Interactive Tutorial: Surgery Treatment Of Coronary Artery Disease And Heart Transplant Flashcards
CAD
Types:
- Stable angina
- ACS
- Unstable angina
- Non-STEMI
- STEMI - Sudden death
5-year survival of CAD: - Left main: 50% - 3 vessel: 70% - 2 vessel: 88% - 1 vessel: 90-95% —> Other interfering risk factors: LV function, extent of Ischaemia, anatomy of lesion, arrhythmia, DM, recent MI etc.
Diagnosis:
- History, P/E —> Determine Low, Intermediate, High risk patient of having CAD
- Low / Intermediate risk:
—> Able to exercise —> **Stress test / Exercise ECG (aka treadmill)
—> Not able to exercise —> **CT coronary (Iodine contrast), **MRI (Gadolinium contrast) / **Stress Echo, **Perfusion study (Thallium contrast)
- High risk:
—> **Catheter coronary angiogram (still Gold standard) —> Vessels narrowed >50% diameter considered significant
Other classification:
- Perfusion study and Viability study
- SPECT scan (aka Thallium scan —> Perfusion study)
- PET scan
- MRI
- Stress Echo - Anatomical study
- CT coronary angiogram
- Catheter coronary angiogram with functional flow reserve
Treatment options of Stable angina
- Medical treatment
- ABCDE
—> Aspirin + Anti-anginal
—> Beta blocker + BP control
—> Cholesterol + Cigarette control
—> Diet + DM
—> Exercise + Education - PCI
- CABG
Choice: Balance between risks + benefits
Benefits: Relieve symptoms + Improve survival
Risks: Morbidity + Mortality
Indications for Revascularisation
2 Determining factors:
- Symptom
- Not controlled by optimum medical therapy - Prognosis
- Anatomy (Left main / 3 vessel)
- Ischaemic region
PCI vs CABG
CABG:
- **Left main
- **3 vessel disease with LV dysfunction
(- In reality: CABG > PCI if more risk factors)
Risk factors:
- Impaired ventricular function (EF <50%)
- DM
- Difficult coronary anatomy (e.g. proximal lesions, total occlusion, diffuse disease, calcified vessel)
Efficacy:
- CABG > PCI in 10 years
—> PCI has higher rate of recurrence angina, reoperation rate (∵ in stent re-stenosis)
—> PCI has slightly higher risk of MI / death in 10 years
***CABG
Area of Grafts:
- Aorta —> Posterior descending artery from RCA
- Aorta —> LAD
- Aorta —> Obtuse marginal branch from LCx
Conduit:
- ***Left internal mammary artery (LIMA)
- “best” conduit
- underneath left side of sternum
- patency >90% in 10 years
- usually anastomosed to LAD (∵ cover most area of myocardium) - ***Radial artery
- arterial graft theoretically more patent than venous graft
- patency ~70% in 10 years
- can be harvested by minimally invasive method - ***Long saphenous vein
- most commonly used
- patency ~50% in 10 years
- can be harvested by minimally invasive method - Other less commonly used conduits
- Right internal mammary artery (RIMA)
- Gastroepiploic artery
- Inferior epigastric artery
- Short saphenous vein
- Homograft (very poor patency rate)
Approach:
- Open: Median sternotomy (still most frequently used)
- Minimally invasive surgery (MIS)
- MIDCAB (Minimally invasive direct CA bypass) —> harvest LIMA and directly graft onto LAD
- Robotic
Anastomosis:
- Distal anastomosis
- End to side
- Sequential graft (一條graft配給兩條CA —> end to side + side to side) - Proximal anastomosis (LIMA graft no need proximal anastomosis, branch from left subclavian artery)
- Aorta
- Y-graft
Cardiopulmonary bypass
- Stop heart from beating —> But have to do Myocardial protection
- Aim: Bloodless + Motionless surgical field
Off pump CABG (without Cardiopulmonary bypass) —> Use in high risk patients (e.g. atherosclerotic aorta —> cannot find site to cannulate for cardiopulmonary bypass): Pros: - Less bleeding - Less renal failure - Less stroke in atherosclerotic aorta
Cons:
- Less no. of grafts
- Less long term patency
- Technical demanding
Post-op medications
- GTN infusion
- Prevent spasm of ***IMA
- No specific duration, usually stop next day - Diltiazem infusion
- Prevent spasm of ***RA
- Usually stop when oral Diltiazem started
