxidation, and the right ventricle, which is one of the heart’s chambers. Its job is to allow blood to flow from the heart to the lungs through the pulmonary artery. The need for pulmonary valve replacement is usually due to stenosis, which restricts blood flow. Stenosis may be caused by a congenital defect, infection, or carcinoid syndrome.

Why it’s done

Aortic valve disease treatment depends on the severity of your condition, whether you’re experiencing signs and symptoms, and if your condition is getting worse.

Types of aortic valve disease that may require treatment with aortic valve repair or replacement include:

• Aortic valve regurgitation: This occurs when blood flows backward through the aortic valve into the left ventricle each time the ventricle relaxes rather than in the normal, one-way direction from the ventricle to the aorta. Back flow may be caused by a dysfunctional or leaky valve. This may be due to deterioration of the valve, an abnormal valve shape present at birth (congenital heart disease) or by a bacterial infection.
• Aortic valve stenosis. The stenosis causes the aortic valve to become narrowed or obstructed, which makes it harder for the heart to pump blood into the aorta. This may be caused by congenital heart disease, thickening of the valve’s closure flaps (leaflets) or post-inflammatory changes, such as those associated with rheumatic heart disease.
• Congenital heart disease. Having this may contribute to aortic valve regurgitation or stenosis, as well as result in other problems that prevent the aortic valve from working properly. For example, a person may be born with an aortic valve that doesn’t have enough tissue flaps (cusps), the valve may be the wrong size or shape, or there may not be an opening to allow blood to flow normally (atresia).

For some people with mild aortic valve disease without symptoms, careful monitoring under a doctor’s supervision may be all that’s needed.

But in most cases, aortic valve disease and dysfunction get worse despite medical treatment. Most aortic valve conditions are mechanical problems that can’t be successfully treated with medication alone. Such conditions eventually require surgery to reduce symptoms and your risk of complications, such as heart failure, heart attack, stroke or death due to sudden cardiac arrest.

The Procedure

Heart valve replacement surgery is performed under general anesthesia with techniques that are either conventional or minimally invasive. Conventional surgery requires a large incision from your neck to your navel. If you have less invasive surgery, the length of your incision can be shorter and you can also reduce your risk of infection.

For a surgeon to successfully remove the diseased valve and replace it with a new one, your heart must be still. You’ll be placed on a bypass machine that keeps blood circulating through your body and your lungs functioning during surgery. Your surgeon will make incisions into your aorta, through which the valves will be removed and replaced.

Risks

Aortic valve repair and aortic valve replacement surgery risks vary depending on your health, the type of procedure and the expertise of your health care team. To minimize potential risk, aortic valve surgery should generally be performed at a center with a multidisciplinary heart team experienced in these procedures and that performs high volumes of aortic valve surgeries.

Risks associated with aortic valve repair and aortic valve replacement surgery may include:

• Bleeding
• Blood clots
• Valve dysfunction in replacement valves
• Heart rhythm problems
• Infection
• Stroke
• Death

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How you prepare

Before surgery to have your aortic valve repaired or replaced, your doctor and treatment team will explain to you what to expect before, during and after the surgery and potential risks of the surgery.

Discuss with your doctor and treatment team any questions you may have about the procedure.

Before being admitted to the hospital for your surgery, talk to your caregivers about your hospital stay and discuss any help you may need when you return home.

Food and medications

Talk to your doctor about:

• When you can take your regular medications and whether you can take them before your surgery
• When you should stop eating or drinking the night before the surgery

Clothing and personal items

Your treatment team may recommend that you bring several items to the hospital including:

• A list of your medications
• Eyeglasses, hearing aids or dentures
• Personal care items, such as a brush, comb, shaving equipment and toothbrush
• Loosefitting, comfortable clothing
• A copy of your advance directive or living will
• Items that may help you relax, such as portable music players or books
• Any prescribed medical devices or equipment

During surgery, avoid wearing:

• Jewelry
• Eyeglasses
• Contact lenses
• Dentures
• Nail polish

Your body hair will be shaved off at the location where the procedure will take place.

What you can expect

Before the procedure

For most aortic valve repair and aortic valve replacement procedures, you’ll receive anesthetics so you won’t feel any pain, and you’ll be unconscious during the surgery.

You’ll also be connected to a heart-lung bypass machine, which keeps blood moving through your body during the procedure.

During the procedure

Aortic valve repair

Aortic valve repair is usually performed through traditional open-heart surgery and opening of the chest bone (sternotomy). Doctors wire the bone back together after the procedure to prevent movement and aid in healing.

Aortic valve repair procedures may involve several different types of repair, including:

• Inserting tissue to patch holes or tears in the flaps (perforated cusps) that close off the valve
• Adding support at the base or roots of the valve
• Separating fused valve cusps
• Reshaping or removing tissue to allow the valve to close more tightly
• Tightening or reinforcing the ring around a valve (annulus) by implanting an artificial ring (annuloplasty)

Aortic valves that can’t open fully due to aortic valve stenosis may be repaired with surgery or temporarily with a less invasive procedure called balloon valvuloplasty — which uses an approach called cardiac catheterization. You’re usually awake during cardiac catheterization.

During balloon valvuloplasty, your doctor inserts a thin, hollow tube (catheter) in a blood vessel, usually in your groin, and threads it to your heart. The catheter has a balloon at its tip that can be inflated to help stretch the narrowed aortic valve and then deflated for removal.

Balloon valvuloplasty is often used to treat infants and children with aortic valve stenosis. However, the valve tends to narrow again in adults who have had the procedure, so it’s usually only performed in adults who are too ill for surgery or who are waiting for a valve replacement. You may need additional procedures to treat the narrowed valve over time.

Some replacement heart valves may begin to leak or not work as well over time. These issues can be fixed using surgery or a catheter procedure to perform aortic valve repair by inserting a plug or device to fix a leaking replacement heart valve.

Aortic valve replacement

In this procedure, your doctor removes the aortic valve and replaces it with a mechanical valve or a valve made from cow, pig or human heart tissue (valve). Another type of biological tissue valve replacement that uses your own pulmonary valve is sometimes possible.

Often, biological tissue valves eventually need to be replaced because they degenerate over time. If you have a mechanical valve, you’ll need to take blood-thinning medications for the rest of your life to prevent blood clots. Doctors will discuss with you the risks and benefits of each type of valve and discuss which valve may be appropriate for you.

Aortic valve replacement surgery may be performed through traditional open-heart surgery or minimally invasive methods, which involve smaller incisions than those used in open-heart surgery. Transcatheter aortic valve replacement (TAVR) is another type of minimally invasive aortic valve replacement that has a nonsurgical approach. It is also sometimes called transcatheter aortic valve implantation (TAVI).

But minimally invasive aortic valve replacement is less common because not all situations are best addressed by this method of access to the damaged valve. When performed by experienced surgeons and centers, the results are similar to those with traditional open-heart surgery.

After the procedure

If you had open-heart surgery, you’ll generally spend a day or more in the intensive care unit (ICU). You’ll be given oxygen, fluids, nutrition and medications through intravenous (IV) lines. Other tubes will drain urine from your bladder and drain fluid and blood from your chest.

After the ICU, you’ll be moved to a regular hospital room for several days. The time you spend in the ICU and hospital can vary, depending on your condition and procedure.

During your hospital stay, your treatment team will:

• Watch for signs of infection in your incision sites
• Periodically check your blood pressure, breathing and heart rate
• Work with you to manage any pain you have after surgery
• Encourage you to walk regularly to gradually increase your activity and do breathing exercises as you recover

Recovery time depends on your procedure, overall health before the procedure and any complications.

Your doctor may advise you to avoid driving a car or lifting anything more than 10 pounds for several weeks. Your doctor will discuss with you when you can return to normal activities.

