Lecture 2 (CAD)-Exam 1 Flashcards
- What is Atherosclerosis?
- What is stenosis?
Atherosclerosis
* Process in which fatty deposits known as plaques, build up on the inner walls of arteries
* Over time the plaques grow and cause the arterial walls to thicken and narrow the blood vessel
Stenosis
* Abnormal narrowing within a blood vessel; most often caused by atherosclerosis
- What is embolism?
- What is Thrombus?
- What is ischemia?
- What is necrosis/infaraction?
Coronary Arteries: Left side
* Have what?
* The left main divides into what?
* The LAD branches are called?
* The LCX branches are called what?
Coranary Artery Anatomy:
* What is the Right side supply?
* What does the RCA?
- Right coronary artery (RCA)
- The RCA supplies the posterior portion of the interventricular septum and gives off the posterior descending artery (PDA) – most of the time (left or right sided dominated)
What is the coronary sinus?
the major venous tributary of the greater cardiac venous system; it is responsible for draining most of the deoxygenated blood leaving the myocardium.
* Drain into RA
Left Anterior Descending (LAD) Artery: the LAD supplies blood what?
Left Anterior Descending (LAD) Artery: the LAD supplies blood to the anterior (front) part of the left ventricle, the anterior two-thirds of the interventricular septum, and the apex (tip) of the heart.
Left Circumflex (LCX) Artery: The LCX supplies blood where?
Left Circumflex (LCX) Artery: The LCX supplies blood to the lateral (side) and posterior (back) parts of the left ventricle and left atrium. In some individuals, the LCX may also supply the sinoatrial (SA) node and the atrioventricular (AV) node
RCA Main Branch: The RCA supplies blood where?
RCA Main Branch: The RCA supplies blood to the right atrium and right ventricle. It also supplies the inferior (bottom) part of the left ventricle and a portion of the posterior interventricular septum.
Right Marginal Artery: This branch supplies what?
branch supplies blood to the right ventricle’s lateral wall
Posterior Descending Artery (PDA): In most individuals (about 85%), the PDA originates where?
In most individuals (about 85%), the PDA originates from the RCA and supplies the posterior third of the interventricular septum and part of the inferior wall of the left ventricle.
DOMINANT CIRCULATION
* What is the dominant circulation?
* What is left dominant ciculation?
* What is co-dominant circulation?
Atherosclerosis
* What happens to the arteries?
* What type of process?
* Typically at regions of what?
- Chronic inflammatory disease of the arteries
- Principally a lipid-driven process (LDLs) initiated by the accumulation of low-density lipoproteins and an active inflammatory process in focal areas
- Typically at regions of branch points in arteries (need to take care of both vessels)
Atherosclerosis
* Considered the primary cause of what?
Considered a primary cause of heart attacks, stroke, and peripheral arterial disease
* Underlying cause of 50% of all deaths in westernized society
What are modifiable risk factors of atherosclerosis? (7)
What are non-modifiable risk factors of atherosclerosis?
Atherosclerosis
* Atherosclerotic cardiovascular disease mainly involves what?
the heart and brain
Ischemic heart disease (IHD)
* 610,000 people die of what?
* Coronary heart disease is what?
* 75% of acute myocardial infarctions occur from what?
- 610,000 people die of heart disease every year
– 1 of every 4 deaths - Coronary heart disease is the leading cause of death in the western world killing over 370,000 people annually
- 75% of acute myocardial infarctions occur from plaque rupture
Ischemic stroke
* Stroke from any cause represents what?
represents the fifth leading cause of death and the major cause of serious long-term disability in adults in the IS
- Ischemic strokes are the most common type of stroke – happens with what?
- Nearly 795,000 people suffer from
- Ischemic strokes are the most common type of stroke – happens with a blood clot in an area of narrowing due to plaque
- Nearly 795,000 people suffer from stroke every year, resulting in about 140,000 deaths
Atherosclerosis
* Vessel involvement throughout the body determines disease. Explain the different areas?
- Coronary involvement -> Ischemic heart disease
- Cerebrovascular involvement -> CVA (stroke)
- Mesenteric arteries -> Mesenteric infarction (bowel ischemia)
- Lower extremities -> Claudication, PVD
Ischemic Heart Disease
* What is the clinical spectrum?
