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Surgical Management of Ischemic Heart Disease- an update

Dr. Md. Rezwanul Hoque


MBBS, MS, FCPS, FRCSG, FRCSED

Associate Professor Department of Cardiac Surgery BSMMU

Historical Perspective

1876- Adam Hammer establishes that angina is due to interruption of coronary blood supply. 1950- Arthur Vineburg accomplished myocardial revascularization by rerouting IMA into heart muscle allowing it to bleed & nourish 1953- DW Gordon Murray reported placement of arterial graft into coronary circulation 1955- Sidney Smith first used RSVG 1964- The first planned CABG recorded is credited to Kolesov of Russia . He anastomosed LIMA to LAD without CPB and angiographic verification. 1968- RG Favaloro, Cleveland clinic reported first large series of CABG 1973- Benetti, Calafiorie introduced beating heart surgery, LIMA to LAD

CABG

Coronary artery bypass grafting is a surgical procedure performed to relieve angina and reduce the risk of death from coronary artery disease. Arteries or Veins from elsewhere in the patient's body are grafted to the coronary arteries to bypass atheroscleroic narrowing and improve the blood supply to the coronary circulation supplying the myocardium(heart muscle).

Reasons to recommend CABG

relief of angina survival benefit to treat or prevent morbidities such as myocardial infarction, arrhytmias, or heart failure improvement in exercise tolerance

Landmark study favouring CABG


Randomised Trials (Medical vs Surgery) Veterans Administration (VA) Cooperative Study European Coronary Surgery Survey (ECSS) Coronary Artery Surgery Survey (CASS) Non-Randomised Studies 1972-1974 1973-1976 1975-1979

CASS registry (25000 patients)


Duke University databank (10000 patients)

Coronary Artery Surgery Survey (CASS) 1975-1979


Class I or II angina normal LV function 5-year survival surgery- 92% medical- 92% Class III or IV angina 3VD, EF<50% 5-year survival surgery- 82% medical- 52%

Medical versus CABG


meta-analysis of 7 trials, 1972-1984, n: 2649 patients

5-year survival survival


medical: 84.2% surgery: 89.8%

10-year

69.5% 73.6%

VA, European, CASS, Texas, Oregon, New Zealand Trials


Yusuf S. et al. Lancet 1994;344:563-570

Scientific Basis for Coronary Surgery


Randomised Trials (PTCA with or without stent vs Surgery)

Randomised Intervention Treatment of Angina Trial (RITA) Bypass Angioplasty Revascularisation Investigations Randomised Trial (BARI) CABRI ERACHI GABI EAST

PTCA & Stenting

Percutaneous coronary angioplasty is a method of treating localized coronary stenosis by dilatation using special double lumen balloon catheter.

A stent is a small metal mesh tube used as a scaffold to support inside coronary arteries after dilatation. Bare metal stent Cobalt- Chromium stent Drug eluting stent

Angioplasty versus CABG, BARI trial Bypass Angioplasty Revascularization Investigation

5- year mortality
angioplasty surgery 13.7% 10.7%

Absolute difference: 3% P = 0.19

Angioplasty versus CABG,BARI trial


Bypass Angioplasty Revascularization Investigation

The entire difference was confined to patients who had treated diabetes mellitus
7- year mortality among patients with DM

angioplasty surgery

44.3% 23.6%

CABG vs. stent

Arts- event free survival similar, repeat revascularization higher with stent (more in diabetic). SOS- repeat revascularization 21%(PTCA) vs. 8%(CABG), p<0.0001 Awesome- survival benefit similar, revascularization rate decreased with DES.

