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Surgery of Coronary Artery Disease Ischemic Heart Disease IHD – imbalance between myocardial oxygen demand and supply: Coronary Artery Disease Printzmetal Angina Syndrome X Coronary Artery Disease (CAD) Deficiency in blood supply to myocardium caused by stenotic atheromatous lesions in major branches of coronary arteries Clinical Forms of CAD Stable Angina Unstable Angina Acute Coronary Syndrome Myocardial Infarction Ischemic Myocardiopathy (Left Ventricular Remodeling, Mitral Regurgitation) Prevalence of CAD About 50% of total mortality in Europe and North America is due to cardiovascular diseases 100.000 of Acute Myocardial Infarctions in Poland each year The older population the more prevalent CAD Complex Etiology of Atheromatosis Genetic (family history) Metabolic (hyperlipidemia, diabetes) Life Style (obesity, smoking, lack of exercise) Infectious and Inflammatory? Risk Factors of CAD Sex - male Age - older Family History Arterial Hypertension Hyperlipidemia Smoking Obesity Symptoms of CAD (1) Angina – retrosternal chest pain, usually related to the exercise Canadian Cardiovascular Society (CCS) Classification of Angina: I class – only in extreme exercise II class – in moderate exercise III class – in every exercise IV class – also in rest Symptoms of CAD (2) Dyspnea (in Ischemic Myocardiopathy or Mitral Regurgitation) New York Heart Association (NYHA) classification of dyspnea (I-IV class) When NYHA class higher than CCS class – poor prognosis Pathology of CAD (1) Atheromatous Plaque Stable (fibrous) Stable Angina Unstable (ulceration + thrombus) Unstable Angina Acute Myocardial Infarction (AMI) (necrosis) Pathology of CAD (2) Complications of CAD Chronic ischemia – AMI -necrosis -fibrosis LV Remodeling Pump failure Cardiomyopathy Mitral Regurgitation (MR) Rapture of myocardium Cardiogenic Shock Acute VSD Acute MR Tamponade (free wall) Pathophysiology of CAD Consequences of Coronary Artery Stenosis: Up to About More than 100% 50% - asymptomatic 75% - exercise angina 90% - rest angina - AMI Diagnostics of CAD Methods History Angina (CCS) Risk Factors Non-invasive ECG Rest Exercise 24-hours Echocardiography Invasive Coronary Angiography Evidence taken from Exercise ECG Clinically positive (angina) ECG positive (ST segment abnormalities) localization: anterior, lateral, posterior Exercise tolerance (in METs*) * MET – metabolic equivalent – rest oxygen demand = 30 ml/kg/min Evidence taken from Echocardiography Global systolic function of left ventricle – left ventricular ejection fraction (LVEF): Good Moderately impaired Poor – LVEF>50% –LVEF 30-50% –LVEF<30% Regional systolic abnormalities (hypokinesis, akinesis, dyskinesis) Mitral Regurgitation Indications for Coronary Angiography Typical Angina (even with negative ECG exercise test) Positive ECG exercise test Unstable Angina / Acute coronary syndrome (primary rescue PCI) After Myocardial Infarction especially when angina persists Technique of Coronary Angiography Selective coronary artery catheterization via femoral or radial artery Administration of iodine contrast X-ray motion picture Evidence taken from Coronary Angiography Presence of lesions in coronary arteries Degree of stenosis (0-100%) Localization of lesions (proximal or distal) Type of lesions (A, B or C) What is a significant stenosis of coronary artery? Left main stem (LMS) stenosis of 50% or more Other vessels stenosis of 75% or more Clinical Value of Coronary Angiography in Decision Making Evidence of CAD Medical Treatment Invasive Cardiology PCI Surgical Treatment Invasive Cardiology or Surgery? The most important disadvantage of PCI is still high rate of re-stenosis, reaching 30% per year (10% using DES) CAD INVASIVE: Acute coronary syndrome One- or two- vessels disease Type A lesions Good LV function Non-diabetics SURGERY: LMS stenosis 3-vessels disease Poor LV function Diabetics Anatomy of Coronary Arteries Anatomy of Left Coronary Artery Left Main Stem LMS Left Anterior Descending LAD Circumflex Cx Diagonal Branches Dg1, Dg2 etc. Marginal Branches Mg1, Mg2 etc. Anatomy of Right Coronary Artery Right Coronary Artery RCA Right Posterior Descending RPD Postero-Lateral PL The Milestones of Coronary Surgery 1959 1964 1967 1991 Sonnes Kolesov Coronary angiography