1. Surgery of Coronary Artery Disease

2. Ischemic Heart Disease
IHD – imbalance between myocardial oxygen demand and supply:
Coronary Artery Disease
Printzmetal Angina
Syndrome X

3. Coronary Artery Disease (CAD)
Deficiency in blood supply to myocardium caused by stenotic atheromatous lesions in major branches of coronary arteries

4. Clinical Forms of CAD Stable Angina Unstable Angina
Acute Coronary Syndrome
Myocardial Infarction
Ischemic Myocardiopathy (Left Ventricular Remodeling, Mitral Regurgitation)

5. Prevalence of CAD
About 50% of total mortality in Europe and North America is due to cardiovascular diseases
of Acute Myocardial Infarctions in Poland each year
The older population the more prevalent CAD

6. Complex Etiology of Atheromatosis
Genetic (family history)
Metabolic (hyperlipidemia, diabetes)
Life Style (obesity, smoking, lack of exercise)
Infectious and Inflammatory?

7. Risk Factors of CAD Sex - male Age - older Family History
Arterial Hypertension
Hyperlipidemia
Smoking
Obesity

8. 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

9. 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

10. Pathology of CAD (1)

11. Pathology of CAD (2)

12. Pathophysiology of CAD
Consequences of Coronary Artery Stenosis:
Up to 50% - asymptomatic
About 75% - exercise angina
More than 90% - rest angina
100% AMI

13. Diagnostics of CAD

14. 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

15. Evidence taken from Echocardiography
Global systolic function of left ventricle – left ventricular ejection fraction (LVEF):
Good – LVEF>50%
Moderately impaired –LVEF 30-50%
Poor –LVEF<30%
Regional systolic abnormalities (hypokinesis, akinesis, dyskinesis)
Mitral Regurgitation

16. 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

17. Technique of Coronary Angiography
Selective coronary artery catheterization via femoral or radial artery
Administration of iodine contrast
X-ray motion picture

18. 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)

19. What is a significant stenosis of coronary artery?
Left main stem (LMS) stenosis of 50% or more
Other vessels stenosis of 75% or more

20. Clinical Value of Coronary Angiography in Decision Making

21. Invasive Cardiology or Surgery
Invasive Cardiology or Surgery? The most important disadvantage of PCI is still high rate of re-stenosis, reaching 30% per year (10% using DES)

22. Anatomy of Coronary Arteries

23. Anatomy of Left Coronary Artery

24. Anatomy of Right Coronary Artery

25. The Milestones of Coronary Surgery
1959 Sonnes Coronary angiography
1964 Kolesov Graft:LITA-LAD (no CPB, no Angiography)
1967 Favaloro CABG
1991 Benetti OPCAB

26. Idea of Surgical Treatment of CAD
Revascularization of the heart via by-passing significantly narrowed coronary arteries to enhance blood supply to ischemic regions of myocardium

27. The Goals of Surgery in CAD
To prolong a lifetime
To improve a quality of living
To prevent myocardial infarction and its complications

28. Surgical Revascularization Procedures
Coronary Artery By-Pass Grafting (CABG) - CLASSIC
Off-Pump Coronary Artery By-Pass (OPCAB) – NO CPB
Minimally Invasive Coronary Artery By-Pass (MID-CAB) – NO STERNOTOMY
Transmural Laser Revascularization (TMLR) - ALTERNATIVE

29. 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

30. 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

31. OPCAB

32. Cardio-Pulmonary Bypass (CPB)

33. 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)

34. 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 two-vessels 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)

35. 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

36. Scheduled or emergency CABG?

37. 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)

38. 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

39. CABG-Technique Medial Sternotomy Use of CPB
Saphenous by-pass grafts (SBG) or arterial grafts

40. Material for Grafts in CABG
Saphenous vein (SBG)
Left internal thoracic artery (LITA)
Right internal thoracic artery (RITA)
Radial artery (RA)
Gastroepiploic artery

41. 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

42. CABG

43. Venous grafts

44. Venous sequential graft

45. Harvested LITA

46. Graft: LITA to LAD

47. Harvesting and anastomosing of Radial Artery

48. 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

49. Typical uncomplicated course after CABG
ICU 1-2 days:
Artificial ventilation <12 hours
Chest tubes – 2 days
Hospital stay – about 1 week
Antibiotics – 4 days
Rehabilitation 2-3 weeks
Most of the patients returns to normal activity in few months

50. Standard Medication after CABG „A B S”
ASA mg daily
Beta-Blockers
Statins

51. Secondary Prevention after CABG
Lipids control
Glucose control
Weight control
Arterial pressure control
Smoking cessation
Moderate exercise