Angioplasty versus CABG New York State Registry-1999

3-year survival longer survival with CABG for;


proximal LAD stenosis 3-vessel disease

Percutaneous in-situ coronary venous arterialization(PICVA)

Selective Coronary Vein Perfuses Myocardium Arterial Supply From Proximal Coronary Artery Single Connection Made Percutaneously Vein Blocked Proximally Bypasses Artery Completely

Transvascular Inc, with permission

Median Survival Medical Therapy versus CABG


medical 6.6 yrs 6.2 yrs surgery 13.3 yrs 13.1 yrs Survival benefit

LMS disease LM equivalent 3-VD Proximal LAD disease Impaired LV function

Indications for CABG in Asymptomatic or Mild Angina

Class I 1. Significant left main coronary artery stenosis. 2. Left main equivalent: significant (70%) stenosis of the proximal LAD and proximal left circumflex artery. 3. Three-vessel disease. (Survival benefit is greater in patients with abnormal LV function; eg, EF <0.50.) Class IIa Proximal LAD stenosis with 1- or 2-vessel disease.* Class IIb One- or 2-vessel disease not involving the proximal LAD. Class III

Indications for CABG in Stable Angina


Class I 1. Significant left main coronary artery stenosis. 2. Left main equivalent: significant (70%) stenosis of the proximal LAD and proximal left circumflex artery. 3. Three-vessel disease. (Survival benefit is greater when LVEF <0.50.) 4. Two-vessel disease with significant proximal LAD stenosis and either EF <0.50 or demonstrable ischemia on noninvasive testing. 5. One- or 2-vessel CAD without significant proximal LAD stenosis, but with a large area of viable myocardium and high-risk criteria on noninvasive testing. 6. Disabling angina despite maximal noninvasive therapy, when surgery can be performed with acceptable risk. If angina is not typical, objective evidence of ischemia should be obtained.

Indications for CABG in Stable Angina -contd


Class IIa 1. Proximal LAD stenosis with 1-vessel disease.* 2. One- or 2-vessel CAD without significant proximal LAD stenosis, but with a moderate area of viable myocardium and demonstrable ischemia on noninvasive testing. Class III 1. One- or 2-vessel disease not involving significant proximal LAD stenosis, in patients who have mild symptoms that are unlikely due to myocardial ischemia or who have not received an adequate trial of medical therapy and (A) Have only a small area of viable myocardium or (B) Have no demonstrable ischemia on noninvasive testing. 2. Borderline coronary stenoses (50% to 60% diameter in locations other than the left main coronary artery) and no demonstrable ischemia on noninvasive testing. 3. Insignificant coronary stenosis (<50% diameter reduction).

Indications for CABG in Unstable Angina/non- Q Wave MI


Class I 1. Significant left main coronary artery stenosis. 2. Left main equivalent: significant (70%) stenosis of the proximal LAD and proximal left circumflex artery. 3. Ongoing ischemia not responsive to maximal nonsurgical therapy. Class IIa Proximal LAD stenosis with 1- or 2-vessel disease. Class IIb One- or 2-vessel disease not involving the proximal LAD. Class III

Indications for CABG in ST-Segment Elevation (Q-Wave) MI


Class I None. Class IIa Ongoing ischemia/infarction not responsive to maximal nonsurgical therapy. Class IIb 1. Progressive LV pump failure with coronary stenosis compromising viable myocardium outside the initial infarct area. 2. Primary reperfusion in the early hours (6 to 12 hours) of an evolving ST-segment elevation MI. Class III Primary reperfusion late (12 hours) in an evolving ST-segment elevation MI without ongoing ischemia.

Indications for CABG in Patients


With Poor LV Function

Class I 1. Significant left main coronary artery stenosis. 2. Left main equivalent: significant (70%) stenosis of the proximal LAD and proximal left circumflex artery. 3. Proximal LAD stenosis with 2- or 3-vessel disease. Class IIa Poor LV function, with significant viable noncontracting revascularizable myocardium and without any of the above anatomic patterns. Class III Poor LV function, without evidence of intermittent ischemia and without evidence of significant revascularizable viable myocardium.