Results

After aortic valve repair or aortic valve replacement surgery, you may eventually be able to return to daily activities, such as working, driving and exercise.

You’ll still need to take certain medications and attend regular follow-up appointments with your doctor. You may have several tests to evaluate and monitor your condition.

Your doctor and health care team may instruct you to incorporate healthy lifestyle changes — such as physical activity, a healthy diet, stress management and avoiding tobacco use — into your life to reduce the risk of future complications and promote a healthy heart.

Your doctor may recommend that you participate in cardiac rehabilitation — a program of education and exercise designed to help you improve your health and help you recover after heart surgery.

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Intra-aortic balloon counterpulsation (IABP) is sometimes used in critically ill patients with cardiac disease. By increasing diastolic arterial pressure and decreasing systolic pressure, it reduces left ventricular afterload. IABP may be beneficial in subjects with cardiogenic shock, mechanical complications of myocardial infarction, intractable ventricular arrhythmias, or advanced heart failure or those who undergo “high-risk” surgical or percutaneous revascularization, but the evidence to support its use in these patient groups is largely observational. Contraindications to IABP include severe peripheral vascular disease as well as aortic regurgitation, dissection, or aneurysm. The potential benefits of IABP must be weighed against its possible complications (bleeding, systemic thromboembolism, limb ischemia, and, rarely, death).

Intra-aortic balloon counterpulsation is a method of temporary mechanical circulatory support that attempts to create more favorable balance of myocardial oxygen supply and demand by using the concepts of systolic unloading and diastolic augmentation. As a consequence, cardiac output, ejection fraction, and coronary perfusion are increased, with a concomitant decrease in left ventricular (LV) wall stress, systemic resistance to LV ejection, and pulmonary capillary wedge pressure. The following review discusses the hemodynamic, clinical, and technical aspects of this important modality for hemodynamic support.

History of the procedure

The principle of aortic counterpulsation was originally described by Dr. Adrian Kantrowitz in 1959 using a dog model in which the hemidiaphragm was wrapped around the thoracic aorta, which, by electrical stimulation of the phrenic nerve, was made to contract during diastole.

Pathophysiology

The IABP improves many of the hemodynamic perturbations of circulatory failure and cardiogenic shock. Therefore, understanding the pathophysiology of this dramatic manifestation of heart failure is important. Cardiogenic shock is characterized by end-organ tissue hypoperfusion, which initiates a series of counter-regulatory mechanisms. The classic understanding of the interplay between the underlying pathophysiology and counter-regulatory mechanisms is that of a downward spiral in which compensatory mechanisms such as peripheral vasoconstriction, tachycardia, and neurohormonal regulatory activation contribute to further worsening of left ventricular failure.

While a comprehensive discussion of the hemodynamics of cardiogenic shock is beyond the scope of this review, it is worthwhile to note the following:

Cardiogenic shock is the most common cause of death from acute myocardial infarction. According to data from the SHOCK registry, the mortality from cardiogenic shock complicating acute myocardial infarction is 50-80%. ^[5] In addition, data indicate that anterior myocardial infarction is the most common territory leading to cardiogenic shock. In the SHOCK registry, 55% of infarctions were anterior. ^[5] Cardiogenic shock is diagnosed at the bedside by observing the clinical signs of end-organ hypoperfusion such as altered mental status, cool and mottled extremities, and oliguria. The diagnosis is confirmed by demonstrating hemodynamic criteria consistent with myocardial dysfunction.

Mechanical complications of acute myocardial infarction can precipitate cardiogenic shock or contribute to preexisting cardiogenic shock. These include acute mitral regurgitation, postinfarction ventricular septal defect, and left ventricular free wall rupture. For more information, see Medscape Drugs & Diseases article Complications of Myocardial Infarction.

Catecholamine vasopressors to treat hypotension in the setting of cardiogenic shock should be used judiciously to maintain coronary perfusion pressure but also minimize additional myocardial oxygen demand through increasing afterload and genesis of dysrhythmias.

Reperfusion of ischemic myocardium has been shown to provide long-term survival benefit in the setting of cardiogenic shock related to acute myocardial infarction. ^[5]

The above highlights of cardiogenic shock pathophysiology set the stage for the following discussion of counterpulsation hemodynamics.

Basic principles of counterpulsation

Counterpulsation is a term that describes balloon inflation in diastole and deflation in early systole. Balloon inflation causes ‘volume displacement’ of blood within the aorta, both proximally and distally. This leads to a potential increase in coronary blood flow and potential improvements in systemic perfusion by augmentation of the intrinsic ‘Windkessel effect’, whereby potential energy stored in the aortic root during systole is converted to kinetic energy with the elastic recoil of the aortic root.

Physiological effects of IABP therapy

The primary goal of IABP treatment is to improve the ventricular performance of the failing heart by facilitating an increase in myocardial oxygen supply and a decrease in myocardial oxygen demand. Although these effects are predominately associated with enhancement of LV performance, IABP may also have favourable effects on right ventricular (RV) function by complex mechanisms including accentuation of RV myocardial blood flow, unloading the left ventricle causing reduction in left atrial and pulmonary vascular pressures and RV afterload. IABP inflates at the onset of diastole, thereby increasing diastolic pressure and deflates just before systole, thus reducing LV afterload. The magnitude of these effects depends upon:

• Balloon volume: the amount of blood displaced is proportional to the volume of the balloon.
• Heart rate: LV and aortic diastolic filling times are inversely proportional to heart rate; shorter diastolic time produces lesser balloon augmentation per unit time.
• Aortic compliance: as aortic compliance increases (or SVR decreases), the magnitude of diastolic augmentation decreases.

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Myocardial oxygen supply and demand

Inflation of IAB during diastole increases the pressure difference between aorta and left ventricle, the so-called diastolic pressure time index (DPTI). The haemodynamic consequence of this is an increase in coronary blood flow and, therefore, myocardial oxygen supply. Myocardial oxygen demand is directly related to the area under the LV systolic pressure curve, termed as tension time index (TTI). Balloon deflation during systole causes a reduction in the LV afterload, thereby decreasing TTI. Thus, the ratio of oxygen supply (DPTI) to oxygen demand (TTI), known as the endocardial viability ratio (EVR), should increase if the IABP is working optimally. This can be evidenced by a decrease in coronary sinus lactate.

Coronary perfusion

According to the Hagen Poiseuille principle, flow through a tube is directly proportional to the pressure difference across it and the fourth power of the radius while being inversely proportional to the length of the tube and the viscosity of fluid flowing through it. Hence, in patients with severe coronary artery disease in whom autoregulation is perceived to be absent, coronary blood flow is directly related to diastolic perfusion pressure. Therefore, IABP should theoretically improve coronary flow in these patients.

Renal function

Renal blood flow can increase up to 25%, secondary to increase in cardiac output. Decrease in urine output after insertion of IABP should raise the suspicion of juxta-renal balloon positioning.

Haematological effects

The haemoglobin levels and the haematocrit often decrease by up to 5% because of haemolysis from mechanical damage to the red blood cells. Thrombocytopenia can result from mechanical damage to the platelets, heparin administration, or both

Indications

Indications and contraindications for the use of IABP therapy

Indications
Acute myocardial infarction	Refractory LV failure
Cardiogenic shock	Refractory ventricular arrhythmias
Acute MR and VSD	Cardiomyopathies
Catheterization and angioplasty	Sepsis9
Refractory unstable angina	Infants and children with complex cardiac anomalies10
Cardiac surgery
Weaning from cardiopulmonary bypass
Contraindications
Absolute	Relative
Aortic regurgitation	Uncontrolled sepsis
Aortic dissection	Abdominal aortic aneurysm
Chronic end-stage heart disease with no anticipation of recovery	Tachyarrhythmias
Aortic stents	Severe peripheral vascular disease
	Major arterial reconstruction surgery

Acute myocardial infarction

IABP is aimed at achieving haemodynamic stability until a definitive course of treatment or recovery occurs. By decreasing myocardial work and SVR, intracardiac shunting, mitral regurgitation, or both (if present) are reduced while coronary perfusion is enhanced.