Graft:LITA-LAD (no CPB, no Angiography) Favaloro CABG Benetti OPCAB Idea of Surgical Treatment of CAD Revascularization of the heart via bypassing significantly narrowed coronary arteries to enhance blood supply to ischemic regions of myocardium The Goals of Surgery in CAD To prolong a lifetime To improve a quality of living To prevent myocardial infarction and its complications Surgical Revascularization Procedures Coronary Artery By-Pass Grafting (CABG) CLASSIC Off-Pump Coronary Artery By-Pass (OPCAB) – NO CPB Minimally Invasive Coronary Artery ByPass (MID-CAB) – NO STERNOTOMY Transmural Laser Revascularization (TMLR) - ALTERNATIVE CABG – The Classic Coronary Operation Since 1967 when Favaloro from Cleveland Clinic in USA performed the first CABG it has become one of the most popular surgical procedure in the world CABG or OPCAB? The biggest advantage of OPCAB is avoidance of complications related to CPB e.g. SIRS and slightly lower costs However, OPCAB provides less completeness of revascularization and worse precision of anastomosis (moving operating area) Classic indication for OPCAB is isolated stenosis of LAD not suitable for PCI e.g. amputation OPCAB Cardio-Pulmonary Bypass (CPB) Cardio-Pulmonary By-Pass (CPB) Extracorporeal circulation (ECC) Requires full heparinization of the patient Main elements: System of cannules, tubes and filters Oxygenator Pumps (arterial and suction) Side effects Blood cells damage Systemic Inflammatory Response Syndrome (SIRS) Indications for CABG Left main stem stenosis > 50% Equivalent of LMS stenosis (proximal stenosis of LAD and Cx > 75%) Three-vessels disease (stenoses of RCA, LAD and Cx or their branches >75%) Proximal LAD stenosis >75% with one- or twovessels disease, with excessive part of myocardium in jeopardy, especially in patients with poor LV function and/or in diabetics (not suitable for PCI, method of choice if isolated– OPCAB) Counter-indications for CABG Acute myocardial infarction (2 weeks) Use of antiplatelet drugs like ticlopidine or clopidogrel (2 weeks or platelet concentrate – if emergency) Lack of graftable distal vessels (diameter of at least 1,5mm) – consider TMLR Scheduled or emergency CABG? When to operate? Stable Scheduled Weeks Asymptomatic LMS Urgent Days Unstable Emergency Hours Patient’s Preparation to Scheduled CABG Red cells concentrate (autotransfusion, family donations) Coagulometry Cessation of antiplatelet drugs (2 weeks before surgery) Optimal medical treatment (beta-blockers, statins, control of glycemia in diabetics) Co-morbidities (carotid doppler, gastroscopy) Predictors of Outcomes after CABG Age > 60 years Female sex Poor LV function Re-do operation Emergency Obesity Co-morbidities Renal failure Chronic Obturatory Pulmonary Disease Stroke Generalized atherosclerosis CABG-Technique Medial Sternotomy Use of CPB Saphenous by-pass grafts (SBG) or arterial grafts Material for Grafts in CABG Saphenous vein (SBG) Left internal thoracic artery (LITA) Right internal thoracic artery (RITA) Radial artery (RA) Gastroepiploic artery Venous or arterial grafts? Arterial grafts are generally better than venous – e.g. LITA patency rate after 20 years is 90% whereas 50% of SBGs is occluded after 10 years. GOLDEN STANDARD: LITA to LAD! Totally arterial revascularization is especially indicated in young patients and in those with bilateral crural varicosity CABG Venous grafts Venous sequential graft Harvested LITA Graft: LITA to LAD Harvesting and anastomosing of Radial Artery Outcomes of CABG Mortality rate 1-5% - depends mostly of patients’ profile (see predictors of outcomes ) Common postop. complications: Excessive bleeding, heart tamponade Perioperative myocardial infarction - low cardiac output Stroke or psycho-organic syndromes Acute renal failure Hemothorax, pneumothorax Sternal dehiscence, mediastinitis Typical uncomplicated course after CABG ICU 1-2 days: Hospital stay – about 1 week Artificial ventilation <12 hours Chest tubes – 2 days Antibiotics – 4 days Rehabilitation 2-3 weeks Most of the patients returns to normal activity in few months Standard Medication after CABG „A B S” ASA 150-300 mg daily Beta-Blockers Statins Secondary Prevention after CABG Lipids control Glucose control Weight control Arterial pressure control Smoking cessation Moderate exercise