Indications for CABG in Life-Threatening Ventricular Arrhythmias

Class I Left main coronary artery stenosis. Three-vessel coronary disease. Class IIa Bypassable 1- or 2-vessel disease causing life-threatening ventricular arrhythmias. Proximal LAD disease with 1- or 2-vessel disease. Class III Ventricular tachycardia with scar and no evidence of ischemia.

Indications for CABG after failed PTCA


Class I Ongoing ischemia or threatened occlusion with significant myocardium at risk. Hemodynamic compromise. Class IIa Foreign body in crucial anatomic position. Hemodynamic compromise in patients with impairment of the coagulation system and without previous sternotomy. Class IIb Hemodynamic compromise in patients with impairment of the coagulation system and with previous sternotomy. Class III Absence of ischemia. Inability to revascularize due to target anatomy or no-reflow state.

Indications for CABG in Patients with Previous CABG


Class I Disabling angina despite maximal noninvasive therapy. (If angina is not typical, then objective evidence of ischemia should be obtained.) Class IIa Bypassable distal vessel(s) with a large area of threatened myocardium by noninvasive studies. Class IIb Ischemia in the non-LAD distribution with a patent IMA graft to the LAD supplying functioning myocardium, without an aggressive attempt at medical management and/or percutaneous revascularization.

Coronary Artery Bypass Grafting(CABG)

Annual incidence of Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting in the UK

Procedures (thousands)

40 30 20 10 0

CABG

PCI

Summary- Indication for CABG

Left main disease/ Left main equivalent disease 3 vessel disease particularly with LV dysfunction and DM Proximal LAD lesion where stenting risky Failed PTCA and stenting Concomitant valve/intracardiac surgery Complication of MI, VSD/MR/ aneurysm where surgery would give better outcome than conservative measures

Scope of PTCA being expanded, Surgeons have to deal with more complicated cases with less expertise

SURGERY
Choice of conduits

Long saphenous vein Short saphenous vein Upper limb veins LITA RITA Radial artery Gastroepiploic artery Inferior epigastric artery Cryopreserved allografts

Graft Patency Rates


Conduit 5 year 10 year 95% left internal 96% thoracic artery right internal 93% thoracic artery Radial artery 90% Saphenous vein 75%

90%

80% 50%

CABG- alternative approach

Minimally Invasive CABG (MICAS): This refers to all techniques of CABG wherein there is no use of CPB. It also includes operations involving lesser incisions than a standard full median sternotomy. Minimally invasive Direct CABG (MIDCAB): This is usually restricted to LIMA-LAD or single vessel anastomosis done through a short incision in the fourth left intercostal space and entering the pericardium through the bed of excised cartilage.

CCABG/ OPCABG

Conventional Perfect anastomosis on still heart. Complication of CPBInflammatory, Bleeding, Hepatorenal, Embolic, neurocognitive?. Cost of Heart-lung machine/Oxygenator Longer ICU/ Hospital stay Mortality 1-2% in low risk patient

Less perfect anastomosis in inexperienced hand Avoids CPB complication Cost of shunt, stabilizer, positioner Less Hepatorenal, lung, bleeding complication? neurocognitive? Shorter ICU/ Hospital stay Mortality 1-2% in low risk patient

Port-access CABG( PA-CABG)

Port-access CABG surgery is performed through small incisions or access ports made through the intercostal spaces between the patient's ribs, resulting in greatly reduced pain and morbidity to the patient. In situ arterial bypass grafts, such as the internal mammary arteries and/or the right gastroepiploic artery, are prepared for grafting by thoracoscopic or laparoscopic takedown techniques.

Free grafts, such as a saphenous vein graft or a free arterial graft, can be used to augment the in situ arterial grafts.

The graft vessels are anastomosed to the coronary arteries under direct visualization through a cardioscopic microscope inserted through an intercostal access port. Retraction instruments are provided to manipulate the heart within the closed chest of the patient to expose each of the coronary arteries for visualization and anastomosis.