Severe mitral regurgitation secondary to papillary muscle dysfunction or rupture after myocardial infarction can lead to significant haemodynamic instability. This can initially be managed by IABP, pending definitive surgery.

Ventricular arrhythmias

IABP is also effective in stabilizing patients with refractory ventricular ectopy after myocardial infarction by increasing the coronary perfusion pressure, reducing ischaemia and trans-myocardial wall stress, and maintaining adequate systemic perfusion.

Cardiogenic shock

This is life-threatening complication of acute myocardial infarction, is characterized by low cardiac output, hypotension unresponsive to fluid administration, elevated filling pressures and tissue hypoperfusion leading to oliguria, hyperlactaemia, and altered mental status. IABP therapy is considered to be a class I indication (ACC/AHA guidelines) for the management of cardiogenic shock not rapidly reversed by pharmacological therapy.

Unstable angina

Unstable angina refractory to drug treatment is an indication for IABP. These patients are at increased risk of developing acute myocardial infarction and death. By improving the haemodynamic condition of these patients, IABP can facilitate further percutaneous interventions or bridge the patient to surgery.

Refractory ventricular failure

IABP has a role in managing patients with refractory ventricular failure outside the setting of acute myocardial infarction, such as those with cardiomyopathy or severe myocardial damage associated with viral myocarditis. This can aid the progression to more definitive treatments such as ventricular assist device or cardiac transplantation.

Cardiac surgery

IABP is used for stabilization of patients with acute myocardial infarction referred for urgent cardiac surgery. IABP support is often initiated in the cardiac catheterization laboratory and continued through the perioperative period. Elective placement is considered in high-risk patients such as those with significant left main stem disease, severe LV dysfunction (ejection fraction <30%), congestive heart failure, cardiomyopathy, chronic renal failure, or cerebrovascular disease. Weaning from cardiopulmonary bypass may be difficult in cases where aortic cross-clamping is prolonged, revascularization is only partially achieved, or pre-existing myocardial dysfunction is present. Separation from cardiopulmonary bypass may be marked by hypotension and a low cardiac index despite the administration of inotropic drugs. The use of IABP in this setting decreases LV resistance, increases cardiac output, and increases coronary and systemic perfusion, facilitating the patient’s weaning from cardiopulmonary bypass.

Contraindications

It is contraindicated in patients with aortic regurgitation because it worsens the magnitude of regurgitation. IABP insertion should not be attempted in case of suspected or known aortic dissection because inadvertent balloon placement in the false lumen may result in extension of the dissection or even aortic rupture. Similarly, aortic rupture can occur if IABP is inserted in patients with sizable abdominal aortic aneurysms. Patients with end-stage cardiac disease should not be considered for IABP unless as a bridge to ventricular assist device or cardiac transplantation.

IABP device placement should be avoided in patients with severe peripheral vascular disease. Percutaneous femoral IABP device insertion is contraindicated in the presence of bilateral femoral–popliteal bypass grafts. Uncontrolled sepsis and bleeding diathesis are relative contraindications to the placement of IABP device.

Procedure

1. A device with a polyurethane balloon is inserted through the femoral artery;
2. The balloon is held up to the aortic arch under radiological control and is installed below the left subclavian artery;
3. By periodically inflating and deflating the balloon in accordance with the phases of the cardiac cycle, temporary support of the pumping function of the heart is provided.

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Cardiovascular disease (CVD) is one of the leading causes of death worldwide and is the leading cause of death in the United States.

Cardiac rehabilitation is a complex, interprofessional intervention customized to individual patients with various cardiovascular diseases such as:

• Coronary artery disease (CAD),
• Heart failure
• Myocardial infarctions
• Patients who have undergone cardiovascular interventions such as coronary angioplasty or coronary artery bypass grafting

Coronary bypass surgery redirects blood around a section of a blocked or partially blocked artery in your heart. The procedure involves taking a healthy blood vessel from your leg, arm or chest and connecting it below and above the blocked arteries in your heart. With a new pathway, blood flow to the heart muscle improves.

Coronary bypass surgery doesn’t cure the heart disease that caused the blockages, such as atherosclerosis or coronary artery disease. However, it can ease symptoms, such as chest pain and shortness of breath. For some people, this procedure can improve heart function and reduce the risk of dying of heart disease.

Coronary artery bypass grafting (CABG) is a type of surgery that improves blood flow to the heart. It’s used for people who have severe coronary heart disease (CHD), also called coronary artery disease.

CHD is a condition in which a substance called plaque (plak) builds up inside the coronary arteries. These arteries supply oxygen-rich blood to your heart. Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood.

Plaque can narrow or block the coronary arteries and reduce blood flow to the heart muscle. If the blockage is severe, angina (an-JI-nuh or AN-juh-nuh), shortness of breath, and, in some cases, heart attack can occur. (Angina is chest pain or discomfort.)

CABG is one treatment for CHD. During CABG, a healthy artery or vein from the body is connected, or grafted, to the blocked coronary artery. The grafted artery or vein bypasses (that is, goes around) the blocked portion of the coronary artery.

Other Names for Coronary Artery Bypass Grafting

• Bypass surgery
• Coronary artery bypass surgery
• Heart bypass surgery

CHD isn’t always treated with CABG. Many people who have CHD can be treated other ways, such as with lifestyle changes, medicines, and a procedure calledangioplasty (AN-jee-oh-plas-tee). During angioplasty, a small mesh tube called astent may be placed in an artery to help keep it open.

CABG or angioplasty with stent placement may be options if you have severe blockages in your large coronary arteries, especially if your heart’s pumping action has already been weakened.

CABG also may be an option if you have blockages in the heart that can’t be treated with angioplasty. In this situation, CABG is considered more effective than other types of treatment.

If you’re a candidate for CABG, the goals of having the surgery include:

• Improving your quality of life and decreasing angina and other CHD symptoms
• Allowing you to resume a more active lifestyle
• Improving the pumping action of your heart if it has been damaged by a heart attack
• Lowering the risk of a heart attack (in some patients, such as those who have diabetes)
• Improving your chance of survival

You may need repeat surgery if the grafted arteries or veins become blocked, or if new blockages develop in arteries that weren’t blocked before. Taking medicines as prescribed and making lifestyle changes as your doctor recommends can lower the chance of a graft becoming blocked.

Why it’s done

Coronary bypass surgery is one treatment option if you have a blocked artery to your heart.

You and your doctor might consider it if:

• You have severe chest pain caused by narrowing of several arteries that supply your heart muscle, leaving the muscle short of blood during even light exercise or at rest.
• You have more than one diseased coronary artery, and the heart’s main pumping chamber — the left ventricle — isn’t functioning well.
• Your left main coronary artery is severely narrowed or blocked. This artery supplies most of the blood to the left ventricle.
• You have an artery blockage that can’t be treated with a procedure that involves temporarily inserting and inflating a tiny balloon to widen the artery (angioplasty).
• You’ve had a previous angioplasty or placement of a small wire mesh tube (stent) to hold the artery open that hasn’t been successful. Or you’ve had a stent placement, but the artery has narrowed again.

Coronary bypass surgery might also be performed in emergency situations, such as a heart attack, if you’re not responding to other treatments.

Even with coronary bypass surgery, you’ll need to make lifestyle changes after surgery. Medications are prescribed routinely after coronary bypass surgery to lower your blood cholesterol, reduce the risk of developing a blood clot and help your heart work as well as possible.

Physical Exam and Diagnostic Tests

To decide whether you’re a candidate for CABG, your doctor will do a physical exam. He or she will check your cardiovascular system, focusing on your heart, lungs, and pulse.