Asymptomatic patients
Prinzmetal angina/variant angina/vasospastic angina
Stable Angina
Acute Coronary Syndrome
* Unstable angina
* STEMI/NSTEMI
Ischemia: Type I and type 2
* Type 1 ischemia occurs in who?
* Type II ischemia occurs to due to what?
* What is demand ischemia?
Type 1 ischemia occurs in those with atherosclerotic plaque rupture and thrombosis– reduced blood flow from arterial blockage
Type II ischemia occurs to due to demand/supply mismatch without acute atherothrombosis
* Demand ischemia – occurs when tissue oxygen demand exceeds available supply, typically as a result of increased activity or the bodies inability to deliver oxygenated blood in a timely fashion
Asymptomatic patients
* Vague complaints/things that don’t fit normal symtoms
- Female gender (different sxs)
- Patients with diabetes (messed up pain receptors)
- Older age
Prinzmetal/variant angina
* An angina that occurs due to what?
* Can occurs when?
* Can be triggered by?
- An angina that occurs due to spasms (sudden, intense contractions) of the coronary arteries, temporarily reduces blood flow to the heart muscle (myocardium)
- Can occur at rest and is often unpredictable
- Can be triggered by stress, exposure to cold, or certain medications
Prinzmetal/variant angina
* Main symptom is what?
* More common in who?
* What is the gold standard?
* Responds well to medications such as what?
- Main symptom is chest pain described as squeezing, pressure, or tightness
- More common in younger adults
- Gold standard is coronary angiography – will demonstrate coronary spasm – hallmark of PVA
- Responds well to medications such as calcium channel blocker, nitroglycerin
- What is angina?
Also known as angina pectoris – it is a symptom characterized by chest pain or discomfort that occurs when the myocardium does not receive enough oxygen-rich blood
Stable angina:
* What is it?
* Occurs in what pattern? Relived by?
* A temporary reduction in what?
- Myocardial ischemia secondary to exertion (Imbalance between myocardial oxygen demand and delivery)
- Occurs in a predictable pattern and is relieved by rest or medication (nitroglycerin)
- A temporary reduction in blood flow to the heart – fixed/stable stenosis
*
Stable angina
* What are the symptoms?
* What is anginal equivalent?
- Chest Pain or angina pectoris (squeezing/pressure/substernal) that builds up rapidly in 30 seconds and typically disappears within 5 -15 minutes with rest
- Aching, heaviness, pressure, squeezing or dull mid-sternal discomfort with radiation to the neck, jaw, left shoulder, or arm
- “Anginal equivalent”: SOB, fatigue, nausea/reflux/indigestion, diaphoresis, dizziness, jaw pain, arm pain
Stable angina
* What are Factors that increase myocardial oxygen demand (a natural stress test)?
- Arrythmias
- Fever
- HTN
- Cocaine use
- Aortic stenosis
- Anemia (decrease hemoglobin)
- CHF (HTN+vasular spasm)
What is not normally cardiac symptoms?
sharp, seconds, pleuritic, positional, tender to palpation
What is acute cornonary syndrome?
- Unstable angina
- NSTEMI/STEMI
Unstable angina
* What is it?
* What happens with symtoms?
* More what?
* Considered for ?
- New onset angina
- Worsening symptoms with activity and/or at rest
- More unpredictable
- Considered for urgent or emergent evaluation
Unstable Angina:
* What is shown on EKG?
- Mild to moderate ST-segment depression may be seen during episodes of chest pain.
- Transient T-wave inversion may also be seen during or shortly after an episode of chest pain.
- May have a normal EKG, especially if the episode of chest pain has resolved by the time the EKG is performed. Transient changes that disappear when pain free
Unstable Angina
* Absence of what?
* No evidence of ?
- Absence of elevated cardiac enzymes
- No evidence of cardiac myocyte necrosis
STEMI
* What is it?
* Defined based on what?
* What happens to the patient?
* Most deaths occur within? Why?
- Complete and prolonged occlusion of a coronary blood vessel
- Defined based on ECG criteria
- Half die before they reach the hospital
- Most deaths occur within 1 hour of onset due to ventricular fibrillation
NSTEMI
* What happens?
* Defined by what?
* Evidence of what?
- usually results from severe coronary artery narrowing, transient occlusion, or microembolization of thrombus
- Defined by an elevation of cardiac biomarkers in the absence of ST elevation
- Evidence of myocyte ischemia
Clinical Symptoms of ACS
* what is going on with pain?
