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Ischaemic Heart Disease

Ischaemic Heart Disease. Role of Surgery in Ischaemic Heart Disease. Chronic angina unstable angina Complications of myocardial infarction mitral regurgitation due to papillary muscle dysfunction/rupture post-infarction VSD (ventricular septal rupture)

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Ischaemic Heart Disease

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  1. Ischaemic Heart Disease

  2. Role of Surgery in Ischaemic Heart Disease • Chronic angina • unstable angina • Complications of myocardial infarction • mitral regurgitation due to papillary muscle dysfunction/rupture • post-infarction VSD (ventricular septal rupture) • post-infarction ventricular aneurysm

  3. IHDAssessment • Clinical Factors • Coronary Anatomy (Arteriography) • Ventricular Function

  4. Clinical Factors • Significant disability from moderate to severe angina • Class III or IV symptoms • ‘symptoms on ordinary activity or at rest’ • Unresponsive to optimal medical care • control of: • blood pressure • arrhythmias • metabolic abnormalities • treatment of associated illnesses • anaemia • hyperthyroidism • ABSTINENCE FROM SMOKING • optimal drug therapy • nitrates • ß blockers • calcium channel antagonists • ACE inhibitors • K+ channel openers

  5. Canadian Cardiovascular SocietyClassification of Angina CLASS ACTIVITY I 'Ordinary physical activity does not cause angina'; for example walking or climbing stairs, angina occurs with strenuous or rapid or prolonged exertion at work or recreation. II 'Slight limitation of ordinary activity'; for example, angina occurs walking or stair climbing after meals, in cold, in wind, under emotional stress or only during the few hours after awakening, walking more than two blocks on the level or climbing more than one flight of ordinary stairs at a normal pace and in normal conditions. III 'Marked limitation of ordinary activity'; for example, angina occurs walking one or two blocks on the level or climbing one flight of stairs in normal conditions and at a normal pace. IV 'Inability to carry on any physical activity without discomfort - angina syndrome may be present at rest' Source: Circulation, vol. 54, p. 522, 1976

  6. Canadian Cardiovascular SocietyClassification of AnginaUnstable Angina CLASS ACTIVITY IV 'Inability to carry on any physical activity without discomfort - angina syndrome may be present at rest’ IVa Symptom deterioration now controlled on additional oral medical therapy. IVb Continued pain symptoms despite maximal oral medical therapy. IVc Continued pain symptoms despite iv therapy

  7. Coronary Anatomyarteriography • 75% luminal obstruction of a major branch • Adequate distal run-off • distal vessel free of lesions >25% • lumen diameter 1.5mm • 50% obstruction in LMCA

  8. Left Coronary Artery

  9. Left Coronary Angiogram

  10. Right Coronary Artery

  11. Right Coronary Angiogram

  12. Ventricular Functiondirect relation to operative mortality • Ejection Fraction • Wall Motion Score • LVEDP

  13. Ejection Fraction

  14. Anterobasal LA Anterolateral LV Apical Posterobasal Diaphragmatic Wall Motion Score • Normal • Moderate hypokinesia • Severe hypokinesia • Akinesia • Dyskinesia • Aneurysm

  15. Case Study1 • 65yr male • angina x 7yr CCS III stable • dyspnoea on exertion NYHA III • MI x 2 1995, 2001 Risk Factors • Family history of IHD • Hypercholesterolaemia • hypertension • ex-smoker for 2months

  16. Case Study 1 Medication Aspirin Clopidogrel Atenolol Diltiazem Ramipril Simvastatin Coronary Angiography Operation Coronary Artery Bypass Grafts without Cardiopulmonary Bypass 17/5/02 LIMA-LAD, LRA - OM1, PDRCA

  17. Case Study 1 • Postop day 2 Atrial Fibrillation • commence on digoxin • rhythm return to sinus rhythm day 4 • Home on day 7 • Out-patient clinic review at 7 week postoperatively

  18. Coronary Artery Bypass Graft

  19. Saphenous Vein Graft Patency

  20. Left Internal Mammary Artery Graft

  21. LIMA Patency

  22. Landmark Paper 1 • 10 year survival % • With LIMA 1VD - 93.4 2VD - 90.0 3VD - 82.6 • Veins only 1VD - 88 2VD - 79.5 3VD - 71.0 p=0.05 p=0.0001 p=0.0001 • x 1.6 risk of death • x 1.4 risk of late MI • x 2.0 risk of reoperation • Loop FD, Lytle B et al, N Engl J Med, 1986

  23. “Conventional” Coronary Artery Bypass Surgery

  24. Landmark Paper 2 • Two Internal Thoracic Artery grafts are better than one • Lytle B et al J Thorac Cardiovasc Surg 1999 • death, reoperation and PTCA were more frequent in single IMA group

  25. Other Arterial Conduits? • right gastroepiploic artery • inferior epigastic artery • radial artery

  26. Right Gastroepiploic Artery

  27. Right Gastroepiploic Artery

  28. Inferior Epigastric artery free graft

  29. Radial Arteryfree graft

  30. Graft Patencies ?

  31. Coronary Artery Bypass Graftingoverall increased quality of life • Better relief of angina • Fewer limitations of activity • Reduced need for medication • Improved exercise tolerance testing

  32. Coronary Artery Bypass Graftingoverall increased quality of life angina improved angina free

  33. Coronary Artery Bypass GraftingMortality

  34. Perioperative Complications of CABG • Myocardial infarction 3-5% • Hypertension • Cathecolamines • Renin-angiotensin • Graft occlusion • Conduit damage during harvest • Inadequate distal run-off • Technical inadequacy

  35. Case Study 2 • 54yr male • CABG x 3 ( LIMA - LAD, SVG - OM2, PDRCA) 1994 • Recurrence of angina 5yrs ago • CCS II Stable • Dyspnoea NYHA II Risk Factors • Hypercholesterolaemia • Family history of IHD • Ex-smoker 3months CVA 3yrs ago

  36. Case Study 2 PMH • Cholecystectomy 6yr Drugs bisoprolol Atrovastatin Imdur Aspirin GTN Spray Coronary Angiography Operation 2/11/01 Redo CABG ( LRA - OM2 ) through L thoracotomy

  37. Case Study 2 • Postop L Basal Atelectasis required physiotherapy • Home on day 6 • Reviewed at out-patient clinic at 6 weeks • Commenced cardiac rehabilitation programme

  38. Return of Anginal Symptoms • Graft closure • Progress of lesions • New lesions

  39. Case Study 3 • 71yr Male • CABG( SVG-LAD,OM1,RCA) 1985 • angina for 12 yrs CCS II Stable • dyspnoea NYHA IV • history of CCF Risk Factors • Hypercholesterolaemia • Hypertension • COAD • Ex-smoker

  40. Case Study 3 Drugs Imdur frusemide Ramipril amlodipine Aspirin atrovastatin nicorandil LV angiography and coronary angiography Operation 14/1/02 LV Aneurysmectomy Postop- inotropic support for 3 days

  41. Case Study 3 • Transferred to ward on day 5 • Home on day 10

  42. Role of Surgery in Ischaemic Heart Disease • Chronic angina • unstable angina • Complications of myocardial infarction • mitral regurgitation due to papillary muscle dysfunction/rupture • post-infarction VSD (ventricular septal rupture) • post-infarction ventricular aneurysm

  43. ? Long Term Survival

  44. Veterans Administration Co-operative Study (VACOOP) • European Coronary Artery Surgery Study (ECSS) • Coronary Artery Surgery Study (CASS) • Seattle Heart Watch (SHW)

  45. PALLIATIVE

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