Ischaemic Heart Disease (PowerPoint download)

Document Sample
Ischaemic Heart Disease (PowerPoint download) Powered By Docstoc
					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
 Canadian Cardiovascular Society
                  Classification 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
Canadian Cardiovascular Society
        Classification of Angina
           Unstable 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
      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

                         Anterobasal                  1.   Normal
LA
                                                      2.   Moderate hypokinesia
                                     Anterolateral
                                                      3.   Severe hypokinesia
                LV
                                                      4.   Akinesia
                                             Apical   5.   Dyskinesia
                                                      6.   Aneurysm
 Posterobasal
                     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    Clopidogrel
Atenolol   Diltiazem
Ramipril   Simvastatin
Coronary Angiography

Operation
Coronary Artery Bypass Grafts without
  Cardiopulmonary Bypass                17/5/02
LIMA-LAD, LRA - OM1, PDRCA
                    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
patency (%)




               60
               50                         SVG
               40
               30
               20
               10
                0
                    1 yr   5 yr   10 yr
Left Internal Mammary Artery
             Graft
                       LIMA Patency

              100
               90
               80
               70
patency (%)




               60
               50                          LIMA
               40
               30
               20
               10
                0
                    1 yr    5 yr   10 yr
              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
                         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
        patency (%)




                       60
                                                  SVG
                       50
                                                  LIMA
                       40
                       30
                       20
                       10
                        0
                            1 yr   5 yr   10 yr
        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
                           Graft Patencies
              100
               90
               80
               70                              SVG
patency (%)




                                               LIMA
               60
                                               F. LIMA
               50
                                               Radial
               40
                                               GEA
               30
                                               IEA
               20
               10
                                          ?
                0
                    1 yr        5 yr    10yr
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%
               angina
    90%
    80%        improved
    70%
    60%                     angina
    50%                     improved
              angina free
    40%                     angina free
    30%
    20%
    10%
     0%
Coronary Artery Bypass Grafting
                                         Mortality
                 1400                                                       10
                 1200
Number of CABG




                                                                            8
                 1000
                  800                                                       6
                                                                                 %
                  600                                                       4
                  400
                                                                            2
                  200
                    0                                                       0
                        95/96    96/97    97/98   98/99     99/00   00/01
                                              Year

                    Number      Deaths    % CTC mortality     % UK mortality
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      Atrovastatin
Imdur           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)         1985
• angina for 12 yrs     CCS II   Stable
• dyspnoea NYHA IV
• history of CCF
Risk Factors
• Hypercholesterolaemia
• Hypertension
• COAD
• Ex-smoker
                  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
                  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
        ?
Long Term Survival
 Veterans Administration Co-operative Study (VACOOP)
 European Coronary Artery Surgery Study (ECSS)
 Coronary Artery Surgery Study (CASS)
 Seattle Heart Watch (SHW)
PALLIATIVE

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:37
posted:12/15/2011
language:Latin
pages:45