Diseases of the Thoracic Aorta
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Surgery for Ischemic Heart Disease Department of Thoracic & Cardiovascular Surgery Seoul National University Hospital
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Coronary Heart Disease Introduction Definition Narrowing of the coronary arteries caused by atherosclerosis that, when sufficiently severe, limits the flow of blood to the myocardium History Sones and Shirey ; Coronary cinearteriography in 1960s Vineberg & Miller ; Implantation of IMA into myocardium in 1951 Kolesov ; Internal mammary artery to LAD anastomosis in 1964 Favaloro & Effler ; Saphenous vein bypass grafting in 1967 Flemma & Johnson et al ; Sequential anastomosis in 1971
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Stenotic Coronary Artery Disease Morphology Development of coronary artery stenosis The arteriosclerotic process 2. Myocardial Infarction & morphologic sequelae 1) The resultant infarction may be transmural infarction, subendocardial infarction and the process of infarction is complex 2) Healing of acute myocardial infarction leaves a scarred area of myocardium (aneurysm) Arteriosclerotic plaque rupture and thrombosis Fissuring, or rupture of plaque is the genesis of unstable angina & AMI and common in less than 50% reduction
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Stenotic Coronary Heart Disease Arteriosclerotic process Consists of focal intimal accumulations of lipids, complex carbohydrates, blood & blood products, fibrous tissue, & calcium deposits , associated with changes in the media Fibrolipoid plaques become very thick & encroach upon the lumen of the artery, possibly progress or rarely gradual regression of plaque swelling Thrombosis occasionally complicates the process, sudden complete obstruction may result. The arteriosclerotic process usually affects multiple coronary arteries( 40% in 3 vessels, 30% in 2 vessels) & usually involves the proximal portion of large coronary artery , particularly at or just beyond the sites of branching . Right and left anterior descending systems are more frequently involved than the circumflex.
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Coronary Artery Anatomy
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Coronary Heart Disease Clinical features & diagnosis Routine methods - Non invasive tests ; CPA, EKG (rest and exercise) Coronary arteriography - provide definitive information Recording & reporting data from coronary arteriography Average diameter loss Cross sectional area loss 67% 90% 50% 75% 33% 50% 4. Tests of left ventricular function
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Left Ventricular Function Tests of function Tests of ventricular function continue to evolve, & the listing of these is of little use. Some general concepts underlying all such tests are important LV function at rest and during exercise LV systolic and diastolic function Global and segmental LV function Load-independent LV function
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Stenotic Coronary Artery Disease Natural history Progression of stenotic coronary artery disease Evolution of left ventricular dysfunction Dysfunction only with stress Dysfunction at rest Unfavorable outcome events Stable angina Unstable angina Acute myocardial infarction Death 4. Incremental risk factors for unfavorable events
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Stenotic Coronary Artery Disease Risk factors for unfavorable events Severity & distribution of reduction in the regional coronary flow reserve Rate of progression of coronary atherosclerosis Nature of the coronary atherosclerotic plaque Amount and distribution of myocardial scar Secondary conditions 1) Hemodynamic instability. 2) Ischemic instability. 3) Ventricular electrical instability Coexisting diseases 1) Older age, 2) Diabetes, 3) Hypertension, 4) Others ; COPD, Smoking, CRF.
