The Value of Preoperative Administration of Aminophylline as a Cardio Protective Agent During Coronary Artery Bypass Grafting

Introduction to Ischemic Heart Disease SurgeryByStaff Members of Dept. of Cardiothoracic Surgery

Disclosures

2

Learning ObjectivesAt the end of this lecture you should understand:Coronary arteries circulationTreatment options available of IHDsEvolution of CABGGuidelines of treatment of IHDs

Coronary Circulation

The Coronary arteries are two main distributions (right and left),supplied by three vessels: right coronary artery(RCA),left anterior descending (LAD) and circumflex artery (CX)

Left main stem :Arises from the left coronary ostia in left sinus of Valsalva, dividing after 1-2 cm into LAD ,CX and occasionally a third artery: the intermediate

Right Coronary artery : Arises from the right coronary ostia in right sinus of Valsalva, gives many branches and ends as PDA

Dominance of Coronary circulation:It depends on the origin of the PDA ,in 85-90% of hearts it arises from the RCA hence Right Dominant", in the other 10-15% hearts are Left Dominant4

Pathophysiology of IHDsStenotic coronary artery disease (CAD) is narrowing of the coronary arteries caused by thickening and loss of elasticity of the arterial wall (ATHERSCLEROSIS).

In patients with symptoms that warrant coronary angiography:40% have three-vessel disease (3VD)30% have two-vessel-disease (2VD)10-20% have a significant stenosis of the left main stem (LMS)95% with one completely occluded vessel have a significant stenosis in at least one other vessel

Pathophysiology contd.The ostia of large arteries and sites of branching are usually involved.The disease is a continuous process ;this influences the main strategy for treatment.

Treatment modalities of IHDsMedical TherapyPercutaneous transluminal coronary angioplasty (PTCA)And Stenting (bare metal and drug-eluting)Coronary Artery Bypass Grafting (CABG)

Evidence of CABGCABG has been compared to medical therapy,PTCA and PCI in many randomized controlled trials (RCTs) and large registries.The most important comparison is CABG vs. PCI :15 large RCTsThe most important are SYNTAX,SYNTAX II : Death at 3 years double in PCI patients (11% vs. 4.5 % in CABG),While in lower coronary complexity death and MACCE was the same for both PCI and CABG

NB. SYNTAX = synergy between percutaneous coronary intervention with TAXUS and cardiac surgery

Evidence of CABG

Planning for CABGKey factsThere are different ways of performing almost every element of CABG.Several factors are taken into account when planning a CABG to provide minimum morbidity and mortality,and longest graft patency and life expectancy.History,Examination,Blood tests,CXR,Cardiac and Coronary angiography,Echocardiography,Myocardial perfusion studies,Carotid duplex and CT scan are among theses steps of proper planning.

Conduit SelectionArterial Conduits:Left internal mammary artery Right internal mammary arteryRadial arteryRight gastro epiploic arteryRight inferior epigastric arteryVenous Conduits:Long saphenous veinShort saphenous veinCephalic veinSaphenous vein (stored)

Harvesting of Conduits

Direct vision

Harvesting of ConduitsEndoscopic

Evolution of CABGPrior to 1930s, heart surgery seen as impossible, with high morbidity and mortalitySurgery of the heart has probably reached the limits set by nature to all surgery Stephen Paget, 1896, Surgery of the Chest

1937: Dr. John Gibbon designs heart-lung machine, which enables cardiopulmonary bypass (CPB)

1955: Vineburg and Buller implant internal mammary artery into myocardium to treat cardiac ischemia and angina

1958: Longmire, Cannon and Kattus at UCLA perform first open coronary artery endarterectomy without CPB

During 1960s and 1970s, CPB and cardioplegic arrest are adopted, allowing Coronary Artery Bypass Graft (CABG) to emerge as a viable surgical treatment

Nowadays CABGConventional CABG Surgery: via median sternotomy utilizing the CPBBeating On-Pump CABGOff-Pump CABG(OPCAP)Minimally Invasive Direct CABG (MIDCAB) Endoscopic Atraumatic Coronary Artery Bypass (EndoACAB)Port-access CABGTECAB (Totally Endoscopic Coronary Artery Bypass Grafting)

CABG

TECAB

Stent or SurgeryStentLess hospital stayLess cost Less invasiveDrug Eluting StentsDM?!No infectionLess incidence of strokeSurgerycosts for stents and surgery are approximately equal after 2 yearsMinimally invasive surgeries (MIDCAB and port-access) will result in fewer complications from surgery and a shorter hospital stayUnmatched superiority of Total Arterial Revascularization Diabetics have a substantially better response to CABG than to angioplasty and stenting

Useful linkshttp://www.ctsnet.org/http://wiki.ctsnet.org/https://www.facebook.com/CTSNethttp://www.eacts.org/http://www.eacts.org/residents/useful-links/

In the futureThe best of two worlds is coming Heart Team Hybrid rooms

Hybrid Room

Thank you