- Last for 3-6 months - Aspirin
- Early aspirin improve early vein graft patency —> best to take within 6 hours post-op, no benefit if >48 hours
- Life long for post-CABG - Beta blocker
- Early resume beta blocker reduce post-op AF + decrease cardiac workload - Lipid lowering drugs
- Improve vein graft long term patency
Complications of CABG
- Risk stratification according to EuroScore: Most 1-2%
Major risk:
- Bleeding
- CVA
- MI
- Arrhythmia
- Infection
- Acute renal failure (requiring temporary renal replacement therapy)
Complication: Peri-operative MI
Causes:
- Poor myocardial protection techniques
- Graft occlusion
- Emboli to grafts / native coronary arteries
Diagnosis:
- Chest pain (NOT accurate ∵ concomitant chest wall wound pain)
- Cardiac enzyme
- CKMB >5x normal
- Tnl >10x normal - ECG
- New Q wave, ST changes (compare to previous ECG!!!) - Echo
- New regional wall movement abnormality
Treatment (depend on Haemodynamic status):
Stable / Suspicious:
1. LMWH
Unstable:
- IABP (intra-aortic balloon pump)
- Coronary angiogram
- ?Redo
Complication: AF
- Up to 40% of patient will have post-op AF
Risk factors:
- Old age
- COAD
- Withdrawal of Beta blocker
Problems:
- Loss of 20% CO
- Risk of thromboembolism (esp. >48 hours)
Preventive measures:
- Keep K, Mg normal
- Resume Beta-blocker
- Amiodarone, Sotalol, Mg supplement
Treatment
Stable:
1. Pharmacological cardioversion
2. Rate control + Anticoagulation (if AF is chronic / >48 hours, difficult in Pharmacological cardioversion)
Unstable:
1. DC cardioversion
Complication: Stroke
- 3% risk in CABG patients
- Prolonged hospital stay, increase morbidity + mortality
Risk factors:
- History of stroke
- Old age
- Carotid artery disease
- Emergency operation
- Atherosclerotic aorta
Diagnosis:
1. CT brain (diagnosis + treatment if haemorrhage)
Prevention:
- Off pump CABG
- Alternative cannulation sites (avoid dislodging atherosclerotic plaques when cannulating ascending aorta)
- Special device
- Circulatory arrest
Special situations in Surgical management of IHD
- Primary CABG for STEMI
- Shock due to MI (Post-MI shock)
- Acute post-MI mechanical complications
- MR
- VSD - Chronic post-MI mechanical complications
- Aneurysm of LV
- Heart failure
- Primary CABG for STEMI
- Less common
- Golden period usually passed when arrive OT
- Advance of primary ***PCI
Post-MI CABG:
- Best to delay 3-7 days if stable and pain free
- Possibly due to ***reperfusion injury
- Shock due to MI (Post-MI shock)
- 0.2% of MI
- ***>40% myocardium is loss before developing shock
- High 30-day mortality ~70%
- SHOCK trial: CABG would have better 1 year survival compared to medical treatment
- Surgical mortality ~50%
- Tendency is stabilise —> CABG later
- Acute post-MI mechanical complications: MR
- Papillary muscle dysfunction / rupture ***after 3-5 days (muscle slowly necrosis)
- Usually postero-medial papillary muscle due to sole blood supply by 1 coronary artery
Clinical features:
- SOB, Shock (~***day 3-5 post-MI)
- New Pan-systolic murmur
- Congested lung field on CXR
Diagnosis:
1. Echo
Treatment:
- Support by Inotropes + IABP
- Urgent operation
- MV repair / MVR
- +/- CABG
- Acute post-MI mechanical complications: VSD
- Mortality >50% in first day
- Most common ***Anterior VSD from LAD infarct
Clinical features (~MR):
- SOB, Shock (~***day 3-5 post-MI)
- New Pan-systolic murmur
- Congested lung field on CXR
Diagnosis:
1. Echo
Treatment:
- Support by Inotropes + IABP
- Delayed operation if stable until fibrosis around VSD
- ∵ myocardium is fragile after MI —> early operation cannot close defect effectively
- Chronic post-MI mechanical complications: Aneurysm of LV
- Success of primary PCI —> reduce incidence of acute mechanical complication post-MI
- Patient survive longer after IHD / MI
- Translate to more chronic problem
Aneurysm of LV:
- Affect LV efficiency
- LV clots (more stagnant blood flow in hypokinetic aneurysm area)