- Usually severe & intolerable; retrosternal, central (may radiate to left/right/both arm, neck, jaw)
- Remember - atypical presentation in women, elderly and diabetics
- Prolonged: 20 minutes to hours, does it stop with rest or not?
- Quality: “heavy”, “crushing,” “constricting,” “compressing,” “oppressing”, stabbing
- Can also be described as pressure, squeezing, burning
- Chest pain is caused by ischemia, not infarction (Supply and demand)
Clinical Symptoms of ACS
* What are some other sxs besides chest pain?
- Nausea/vomiting: The inferior part of the heart is often supplied by the right coronary artery. An infarction in this area can lead to stimulation of the vagus nerve, which can cause nausea and vomiting.
- Weakness
- Dizziness, palpitations
- Cold sweat, sense of impending doom
- Diaphoresis (sweating) is a predictor of ACS (ST segment elevation)
ACS Physical exam
* What is often seen?
* What can be heard?
* What is normal but what can be associated with CHF?
* What present can indicate CHF?
- General distress and diaphoresis are often seen
- Heart sounds are frequently normal, possible gallop and murmur can be heard.
- Lung exam is normal, although at times crackles may be heard pointing toward associated congestive heart failure (CHF)
- Bilateral leg edema may be present indicating CHF
ACS Physical exam
Levine sign- closed fist over the chest
ACS Physical exam: The rest of the systems are typically within normal limits:
1. The presence of abdominal tenderness to palpation should make the provider consider what?
2. The presence of unequal pulses warrants consideration of what?
3. The presence of unilateral leg swelling should warrant what?
- pancreatitis and gastritis.
- aortic dissection
- pulmonary emboli
What is levine sign?
ACS-Closed fist over chest
Precipitating Factors for ACs
* When does it commonly occur?
* What does the sympathetic nervous system do?
* Adrenal glands releases what?
- More commonly occur within a few hours of awakening
- Sympathetic nervous system increases heart rate variability and increase in heart rate
- Adrenal glands release adrenaline/cortisol which can trigger rupture of plaques in the coronary arteries
Precipitating Factors for ACs
* What type of stress?
* What type of excerise?
* What else? (2)
- Emotional stress
- Vigorous physical exercise
- Medical illness
- Surgery
Diagnostic process of ASC:
* What dx testing in outpt?
- EKG – should be the initial diagnostic test
- Coronary CT calcium score
- Stress Test (exercise treadmill test, nuclear stress test, dobutamine or adenosine stress test, stress echo)
Diagnostic process of ASC
* What is inpatient?
* What are the lab studies?
- Cardiac catheterization + all the outpt dx testing
- Labs:Troponin, CKMB, BNP
EKG –
* What is the inital dx test?
* What are the 2 most characteristic features of AMI? Seen in how many people?
* STEMI will have what?
* injury pattern” occurs with what?
- The initial diagnostic test which should be ordered is the EKG
- ST elevation and Q waves are the 2 most characteristic features of AMI. Seen only in 50% of patients at presentation
- STEMI will have ST elevation of 1mm or more in at least 2 contiguous leads
- “injury pattern” occurs with transmural ischemia
EKG
* NSTEMI with have what? What is common?
* Unstable angina and NSTEMI will have what?
* What is EKG Evolution?
- NSTEMI with have new ST depression occurs in ~ 1/3 of patients
- T- wave changes are common, but non-specific – unless they are new and are deep T-wave inversions
- Unstable angina and NSTEMI will have signs of ischemia (ST depression or new T wave inversion).
- EKG Evolution: good idea to repeat the EKG frequently if ACS is suspected, as the initial EKG may be normal.
Q waves:
* Shape?
* Indicates what?
* Sign of what?
- Deep, wide, larger than 1 box
- Indicates prior MI
- Sign of irreversible myocardial damage from previous MI, indicates scar/dead myocardium
Computed Tomographic Scanning (CT)
* Can detect what?
* appropriate prognostic value for the determination of what?
* Not used how?
- Can detect amounts of coronary artery calcium as an indicator of atherosclerosis in the coronary arterial tree
- appropriate prognostic value for the determination of coronary artery stenosis but not for discriminating between different severities of stenoses
- Not used alone. Combined with other info such as risk factors for coronary artery disease.
