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COMPLICATIONS OF CARDIOTHORACIC SURGERY

By its very nature cardiothoracic surgery is associated with several immediately

life threatening complications, as well as many common and major
complications. The fact that the benefits of cardiothoracic surgery outweigh the
risks in all but the most moribund of patients. results from recognition ofThis
attaches a lot of importance to the importance of adapting the management of
the procedure to avoid the most important complications, as well as
increasiincreased ng experience in recognising and treating the remaining
problems. This chapter describes the complications associated with
cardiothoracic surgery in three sections,: general, cardiac and thoracic.

1.General complicationsComplications

Respiratory compromiseCompromise

A thoracotomy causes more respiratory compromise than a median sternotomy.

The additional, specific respiratory problems of subsequent operation, e.g., lung
resection, and cardiopulmonary bypass, is are discussed in the relevant sections
below. After Following thoracic surgery pulmonary dysfunction is maximal for 24
hours post-operatively. (1). Seventy two hours post-operativelylater, the vital
capacity may be less than 50% of the pre-operative values (2),. It and takes two
weeks to return to normal. The Ttotal lung compliance falls by 25%, and dead
space is increased. Atelectasis is present in over 50% of the patients and is
associated with increased intrapulmonary shunts, and raised pulmonary vascular
resistance. Consequently, these Over 50% of patients consequently have a PaO2
(PaO2 what?) on when the room air of is less than 7.5 kPa. The Ffactors
contributing to these changes in pulmonary function can be classified as pre,
intra and postoperative. -operative, intra-operative and post-operative.
Important pre-operative risk factors for post-operative respiratory dysfunction
include sSmoking, recent respiratory infection, respiratory disease, commonly
obstructive airways disease, and obesity are some preoperative risk factors
responsible for postoperative respiratory dysfunction. The vast majority of
patients undergoing cardiac surgery and lung resection surgeriesy have a history
of smoking. Chronic smokers almost invariably have evidence of chronic
obstructive airways disease. Exertional dyspnoea, sputum production or wheeze
is associated with most (does this mean that of all postoperative pulmonary
complications, exertional dyspnoea, sputum production or wheeze are
associated with over 5 x ?% of cases? Its not very clear as it is right now. Maybe
you can give a percentage of cases where these conditions accompany the
complications) over five times the rate of post-operative pulmonary
complications, and a third of these patients will have pulmonary complications
requiring additional therapy. By Sgiving uptopping smoking eight weeks or more
before surgery, has been shown to reduce some of the chronic changes in the
bronchopulmonary tree are reduced and decrease the rate of pulmonary
complications decreases to less than 15%;, but pulmonary complications are
probably increased in patients who stop smoking less than eight weeks before
surgery. A recent respiratory infection is an indication for cancelling non-
emergency cardiac and lung resection surgery, as because increased or purulent
secretions can lead to atelectasis, pneumonia, bronchial plugging and eventual
occlusion of smaller endotracheal tubes requiring reintubation. These patients
are almost inevitably elderlygeriatric; : resting PaO2 decreases linearly with age
and patients over 75 years of age are at greater risk of pulmonary problems.

Obesity increases the risk of post-operative atelectasis.: in In the a morbidly

obese patient, sleep apnoea and chronic atelectasis may lead to pulmonary
hypertension, which contributes to postoperative respiratory insufficiency..
Pulmonary hypertension, which is present in up to a quarter25% of the patients
undergoing mitral valve surgery. , contributes to respiratory insufficiency post-
operatively.

The Cchoice of incision, opening the pleura and handling the lungs, and the use
of cardiopulmonary bypass have a major impact on respiratory function post-
operatively. Both median sternotomy and thoracotomy are associated with
decreased lung capacities post-operatively;: left left lower lobe collapse occurs in
over 50% of on-pump coronary bypass patients. The increased pain associated
with a thoracotomy further predisposes patients to atelectasis, and : an epidural
is a key part ofto improving postoperative respiratory function in the post-
operative period. Either The pleura may be opened deliberately or inadvertently
during surgery, and although the evidence is mixed as to whether this increases
the risk of post-operative atelectasis and effusions, increased handling of the
lung is probably detrimental. The Ddamage to either the phrenic nerve whileen
opening the chest, harvesting the internal mammary artery, creating a window in
the pleura, or using topical cooling