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Surgery of Coronary Artery Surgery of Coronary Artery DiseaseDisease
Ischemic Heart DiseaseIschemic Heart Disease
IHD – imbalance between myocardial IHD – imbalance between myocardial oxygen demand and supply:oxygen demand and supply:
Coronary Artery DiseaseCoronary Artery Disease Printzmetal AnginaPrintzmetal Angina Syndrome XSyndrome X
Coronary Artery Disease Coronary Artery Disease (CAD)(CAD)
Deficiency in blood supply to Deficiency in blood supply to myocardium caused by stenotic myocardium caused by stenotic atheromatous lesions in atheromatous lesions in majormajor branches of coronary arteriesbranches of coronary arteries
Clinical Forms of CADClinical Forms of CAD
Stable AnginaStable Angina Unstable AnginaUnstable Angina Acute Coronary SyndromeAcute Coronary Syndrome Myocardial InfarctionMyocardial Infarction Ischemic Myocardiopathy (Left Ischemic Myocardiopathy (Left
Ventricular Remodeling, Mitral Ventricular Remodeling, Mitral RegurgitationRegurgitation))
Prevalence of CADPrevalence of CAD
About 50% of total mortality in About 50% of total mortality in Europe and North America is due to Europe and North America is due to cardiovascular diseasescardiovascular diseases
100.000 of Acute Myocardial 100.000 of Acute Myocardial Infarctions in Poland each yearInfarctions in Poland each year
The older population the more The older population the more prevalent CADprevalent CAD
Complex Etiology of Complex Etiology of AtheromatosisAtheromatosis
Genetic (family history)Genetic (family history) MetMetaabolic (hyperlipidemia, diabetes)bolic (hyperlipidemia, diabetes) Life Style (obesity, smokingLife Style (obesity, smoking, lack of , lack of
exerciseexercise)) Infectious and InflammatoryInfectious and Inflammatory??
Risk Factors of CADRisk Factors of CAD
Sex - maleSex - male Age - olderAge - older Family HistoryFamily History Arterial HypertensionArterial Hypertension HyperlipidemiaHyperlipidemia SmokingSmoking ObesityObesity
Symptoms of CAD (1)Symptoms of CAD (1)
Angina – retrosternal chest pain, Angina – retrosternal chest pain, usually related to the exerciseusually related to the exercise
Canadian Cardiovascular Society Canadian Cardiovascular Society (CCS) Classification of Angina:(CCS) Classification of Angina:
I class – only in extreme exerciseI class – only in extreme exercise II class – in moderate exerciseII class – in moderate exercise III class – in every exerciseIII class – in every exercise IV class – also in restIV class – also in rest
Symptoms of CAD (2)Symptoms of CAD (2)
Dyspnea (in Ischemic Dyspnea (in Ischemic Myocardiopathy or Mitral Myocardiopathy or Mitral Regurgitation)Regurgitation)
New York Heart Association (NYHA) New York Heart Association (NYHA) classification of dyspnea (I-IV class)classification of dyspnea (I-IV class)
When NYHA class higher than CCS When NYHA class higher than CCS class – poor prognosisclass – poor prognosis
Pathology of CAD (1)Pathology of CAD (1)
Atheromatous Plaque
Stable (fibrous)
Unstable(ulceration + thrombus)
Unstable Angina
Acute Myocardial Infarction (AMI)(necrosis)
Stable Angina
Pathology of CAD (2)Pathology of CAD (2)
Complications of CAD
Chronic ischemia –
-fibrosisAMI -necrosis
LV Remodeling
Cardiomyopathy
Mitral Regurgitation (MR)
Pump failure Rapture of myocardium
Acute VSD
Acute MR
Tamponade (free wall)
Cardiogenic Shock
Pathophysiology of CADPathophysiology of CAD
Consequences of Coronary Artery Consequences of Coronary Artery Stenosis:Stenosis:
Up to Up to 50% - asymptomatic50% - asymptomatic About About 7755% - exercise angina% - exercise angina More thanMore than 90% - rest angina90% - rest angina 100% 100% - AMI- AMI
Diagnostics of CADDiagnostics of CAD
Methods
History Non-invasive Invasive
Angina (CCS)Risk Factors
ECGRest
Exercise24-hours
EchocardiographyCoronary
Angiography
Evidence taken from Exercise Evidence taken from Exercise ECGECG
Clinically positive (angina)Clinically positive (angina) ECG positive (ST segment abnormalities)ECG positive (ST segment abnormalities)
localization: anterior, lateral, localization: anterior, lateral,
posteriorposterior Exercise tolerance (in METsExercise tolerance (in METs**))
* * MET – metabolic equivalent – rest MET – metabolic equivalent – rest oxygen demand = 30 ml/kg/minoxygen demand = 30 ml/kg/min
Evidence taken from Evidence taken from EchocardiographyEchocardiography
Global systolic function of left Global systolic function of left ventricle – left ventricular ejection ventricle – left ventricular ejection fraction (LVEF):fraction (LVEF): Good Good – LVEF>50%– LVEF>50% Moderately impaired Moderately impaired –LVEF 30-50%–LVEF 30-50% Poor Poor –LVEF<30%–LVEF<30%
Regional systolic abnormalities Regional systolic abnormalities (hypokinesis, akinesis, dyskinesis)(hypokinesis, akinesis, dyskinesis)
Mitral Regurgitation Mitral Regurgitation
Indications for Coronary Indications for Coronary AngiographyAngiography
Typical Angina (even with negative Typical Angina (even with negative ECG exercise test)ECG exercise test)
Positive ECG exercise testPositive ECG exercise test Unstable Angina / Acute coronary Unstable Angina / Acute coronary
syndromesyndrome ( (primary rescue PCIprimary rescue PCI)) After Myocardial Infarction especially After Myocardial Infarction especially
when angina persistswhen angina persists
Technique of Coronary Technique of Coronary AngiographyAngiography
Selective coronary artery Selective coronary artery catheterization via femoral or radial catheterization via femoral or radial arteryartery
Administration of Administration of iodineiodine contrast contrast
X-ray motion pictureX-ray motion picture
Evidence taken from Coronary Evidence taken from Coronary AngiographyAngiography
Presence of lesions in coronary Presence of lesions in coronary arteriesarteries
Degree of stenosis (0-100%)Degree of stenosis (0-100%)
Localization of lesions (proximal or Localization of lesions (proximal or distal)distal)
Type of lesions (A, B or C)Type of lesions (A, B or C)
What is a significant stenosis of What is a significant stenosis of coronary arterycoronary artery??
Left main stem (LMS) stenosis of 50% Left main stem (LMS) stenosis of 50% or moreor more
Other vessels stenosis of 75% or Other vessels stenosis of 75% or moremore
Clinical Value of Coronary Clinical Value of Coronary Angiography in Decision Angiography in Decision
MakingMaking
Evidence of CAD
Medical Treatment
InvasiveCardiology
PCI
Surgical Treatment
Invasive Cardiology or Invasive Cardiology or SurgerySurgery??
The most important disadvantage of PCI is still high The most important disadvantage of PCI is still high rate of re-stenosis, reaching rate of re-stenosis, reaching 330% per year0% per year (10% (10%
usingusing DES) DES)CAD
INVASIVE:
Acute coronary syndromeOne- or two- vessels disease
Type A lesionsGood LV function
Non-diabetics
SURGERY:
LMS stenosis3-vessels diseasePoor LV function
Diabetics
Anatomy of Coronary Arteries
Anatomy of Left Coronary Anatomy of Left Coronary ArteryArtery
Left Main StemLMS
Left Anterior DescendingLAD
CircumflexCx
Diagonal BranchesDg1, Dg2 etc.
Marginal BranchesMg1, Mg2 etc.