88.6% sensitivity and 86.2% specificity
Computed Tomographic Scanning (CT)
* A higher coronary calcium-score suggests what?
* With use of what?
- A higher coronary calcium-score suggest higher chance of significant narrowing of coronaries and higher risk of future heart attack
- With use of IV contrast, noninvasive coronary angiography is possible via CT scan
CT: Calcium-Score screening heart scan
* What is the scoring system? (3)
Agatston Score
* 0 = no calcium is seen. Low chance of developing a heart attack in the future.
* 100 to 300 = Moderate plaque deposits. Associated with a relatively high risk of a heart attack or other heart disease over the next three to five years.
* A score greater than 300 is a sign of very high to severe disease and heart attack risk.
Stress Testing
* What are the different types?
Algorithm for identifying patients who should be referred for stress testing and pathway for determining whether a standard treadmill exercise with ECG alone is adequate
Exercise Stress test
* Most widely used test for both the diagnosis of what?
* What is happening before, during and after exerise?
* Standardized incremental increase in what?
* May not detect what?
- Most widely used test for both the diagnosis of Ischemic Heart Disease (IHD) and the estimation of the risk and prognosis.
- Non-invasive, affordable screening test
- 12-lead EKG before, during, and after exercise
- Standardized incremental increase in external workload while symptoms, EKG and blood pressure are monitored.
- May not detect low grade stenosis (<50%)
Exercise Stress test
* Positive if what?
* Effected by what?
* Negative test does not exclude what?
- Positive if >2mm ST depression and/or hypotension
- Effected by baseline ECG changes
- Negative test does not exclude CAD
Exercise Stress test
* Discontinued if what?
Bruce Protocol
* What are the stages?
* What is the expectation?
High-risk for stress test criteria
* BP?
* Early positivity, within what?
* _ recovery
* Diffuse what?
* More than what?
* What type of elevation?
Nuclear stress test
* This test uses what?
* The tracers are detected using what? What does it allow?
* Then have the patient exercise or give pharmacologic agent. What is the drug?
Nuclear stress test
* Pharmacological stress test utilized for patients with what?
Stress echo
* Diagnostic test that evaluates what?
* Combines the use of what?
Stress echo
* What does it evaluate?
- Wall motion – how the heart contracts, reduced or abnormal wall motion can indicate areas of ischemia
- Can assess how the heart valves function during increased workload
- Can indicate if CAD is suspected
Tropnin:
* What are they?
* What are the three types?
Troponins are regulatory proteins found in skeletal and cardiac muscle and play a role in muscle contraction
3 types:
* Troponin C is present in both cardiac and skeletal tissue
* Troponin T is also found in both cardiac (more) and skeletal tissue
* Troponin I is cardiac specific
troponin
* When damage or death of cardiac tissue occurs, what is released?
* What is the rise? What is detectable sooner?
- When damage or death of cardiac tissue occurs, cardiac troponin (cTn) is released into circulation by cardiac muscle cells
- Traditional troponin begins to rise 4-6 hours after symptom onset, peaks by 18-24 hours, BUT remains in detectable levels for > 72-96 hours
- High sensitivity troponin is detectable sooner
High sensitivity troponin
* Troponin has been a biomarker since late 1980’s but has emerged as what?
* What is the next generation?
* The high sensitivity test can measure what? Must have what?
* Troponin is traditionally ordered as?
Brain natriuretic peptide BNP/NT-probnp
* What are they?
* What do they regulate?
* Is used as what?
* BNP is expressed predominantly by what?
Natriuretic peptides (NP’s) are key proteins that improve and regulate circulation
* They regulate blood pressure, inhibit cardiac hypertrophy and remodeling
* Is used as a biomarker for congestive heart failure
BNP is expressed predominantly by cardiomyocytes
Brain natriuretic peptide BNP/NT-probnp
* When is it released?
* Guides what?
- When there is ventricular distention/myocardial muscle stretching, it is released by those cardiac cells
- Guides diagnoses and treatment of congestive heart failure
ckmb
* What is it?
* What are the three types?
Creatinine kinase is an enzyme that catalyzes the reversible phosphorylation of creatinine by ATP
* CKBB – found in central nervous system (brain)
* CKMM- found in adult skeletal muscle
* CKMB – found in myocardium (1-2% in skeletal too)
- When is CK-MB elevated?
