Ischaemic Heart Disease

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 gt25
• 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
Wall Motion Score

• Normal
• Moderate hypokinesia
• Severe hypokinesia
• Akinesia
• Dyskinesia
• Aneurysm

15
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

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
• p0.05 p0.0001 p0.0001
• 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