Cardiothoracic and Vascular Surgery

01Purpose and scope

• This manual supports the course Cardiothoracic and Vascular Surgery. It describes how the work is actually done by surgical teams that operate on the heart, great vessels, lungs, esophagus, and the arteries and veins outside the heart. It is written as a reference for surgical residents, perfusion staff, operating room nurses, physician assistants, and allied professionals who join these teams or need to understand their workflow.
• The field covers elective and emergency procedures such as coronary artery bypass grafting, valve repair and replacement, thoracic aortic repair, lung resection, carotid endarterectomy, peripheral bypass, and endovascular repair of aortic aneurysms. Some cases are done open, some through smaller incisions, and some through catheter-based access with surgical input in a hybrid room. This manual does not teach operative technique in detail. Technique is learned through supervised training, simulation, and approved institutional protocols.
• This guidance does not replace qualified professional judgment, approved procedures, credentialing requirements, or the authorization of the operating surgeon and institution. Clinical decisions belong to the treating team, and local policy governs who may perform, assist, or supervise each step.

02Core principles

• Patient selection comes before technique. A well executed operation on the wrong patient, at the wrong time, or without informed consent is still a poor result. Teams weigh anatomy, comorbidities, frailty, prior operations, and the patient's goals before committing to a plan.
• Work as a team with defined roles. Cardiothoracic and vascular cases involve surgeons, anesthesiologists, perfusionists, cardiac or vascular nurses, imaging specialists, and sometimes interventional cardiologists. Each person owns a specific set of checks, and a clear habit of speaking up during the case matters more than rank.
• Plan for the complication before it happens. Bleeding, arrhythmia, stroke, air or embolic events, prolonged ventilation, and acute kidney injury are predictable. Strong teams name the contingency before the incision, including blood product availability, conditions for converting to bypass, and access for rescue imaging.
• Measure what happens after the operation. Mortality, stroke, reoperation, infection, length of stay, and return to function are the feedback that changes practice. Surgeons and programs should review their own results against recognized national registries where these exist, and should read those results with an eye to case mix.

03Planning and preparation

• Preoperative evaluation starts with the indication. Computed tomography angiography, transthoracic or transesophageal echocardiography, and duplex ultrasound define the lesion and its relationship to nearby structures. Pulmonary function tests, coronary angiography when indicated, renal function, and hematologic values inform risk. The operative note later should reflect why surgery was chosen over medical management or an endovascular option.
• Consent is a conversation, not a form. Discuss expected benefit, specific risks such as stroke, sternal wound problems, or limb loss, realistic recovery times, and what the team will do if an unexpected finding appears during the case. Use a qualified interpreter when needed and record the discussion in the chart.
• Scheduling and equipment need attention well before the case day. Confirm blood bank availability, cell salvage equipment, the bypass circuit setup, hybrid room time for endovascular work, intensive care bed availability, and implant inventory. For valve or aortic devices, verify the correct size and confirm that the device is approved for the intended use in your jurisdiction.
• A preoperative briefing brings the team together. The group reviews the procedure, expected duration, antibiotic timing, anticoagulation plan, and rescue plan. Many programs use a structured briefing and a surgical safety checklist adapted from the World Health Organization model, and local versions usually add cardiac or vascular specific items.

04Recommended workflow

1. 1
   : Confirm identity, planned procedure, laterality, consent, and site marking before induction. Check that imaging is on the screen and that the correct side or segment is identified.
2. 2
   : Establish monitoring. This includes an arterial line and central venous access for most cardiac cases. For valve, aortic, and complex cardiac work, transesophageal echocardiography is used to assess function, look for residual air, and confirm the repair before separation from bypass.
3. 3
   : Prepare and drape so that the groin, chest, neck, or extremity is accessible as the plan requires. For sternotomy, confirm that the field allows safe use of the sternal saw and cannula placement. For endovascular access, confirm fluoroscopy positioning before the drapes are sealed.
4. 4
   : Give heparin and establish cardiopulmonary bypass or distal perfusion when the plan requires it. Record activated clotting time targets and the times of heparin dosing, cannulation, and bypass initiation, because these numbers are needed later for reversal and for review.
5. 5
   : Perform the core operative steps in the planned sequence. The surgeon announces major stages such as aortic cross clamp application, the start of a proximal anastomosis, or valve implantation, so the perfusionist, anesthesiologist, and nurses can prepare for the next phase.
6. 6
   : Assess the repair before coming off support. Check hemodynamics, graft flow measurements, valve gradients, and echocardiographic findings. Address residual leaks, dissections, or gradients before closure, even when that means extending the case.
7. 7
   : Reverse heparin, achieve hemostasis, and complete the count of sponges, needles, and instruments. Document the count result and the reversal dose. Treat a discrepancy as a stop until it is resolved.
8. 8
   : Close, dress, and transfer the patient to intensive care or recovery with a structured handover. The handover covers anticoagulation plans, estimated blood loss, transfusion totals, bypass and cross clamp times, implanted devices, and any intraoperative events that the receiving team must watch.