Anatomy of Right Coronary Anatomy of Right Coronary ArteryArtery
Right Coronary ArteryRCA
Right Posterior DescendingRPD
Postero-LateralPL
The Milestones of Coronary The Milestones of Coronary SurgerySurgery
19591959 SonnesSonnes Coronary Coronary angiographyangiography
19641964 KolesovKolesov Graft:LITA-LAD (no Graft:LITA-LAD (no CPB, no CPB, no
Angiography)Angiography) 19671967 FavaloroFavaloro CABGCABG 19911991 Benetti Benetti OPCABOPCAB
Idea of Surgical Treatment of Idea of Surgical Treatment of CADCAD
Revascularization of the heart Revascularization of the heart viavia by- by-passing significantly narrowed passing significantly narrowed coronary arteries to enhance blood coronary arteries to enhance blood supply to ischemic regions of supply to ischemic regions of myocardiummyocardium
The Goals of Surgery in CADThe Goals of Surgery in CAD
To prolong a lifetimeTo prolong a lifetime
To improve a quality of livingTo improve a quality of living
To prevent myocardial infarction and To prevent myocardial infarction and its complicationsits complications
Surgical Revascularization Surgical Revascularization ProceduresProcedures
Coronary Artery By-Pass Grafting Coronary Artery By-Pass Grafting (CABG) (CABG) - - CLASSICCLASSIC
Off-Pump Coronary Artery By-Pass Off-Pump Coronary Artery By-Pass (OPCAB)(OPCAB) – NO CPB – NO CPB
Minimally Invasive Coronary Artery By-Minimally Invasive Coronary Artery By-Pass (MID-CAB)Pass (MID-CAB) – NO – NO STERNOTOMY STERNOTOMY
Transmural Laser Revascularization Transmural Laser Revascularization (TMLR) - ALTERNATIVE(TMLR) - ALTERNATIVE
CABG – The Classic Coronary CABG – The Classic Coronary OperationOperation
Since 1967 when Favaloro from Since 1967 when Favaloro from Cleveland Clinic in USA performed Cleveland Clinic in USA performed the first CABG it has become one of the first CABG it has become one of the most the most popularpopular surgical surgical procedure procedure in the worldin the world
CABG or OPCAB?CABG or OPCAB?
The biggest advantage of OPCAB is The biggest advantage of OPCAB is avoidance of complications related to CPB avoidance of complications related to CPB e.g. SIRS and slightlye.g. SIRS and slightly lower costslower costs
However, OPCAB provides less completeness However, OPCAB provides less completeness of revascularization and worse precision of of revascularization and worse precision of anastomosis (moving operating area)anastomosis (moving operating area)
Classic indication for OPCAB is isolated Classic indication for OPCAB is isolated stenosis of LAD not suitable for PCIstenosis of LAD not suitable for PCI e.g. e.g. amputationamputation
OPCABOPCAB
Cardio-Pulmonary Bypass (CPB)
Cardio-Pulmonary By-Pass Cardio-Pulmonary By-Pass (CPB)(CPB)
Extracorporeal circulation (ECC)Extracorporeal circulation (ECC) Requires full heparinization of the Requires full heparinization of the
patientpatient Main elements:Main elements:
System of cannules, tubes and filtersSystem of cannules, tubes and filters OxygenatorOxygenator Pumps (arterial and suction)Pumps (arterial and suction)
Side effectsSide effects Blood cells damageBlood cells damage Systemic InflammatorySystemic Inflammatory Response Syndrome (SIRSResponse Syndrome (SIRS))
Indications for CABGIndications for CABG
Left main stem stenosis > 50%Left main stem stenosis > 50% Equivalent of LMS stenosisEquivalent of LMS stenosis (proximal (proximal
stenosis of LAD and Cx > 7stenosis of LAD and Cx > 755%)%) Three-vessels diseaseThree-vessels disease (stenoses of RCA, (stenoses of RCA,
LAD and Cx or their branches >7LAD and Cx or their branches >755%)%) Proximal LAD stenosisProximal LAD stenosis >7 >755% with one- or % with one- or
two-vessels disease, with excessive part of two-vessels disease, with excessive part of myocardium in jeopardy, especially in myocardium in jeopardy, especially in patients with poor LV function and/or in patients with poor LV function and/or in diabeticsdiabetics (not (not suitable for PCI, method of suitable for PCI, method of choice if isolated– OPCAB)choice if isolated– OPCAB)
Counter-indications for Counter-indications for CABGCABG
Acute myocardial infarction (2 Acute myocardial infarction (2 weeks)weeks)
Use of antiplatelet drugs like Use of antiplatelet drugs like ticlopidine or clopidogrel (2 weeks or ticlopidine or clopidogrel (2 weeks or platelet concentrate – if emergency)platelet concentrate – if emergency)
Lack of graftable distal vessels Lack of graftable distal vessels (diameter of at least 1,5mm)(diameter of at least 1,5mm) – – considerconsider TMLR TMLR
Scheduled or emergency Scheduled or emergency CABGCABG??
When to operate?