- High sensitivity, but low specificity – there is what?
* First appears when?
* Peaks when?
* Usually detectable?
* reported as what?
Cardiac Catheterization
* Gold standard of what?
* Can be what?
* Variety of catheter-based interventions can be used to alleviate what?
* Certain stenotic valvular and arterial lesions can be treated with what?
- Gold standard test - assessment of coronary artery anatomy by coronary angiography
- Therapeutic or diagnostic
- Variety of catheter-based interventions can be used to alleviate the obstruction to blood flow in the coronary arteries. (PCI, PTCA, balloon angioplasty)
- Certain stenotic valvular and arterial lesions can be treated with catheter-delivered balloon expansion, deployment of stents, or stent mounted bioprosthetic valves
Cardiac Catheterization
* Interpretation is what?
* What are the two types?
Interpretation is subjective, tools to evaluate degree of stenosis: IVUS, iFR
* IVUS- intravascular US – specialized US probe that images the inside of the vessel
* iFR – instantaneous wave free ration – pressure based index that provides a measure of pressure difference across a coronary artery stenosis
CAD
* What is it?
Coronary artery disease (CAD) is a narrowing of the coronary arteries with atherosclerotic plaque. This limits the supply of oxygen rich blood to the heart muscle
* Lower yield: Heart disease is the leading cause of death among men and women in the United States. Coronary artery disease affects 16.5 million Americans. The American Heart Association (AHA) estimates that someone in the US has a heart attack about every 40 seconds. In addition, for patients with no risk factors for heart disease, the lifetime risk of having cardiovascular disease is 3.6% for men and less than 1% for women. Having 2 or more risk factors increase the lifetime risk of cardiovascular disease to 37.5% for men and 18.3% in women
What are the risk factors of CAD?
Risk factors: male, advanced age, race, smoking, diabetes, family history, dyslipidemia, life style
Treatment strategies
* For Stemi, Nstemi, stable/unstable angina
* For revascularization?
- What is the stemi treatment?
- What is the time frame?
MONA
* Morphine
* Oxygen
* Nitroglycerin/nitrates
* Aspirin 325mg
First medical contact to device time
* 90 min at PCI capable hospital
* 120 min at non-capable PCI hospital
What are the different fibrolytic agents?
What are the absolute and relative contraindictation?
Medical Treatment for NSTEMI/Unstable angina
* Similar to what?
* What what is different?
Stable angina Medical treatment
* What is the goal?
* What are the different options and what do they do?
Goal is to reduce progression:
* Manage Dyslipidemia – high intensity statin
* Antiplatelet – ASA +/- others (see next slide!)
* Beta-blockers - slow the heart, allow increased ventricular filling, and reduce oxygen demand (improves mortality)
* Calcium-channel blockers reduce afterload and contractility and dilate coronary arteries
* Nitrates (decreases pre-load, dilate coronary arteries)
Stable angina Medical treatment
* What is used to assess severity?
Exercise stress test/stress echo to assess severity
Aspirin:
* What is the dose and timing?
* Given to who?
* Inhibits what?
* What is the maintenance dose?
- 325 mg x 1 given at time of ACS event
- Given to all patients unless contraindicated
- Inhibits platelet aggregation & development of coronary thrombosis
- Maintenance dose 81mg daily
Clopidogrel (Plavix) or Ticagrelor (Brilinta)
* Fast or slow?
* better what?
* Loaded before what?
* What is the MOA?
*
Glycoprotein IIb/IIIa inhibitors (inhibit platelet aggregation)
* What are the side effects?
* What are the types?
SE: Bleeding and thrombocytopenia
* Abciximab (ReoPro)
* Eptifibatide (Integrilin)
* Tirofiban (Aggrastat)
What is the Long-term Management for CAD patients?
What are the revascularization options ?
Percutaneous coronary intervention (PCI)/Percutaneous Transluminal Coronary Angioplasty (PTCA)
* Preferred to thrombolytics/fibrinolytics
Coronary artery bypass grafting (CABG)
What is angioplasty? What is an angioplasty and stenting?
PCI/PTCA
* What type of procedure?
* What needs to be given for 12 months?
* Acess through what?
* PCI carries increased risk of what?
