surgical treatment of coronary artery disease

Question 1

when to use?

Question 2

medical treatment?>

Answer 2

Nitrates
Beta blockers
Calcium antagonists

Statins
Antiplatelet agents
ACE Inhibitors, diuretics, etc.

Question 3

ptca only?

Answer 3

PTCA only:

MASS I & II
BARI
EAST
CABRI
GABI
RITA

Question 4

stenting only?

Answer 4

Stenting:

ARTS
ERACI-2
SOS

Question 5

cabg dictated by?

Question 6

indications for CABG?

Answer 6

Failure of medical therapy
Unstable angina
Left main disease
Triple vessel disease
Post-infarction angina
Acute MI with shock
Failed PTCA

Question 7

objectives of CABG?

Answer 7

Relieve ischaemia
Prevent MI
Preserve LV function
Prolong survival
Restore quality of life

Question 8

coronary revascularisation, pre operative evaluation?

Question 9

specific investigations for coronary revasculrisation?

Answer 9

Electrocardiogram
Exercise Tolerance Test
Coronary angiogram

stress echo, perfusion scan

Question 10

predictors of operative risk?

Answer 10

Predictors of Operative Risk:

Urgency of operation
Age
Prior heart surgery
Gender
LV dysfunction
Presence of Left main stenosis
Number of major vessels with >70% stenosis
Others…..

PARSONNET score EuroScore

Question 11

parsonet (P) and euroscore (ES)

Answer 11

Question 12

coronary revsscularisationprocedure?

Answer 12

median sternotomy (cut down the strnum) used for:

• cardiopulmonary bypss
• cardioplegic arrest
• ypass of major vessels with >50% stenosis
• Anastomaosis of conduit onto coronary artery beyond point of stenosis

Question 13

when to do cardiopulmonary bypass?

Answer 13

Motionless, decompressed heart.
Stable, bloodless operative field.
Good access and visualisation of coronary arteries.

CPB brings relative technical ease to the field of cardiac surgery
Facilitating surgery both inside and on the surface of the heart.
When used in combination with cardioplegic arrest, it provides a motionless, bloodless, stable operative field, which permits good access to and visualisation of target structures within the heart and on its surface.
Its use has supported the tremendous advances that have been witnessed in cardiac surgery in the last 50 years.

Question 14

what is needed for a cardiopulmonary bypass achine?

Answer 14

rservois, pump, membrane oxygenator/heat exchanger, filter, venpous cannula, arterial cannula

Question 15

how does the bypass machine help?

Answer 15

helps with:

hypothermia

cardioplegic arrest

Question 16

veins for revadculatisation by bypass for coronary artery

Answer 16

Conduits:
Long Saphenous vein

Ease of harvest
Good handling
Patency:
80% @ 1Mo
50% @ 10 Yrs

Conduits:
Internal mammary
Artery (thoracic)

Easy harvest
Single or bilateral
Patency:
99% @ 1 Mo
95% @ 10 Yrs

Conduits:
Radial artery

Increasingly used
Allen’s Test
Low morbidity
Patency:
? 80-85% @ 5 Yrs

Conduits:
Gastroepiploic artery

Limited use
Highly vasoactive
Abdominal incision
Patency ?

Conduits:
Inferior Epigastric artery

Infrequently used
Stable vasoactivity
Abdominal incision
Patency ?

Question 17

techniques

Answer 17

anastomotic technique - add vein straight o coronary artery and bypass

sequential anastomosis - link coronary arteries with vein

composite grafts - link aorta and LAD (proximal anastomsis) with one vein then add another vein to that vein (sequential anastomosis) and make a circumflex artery

Question 18

potential complications?

Answer 18

Perioperative MI (2-3%)
Low Cardiac Output (<1%)
Arrhythmias (AF, VT, VF)
TIA / CVA
Bleeding
Tamponade (<1%)

Renal complications (2-5%)
Prolonged ventilation (2%)
Pulmonary infection (5%)
Wound Infection (2-3%)
Mediastinitis
Sternal dehiscence
Neuropsychological deficit (?30-50%)