Surgical Surgical Treatment of Treatment of Ischaemic Heart Ischaemic Heart DiseaseDisease

Division of Division of Cardiothoracic SurgeryCardiothoracic Surgery

UWI MonaUWI Mona

Coronary Arterial DiseaseCoronary Arterial Disease Atherosclerosis in Atherosclerosis in

native coronary native coronary vessels (multi-vessels (multi-factorial)factorial)

Blocks developBlocks develop Partial blocks prone Partial blocks prone

to platelet clotsto platelet clots Large plaques Large plaques

prone to fracture prone to fracture clots formclots form

Myocardial Myocardial Infarction(MI)Infarction(MI)

AnginaAngina: Chest Pain due to : Chest Pain due to inadequate Blood Flow inadequate Blood Flow IschaemiaIschaemia

Unlike MI, Unlike MI, angina angina may be may be reversiblereversible

Some form of Some form of intervention may intervention may alleviate symptomsalleviate symptoms

(open or less-invasive (open or less-invasive surgery; angioplasty surgery; angioplasty +/- stenting)+/- stenting)

Coronary Bypass: Coronary Bypass: Bypasses the BlockBypasses the Block

How is the occlusion How is the occlusion bypassed?bypassed?

Most procedures are done on a non-beating Most procedures are done on a non-beating heartheart

Cardiopulmonary Bypass Machine (CPB) is Cardiopulmonary Bypass Machine (CPB) is used to take over the pumping function of used to take over the pumping function of the heart, and the gas exchange function of the heart, and the gas exchange function of the lungsthe lungs

Cardioplegia is given to stop the electrical Cardioplegia is given to stop the electrical activity of the heartactivity of the heart

Therefore, the heart is still, and the delicate Therefore, the heart is still, and the delicate operation can be performed with great operation can be performed with great precisionprecision

The Cardiopulmonary The Cardiopulmonary Bypass MachineBypass Machine

The CPB CircuitryThe CPB Circuitry

The Appearance of the The Appearance of the Heart on Opening the Heart on Opening the SternumSternum

Anastomosing the Internal Mammary Anastomosing the Internal Mammary Artery to the Left Anterior Artery to the Left Anterior Descending Coronary ArteryDescending Coronary Artery

The Completed LIMA-LAD The Completed LIMA-LAD AnastomosisAnastomosis

Saphenous Vein(green arrow) being Saphenous Vein(green arrow) being anastomosed to Coronary Artery(red anastomosed to Coronary Artery(red arrow)arrow)

Completed SV-Coronary Completed SV-Coronary AnastomosisAnastomosis

CABG can be done on a CABG can be done on a BEATING HEART:BEATING HEART:

What are the results?What are the results?

Best results are for open surgery Best results are for open surgery using cardiac arrest (30 yrs using cardiac arrest (30 yrs experience)experience)

Newer techniques such as Beating Newer techniques such as Beating Heart Surgery, Minimal Access Heart Surgery, Minimal Access CABG, Robot-assisted CABG, are all CABG, Robot-assisted CABG, are all in early stagesin early stages

For multivessel disease, surgery still For multivessel disease, surgery still superior to angioplasty/stentingsuperior to angioplasty/stenting

A Late A Late ComplicationComplication

Patent LIMAPatent LIMA

Graft with distally Graft with distally blocked native blocked native coronary arterycoronary artery

Angioplasty and StentingAngioplasty and Stenting

A catheter-based procedure performed A catheter-based procedure performed by cardiologists in the CATH LAB which by cardiologists in the CATH LAB which can can dilate dilate and and maintainmaintain the lumen of a the lumen of a partially blocked coronary artery through partially blocked coronary artery through the insertion of a the insertion of a tiny metallic mesh tubetiny metallic mesh tube

Very good short-term (< 5 yrs) results, Very good short-term (< 5 yrs) results, but poor longer term results when but poor longer term results when compared to traditional surgical therapycompared to traditional surgical therapy

Pre- and Post- AngioplastyPre- and Post- Angioplasty

Stent is left inside Stent is left inside coronary artery and holds coronary artery and holds lumen openlumen open

ConclusionsConclusions

CABG is one of the most successful CABG is one of the most successful operations ever devisedoperations ever devised

Hundreds of thousands of procedures Hundreds of thousands of procedures worldwide yearlyworldwide yearly

Surgery has best long-term results, Surgery has best long-term results, although angioplasty techniques are although angioplasty techniques are improving long-term outlooksimproving long-term outlooks

All of these interventions are PALLIATIVE All of these interventions are PALLIATIVE THERAPIES, ie. The underlying disease THERAPIES, ie. The underlying disease may continue to cause problems post-opmay continue to cause problems post-op