Your doctor also will ask you about any symptoms you have, such as chest pain or shortness of breath. He or she will want to know how often and for how long your symptoms occur and how severe they are.

Tests will be done to find out which arteries are clogged, how much they’re clogged, and whether there’s any heart damage.

EKG (Electrocardiogram)

An EKG is a simple test that detects and records your heart’s electrical activity. This test is used to help detect and locate the source of heart problems.

An EKG shows how fast your heart is beating and its rhythm (steady or irregular). It also records the strength and timing of electrical signals as they pass through each part of your heart.

Stress Test

Some heart problems are easier to diagnose when your heart is working hard and beating fast. During stress testing, you exercise (or are given medicine if you’re unable to exercise) to make your heart work hard and beat fast while heart tests are done.

These tests may include nuclear heart scanning, echocardiography, and magnetic resonance imaging (MRI) and positron emission tomography (PET) scanning of the heart.

Echocardiography

Echocardiography (EK-o-kar-de-OG-ra-fee), or echo, uses sound waves to create a moving picture of your heart. The test provides information about the size and shape of your heart and how well your heart’s chambers and valves are working.

The test also can identify areas of poor blood flow to the heart, areas of heart muscle that aren’t contracting normally, and previous injury to the heart muscle caused by poor blood flow.

There are several types of echo, including stress echo. This test is done both before and after a stress test. A stress echo usually is done to find out whether you have decreased blood flow to your heart, a sign of CHD.

Coronary Angiography

Coronary angiography uses dye and special x rays to show the insides of your coronary (heart) arteries. During the test, a long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck.

The tube is then threaded into your coronary arteries, and the dye is injected into your bloodstream. Special x rays are taken while the dye is flowing through your coronary arteries.

The dye lets your doctor study the flow of blood through your heart and blood vessels. This helps your doctor find blockages that can cause a heart attack.

Risks

Because coronary bypass surgery is an open-heart surgery, you might have complications during or after your procedure. Possible complications include:

• Bleeding
• An irregular heart rhythm
• Infections of the chest wound
• Memory loss or trouble thinking clearly, which often improves within six to 12 months
• Kidney problems
• Stroke
• Heart attack, if a blood clot breaks loose soon after surgery

Your risk of developing complications is generally low, but it depends on your health before surgery. Your risk of complications is higher if the surgery is done as an emergency procedure or if you have other medical conditions, such as emphysema, kidney disease, diabetes or blocked arteries in your legs.

How you prepare

Your doctor will give you specific instructions about activity restrictions and changes in your diet or medications that you should make before surgery.

Make arrangements for assistance after your surgery. It will take about four to six weeks for you to recover to the point where you can resume driving, return to work and perform daily chores.

What you can expect

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Before the procedure

If your coronary bypass surgery isn’t performed as emergency surgery, you’ll likely be admitted to the hospital the morning of the surgery.

During the procedure

Coronary bypass surgery generally takes between three and six hours and requires general anesthesia. The number of bypasses you need depends on where in your heart and how severe your blockages are.

For general anesthesia, a breathing tube is inserted through your mouth. This tube attaches to a ventilator, which breathes for you during and immediately after the surgery.

Most coronary bypass surgeries are done through a long incision in the chest while a heart-lung machine keeps blood and oxygen flowing through your body. This is called on-pump coronary bypass surgery.

The surgeon cuts down the center of the chest along the breastbone and spreads open the rib cage to expose the heart. After the chest is opened, the heart is temporarily stopped with medication and a heart-lung machine takes over to circulate blood to the body.

The surgeon takes a section of healthy blood vessel, often from inside the chest wall or from the lower leg, and attaches the ends above and below the blocked artery so that blood flow is redirected around the narrowed part of the diseased artery.

Other surgical techniques your surgeon might use include:

• Off-pump or beating-heart surgery. This procedure involves doing surgery on the beating heart using special equipment to stabilize the area of the heart the surgeon is working on. This type of surgery is challenging because the heart is still moving. It’s not an option for everyone.
• Minimally invasive surgery. A surgeon performs coronary bypass through small incisions in the chest, often with the use of robotics and video imaging that help the surgeon operate in a small area. Variations of minimally invasive surgery might be called port-access or keyhole surgery.

After completing the graft, the surgeon will restore your heartbeat, disconnect you from the heart-lung machine and use wire to close your chest bone. The wire will remain in your body after the bone heals.

After the procedure

Expect to spend a day or two in the intensive care unit. The breathing tube will remain in your throat until you are awake and able to breathe on your own.

Cardiac rehabilitation often begins while you’re still in the hospital. You’ll be given an exercise and education program designed to help you recover. You’ll continue with monitored programs in an outpatient setting until you can safely follow a home-based maintenance program.

Barring complications, you’ll likely be discharged from the hospital within a week. You still might have difficulty doing everyday tasks or walking a short distance. If, after returning home, you have any of the following signs or symptoms, call your doctor:

• Fever
• Rapid heart rate
• New or worsened pain around your chest wound
• Reddening around your chest wound or bleeding or other discharge from your chest wound

Expect a recovery period of about six to 12 weeks. If you have your doctor’s OK, you can return to work, begin exercising and resume sexual activity after four to six weeks.

Results

After surgery, most people feel better and might remain symptom-free for as long as 10 to 15 years. Over time, however, it’s possible that other arteries or even the new graft used in the bypass will become clogged, requiring another bypass or angioplasty.

Your results and long-term outcome will depend in part on taking your medications to prevent blood clots, lower blood pressure, lower cholesterol and help control diabetes. It’s also important to follow healthy-lifestyle recommendations, including these:

• Stop smoking.
• Follow a healthy-eating plan, such as the DASH diet.
• Achieve and maintain a healthy weight.
• Exercise regularly.
• Manage stress.

Recovery in the Hospital

After surgery, you’ll typically spend 1 or 2 days in an intensive care unit (ICU). Your heart rate, blood pressure, and oxygen levels will be checked regularly during this time.

An intravenous line (IV) will likely be inserted into a vein in your arm. Through the IV line, you may get medicines to control blood circulation and blood pressure. You also will likely have a tube in your bladder to drain urine and a tube to drain fluid from your chest.

You may receive oxygen therapy (oxygen given through nasal prongs or a mask) and a temporary pacemaker while in the ICU. A pacemaker is a small device that’s placed in the chest or abdomen to help control abnormal heart rhythms.

Your doctor may recommend that you wear compression stockings on your legs as well. These stockings are tight at the ankle and become looser as they go up the leg. This creates gentle pressure up the leg. The pressure keeps blood from pooling and clotting.

While in the ICU, you’ll also have bandages on your chest incision (cut) and on the areas where an artery or vein was removed for grafting.

After you leave the ICU, you’ll be moved to a less intensive care area of the hospital for 3 to 5 days before going home.

Recovery at Home

Your doctor will give you specific instructions for recovering at home, especially concerning:

• How to care for your healing incisions
• How to recognize signs of infection or other complications
• When to call the doctor right away
• When to make followup appointments

You also may get instructions on how to deal with common side effects from surgery. Side effects often go away within 4 to 6 weeks after surgery, but may include:

• Discomfort or itching from healing incisions
• Swelling of the area where an artery or vein was removed for grafting
• Muscle pain or tightness in the shoulders and upper back
• Fatigue (tiredness), mood swings, or depression
• Problems sleeping or loss of appetite
• Constipation
• Chest pain around the site of the chest bone incision (more frequent with traditional CABG)

Full recovery from traditional CABG may take 6 to 12 weeks or more. Less recovery time is needed for nontraditional CABG.

