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