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Samenvatting Cardiochirurgie prof. François Problemen van hart en bloedvaten
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Samenvatting Cardiochirurgie prof. François Problemen van hart en bloedvaten AJ 23-24
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Prof. François AJ 23-24Inhoudsopgave Cardiochirurgie
1. Hartchirurgie: algemeen ........................................................................................................................ 3
1.1. Basiskennis: anatomie en fysiologie van het hart ................................................................................... 3
1.2. Cardiochirurgische ingrepen................................................................................................................... 5
1.2.1. Opera)etoegang .................................................................................................................................... 5
1.2.2. Extracorporele circula)e (ECC) ................................................................................................................ 5
1.2.3. Post-opera)eve complica)es na hartchirurgie ......................................................................................... 6
1.2.4. Postopera)ef verloop na hartopera)e ..................................................................................................... 8
2. Coronaire bypass ................................................................................................................................... 9
2.1. Coronairen: anatomie ............................................................................................................................ 9
2.2. AantasDng van de coronairen................................................................................................................. 9
2.3. Coronaire chirurgie .............................................................................................................................. 10
2.3.1. CABG ................................................................................................................................................... 10
2.4. PrevenDe op lange termijn ................................................................................................................... 13
3. Hartklepchirurgie ................................................................................................................................. 14
3.1. Hartkleppen: anatomie ........................................................................................................................ 14
3.2. Hartkleppen: afwijkingen ..................................................................................................................... 14
3.2.1. Stenose ................................................................................................................................................ 14
3.2.2. Insufficiën)e / regurgita)e.................................................................................................................... 15
3.3. Hartkleppen: chirurgische technieken .................................................................................................. 15
3.4. PreoperaDeve voorbereiding voor klepoperaDe ................................................................................... 16
3.5. Aortaklepstenose ................................................................................................................................. 17
3.6. AortaklepinsufficiënDe ......................................................................................................................... 18
3.7. MitralisklepinsufficiënDe ..................................................................................................................... 19
3.8. EndocardiDs van de hartkleppen .......................................................................................................... 21
1
,Prof. François AJ 23-24
4. Aortachirurgie...................................................................................................................................... 23
4.1. Aorta: anatomie................................................................................................................................... 23
4.2. Aortapathologie: aneurysma................................................................................................................ 23
4.3. Aortapathologie: dissecDe ................................................................................................................... 25
4.4. Diagnose aorta aneurysma/dissecDe ................................................................................................... 26
4.5. Behandeling aorta aneurysma/dissecDe .............................................................................................. 27
4.5.1. Medische behandeling .......................................................................................................................... 27
4.5.2. Open heelkunde.................................................................................................................................... 27
5. Chirurgische technieken bij harQalen ................................................................................................... 30
5.1. BehandelingsopDes bij harQalen .......................................................................................................... 31
5.1.1. IABP (Intra Aor)c Balloon Pump) ........................................................................................................... 31
5.1.2. ECMO (Extracorporeal Membrane Oxygena)on) / ECLS (Extracorporeal Life Support) ............................. 32
5.1.3. Steunhart / assist devices (heart mate, heartware, …) ............................................................................ 32
5.1.4. HarTransplanta)e ................................................................................................................................ 33
6. Chirurgie bij aangeboren hartafwijkingen ............................................................................................ 35
6.1. Behandeling aangeboren hartafwijkingen ............................................................................................ 35
6.1.1. Coarcta)o aortae ................................................................................................................................. 36
6.1.2. Septumdefecten ................................................................................................................................... 37
6.1.3. Tetralogie van Fallot (TOF) .................................................................................................................... 39
6.1.4. Transposi)e van de grote vaten (TGA) ................................................................................................... 40
6.2. Opvolging na chirurgie/intervenDe voor congenitale afwijkingen ......................................................... 41
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,Prof. François AJ 23-24
1. Hartchirurgie: algemeen
1.1. Basiskennis: anatomie en fysiologie van het hart
Anatomie:
• Hartspier
o Endocard (dun glad vlies)
o Myocard (dwarsgestreept spierweefsel)
o Epicard (dun vlies tegen pericard)
• Coronairen
o A. coronaria dextra
§ A. atrioventriculare
§ A. posterior descendens
o A. coronaria sinistra
§ A. circumflexa
§ LeI anterior descending artery (LAD)
• Kleppen
o AV-kleppen: mitralis- en tricuspidalisklep
o Aorta- en pulmonalisklep
• Geleiding
o Sinusknoop
o AV-knoop
o His bundel
o Linker- en rechterbundeltak (LAF en LPF)
o Purkinje vezels
• Normale circulaVe
o MacrocirculaVe
o MicrocirculaVe
o O2-transport
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, Prof. François AJ 23-24
Hartcyclus:
• Diastole:
o Hart ontspant zich en vult zich met bloed
o 2 fasen:
§ Passieve vulling (vulling atria)
§ Atriale contracVe/atriale kick + opening AV-kleppen (vulling ventrikels)
• Systole
o Hart trekt samen en ejecteert het bloed
o 2 fasen:
§ AV-kleppen sluiten
§ Ventriculaire contracVe + aorta- en pulmonalisklep openen
Normale hemodynamica:
• Drukken in het hart
o RA: 2-8 mmHg (CVD)
o LA: 2-10 mmHg
o RV: 15-30/2-8 mmHg
o LV: 100-140/3-12 mmHg
o Pulmonalis: 15-30/4-12 mmHg
o Aorta: 100-140/60-90 mmHg
• Hartdebiet / cardiac output (CO)
Bij ondervulling treedt VC op
o = slagvolume (+/-70 ml) x harbrequenVe è Systolische BP blij9 behouden
o ~ 5L/min maar het circulerend debiet is lager
o Aeankelijk van preload, aIerload en contracVliteit
o Hartdebiet zegt meer over vullingstoestand en circulaVe van de paVënt dan BP
o Cardiale index (CI) = CO/BSA
Frank-Starling mechanisme:
hartdebiet bij preload tot een bepaald plateau wordt bereikt
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