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role of physiotherapy

Cardiac rehabilitation program

Cardiac rehabilitation programs aim to limit the psychological and physiological stresses of CVD, reduce the risk of mortality secondary to CVD, and improve cardiovascular function to help patients achieve their highest quality of life possible. Accomplishing these goals is the result of improving overall cardiac function and capacity, halting or reversing the progression of atherosclerotic disease, and increasing the patient’s self-confidence through gradual conditioning

CR ere the process by which patients with cardiac disease, in partnership with a multidisciplinary team of health professionals are encouraged to support and achieve and maintain optimal physical and psychosocial health. The involvement of partners, other family members, and carers is also important”

They require a team approach, including a multidisciplinary the multidisciplinary team including:

• Cardiologist/Physician and co-coordinator to lead cardiac rehabilitation
• Clinical Nurse Specialist
• Physiotherapist
• Clinical nutritionist/Dietitian
• Occupational Therapist
• Pharmacist
• Psychologist
• Smoking cessation counselor/nurse
• Social worker
• Vocational counselor
• Clerical Administration

It is essential that all cardiac rehabilitation staff have appropriate training, qualifications, skills, and competencies to practice within their scope of practice and recognise and respect the professional skills of all other disciplines involved in providing comprehensive cardiac rehabilitation. The cardiac rehabilitation team should actively engage and effectively link with the general practitioner and practice nurses, sports and leisure industry where phase IV is conducted, community pharmacists and other relevant bodies to create a long-term approach to CVD management.

Indication

Cardiac rehabilitation should be offered to all cardiac patients who would benefit:

• Recent myocardial infarction
• Acute coronary artery syndrome
• Chronic stable angina
• Congestive heart failure
• After coronary artery bypass surgery
• After a percutaneous coronary intervention
• Valvular surgery
• Cardiac transplantation

CR begins as soon as possible in intensive care units (only if the patient is in stable medical condition). Intensity of rehabilitation depends on the patient’s condition and complications in the acute phase of disease. Randomized controlled trials and systematic analysis show that early mobilization improved physical function (distance walked during the 6-min walking test improved by 54 m) at the discharge in patients after cardiac surgery. Another prospective randomized clinical trial improved postoperative functional capacity (6-minute walk test) shorten the duration of mechanical ventilation, dependence on oxygen therapy, and reduced the time of hospital stay in patients who underwent elective Coronary artery bypass graft surgery.

Goals of Cardiac Rehabilitation

Comprehensive cardiac rehabilitation program should contain specific core components.

These components should optimize cardiovascular risk reduction, reduce disability, encourage active and healthy lifestyle changes, and help maintain those healthy habits after rehabilitation is complete. Cardiac rehabilitation programs should focus on:

• Patient assessment nutritional counseling
• Weight management
• Blood pressure management
• Lipid management
• Diabetes management
• Tobacco cessation
• Psychosocial management
• Physical activity counseling
• Exercise training

Individual Risk Assessment

CR can be tailored to meet individual needs thus a thorough assessment and evaluation of the CV risk factor profile of the patient should be undertaken at the beginning of the programme. This should be accompanied by ongoing assessment and reassessment throughout and upon completion of the programme.

Phases of Cardiac Rehabilitation

Cardiac rehabilitation consists of 3 phases.

Phase I: Clinical phase

This phase begins in the inpatient setting soon after a cardiovascular event or completion of an intervention. It begins by assessing the patient’s physical ability and motivation to tolerate rehabilitation. Therapists and nurses may start by guiding patients through non-strenuous exercises in the bed or at the bedside, focusing on a range of motion and limiting hospital deconditioning. The rehabilitation team may also focus on activities of daily living (ADLs) and educate the patient on avoiding excessive stress. Patients are encouraged to remain relatively rested until completion of treatment of comorbid conditions, or post-operative complications. The rehabilitation team assesses patient needs such as assistive devices, patient and family education, as well as discharge planning.

Phase II: Outpatient cardiac rehab

Once a patient is stable and cleared by cardiology, outpatient cardiac rehabilitation may begin. Phase II typically lasts three to six weeks though some may last up to up to twelve weeks. Initially, patients have an assessment with a focus on identifying limitations in physical function, restrictions of participation secondary to comorbidities, and limitations to activities. A more rigorous patient-centered therapy plan is designed, comprising three modalities: information/advice, tailored training program, and a relaxation program. The treatment phase intends to promote independence and lifestyle changes to prepare patients to return to their lives at home.

Phase III: Post-cardiac rehab. Maintenance

This phase involves more independence and self-monitoring. Phase III centers on increasing flexibility, strengthening, and aerobic conditioning.

Goal: facilitate long term maintenance of lifestyle changes, monitoring risk factor changes and secondary prevention.

Options:

• Educational sessions
• Support groups
• Telephone follow up
• Review in clinics
• Outreach programmes
• Exercise program organised by qualified phase IV gym instructor
• Links with GP and primary health care team
• Ongoing involvement of partners/spouses/family

A randomized controlled study shows positive outcomes with the internet-based remote home-based cardiac rehabilitation program

NB There is also a pre-surgery phase, where the patient starts cardiovascular rehabilitation. A small number of studies demonstrate that the post-surgical pathway is better tolerated by patients.

Warm-Up

Purpose: Prepare the body for exercise by raising the pulse rate in a graduated and safe way

Effects:

• redistributes blood to active tissues
• increases muscle temperature and speed of muscle action and relaxation
• prepares the mind
• prepares the muscle for the ROM involved for the conditioning period

Should include pulse raising activities (5 minutes) eg) marching on the spot, walking, low-level cycle followed by stretching of the major muscle groups (5 mins) followed by more pulse raising activity.

NB: should try to keep feet moving at all times to maintain HR and body temp and avoid pooling.

Main Class

For group rehab circuit training seems most popular. Depending on CV status and functional capacity patients may adopt an interval or continuous approach to the circuit.

Separate stations are set out and participants spend a fixed amount of time at each aerobic station (30secs-2mins) before moving onto the next station which may be rest or active recovery in the form of resistance work targeted at specific muscle groups.

Resistance work as set out by ACSM 2006 – 10-15 reps to moderate fatigue of 8-10 exercises.

Individualisation of the CV component can be achieved by varying; duration spent at each CV station, intensity (increase resistance, speed or ROM), period of rest, overall duration of the class

Cool Down

10 minutes at the end

Goal: bring the body back to its resting state

Should incorporate movements of diminishing intensity and passive stretching of the major muscle groups.

Necessary because of;

• Increased risk of hypotension
• Older hearts take longer to return to resting levels
• Raised sympathetic activity during exercise increases the risk of arrhythmias immediately post exercise.

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“Surgery” means a procedure performed for the purpose of structurally altering the human body by incision or destruction of tissues and is part of the practice of medicine for the diagnostic or therapeutic treatment of conditions or disease processes.

• Surgery can be done by any instruments causing localized alteration or transportation of live human tissue, which include lasers, ultrasound, ionizing radiation, scalpels, probes, and needles.
• During surgery the tissue can be cut, burned, vaporized, frozen, sutured, probed, or manipulated by closed reduction for major dislocation and fractures, or otherwise altered by any mechanical, thermal, light-based, electromagnetic, or chemical means.
• Injection of diagnostic or therapeutic substances into body cavities, internal organs, joints, sensory organs, and the central nervous system is also considered to be surgery

Anaesthetics

An anaesthetic is a drug or agent that produces a complete or partial loss of feeling. There are three kinds of anaesthetic: general, regional and local.

General Anaesthetic

A qualified anaesthetist administers the general anaesthetic (intravenously or by gas mask, or both).

• After a few seconds the client becomes unconscious.
• The anaesthetist then inserts a small tube connected to a ventilator into the airway (an endotracheal tube is usually used) or a laryngeal mask.
• The anaesthetist controls the length of time patient is asleep, and constantly monitors pulse, breathing and blood pressure.
• If necessary, the anaesthetist will administer intravenous fluids before, during and after surgery.
• Once the surgery is over other drugs may be injected that will reverse the effect of the anaesthetic and any other drugs used during the operation (such as muscle relaxant).

