Ischemic Heart Disease

Question 1

What are the 2023 Class 1 indications for CABG?

Answer 1

1. Left main disease (CABG>PCI)
2. DM and mvCAD with LAD involvement (CABG (LIMA to LAD) > PCI)

Question 2

What are the 2023 Class 2a indications for CABG?

Answer 2

mvCAD with complex/diffuse disease (SYNTAX>33)

Question 3

What are the 2023 Class 2b indications for CABG?

Answer 3

DM with LM stenosis and low-to-intermediate complexity, can consider PCI as an alternative to CABG

Question 4

What are the indications for pre-op carotid duplex?

Answer 4

Guidelines Class 2a: age >65, L main coronary stenosis, PVD, history of stroke/TIA, hypertension, smoking, DM

SESATS: age >75. Triple vessel disease, L main disease

If positive, confirm with CTA or MRA given low positive predictive valve of U/S

Isolated carotid built without other risk factors —> do NOT screen with U/S

Question 5

What is the timing for CABG after carotid work?

Answer 5

Wait 6 weeks after carotid stenting before CABG (2 weeks for initial hyperperfusion phase and 6 weeks for GpIIb/IIIa inihibitor requirement

Wait 2 weeks after carotid endarterectomy (2 weeks for initial hyperperfusion phase to resolve)

Question 6

When should you do CABG after STEMI?

Answer 6

Reduction in risk if you can wait 1 week, unless angina makes delay impossible

If STEMI, do not stop plavix (risk of stent closure worse than risk of bleeding)

Question 7

Pre-op tests for radial artery conduit?

Answer 7

radial artery studies documenting patent palmar arch
Do not take radial from dominant hand

Question 8

Management of air-hit when weaning ?

Answer 8

1. Check TEE for air in LV, root, or coronary/subendocardium
2. Back on bypass
3. Trendelenberg
4. Drive MAP>80
5. Wait 10 min for air embolus to resolve

Question 9

Patient presents in STEMI but cardiologist cannot stent. What do you do?

Answer 9

Have cardiologist place IABP, perform focused H&P to find out time of total ischemia, STAT echo

Question 10

In STEMI with failed PCI, how does approach differ based on lenght of ischemia?

Answer 10

After 6 hours, unlikely to recover contractive function
After 8 hours, theoretically no benefit of revascularization

If 6 hrs –> CABG
If >8 hrs –> MCS/HF pathway

Question 11

Approach if performing CABG MVR but small left atrium

Answer 11

distals then mitral (give dose of plegia, snare caval tapes)

1. Transspetal (identify fossa ovalis and incise towards SVC)
2. If need more exposure, open L pleural cavity and pull up on umbilical tapes
3. If still can’t see, extend incision over dome of LA towards root of aorta, making sure to leave enough atrium adjacent to aortic root to close

Question 12

CABG Conduit options for diabetics?

Answer 12

Absolutely contraindicated to use BIMA on diabetics (relatively contraindicated in morbidly obese, COPD, or otherwise high risk for sternal wound infections)

Question 13

Stenosis cutoffs for radial?

Answer 13

Never use for stenosis <70% (or (per SESATS) R sided stenosis < 90%)

Use IV dilt or other peripheral CCB for 48 hours post-op to prevent vasospasm

Anastomose off vein hood of proximal, or specific dedicated vein hood, or Y off LIMA (can compromise LIMA if not careful)

Question 14

Mortality Risk for redo-CABG

Answer 14

2-3%

If AS and CAD, cannot do TAVR unless can do PCIs first, then 1 month plavix, then TAVR

Question 15

Pre-op workup for redo CBAG?

Answer 15

PA/CXR, TTE, carotid U/S, noncon CT

PET/CT if hypo/dyskinetic wall on TTE
Conduit studies (vein mapping, radial artery mapping w/ Allen’s test)

Question 16

Dark blood welling up from mediastinum during re-entry for redo-cabg. What do you do?

Answer 16

Pack incision, change femoral lines to cannaulae, go on bypass

Question 17

Redo case with prior CABG. How do you manage LIMA?

Answer 17

Issues with re-entry and myocardial protection

Search for IMA between L edge of aorta and medial aspect of L Lung

Place atraumatic clamp to occlude IMA during arrest period. If IMA cannot be controlled, lower temp to 25 C and leave IMA alone

Question 18

How to manage prior vein grafts in redoCABG?

Answer 18

Avoid manipulation to avoid embolization of prior atherosclerotic debris

Anastomose LIMA distal to previous vein grafts
If no disease distal to prior distal anastomotic site, remove vein graft and leave small cuff and sew new graft to that cuff

Question 19

Redo AVR options in patient with prior CABG?

Answer 19

Sternotomy and temporary occlusion of LIMA
RAMT - cool to 25 and do not identify/occlude arterial grafts

Question 20

Prior LIMA to LAD. Would you offer CABG?

Answer 20

Only if symptomatic ischemia 2/2 sclerotic vein grafts

Question 21

Factors favoring reoperative CABG over PCI

Answer 21

1. Late stenosis (>5 years)
2. Multiple stenotic vein grafts
3. Diffusely stenotic grafts
4. No patent IMA graft
5. Decreased LVEF

Question 22

What are STS Risk Score ranges?

Answer 22

Prohibitive: > 15%
High risk: 8-15%
Intermediate 4-8%
Low: <4%

Question 23

How to handle fibrillation upon redo entry?

Answer 23

• have external pads on prior to prepping; shock at 100-200 J if necessary
• avoid cautery near LV
• if unstable, cannulate (peripheral or central) and go on CPB; if heart distends, manually vent or insert vent
  ideally vent through RSPV.
• If unable, can stab LV apex if exposed, or clamp aorta –> aortotomy –> direct handheld cardioplegia to arrest

Question 24

What are the guidelines for concomitant CABG + CEA?

Answer 24

1. Prior stroke/TIA with significant carotid disease (>50% in men, >70% in women)
2. Asymptomatic but bilateral >=50%
3. Asymptomatic unilateral >=50% with contralateral occlusion

Question 25

Indications for concomitant AVR during CABG?

Answer 25

1. Mod-Sev AS or AI
2. Mild AS + Rapid progression of trans valvular gradients (15-20mmHg/year)
3. Mild AS + Rapid decrease in AVA (0.3 cm2)

Question 26

Indications for Concomitant CABG during AVR or MVr/R?

Answer 26

1. Lesions >=70% reduction in major coronaries
2. Can consider lesions >=50% that have reasonable targets

Question 27

Describe operation for CABG + AVR:

Answer 27

1. TEE
2. Aortic+ Dual stage venous
3. LV Vent
4. XC and ante/retro (if AI, antegrade given directly via Ostia after aortotomy)
5. Distal vein graft and give plegia down coronary conduit
6. Oblique aortotomy into noncoronary sinus
7. AVR, close aortotomy
8. Distal mammary anastomosis
9. Proximal graft anastomoses

Question 28

Indications for concomitant MVr/R and CABG?

Answer 28

1. Moderate or severe IMR not likely to resolve with coronary revacsularization alone
2. Mild MR with HF symptoms
3. Moderate -to-severe MS

Question 29

Indications for MVR in AS + CAD?

Answer 29

mod-severe mitral regurg