- Quick, non-invasive procedure, but does still have risks associated
- Dual antiplatelet therapy for 12 months
- Accessed through the femoral artery or radial artery (first choice)
- PCI carries increased risk of redevelopment of angina requiring repeat angiography and revascularization, specifically in DM patients
PCI/PTCA
* PCI is usually advised for patients with what?
* High risk PCI can be done with?
* Decision best made by?
- PCI is usually advised for patients with one or two vessel disease or high risk patients where surgery is not advisable
- High risk PCI can be done with mechanical support via Impella, IABP
- Decision best made by team approach: cardiologist + cardiac surgeon
PCI Risks
* Where does bleeding and hematoma occur?
* What happens to vascular?
* What type of clots can happen?
- Bleeding and Hematoma: can occur at the catheter insertion site, which is often the femoral or radial artery.
- Vascular Injury: Injury to the artery at the catheter insertion site can lead to complications such as dissection (tearing) or thrombosis (clotting).
- Stent Thrombosis: Blood clots may form within a stent placed during PCI.
PCI Risks:
* What are the cornary artery complications?
- Artery Dissection: The coronary artery can tear during the procedure, potentially leading to further narrowing or blockage.
- Restenosis: Narrowing of the artery may recur in the months following PCI, requiring additional interventions.
- Acute Closure: The treated artery may close suddenly during or after the procedure, leading to chest pain or heart attack.
PCI Risks
* What can happen to the heart muscle?
* Can trigger what?
* Why can the kidney be injuried?
* Why can allergic reaction happen?
- Myocardial Infarction: there is a risk of heart attack during the procedure due to factors such as artery dissection or acute closure.
- Arrhythmias: can trigger abnormal heart rhythms, including ventricular tachycardia or fibrillation
- Kidney Injury: The contrast dye can cause kidney injury, particularly in patients with pre-existing kidney disease.
- Allergic Reactions: allergic reaction to the contrast dye or other materials used during the procedure.
PCI Risks
* What type of exposure?
* What is a rare risk?
- Radiation Exposure: Patients and healthcare providers are exposed to ionizing radiation during the procedure, which may carry long-term risks, especially with repeated exposure.
- Death: Although rare, there is a risk of death associated with PCI, typically 1%, higher in complex cases or patients with significant comorbidities.
Why CABG and not PCI?
- More efficacious in patients with diabetes
- More beneficial in patients with low EF
- AKA BETTER OUTCOMES
Coronary artery bypass grafting
* What does it do?
* Can be performed how?
* Class 1 recommendations for CABG via ACCF/AHA guidelines is what?
CABG Risk factors
* Age?
* What disease state?
* What happens with chronic kidney disease?
* COPD?
- Age: Older age is associated with increased surgical risks, including higher rates of complications such as infection, bleeding, and mortality.
- Diabetes: Increases the risk of wound healing complications and graft failure.
- Chronic Kidney Disease: May increase the risk of postoperative renal complications.
- Chronic Obstructive Pulmonary Disease (COPD): Can increase the risk of respiratory complications postoperatively.
CABG Risk factors
* Peripheral Vascular Disease: May increase the risk of what?
* Left Ventricular Dysfunction: Poor left ventricular function increases the risk of what?
* Emergency Surgery?
* Obesity?
- Peripheral Vascular Disease: May increase the risk of graft failure and other vascular complications.
- Left Ventricular Dysfunction: Poor left ventricular function increases the risk of perioperative complications and mortality.
- Emergency Surgery: CABG performed on an emergency basis (e.g., for acute coronary syndromes) has higher risks compared to elective surgery.
- Obesity: Increases the risk of wound infections, sternal dehiscence, and other complications.
CABG Risk factors
* Previous Cardiac Surgery: A history of prior cardiac surgery may increase what?
* What are Lifestyle Factors?
* Bleeding and Blood Transfusions?
- Previous Cardiac Surgery: A history of prior cardiac surgery may increase the complexity of the procedure and the risk of complications.
- Lifestyle Factors: Smoking and poor adherence to medical treatment may affect outcomes and increase surgical risks.
- Bleeding and Blood Transfusions: Excessive bleeding during or after surgery may require blood transfusions or additional surgery to control bleeding.
CABG Complications
* What are the infections?
* What type of arrhythmias?