Complications from general anaesthetic are rare. It is estimated that around one in every 10,000 people undergoing general anaesthetic die from an unforeseen complication, such as an allergic reaction or a heart attack.

Regional and Local Anaesthetics

Depending on the type of surgery, alternatives to general anaesthetic can include:

1. Regional anaesthetic – or ‘nerve block’. eg, a woman giving birth by caesarean section may have an epidural (an injection into the spine that numbs the body from the waist down).
2. Local anaesthetic – anaesthetic is injected into the immediate area to be operated on.eg a dentist may inject local anaesthetic into the gum before removing a tooth.

Surgical Epidemiology

Surgical approaches are receiving increasing attention as a way to solve many global public health problems. Surgery can play a vital role in helping countries meet their Millennium Development Goals 4, 5 and 6.3

What is surgical epidemiology? Unfortunately, there is not yet an agreed definition for this field. Definitional issues and challenges are greater in developing countries, where WHO wish to encourage the debate on surgical epidemiology. To improve the evidence base for surgery as a cost-effective intervention in developing countries, epidemiologists and surgeons must work together to agree upon a vocabulary and set of definitions. As the saying goes, the eye cannot see what the mind does not know.

Why Physical Therapy Is Important Before You Have Surgery?

It is easy to see why physical therapy is important after surgery. Not only can it help minimize the development of scar tissue around the wound, it can also help a person heal faster and return to full mobility. It may be a little more difficult to see why you need physical therapy before surgery, but participating in it before going under the knife may be even more beneficial in the long run.

Pre-Operative Physical Therapy Reduces Recovery Time

A recent study revealed that pre-operative physical therapy reduces post-operative care by as much as 29 percent in patients who have a total knee or total hip replacement. Not only does this translate to a significant cost savings, it also means recovery time is shortened. Best part? You can see results in as few as one to two pre-operative physical therapy sessions.

In cases of a total knee or total hip replacement, pre-operative physical therapy sessions tend to focus less on building muscle or improving flexibility and more on training on walkers, planning for recovery and teaching patients basic exercises they will perform after surgery.

Pre-Operative Physical Therapy Can Shorten Hospitalization

Patients who are prone to complications after surgery or who are at a high probability for transfer to an acute care rehabilitation facility can shorten the length of their stay with pre-operative physical therapy. From joint replacement to cardio-thoracic surgery, low intensity exercise, under the guidance of a physical therapist, improves circulation which in turn speeds the body’s healing response.

Likewise, patients who build muscle in their core, arms, legs, and back are less likely to experience large amounts of atrophy during their recovery. Such atrophy often delays a patient’s return home even if they are healing well. Even a patient’s balance can be improved before surgery, diminishing the likelihood of falling afterward, which could result in longer hospital stays. 

Pre-Operative Physical Therapy May Prevent Surgery Altogether

Even though pre-operative physical therapy meets a different objective than post-operative physical therapy, working with a therapist before surgery may yield a shocking result. You may not need surgery. While this is not the case with patients who are planning for total joint replacement, physical therapy may help soft tissue injuries heal while restoring function without going under the knife. People tend to think of PT as something you do after surgery.

In reality, physical therapists are experts in restoring movement and function throughout the body, with or without surgical intervention. If you are planning to have surgery on any soft tissues in your body, give pre-operative physical therapy a try first. You may be surprised by your results.

From improving recovery times and shortening hospital stays to improving function and healing of soft tissue injuries, pre-operative physical therapy is a vital key to returning you to activity. If you are in the process of scheduling elective surgery.

Why is Physical Therapy Important After Surgery?

We may not always realize it, but any kind of major surgery is a big deal. It can leave patients weak, immobilized, in pain, and sometimes depressed. Everyone’s goal is to recover quickly and completely, so that they can get back to the meaningful activities they love. More and more, doctors and patients are realizing that physical therapy is one of the most important parts of a healthy and successful outcome after surgery.

What Are The Benefits Of Physical Therapy After Surgery?

The benefits of physical therapy after surgery are increasingly backed up by scientific studies. Getting patients moving is key to a healthy recovery. Physical therapy helps patients regain mobility and recover faster, and it ensures that any replacements or repairs made during surgery heal properly.  Physical therapy is also an excellent option for managing pain and helps many patients avoid or limit opioid medications.

Getting Moving After Surgery Is Key

A National Institutes of Health (NIH) study specifically looking at seniors showed that lack of movement after surgery causes loss of function, muscle weakness, and increases postoperative complications. When patients stay in bed following surgery, they lose muscle strength and heart and lung capacity because of a lack of physical activity. One of the best solutions to this problem is a carefully planned and supervised physical therapy program.

Physical therapy helps patients regain strength and return to daily activity sooner by pushing them to move in a safe environment with the assistance of trained professionals. In the case of seniors, this can help them stay independent and even live longer,

Physical therapy also helps patients manage pain safely, without turning to opioids. And physical activity can have a positive effect on patients’ emotional and psychological state. Exercise does, after all, release endorphins that help create a sense of well being while enhancing your overall mood.

Who Are Candidates For Post-Surgery Physical Therapy?

Physical therapy is a post-surgery boost following many procedures, including:

• Joint replacement surgery: For knee, hip and shoulder replacement surgeries, the NIH recommends early and intense physical therapy tailored to the patient’s needs under the supervision of a trained therapist. This helps patients regain mobility faster and get back to their routine.
• ACL and Meniscus repair: Physical therapy is a must following repair to the ACL knee ligament (often a problem for athletes) along with tears to the meniscal cartilage. Studies show that patients can heal faster and avoid re-injury by building quadriceps and hamstring strength.
• Back surgery: Because of the especially delicate nature of a spinal fusion or disk surgery, this is one case where supervised physical therapy is essential. Your therapist will help you with gentle stretches and exercises to get the blood flowing and gradually work up to daily activities.
• Heart attack/bypass surgery: Physical therapy can prevent cardiopulmonary complications by giving patients a safe opportunity to move. The ability to get supervised low-impact, gradual exercise improves health and can reduce the length of the patient’s hospital stay.

What Should I Expect From Physical Therapy After Surgery?

Most doctors are now recommending that physical therapy start immediately after surgery. You’ll begin with simple exercises involving flexing and stretching and move on to more intense exercise as you recover. Part of your therapist’s job is to safely push you to make progress even when you don’t think you can! Some of the most common types of physical therapy techniques include:

• Range of motion exercises including knee extensions, moving from sitting to standing and circling joints
• Strengthening exercises including leg raises, hamstring and quadriceps contractions, squats using a chair
• Stretching exercises in both a seated and standing position
• Walking and other low-impact cardiovascular exercises, including using an exercise bike. Sometimes after major surgery, just taking a few steps is a big deal, and the sense of accomplishment patients feel as they progress goes a long way in moving recovery forward.

Advances in Surgery

• Lasers became widely used to destroy tumours and other pigmented lesions, some of which are inaccessible by conventional surgery. They are also used to surgically weld detached retinas back in place and to coagulate blood vessels to stop them from bleeding. 
• Stereotaxic surgery uses a three-dimensional system of coordinates obtained by X-ray photography to accurately focus high-intensity radiation, cold, heat, or chemicals on tumours located deep in the brain that could not otherwise be reached. 
• Cryosurgery uses extreme cold to destroy warts and precancerous and cancerous skin lesions and to remove cataracts
• Some traditional techniques of open surgery were replaced by the use of a thin flexible fibre-optic tube equipped with a light and a video connection; the tube, or endoscope, is inserted into various bodily passages and provides views of the interior of hollow organs or vessels. Accessories added to the endoscope allow small surgical procedures to be executed inside the body without making a major incision.