Robotic CABG

Robotic surgery may be used in conjunction with other minimally invasive surgical techniques in coronary artery bypass surgery. Though not definitively proven, robotic repair may provide benefits including:

Shorter hospital stay Less pain and scarring Less risk of infection Less blood loss and fewer transfusions Faster recovery Quicker return to normal activities

Use of Robotics
Used for a number of different elements of the coronary artery bypass grafting (CABG) procedure, often depending on the experience of the center with the robotic system.

Harvesting of the internal thoracic artery (ITA)

Anastomosis of the ITA to the left anterior descending coronary artery.


Left internal mammary artery (LIMA) harvesting and the CABG procedure are performed using the da Vinci telemanipulation system.

A port for the 3D camera is placed in the fourth or fifth left intercostal space at the level of the midclavicular line.
Two ports for the robotic instrumentation are made in the third or fourth intercostal space (right instrument) and in the fifth or sixth intercostal space (left instrument) both at the level of the anterior axillary line
.

da Vinci Surgical Robotic System

Typical set-up of robotic system in operating room

Components of da vinci system

Surgeons console

Articulated wrist

Components-Contd

Video arm

Master handles

TE-CABG
Using the da Vinci robotic surgical system to perform TECAB, surgeons can successfully perform the non-invasive procedure without splitting open the chest and placing the patient on a heart-lung machine.

Hybrid TECABG
A hybrid TECAB approach has also been used, combining both surgical and interventional cardiology procedures to improve blood flow to the heart.
The hybrid procedure involves bypassing blocked arteries and opens other blocked vessels using angioplasty. Using this method, the patient can undergo total revascularization in the least invasive way, Hybrid TECAB procedures are extremely beneficial.

Vein bypasses have a higher occlusion rate, about 20% of veins will occlude within the first year and only about 50% will be functioning in 5 to 6 years.

When these mammary bypasses are combined with stents using TECAB, they function as good as or better than vein bypasses in the long run.

Transmyocardial Revascularization
TMR is a procedure used to relieve severe angina or chest pain in very ill patients who aren't candidates for bypass surgery or angioplasty.

In this procedure, a surgeon makes an incision on the left breast to expose the heart. Then, using a laser, the surgeon drills a series of holes from the outside of the heart into the heart's pumping chamber. From 20 to 40 mm laser channels are placed during the procedure. Bleeding from the laser channels on the outside of the heart stops after a few minutes of pressure from the surgeon's finger.

In some patients TMR is combined with bypass surgery. In those cases an incision through Sternum is used.

TMR
How TMR reduces angina still isn't fully understood The laser may stimulate new blood vessels to grow, called angiogenesis . It may destroy nerve fibers to the heart, making patients unable to feel their chest pain. TMR may be used for people who are high-risk candidates for a second bypass or angioplasty. people whose blockages are too diffuse to be treated with bypass alone. some patients with heart transplants who develop atherosclerosis after their transplant.

TMR

Anastomotic Devices
Anastomotic devices for both the proximal and distal anastomosis. St. Jude Symmetry Aortic Connector Cardica C-Por PASPort Anastomotic Systems with the Converge Anastomotic Coupler).

Gene Therapy in CAD

Encouraging results have been obtained with the angiogenic cytokines vascular endothelial growth factor (VEGF) and basic fibroblast growth factor in animal models, leading to clinical trials in ischemic heart disease. VEGF also has therapeutic potential in a second area of cardiovascular gene therapy, the enhancement of arterioprotective endothelial functions to prevent postangioplasty restenosis and bypass graft arteriopathy. The endothelial cell growth and survival functions of VEGF promote endothelial regeneration, whereas VEGF-induced endothelial production of NO and prostacyclin inhibits vascular smooth muscle cell proliferation.

Stem Cell Therapy

During the last decade, different cell types have been proposed for cellbased cardiac repair. These include foetal cardiomyocytes, skeletal myoblasts, bone marrowderived haematopoietic and mesenchymal stem cells, mouse and hESCs, embryonic stem cell and more recently resident cardiac progenitor cells.

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