Ischemic heart diseaseIschemic heart disease. . Indications and methods of surgical Indications and methods of surgical

treatmenttreatment..

Surgery department Surgery department №№22

IHD classification (WHPO)IHD classification (WHPO)

1. Acute blood flow arrest1. Acute blood flow arrest

2. Stenocardia2. Stenocardia

3. Myocardial infarction3. Myocardial infarction

4. Heart failure4. Heart failure

5. Cardiac rhythm disorders5. Cardiac rhythm disorders

IHD clinical pictureIHD clinical picture

Angina pectoris:Angina pectoris: ( (chest painchest pain on exertion, in cold weather on exertion, in cold weather or emotional situations) or emotional situations)

Acute chest painAcute chest pain: : acute coronary syndromeacute coronary syndrome, , unstable unstable anginaangina or or myocardial infarctionmyocardial infarction("heart attack", severe ("heart attack", severe chest pain unrelieved by rest associated with evidence of chest pain unrelieved by rest associated with evidence of acute heart damage) acute heart damage)

Heart failure:Heart failure: (difficulty in breathing or swelling of the (difficulty in breathing or swelling of the extremities due to weakness of the heart muscle) extremities due to weakness of the heart muscle)

IHD diagnosticsIHD diagnostics

ECGECG

EchocardigraphyEchocardigraphy

CoronarographyCoronarography

VentriculographyVentriculography

IHD treatmentIHD treatment

Non-invasive surgical treatment Non-invasive surgical treatment (could help to turn up the heart on working in conditions of (could help to turn up the heart on working in conditions of

decreased coronary circulation) decreased coronary circulation)

Percutaneus coronary interventionPercutaneus coronary intervention (PCI) (PCI) (balloon angioplasty or coronary stenting)(balloon angioplasty or coronary stenting)

Open heart operationOpen heart operation

IHD invasive treatmentIHD invasive treatment

The best revascularization – The best revascularization –

is full revascularizationis full revascularization

Indications for IHD surgery Indications for IHD surgery treatmenttreatment

Both PCI and CABG are more effective than Both PCI and CABG are more effective than medical management at relieving symptomsmedical management at relieving symptoms Rihal Rihal C, Raco D, Gersh B, Yusuf S (2003)C, Raco D, Gersh B, Yusuf S (2003)

CABG is superior to PCI in multivessel coronary CABG is superior to PCI in multivessel coronary disease disease (SoS trial)(SoS trial)

Patients treated with CABG had lower rates of Patients treated with CABG had lower rates of death and of death or myocardial infarction than death and of death or myocardial infarction than treatment with a treatment with a coronary stentcoronary stent

IHD surgery treatmentIHD surgery treatment

Coronary-aortic bypass grafting (CABG)Coronary-aortic bypass grafting (CABG)

LIMALIMA –to–to -- LAD grafts LAD grafts

Indications for CABGIndications for CABG((Guidelines for CABG Surgery the American College of Guidelines for CABG Surgery the American College of Cardiology and the American Heart AssociationCardiology and the American Heart Association, 1999, 1999 ))

1.1. Significant left main coronary artery stenosis.Significant left main coronary artery stenosis.

2.2. Left main equivalent: significant (70Left main equivalent: significant (70 % %) stenosis of the ) stenosis of the

proximal LAD and proximal left circumflex arteries.proximal LAD and proximal left circumflex arteries.

3. Three-vessel disease. 3. Three-vessel disease.

4. Two-vessel disease with significant proximal LAD stenosis 4. Two-vessel disease with significant proximal LAD stenosis

and either ejection fraction <0.50 or demonstrable and either ejection fraction <0.50 or demonstrable

ischemia on noninvasive testing.ischemia on noninvasive testing.

Indications for CABGIndications for CABG((Guidelines for CABG Surgery the American College of Guidelines for CABG Surgery the American College of Cardiology and the American Heart AssociationCardiology and the American Heart Association, 1999, 1999 ))

5. One- or 2-vessel stenosis without significant proximal LAD 5. One- or 2-vessel stenosis without significant proximal LAD

stenosis, but with a large area of viable myocardium and stenosis, but with a large area of viable myocardium and

high-risk criteria on noninvasive testinghigh-risk criteria on noninvasive testing

..

6. Disabling angina despite maximal noninvasive therapy, 6. Disabling angina despite maximal noninvasive therapy,

when surgery can be performed with acceptable risk.when surgery can be performed with acceptable risk.

2004 2004 ACCACC//AHAAHA CABG guidelines CABG guidelines

Disease of the Disease of the left main coronary arteryleft main coronary artery (LMCA) (LMCA)

Disease of all three coronary vessels (Disease of all three coronary vessels (LADLAD,,LCXLCX and and RCARCA). ).

Diffuse disease not amenable to treatment with a PCI. Diffuse disease not amenable to treatment with a PCI.

CABG historyCABG history In 1952, Demikhov pioneered surgical myocardial In 1952, Demikhov pioneered surgical myocardial

revascularization with the internal mammary artery in canines.revascularization with the internal mammary artery in canines.

However, the invention of beating-heart or off-pump CABG However, the invention of beating-heart or off-pump CABG surgery is often attributed to Kolessov, who, in 1967, used a surgery is often attributed to Kolessov, who, in 1967, used a minithoracotomy incision, anastomosing the left internal minithoracotomy incision, anastomosing the left internal mammary artery (LIMA) to the left anterior descending artery mammary artery (LIMA) to the left anterior descending artery (LAD).(LAD).

Later pioneers of the off-pump technique include Favoloro, Later pioneers of the off-pump technique include Favoloro, Garrett, and associates (in the United States); Trapp and Garrett, and associates (in the United States); Trapp and Bisarya (in Canada); and Ankeney (in the United States)—all of Bisarya (in Canada); and Ankeney (in the United States)—all of whom performed off-pump CABG surgery from 1968 to 1975. whom performed off-pump CABG surgery from 1968 to 1975.

CABGCABG

CABGCABG

CABGCABG

CABGCABG

CABGCABG

Thanks for your attention Thanks for your attention