- Patient may have SOB (∵ lower LV efficiency)
Treatment:
- LV Aneurysmectomy / Ventriculoplasty
- improve in EF + symptom of SOB but NOT survival
- Chronic post-MI mechanical complications: Heart failure
- Repeated MI —> progressive deterioration of function
Treatment:
- Mechanical support (can be bridging therapy to heart transplant)
- ECMO
- LVAD - Heart transplant
***Summary
Indication of CABG
- Symptom
- Prognosis
Common conduits and patency rate
- LIMA (90%)
- RA (70%)
- Long saphenous vein (50%)
Major risks of CABG:
- Peri-operative MI
- AF
- Stroke
Complications from AMI:
- Acute
- MR
- VSD - Chronic
- Aneurysm of LV
- Heart failure
Success of Heart transplant
- Advance in immunosuppressant
- Cyclosporine - Advance in endomyocardial biopsy
- Transvenous endomyocardial biopsy —> reliable mean for monitoring allograft rejection
Indications of Heart transplant
- **End stage cardiac disease
- Mostly end stage heart failure
1. **Dilated cardiomyopathy
2. **Ischaemic cardiomyopathy
3. Valvular cause
4. Hypertrophic cardiomyopathy
Recipient selection:
- Relatively healthy patients with end-stage heart disease
- Refractory to other appropriate medical + surgical therapies
- Possess potential to resume a normal active life
- Ability to maintain compliance with a rigorous medical regimen after cardiac transplantation
Relative CI for Heart transplant
- Recent malignancy
- COPD
- Recent + Unresolved pulmonary infarction / PE
- DM with end-organ damage (neuropathy, nephropathy, retinopathy)
- Peripheral vascular / cerebrovascular disease
- Active peptic ulcer disease
- Current / Recent diverticulitis
- Other systemic illness likely to limit survival / rehabilitation
- Sever obesity / cachexia
- Severe osteoporosis
- Active alcohol / drug abuse
- History of non-compliance / psychiatric illness likely to interfere with long-term compliance
- Absence of psychosocial support
Recipient prioritisation for Heart transplant
More urgent:
- less life expectancy
- more mechanical support
Donor selection
Suggested criteria: - Age <55 - Absence of following: —> Prolonged cardiac arrest —> Septicaemia —> Extracerebral malignancy —> Positive serologies for HIV, HBV, HCV —> Haemodynamic stability without high-dose inotropic support
Workup for Cardiac donor:
- Past medical history + P/E
- ECG
- CXR
- ABG
- ABO compatibility, HIV, HBV, HCV
- **Echo, Pulmonary artery catheter evaluation, **Coronary angiogram
Process:
- Echo
—> Good LVEF >45% —> Proceed
—> Poor LVEF <45% —> Hormonal resuscitation (T3, Vasopressin, Methylprednisolone, Insulin) —> Haemodynamic management (Fluid status, Inotropic support) —> Ok —> Proceed
Procedure of Harvest heart
- Heparin
- Aortic cross clamp
- Cardioplegic solution to stop + protect heart (diffuse into myocardium via coronary artery)
- Left + Right heart decompression (ligate LA + RA)
- Cardiectomy
Organ preservation:
- Current graft preservation techniques —> Safe ischaemic period 4-6 hours
- Single flush of cardioplegic solution —> Static hypothermic storage at 4-10oC
Orthotopic Implantation technique:
- Biatrial technique (suture donor RA with recipient RA)
- Bicaval technique (RA is entirely donor’s)
Immunosuppressants in Heart transplant
Triple therapy:
- CNI
- Cyclosporine
- Tacrolimus - Anti-Proliferative agent
- AZA
- MMF
- Cyclophosphamide (rare) - Corticosteroid
- Prednisone / Prednisolone
Recent:
- Sirolimus (Rapamycin), Everolimus —> block downstream of IL2 receptor
Complications of Heart transplant
Early:
- Infection
- Rejection
Chronic:
- Cardiac allograft vasculopathy (~CAD)
- Renal dysfunction
- Malignancy (∵ prolonged immunosuppressants)
Future of heart transplant
Improvement in:
- Immunosuppressant strategies (decrease rejection + infection)
- Organ preservation techniques (prolong safe ischaemic time, prevent ischaemic damage)
- Mechanical assist devices
- Ventricular restoration surgeries
- Possibility of donor pool expansion