Transcript A few basics of cardiac surgery…. Brett Sheridan, MD Assistant Professor Department of Surgery.

A few basics of cardiac surgery….
Brett Sheridan, MD
Assistant Professor
Department of Surgery
Define the difference between
congenital and acquired (adult) heart
disease.
What is the incidence of congenital
heart disease in the Unites States?
List the 3 most common
causes of death in the US…
1) Heart Disease
2) Cancer
3) Stroke
How many people in the US died from
cardiovascular disease in 2001?
Do more men or women die from
cardiovascular disease?
Define “acute coronary syndrome”
according to the
American Heart Association
Acute coronary syndrome (ACS) is defined
by EITHER acute myocardial infarction or
unstable angina.
These patients are divided into 3 subsets:
ST elevation myocardial infarction (STEMI)
non-ST elevation MI
Unstable angina
Describe the initial stabilizing treatment for
symptomatic ischemic heart disease
presenting in the ER
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ECG within 10 minutes
Supplemental O2
IV access continuous ECG monitoring
Sublingual NTG if SBP > 90 mmHG
Morphine
ASA (chewed)
Labs
If ST elevation > 1mV or LBBB then
reperfusion (fibrinolysis or PTCA)
What is AMI management in first 24
hours?
• Limited activity 12 hrs and monitor 24 hrs
• No prophylactic antiarrythmics
• IV heparin if:
– large anterior MI,
– PTCA, LV thrombus or
– thrombolytics administered
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SQ heparin for all others
ASA indefinitely
IV NTG x 24 hrs
IV beta-blocker if stable
ACE inhibitor if BP permits
Statin therapy
What is a coronary angiogram and why do
we do we perform them?
Percutaneous coronary
angioplasty (PTCA, PCI,…)
What is a percutaneous coronary
intervention (PCI)
Percutaneous coronary angioplasty
(PTCA, PCI,…)
Percutaneous coronary angioplasty
(PTCA, PCI,…)
Acute coronary Syndrome:
On-going myocardial ischemia despite initial Rx
Thrombolytics
Revascularization
PCI
CABG
Why are patients referred for CABG instead
of undergoing a PCI approach to coronary
artery disease?
I.e. which patients benefit from CABG?
Cite 2
prospective randomized trials
comparing PCI vs CABG
for the treatment of multivessel CAD
• Inclusion Criteria
– Symptomatic
– Multivessel CAD
– LVEF > 30%
• Baseline Characteristics
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Class III/IV angina - 66%
Previous MI - 42%
3 vessel CAD - 30%
mean LVEF = 60%
Comparison of Coronary-Artery Bypass Surgery and
Stenting for the Treatment of Multivessel Disease
(Arterial Revascularization Therapies Study Group)
CABG
Patients (n)
Late outcome
Death
MI
CVA
Revascularization *
Event-free survival *
Symptom-free *
Cost *
PCI
605
600
---------------------1 year----------------2.8%
2.5%
4.0%
5.3%
2.0%
1.5%
4%
17%
88%
74%
90%
79%
$13,638
$10,665
Event –free Survival: CABG vs PCIS
14% benefit w/ CABG!
Risk of Repeat Revascularization
16 % benefit w/ CABG!
Risk of Death
3.7 % SURVIVAL benefit w/ CABG!
Conclusions-SoS Trial
• Again, repeat revascularization remains
more common after PCI (with or without a
stent) in multivessel CAD.
• In this study, higher rate of all cause
mortality with PCI
Contrast the difference between
“off-pump” CABG versus the typical
cardiopulmonary bypass supported
CABG.
Traditional CABG
• General anesthetic
• Median sternotomy
• Conduit harvest (LITA,
radial, vein)
• Institution of
cardiopulmonary bypass
(CPB)
• Cardiac arrest
• Placement of
aortocoronary grafts
• Separation from CPB
• Close
Advantages - Traditional CABG
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Still Heart
Exposure and access
Visualization
The most intensely scrutinized procedure
in US medicine
SAFETY
Disadvantages - Traditional
CABG
• Proinflammatory response to CPB
• Suggestion of end-organ injury
– CNS
– Pulmonary
– Renal
• Increased fluid shifts
Off-Pump Gear
Off-Pump Stabilizing Devices
Off-Pump Exposure of PDA
List 10 complications of CABG and there
relative frequency
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Death
Stroke
Bleeding requiring re-op
Wound Problems
Myocardial infarction
Arrhythmias
Pneumonia
Pneumothorax
Cardiac Tamponade
Pericardial Inflammation
Renal Insufficiency
3%
1-2%
3-5%
0.5-5%
2-30%
10-60%
4%
1-2%
3-6%
18%
15-20%
What four medications prevent MI and death
following a myocardial infarction?
Class I
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ASA
Beta-blockers
ACE inhibitor
Statins
A prospective randomized trial
comparing stenting with off-pump coronary surgery
for high-grade stenosis in the proximal left anterior
descending coronary artery: three-year follow-up
JACC, 2002, 40:(11) 1955-1960