Major Categories of Surgery

There are four major categories of surgery:

1. Wound treatment: centred on procuring good healing and the avoidance of infection
2. Extirpative surgery: involves the removal of diseased tissue or organs. Cancer surgery usually falls into this category, with mastectomy, cholecystectomy (removal of the gallbladder), and hysterectomy among the most frequent procedures.
3. Reconstructive surgery: deals with the replacement of lost tissues, whether from fractures, burns, or degenerative-disease processes, and is especially prominent in the practice of plastic surgery and orthopedic surgery eg the use of metal in reconstructing hip joints (THR) and the use of plastic valves to replace heart valves.
4. Transplantation surgery: the use of organs transplanted from other bodies to replace diseased organs in patients. Kidneys are the most commonly transplanted organs

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An anal fissure is a small tear in the thin, moist tissue (mucosa) that lines the anus. An anal fissure may occur when you pass hard or large stools during a bowel movement. Anal fissures typically cause pain and bleeding with bowel movements. You also may experience spasms in the ring of muscle at the end of your anus (anal sphincter).

Anal fissures are very common in young infants but can affect people of any age. Most anal fissures get better with simple treatments, such as increased fiber intake or sitz baths. Some people with anal fissures may need medication or, occasionally, surgery.

An anal fissure is a small cut or tear in the lining of the anus. The crack in the skin causes severe pain and some bright red bleeding during and after bowel movements. At times, the fissure can be deep enough to expose the muscle tissue underneath.

An anal fissure usually isn’t a serious condition. It can affect people of all ages, and it’s often seen in infants and young children since constipation is a common problem in these age groups.

In most cases, the tear heals on its own within four to six weeks. In cases where the fissure persists beyond eight weeks, it’s considered chronic.

Certain treatments can promote healing and help relieve discomfort, including stool softeners and topical pain relievers.

If an anal fissure doesn’t improve with these treatments, you may need surgery. Or your doctor may need to look for other underlying disorders that can cause anal fissures.

causes

An anal fissure most often occurs when passing large or hard stools. Chronic constipation or frequent diarrhea can also tear the skin around your anus. Other common causes include:

• straining during childbirth or bowel movements
• inflammatory bowel disease (IBD), such as Crohn’s disease
• decreased blood flow to the anorectal area
• overly tight or spastic anal sphincter muscles

In rare cases, an anal fissure may develop due to:

• anal cancer
• HIV
• tuberculosis
• syphilis
• herpes

Symptoms

Signs and symptoms of an anal fissure include:

• Pain, sometimes severe, during bowel movements
• Pain after bowel movements that can last up to several hours
• Bright red blood on the stool or toilet paper after a bowel movement
• A visible crack in the skin around the anus
• A small lump or skin tag on the skin near the anal fissure

When to see a doctor

See your doctor if you have pain during bowel movements or notice blood on stools or toilet paper after a bowel movement.

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Risk factors

Factors that may increase your risk of developing an anal fissure include:

• Constipation. Straining during bowel movements and passing hard stools increase the risk of tearing.
• Childbirth. Anal fissures are more common in women after they give birth.
• Crohn’s disease. This inflammatory bowel disease causes chronic inflammation of the intestinal tract, which may make the lining of the anal canal more vulnerable to tearing.
• Anal intercourse.
• Age. Anal fissures can occur at any age, but are more common in infants and middle-aged adults.

Complications

Complications of anal fissure can include:

• Failure to heal. An anal fissure that fails to heal within eight weeks is considered chronic and may need further treatment.
• Recurrence. Once you’ve experienced an anal fissure, you are prone to having another one.
• A tear that extends to surrounding muscles. An anal fissure may extend into the ring of muscle that holds your anus closed (internal anal sphincter), making it more difficult for your anal fissure to heal. An unhealed fissure can trigger a cycle of discomfort that may require medications or surgery to reduce the pain and to repair or remove the fissure.

diagnosis

A doctor can usually diagnose an anal fissure simply by examining the area around the anus. However, they may want to perform a rectal exam to confirm the diagnosis.

During this exam, the doctor may insert an anoscope into your rectum to make it easier to see the tear. This medical instrument is a thin tube that allows doctors to inspect the anal canal.

Using an anoscope may also help your doctor find other causes of anal or rectal pain such as hemorrhoids. In some cases of rectal pain, you may need an endoscopy for better evaluation of your symptoms.

treatment

Most anal fissures don’t require extensive treatment. However, certain home remedies can help promote healing and relieve uncomfortable symptoms. You can treat an anal fissure at home by:

• using over-the-counter stool softeners
• drinking more fluids
• taking fiber supplements and eating more fibrous foods, such as raw fruits and vegetables
• taking a sitz bath to relax the anal muscles, relieve irritation, and increase blood flow to the anorectal area
• applying a nitroglycerin ointment to promote blood flow to the area or a hydrocortisone cream, such as Cortizone 10, to help with inflammation
• applying topical pain relievers, such as lidocaine, to the anus to ease discomfort

If your symptoms aren’t relieved within two weeks of treatment, see your doctor for further evaluation. Your doctor can make sure you have the correct diagnosis and can recommend other treatments.

A calcium channel blocker ointment can relax the sphincter muscles and allow the anal fissure to heal.

Another possible treatment is Botox injections into the anal sphincter. The injections will prevent spasms in your anus by temporarily paralyzing the muscle. This allows the anal fissure to heal while preventing new fissures from forming.

If your anal fissure fails to respond to other treatments, your doctor may recommend an anal sphincterotomy. This surgical procedure involves making a small incision in the anal sphincter to relax the muscle. Relaxing the muscle allows the anal fissure to heal.

Not all anal fissures are a sign of low-fiber diets and constipation. Poorly healing fissures or those located in a position other than the posterior and midline portion of your anus may indicate an underlying condition.

prevention

An anal fissure can’t always be prevented, but you can reduce your risk of getting one by taking the following preventive measures:

• keeping the anal area dry
• cleansing the anal area gently with mild soap and warm water
• drinking plenty of fluids, eating fibrous foods, and exercising regularly to avoid constipation
• treating diarrhea immediately
• changing infants’ diapers frequently

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Epidermoid cysts are small, lumps that develop under the skin. However, this isn’t the correct term for these types of growths. They don’t cause other symptoms and are never cancerous.

Epidermoid cysts are often found on the head, neck, back, or genitals. They range in size from very small (millimeters) to inches across. They look like a small bump, and the overlying skin can be skin-colored, whitish, or yellowish in color.

They’re filled with cheesy-like, white keratin debris. They’re typically painless. Although, they can become inflamed and irritated. They don’t require removal unless bothersome or the diagnosis is in question.

Dermoid cysts (also called epidermoid cysts or dermal/epidermal inclusion cysts) are masses, in children and adults, most commonly found in the:

• Head
• Face
• Neck
• Upper chest

Dermoid cysts are the most common orbital/periorbital tumors found in the pediatric population. They are slow growing, cystic masses, lined by skin and filled with oil and old skin cells.

The term dermoid cysts is used to describe:

• Simple, skin-lined cysts under the skin
• Cysts with hair follicles
• Deeper neck cysts with similar contents of oil, skin, and/or hair follicles

The term dermoid cyst is also sometimes used to describe more complex cystic tumors found in the ovaries of women (teratomas) which are a completely different medical condition not treated in Interventional Radiology.

causes of epidermoid cysts

Buildup of trapped keratin usually causes epidermoid cysts. Keratin is a protein that occurs naturally in skin cells. Cysts develop when the protein is trapped below the skin because of disruption to the skin or to a hair follicle.

These cysts may develop for a number of reasons, but trauma to the skin is typically thought to be the main cause. When numerous, an underlying genetic disorder such as Gardner syndrome may be the cause.

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How are epidermoid cysts diagnosed?