05Quality checks, risk controls and compliance

• Sterile technique, antibiotic prophylaxis timing, and blood transfusion protocols are routine controls in this field. Prophylactic antibiotics are usually given within a set window before incision and redosed during long cases or significant blood loss, but the specific agents and timing should follow your institution's approved guideline and current professional society recommendations. Verify that the guideline is current before relying on it.
• Implanted device tracking is a major control. Record manufacturer, model, lot or serial number, and size for every valve, graft, stent, or endovascular component. Place the device sticker in the chart and the implant log. Many institutions also require a rapid check of the device label against the purchase order before implantation.
• Cardiac implantable electronic devices, such as pacemakers and defibrillators, need a documented plan for pre and postoperative management. Magnet response, programming changes, and reprogramming after the case should be coordinated with device specialists under local policy.
• Reporting and compliance rules vary by jurisdiction. In the United States, patient privacy obligations such as those under HIPAA apply to case records and imaging, and hospitals must follow accreditation and state reporting requirements. Incident and adverse event reporting pathways are set by each institution and by applicable state and federal rules. Check the current authoritative source in your region before drafting policy or reporting an event.
• Credentialing and privileging decide who performs which procedures. Supervision levels for trainees, device specific training, and procedural logs are controlled by the institution and, in training programs, by accreditation bodies. This manual does not set those requirements.

06Collaboration and documentation

• The operative note records the indication, consent, procedure performed, findings, technique in summary, implants used, complications, specimens, estimated blood loss, and the plan for postoperative care. It should be written promptly, and it should match what the perfusion, anesthesia, and nursing records show for times and events. Discrepancies between records are often the first sign of a process problem.
• The perfusion record tracks pump flows, temperatures, cardioplegia doses, activated clotting times, and blood product use on bypass. The anesthesia record tracks drugs, hemodynamics, fluid balance, and airway management. The nursing record tracks counts, positioning, skin protection, and timing of antibiotics. Each of these records is a working document during the case and a legal record afterward.
• Multidisciplinary heart team and vascular conferences bring surgeons, interventional cardiologists, imaging specialists, and sometimes oncology or pulmonary colleagues together to review cases before surgery. These conferences are where indications, alternatives, and shared decisions get settled. Record the discussion and the reasoning, not just the final recommendation.
• Communication with referring physicians matters as much as communication within the operating room. Send a clear summary to the primary care physician and any cardiologist or vascular specialist who will manage follow up, including anticoagulation changes, activity limits, and warning signs that should prompt a call back.

07Measures and continuous improvement

• Programs track indicators that reflect both safety and value. Common measures include operative mortality, stroke, reoperation for bleeding, deep sternal wound infection, unplanned reintubation, acute kidney injury, length of intensive care stay, and readmission within a defined period. For vascular work, limb salvage, graft patency, and amputation rates are useful. Patient reported function and symptom relief add an important perspective that clinical data alone do not capture.
• In the United States, many cardiac programs contribute to the Society of Thoracic Surgeons National Database, and many vascular programs contribute to the Vascular Quality Initiative. These registries use risk adjustment and standardized definitions. Other countries have their own national registries or audit programs. Use the definitions from the registry you contribute to rather than inventing local ones, so that results can be compared fairly.
• Small numbers create noisy results. A single death or stroke in a low volume program can change a rate sharply, so teams should look at trends over longer periods and examine individual cases in morbidity and mortality review. Risk adjustment helps, but it does not remove the effect of case mix. A program that takes sicker patients may have worse raw outcomes and still be performing well.
• Improvement projects work best when they target one specific process, such as antibiotic redosing, bleeding management protocols, or handover content, and measure its effect. Plan the change, run it for a defined period, review the data, and keep it only if it works. Trade-offs are real. Stricter transfusion thresholds may reduce exposure to blood products but could increase the risk of ischemia in some patients, so changes should be reviewed by the full team.

08Common mistakes and how to prevent them

• Incomplete briefings are the most common precursor to avoidable problems. When roles, the rescue plan, or the expected duration are not discussed, team members fill gaps with assumptions. Use the briefing to ask each person to state their role and the one thing that would make them call a stop.
• Underestimating bleeding is another frequent problem. Teams that have not confirmed blood availability, or that wait too long to escalate transfusion, lose valuable time. Agree on triggers for calling for products and for activating massive transfusion protocols before the case starts.
• Incomplete counts and undocumented device details create problems weeks or years later. Make the count a visible, verbal step with a documented result. Scan or record device labels at implantation rather than relying on memory afterward.
• Anticoagulant and antiplatelet reconciliation is often rushed, especially in emergency cases or when a patient arrives from another facility. Review the medication list directly with the patient or family, check the last dose times, and document the plan for restarting therapy after surgery.
• Relying on a single imaging study can lead to surprises in the operating room. Compare the most recent images with the planned approach, look for anatomic variants, and confirm access routes early. Where findings conflict, slow down and resolve the discrepancy before the first incision.
• Weak handovers lead to delayed recognition of problems in the intensive care unit. Use a structured format, state the most important risks in the first sentence, and confirm that the receiving team has read the operative note.

09Practical checklist

• Confirm the indication, consent discussion, and alternatives considered are documented before the day of surgery.
• Verify blood availability, bypass or hybrid room setup, intensive care bed, and implant inventory at least one day ahead.
• Complete the preoperative briefing with explicit roles, expected duration, antibiotic timing, and a named rescue plan.
• Confirm identity, procedure, laterality, and site marking before induction.
• Record heparin dosing, activated clotting times, bypass or perfusion times, and cross clamp times as they occur.
• Assess the repair with imaging or flow measurements before coming off support.
• Complete and document the sponge, needle, and instrument count with a clear result.
• Record every implanted device with manufacturer, model, lot or serial number, and size.
• Reconcile the operative note with the perfusion, anesthesia, and nursing records before the case is closed.
• Give a structured handover to intensive care or recovery that covers anticoagulation, blood loss, and intraoperative events.
• Review complications and outcomes at morbidity and mortality conference and enter data into the applicable registry.

★Learning sources

• Micro Degree: Cardiothoracic and Vascular Surgery
• Micro Degree: Healthcare Administration Practice
• Micro Degree: Physiotherapy Assistant Operations
• Micro Degree: Cardiac Care Support