Infection:
* Wound Infection: Infection at the surgical site, particularly the chest incision.
* Sternal Infection (Mediastinitis): Infection of the breastbone (sternum) and surrounding tissues, which can be serious.
Arrhythmias:
* Atrial Fibrillation: Common after CABG, can increase the risk of stroke and may require treatment.
* Heart Block: May require temporary or permanent pacing.
CABG Complications
* What are pulmonary issues?
* What are renal complications?
Pulmonary Complications:
* Atelectasis: Collapse of lung tissue.
* Pneumonia: Inflammation of the lungs, often related to prolonged mechanical ventilation
Renal Complications:
* Acute Kidney Injury (AKI): May result from reduced perfusion during surgery.
CABG complications
* What are neuro issues?
* What are graft issues?
* What are GI issues?
Neurological Complications:
* Stroke: Risk of stroke during or after surgery due to clots or reduced blood flow.
* Cognitive Dysfunction: Postoperative cognitive decline, sometimes known as “postoperative cognitive dysfunction” (POCD).
Graft Complications: Graft Occlusion- Blockage of the grafts, which can lead to recurrence of symptoms or heart attack.
Gastrointestinal Complications: Gastrointestinal Ischemia- reduced blood flow to the gut, potentially causing damage.
CABG complications
* What increases in risk after surgery?
* What can be inflammed?
* What are long term complications?
* Other complications?
Conduit choices
* What is endoscopic vein harvest?
- Used for larger vessels, less severe stenosis
- Taken via endoscope
Conduit choices
* What is radial artery harvest?
- Can be taken open or endoscopic
- Used for severe stenosis vessels
- Important to use dual-arterial conduit, especially in younger patient
Conduit choices
* What is left internal mammory artery?
- Gold standard conduit for LAD
- Need to ensure the subclavian is patent, can see on the cardiac cath or additional testing
Endoscopic vein harvest
* Common or not?
* Was previously complete how?
* What vein is used?
- Most widely used conduit in coronary artery bypass grafting surgery
- Previously was completed as an open technique - a long skin incision, increased pain, decreased patient satisfaction
- The great saphenous vein is the longest vein in the body, runs anteriorly to the medial malleolus at the foot and then runs in a direction posterior and medial to the knee to the groin and the saphofemoral junction
Endoscopic vein harvest
* SVG compared to radial grafts have what?
* During the first year, SVG graft occlusion can occur in how many causes?
- SVG compared to radial grafts have less durability and increased tendency to degenerate
- During the first year, SVG graft occlusion can occur in 10-15% cases and 50% of them have significant or complete occlusion by ten years
Radial artery harvest
* Radial artery patency graft rate is what?
* Redundancy exists as what?
* Must check what first?
- Radial artery patency graft rate is more than 90% at both one year and 5 years
- Redundancy exists as the brachial artery divides into the ulnar and radial artery, they meet in the hand in the palmer arch
- Must check Allen’s test first to ensure the radial artery can be taken
Radial artery harvest
* What is ulnar, radial and balanced dominance?
- Ulnar dominance is the most common pattern of blood supply to the hand. Studies have shown that approximately 60-65% of people have ulnar dominance.
- Radial Dominance: About 10% of people have radial dominance, where the radial artery is the primary blood supplier to the hand.
- Balanced Dominance: The remaining 25-30% of individuals have balanced or co-dominance, where both the radial and ulnar arteries contribute equally to the blood supply of the hand
Radial artery harvest
* Prone to what?
* Radial artery graft to left sided coronaries with what?
* Radial artery graft to the right sided coronaries with what?
- Radial artery prone to spasm
- Radial artery graft to left sided coronaries with severe stenosis >70% can be reasonable
- Radial artery graft to the right sided coronaries with severe stenosis >90% can be reasonable
Left internal mammary artery
* Gold standard for what?
* Around 90% of LIMA grafts remain free of significant stenosis when?
* Less prone to what?
* Class 1 indication for grafting of what cononary artery?
- The LIMA is the gold-standard conduit and associated with significant improvement in short and long term outcomes and survival of patients undergoing CABG
- Around 90% of LIMA grafts remain free of significant stenosis at 10 years, many up to 20 years
- Less prone to atherosclerotic disease
- Class 1 indication for grafting of the left anterior descending artery (LAD) with LIMA
What is on pump vs off pump?