To diagnose epidermoid cysts, your healthcare provider will examine the bump and surrounding skin, as well as request your medical history. They’ll ask for details on how long the bump has been present and whether it has changed over time.

Healthcare providers can usually diagnose an epidermoid cyst by examination only, but sometimes an ultrasound or a referral to a dermatologist is needed to confirm the diagnosis.

What are the Symptoms of a Dermoid Cyst?

A dermoid cyst usually presents as a painless “mass,” or lump, that is felt in the affected area. Dermoid cysts near the eye may produce pressure on the eyeball resulting in pain and visual problems.

The easiest way to think of a dermoid cyst is “skin being trapped” under the surface in the affected area during fetal development. Just like skin elsewhere in the body that normally produces oil and sheds old cells, the skin trapped in a dermoid continues to make these things which collect and form a cyst or “bubble” under the surface.

Very slowly more oil and old skin cells accumulate within the cyst and the dermoid cyst enlarges. If a dermoid cyst grows into the bone (most often the skull), the hole in the affected bone also grows as the cyst enlarges.

How are epidermoid cysts treated?

Epidermoid cysts typically don’t go away completely on their own, although they may shrink to an unnoticeable size and then grow again. Thus, a dermatologist’s surgical intervention is needed to resolve the condition.

Since epidermoid cysts aren’t dangerous, they don’t pose a health risk. Many are never treated.

If the cyst becomes red, swollen, or painful, changes in size or character, or becomes infected, treatment may be desired. In such cases, treatment options typically include antibiotics. Sometimes the cyst may also be drained or injected with a steroid solution.

If you want complete resolution of the cyst, you’ll typically need to have it surgically removed. Usually, this is delayed to a later date if the cyst is currently inflamed.

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Boils are bacterial infections that form under your skin at a hair follicle. A carbuncle is a cluster of boils that have multiple pus “heads.” They’re tender and painful, and cause a severe infection which could leave a scar. A carbuncle is also called a staph skin infection.

A boil is a painful, pus-filled bump that forms under your skin when bacteria infect and inflame one or more of your hair follicles. A carbuncle is a cluster of boils that form a connected area of infection under the skin.

Boils (furuncles) usually start as red, tender bumps. The bumps quickly fill with pus, growing larger and more painful until they rupture and drain. Areas most likely to be affected are the face, back of the neck, armpits, thighs and buttocks.

You can usually care for a single boil at home. But don’t attempt to prick or squeeze it — that may spread the infection.

A skin abscess happens when pus collects in hair follicles, skin tissues, or under the skin. A furuncle, also known as a boil, is a painful infection that forms around a hair follicle and contains pus.

A carbuncle is collection of boils that develop under the skin. When bacteria infect hair follicles, the follicles can swell and turn into boils and carbuncles.

A furuncle starts as a red lump. It may be tender. The lump rapidly fills with pus, and as it grows it may burst.

Furuncles, boils, and carbuncles typically affect the thighs, armpits, buttocks, face, and neck.

Individuals with weakened immune systems, adolescents, and young adults are more susceptible to furuncles than younger children or older adults.

causes

S. aureus, also known as staph bacteria, live on the skin and inside the nose and throat.

Usually, the body’s immune system keeps them under control, but sometimes they enter the skin through a hair follicle, or through a cut or graze in the skin.

When the skin becomes infected, the immune system responds by sending white blood cells to the affected area to destroy the bacteria. Pus is an accumulation of dead bacteria, dead white blood cells, and dead skin.

The following conditions increase the risk of developing furuncles:

• Diabetes: High levels of blood sugar, or glucose, can reduce the immune system’s ability to respond to infection.
• Medications: Some medications weaken the immune system.
• HIV and some other diseases: Certain conditions weaken the immune systems
• Skin conditions: Psoriasis, eczema, and acne increase susceptibility.

Obesity also increases the risk.

Often, the normal bacteria in a person’s nose or on their skin can lead to an abscess. Sometimes, however, the infection can spread when people share space, materials, or devices, such as clothing and whirlpool footbaths.

Symptoms

Boils

Boils can occur anywhere on your skin, but appear mainly on the face, back of the neck, armpits, thighs and buttocks — hair-bearing areas where you’re most likely to sweat or experience friction. Signs and symptoms of a boil usually include:

• A painful, red bump that starts out small and can enlarge to more than 2 inches (5 centimeters)
• Red, swollen skin around the bump
• An increase in the size of the bump over a few days as it fills with pus
• Development of a yellow-white tip that eventually ruptures and allows the pus to drain out

Carbuncles

A carbuncle is a cluster of boils that form a connected area of infection. Compared with single boils, carbuncles cause a deeper and more severe infection and are more likely to leave a scar. People who have a carbuncle often feel unwell in general and may experience a fever and chills.

When to see a doctor

You usually can care for a single, small boil yourself. But see your doctor if you have more than one boil at a time or if a boil:

• Occurs on your face or affects your vision
• Worsens rapidly or is extremely painful
• Causes a fever
• Gets bigger despite self-care
• Hasn’t healed in two weeks
• Recurs

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Risk factors

Although anyone — including otherwise healthy people — can develop boils or carbuncles, the following factors can increase your risk:

• Close contact with a person who has a staph infection. You’re more likely to develop an infection if you live with someone who has a boil or carbuncle.
• Diabetes. This disease can make it more difficult for your body to fight infection, including bacterial infections of your skin.
• Other skin conditions. Because they damage your skin’s protective barrier, skin problems, such as acne and eczema, make you more susceptible to boils and carbuncles.
• Compromised immunity. If your immune system is weakened for any reason, you’re more susceptible to boils and carbuncles.

Complications

Rarely, bacteria from a boil or carbuncle can enter your bloodstream and travel to other parts of your body. The spreading infection, commonly known as blood poisoning (sepsis), can lead to infections deep within your body, such as your heart (endocarditis) and bone (osteomyelitis).

diagnosis

Your doctor can usually diagnose a carbuncle by looking at your skin. A pus sample may also be taken for lab analysis.

It’s important to keep track of how long you’ve had the carbuncle. Tell your doctor if it’s lasted longer than two weeks. You should also mention if you’ve had the same symptoms before.

If you keep developing carbuncles, it may be a sign of other health issues, such as diabetes. Your doctor may want to run urine or blood tests to check your overall health.

Prevention

It’s not always possible to prevent boils, especially if you have a weakened immune system. But the following measures may help you avoid staph infections:

• Wash your hands regularly with mild soap. Or use an alcohol-based hand rub often. Careful hand-washing is your best defense against germs.
• Keep wounds covered. Keep cuts and abrasions clean and covered with sterile, dry bandages until they heal.
• Avoid sharing personal items. Don’t share towels, sheets, razors, clothing, athletic equipment and other personal items. Staph infections can spread via objects, as well as from person to person. If you have a cut or sore, wash your towels and linens using detergent and hot water with added bleach, and dry them in a hot dryer.

Lifestyle and home remedies

For small boils, these measures may help the infection heal more quickly and prevent it from spreading:

• Warm compresses. Apply a warm washcloth or compress to the affected area several times a day, for about 10 minutes each time. This helps the boil rupture and drain more quickly.
• Never squeeze or lance a boil yourself. This can spread the infection.
• Prevent contamination. Wash your hands thoroughly after treating a boil. Also, launder clothing, towels or compresses that have touched the infected area, especially if you have recurrent infections.

Medical treatment

Your doctor will use one or more of the following medical treatments to heal your carbuncle:

• Antibiotics. These are taken orally or applied to your skin.
• Pain relievers. Over-the-counter medications are typically sufficient.
• Antibacterial soaps. These may be suggested as part of your daily cleaning regimen.
• Surgery. Your doctor may drain deep or large carbuncles with a scalpel or needle.

You should never try to drain a carbuncle yourself. There’s a risk that you’ll spread the infection. You could also end up infecting your bloodstream.

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