Download Surgical Management of Ischaemic Heart Disease

Surgical Management of
Ischaemic Heart Disease
By Dilshan Udayasiri
HMO2
Introducing Mrs Anne Gina
• You’re the intern working in Western
Hospital ED.
• 52yo female presents with Chest Pain. What
do you do next!!!!
History
• Pain came on one hour ago on a background of
having similar pain on exercise over the last 3
weeks.
• Central and crushing
• Radiates up the Jaw
• Associated with SOB, palpitations, presyncope,
diaphoresis.
• Did not go away with rest, still present
• WHAT DO YOU DO NEXT!!
Management
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Obs sats 95%, BP 145/70, HR 100, afebrile
ECG
O2 15L via Hudson Mask
300mcg of anginine sublingually
300mg of asprin
Monitored Bed
2 large bore cannula.
Heparin infusion commenced
Pain relieved.
Bloods and CXR request sent, Cardiology
registrar on the way
Further History
• PHx (Cardiac Risk factors)
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Exsmoker (40 pack year history)
Hypertension
Hyperlipidaemia
T2DM – diet controlled
FHx – Father AMI 50
• SHX
– Lives at home with Husband
• Medications
– Ramipril 2.5mg daily
– Atorvastatin 20mg nocte
• NKDA
• Cardiology Registrar arrives. Is very Happy
with your work. Takes the patient off for
angiography.
The Coronaries
• 2 main coronary arteries
– Right Coronary Artery (RCA)
• Gives of a Posterior Descending artery branch in
approx 70% of patients
• 20% of patients the PDA comes of the left
circumflex and are hence Left dominant
• 10% PDA comes off both and are then Codominant.
• Supplies 25% - 35% of the left ventricle and the SA
node in 60% of cases (otherwise LCx artery)
• Left Main coronary artery
– Divides early into the
• Left anterior descending artery
– Supplies the anterolateral myocardium, interventricular
septum and the apex of the heart. In total it supples 45%55% of the left ventricle.
– Gives off septal (run straight into the intaventricular
septum at 90degrees to surface, and diagonals that supply
the lateral myocardium)
• Left Circumflex
– Gives off obtuse marginals (OMs) as it curves around the
posterior aspect of the heart.
– Supples the SA node in 40% of cases. If nonDominant
supplies 15%-20% of LV, if dominant 40%-50%. Also
supples anterolateral papillary muscles.
Patients Angiography
• LMCA
– Short left main with ostial 90% stenosis
• LAD
– Medium calibre vessel with mild dease throughout
• LCx
– Medium calibre, non-dominant vessel with mild
disease. OM1 is tortuous and mildly diseased. Small
AV branch diffusely diseased distally.
• RCA
– Dominant. Small calibre vessel with diffuse disease
proximally and totally occluded mid vessel.
• Ventriculogram
– Lv Function is severely impaired. There is no mitral
regurgitation
Some common indications for
Coronary Artery Bypass Grafting
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Left main artery disease or equivalent
Triple vessel disease
Abnormal Left Ventricular function.
Failed PTCA.
Immediately after Myocardial Infarction (to
help perfusion of the viable myocardium).
Life threatening arrhythmias caused by a
previous myocardial infarction.
Occlusion of grafts from previous CABGs.
Coronary artery disease with valvular disease
Angina not controlled by maximal medical
therapy
Pt arrives at RMH PAC
• Note History
– Meds are now
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Ramipril 2.5mg daily
Atorvastatin 20mg nocte
Metoprolol 25mg BD
Asprin 100mg daily
GTN spray 400mcg PRN
O/E
• Comfortable, no chest pain
• Obs, BP 140/75, HR 80, sats 98%RA, afeb
• Pulse: ulna and radial present bilaterally, strong
and regular
• Allens test – negative bilaterally
• No carotid Bruits
• No previous scars on chest. Heart sounds are dual
with no added sounds. Chest sounds are vesicular.
• Lower limb pulses are present. No varicose veins
• Right Handed
What do you want to do before
the operation?
• Consent patient for surgery
• Optimise medical management – increase
metoprolol to 50mg BD
• W/H asprin 7/7 prior to surg
• Tests
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TTE
CXR
Bloods (FBE, UEC, Ca/Mg/Phos, Coags, G&S)
Carotid U/S not required
Complications of CABGs
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Bleeding
Infection
Stroke
AMI
Arrythmias
Postperfusion syndrome (pumphead)
Sternal dehiscence
Graft Patency Rates
Conduit
5 year
10 year
left internal
thoracic artery
96%
95%
right internal
thoracic artery
93%
90%
Radial artery
90%
80%
Saphenous vein 75%
50%
In Theatre
• Pt prepared by anaesthetics (peripheral lines, CVC, arterial
lines inserted.)
• Once anaesthetised, TOE inserted.
• Body prepped.
• Conduits harvested
• Heparin commenced
• Chest opened and canulated ready for bypass.
• Aorta clamped and cardioplegia started to stop heart.
• Anastomosis performed.
• Drains and pacing wires inserted
• Cardioplegia ceased pt taken off bypass
• T/fed to ICU
Post Op
• Pt extubated day 1. Weaned off ionotropes and
t/fed to ward.
• First few days post op need to
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Continuous cardiac monitoring.
Monitor drain outputs
Daily bloods + ECGs + CXR + weight
Pt normally commenced on frusemide + iv Abs +
nebulisers on top of normal meds.
– On day 3 post op you are paged by the nurse stating the
patient is tachycardic rate 160, (BP 130/75, sats 95%
2L, no CP)
– ECG is as follows
ECG
What would you do
• Send off bloods
• Think of and treat reversible causes
– Electrolytes
– Ischaemia
– Hyperthyriodsim
• Rate vs Rhythm control