Transcript 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) post-infarction ventricular aneurysm
IHD Assessment • Clinical Factors • Coronary Anatomy (Arteriography) • Ventricular Function
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
CLASS
I II III IV Canadian Cardiovascular Society Classification of Angina
ACTIVITY '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.
'Slight limitation of ordinary activity'
conditions.
; 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
'Marked limitation of ordinary activity'
conditions and at a normal pace.
; for example, angina occurs walking one or two blocks on the level or climbing one flight of stairs in normal
'Inability to carry on any physical activity without discomfort - angina syndrome may be present at rest'
Source: Circulation, vol. 54, p. 522, 1976
Canadian Cardiovascular Society Classification of Angina Unstable Angina
CLASS
IV IVa IVb IVc
ACTIVITY 'Inability to carry on any physical activity without discomfort - angina syndrome may be present at rest’
Symptom deterioration now controlled on additional oral medical therapy.
Continued pain symptoms despite maximal oral medical therapy.
Continued pain symptoms despite iv therapy
Coronary Anatomy arteriography 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
Left Coronary Artery
Left Coronary Angiogram
Right Coronary Artery
Right Coronary Angiogram
Ventricular Function direct relation to operative mortality Ejection Fraction Wall Motion Score LVEDP
Ejection Fraction
Wall Motion Score LA Posterobasal LV Anterobasal Anterolateral 1.
2.
3.
4.
Apical 5.
6.
Normal Moderate hypokinesia Severe hypokinesia Akinesia Dyskinesia Aneurysm Diaphragmatic
Case Study 1 • 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
Case Study 1 Medication Aspirin Atenolol Clopidogrel Diltiazem Ramipril Simvastatin Coronary Angiography Operation Coronary Artery Bypass Grafts without Cardiopulmonary Bypass LIMA-LAD, LRA - OM1, PDRCA 17/5/02
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
Coronary Artery Bypass Graft
Saphenous Vein Graft Patency
100 90 80 70 60 50 40 30 20 10 0 SVG 1 yr 5 yr 10 yr
Left Internal Mammary Artery Graft
100 90 80 70 60 50 40 30 20 10 0 1 yr
LIMA Patency
5 yr 10 yr LIMA
Landmark Paper 1 10 year survival • • With LIMA Veins only1VD - 88 1VD - 93.4
% 2VD - 90.0
2VD - 79.5
3VD - 82.6
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
“Conventional” Coronary Artery Bypass Surgery
100 90 80 70 60 50 40 30 20 10 0 1 yr 5 yr 10 yr SVG LIMA
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
Other Arterial Conduits?
right gastroepiploic artery inferior epigastic artery radial artery
Right Gastroepiploic Artery
Right Gastroepiploic Artery
Inferior Epigastric artery free graft
Radial Artery free graft
100 90 80 70 60 50 40 30 20 10 0 1 yr
Graft Patencies
5 yr 10yr ?
SVG LIMA F. LIMA Radial GEA IEA
Coronary Artery Bypass Grafting overall increased quality of life Better relief of angina Fewer limitations of activity Reduced need for medication Improved exercise tolerance testing
Coronary Artery Bypass Grafting overall increased quality of life
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
angina improved angina free
angina improved angina free
Coronary Artery Bypass Grafting Mortality
1400 1200 1000 800 600 400 200 0 95/96 Number 96/97 Deaths 97/98 Year 98/99 % CTC mortality 99/00 00/01 % UK mortality 10 8 2 0 6 4 %
Perioperative Complications of CABG Myocardial infarction 3-5% Hypertension • Cathecolamines • Renin-angiotensin Graft occlusion • Conduit damage during harvest • Inadequate distal run-off • Technical inadequacy
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
Case Study 2 PMH • Cholecystectomy 6yr Drugs bisoprolol Imdur Atrovastatin Aspirin GTN Spray Coronary Angiography Operation 2/11/01 Redo CABG ( LRA - OM2 ) through L thoracotomy
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
Return of Anginal Symptoms Graft closure Progress of lesions New lesions
Case Study 3 • 71yr Male • CABG( SVG-LAD,OM1,RCA) • angina for 12 yrs • dyspnoea NYHA IV • history of CCF CCS II Risk Factors • Hypercholesterolaemia • Hypertension • COAD • Ex-smoker 1985 Stable
Case Study 3 Drugs Imdur Aspirin frusemide Ramipril atrovastatin nicorandil amlodipine LV angiography and coronary angiography Operation 14/1/02 LV Aneurysmectomy Postop inotropic support for 3 days
Case Study 3 • Transferred to ward on day 5 • Home on day 10
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
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Long Term Survival
Veterans Administration Co-operative Study (VACOOP) European Coronary Artery Surgery Study (ECSS) Coronary Artery Surgery Study (CASS) Seattle Heart Watch (SHW)