StableScheduled
Weeks
Asymptomatic LMSUrgentDays
UnstableEmergency
Hours
Patient’s Preparation to Patient’s Preparation to Scheduled CABGScheduled CABG
Red cells concentrate (autotransfusion, Red cells concentrate (autotransfusion, family donations)family donations)
CoagulometryCoagulometry Cessation of antiplatelet drugs (2 weeks Cessation of antiplatelet drugs (2 weeks
before surgery)before surgery) Optimal medical treatment (beta-blockers, Optimal medical treatment (beta-blockers,
statins, control of glycemia in diabetics)statins, control of glycemia in diabetics) CoCo--morbidities (carotid doppler, morbidities (carotid doppler,
gastroscopy)gastroscopy)
Predictors of Outcomes after Predictors of Outcomes after CABGCABG
Age > 60 yearsAge > 60 years Female sexFemale sex Poor LV functionPoor LV function Re-do operationRe-do operation EmergencyEmergency ObesityObesity CoCo--morbiditiesmorbidities
Renal failureRenal failure Chronic Obturatory Pulmonary DiseaseChronic Obturatory Pulmonary Disease StrokeStroke Generalized atherosclerosisGeneralized atherosclerosis
CABG-TechniqueCABG-Technique
Medial SternotomyMedial Sternotomy Use of CPBUse of CPB Saphenous by-pass grafts (SBG) or Saphenous by-pass grafts (SBG) or
arterial graftsarterial grafts
Material for Grafts in CABGMaterial for Grafts in CABG
Saphenous vein (SBG)Saphenous vein (SBG) Left internal thoracic artery (LITA)Left internal thoracic artery (LITA) Right internal thoracic artery (RITA)Right internal thoracic artery (RITA) Radial artery (RA)Radial artery (RA) Gastroepiploic arteryGastroepiploic artery
Venous or arterial graftsVenous or arterial grafts??
Arterial grafts are generally better than Arterial grafts are generally better than venous – e.g. LITA patency rate after 20 venous – e.g. LITA patency rate after 20 years is 90% whereas 50% of SBGs is years is 90% whereas 50% of SBGs is occluded after 10 yearsoccluded after 10 years..
GOLDENGOLDEN STANDARD: LITA to LAD! STANDARD: LITA to LAD!
Totally arterial revascularization is Totally arterial revascularization is especially indicated in young patients and especially indicated in young patients and in those with bilateral crural varicosityin those with bilateral crural varicosity
CABGCABG
Venous graftsVenous grafts
Venous sequential graft
Venous sequential graft
Harvested LITA
Harvested LITA
Graft: LITA to LAD
Harvesting and Harvesting and anastomosing of Radial anastomosing of Radial
ArteryArtery
Outcomes of CABGOutcomes of CABG
Mortality rate 1-5% Mortality rate 1-5% - - depends mostly depends mostly of patients’ profileof patients’ profile ( (see predictors see predictors of of outcomes outcomes ) )
Common postopCommon postop.. complications: complications: Excessive bleeding, heart tamponadeExcessive bleeding, heart tamponade Perioperative myocardial infarction - low cardiac Perioperative myocardial infarction - low cardiac
outputoutput Stroke or psychoStroke or psycho--organic syndromesorganic syndromes Acute renal failureAcute renal failure Hemothorax, pneumothoraxHemothorax, pneumothorax Sternal dehiscence, mediastinitisSternal dehiscence, mediastinitis
Typical uncomplicated course Typical uncomplicated course after CABGafter CABG
ICU 1-2 days:ICU 1-2 days: Artificial ventilation <12 hoursArtificial ventilation <12 hours Chest tubes – 2 daysChest tubes – 2 days
Hospital stay – about 1 weekHospital stay – about 1 week Antibiotics – 4 daysAntibiotics – 4 days
Rehabilitation 2-3 weeksRehabilitation 2-3 weeks Most of the patients returns to Most of the patients returns to
normal activity in few monthsnormal activity in few months
Standard Medication after Standard Medication after CABGCABG
„A B S”„A B S”
AASA 150-300 mg dailySA 150-300 mg daily BBeta-Blockerseta-Blockers SStatinstatins
Secondary Prevention after Secondary Prevention after CABGCABG
Lipids control Lipids control Glucose controlGlucose control Weight controlWeight control Arterial pressure controlArterial pressure control Smoking cessationSmoking cessation Moderate exerciseModerate exercise
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