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Stenotic Coronary Artery Disease Techniques of operation Preoperative preparation Preparations in the operating room Strategy of the operation Removal and preparation of the vein graft Preparation and use of the internal mammary artery The distal vein graft anastomosis The proximal anastomosis CABG operation with proximal anastomosis done first CABG reoperation
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Removal of vein graft Coronary Artery Bypass Graft
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Preparation of vein graft Coronary Artery Bypass Graft
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Preparation of IMA Coronary Artery Bypass Graft
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Suture technique (1) Coronary Artery Bypass Graft
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Suture technique (2) Coronary Artery Bypass Graft
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Coronary Artery Bypass Graft Suture technique (3)
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Complete operation Coronary Artery Bypass Graft
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Early postoperative care 1. Most are extubated in the operating room or a few hours postoperatively 2. Low dose dopamine may be needed 3. Prevent arrhythmia with drugs 4. Aspirin therapy 5. IABP (intraaortic balloon pump) Coronary Artery Bypass Graft
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Late postoperative care Facilitation of complete recovery from operation Promotion of patency of graft Control of risk factor for atherosclerosis Surveillance for recurrent myocardial ischemia Coronary Artery Bypass Graft
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Coronary Artery Bypass Graft Results of operation Survival Modes of death Incremental risk factors for premature death Freedom from angina, myocardial infarction, sudden death, failure to work, quality of life, Neurobehavioral & neurologic outcome Use of medication Functional status Resting & exercise ventricular perfusion & function Ventricular arrhythmias Post-CABG coronary flow & reserve
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Coronary Artery Bypass Graft Survival Early mortality 1) In early 1990s ; 3% 2) Mode of death ; acute cardiac failure in early or late 2. Time related survival 1) Isolated CABG ; 95, 88, 75, 60% at 1, 5, 10, 15 years 2) The hazard function for death has an early and rapidly declining phase, which merges with a constant phase about 3 months after procedure 3) A third gradual rising phase of hazard becomes about 6 years after operation which results from closure of graft and/or progression of native vessel disease
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Coronary Artery Bypass Graft Incremental risk factors Number of vessels Pre-CABG left ventricular function Unstable angina Older age CABG soon after acute myocardial infarction Coexisting conditions Procedural and institutional risk factors
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Coronary Artery Bypass Graft Freedom from angina 60% are free of angina 10 years after CABG Time related rate of angina return 1) Early phase ; 3 months after operation d/t. incomplete revascularization 2) Late rising phase ; 4 years after operation d/t. closure of graft, progression of native vessel 3. Incremental risk factor
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Coronary Artery Bypass Graft Risk factors for return of angina 1. Incomplete revascularization 2. Nonuse of IMA to LAD 3. Global myocardial ischemic time 4. Cardiopulmonary bypass time 5. Surgeon 6. Date of operation
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Coronary Artery Bypass Graft Perioperative myocardial infarction Definition 1) Appearance of new Q waves in the EKG 2) Elevation of serum levels of myocardial enzymes (CK-MB) Related to myocardial management Risk factor for later death Prevalence ; 2.5 ~ 5%
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Coronary Artery Bypass Graft Surgical results Freedom from infarction is 96% , 64% of patients for at least 5 years , 15 years The hazard function begins to increase after 5 years have elapsed since the CABG operation Freedom from sudden death is 97% of patients for 10 years after CABG. Preoperative poor left ventricular function is the most significant risk factor for sudden death.
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Coronary Artery Bypass Graft Neurologic outcomes Serious but are fortunately considerably less common Result from embolization of atherosclerotic debris from the ascending aorta or from air embolization than from damaging effect of cardiopulmonary bypass Prevalence is 0.5% in relatively young patients 5% in patients over 70 years of age 8% in those over age 75
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Coronary Artery Bypass Graft Etiology of neurologic complications Neurologic complications after CABG have been attributed to the use of cardiopulmonary bypass and manipulation of the aorta. Cerebral emboli and hypoperfusion , as well as the systemic inflammatory response to CPB , are thought to be the main underlying causes. Most emboli arise from manipulation and instrumentation of the heart and aorta, and from the pump circuit With off-pump CABG (ie, surgery on beating heart without the use of CPB), fewer emboli are generated
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Coronary Artery Bypass Graft Neurologic outcomes Neurologic injury remains an important complication & neurologic injury after CABG is divided into two main subtypes Type I injury includes transient ischemic attack, stroke, which has an incidence of 1% to 2%, encephalopathy, and coma Type II injury is more subtle and includes impairment of neurocognitive function and these are defects associated with attention, concentration, short-term memory, fine motor function, and speed of mental and motor responses
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Coronary Artery Bypass Graft Neurocognitive dysfunction The incidence of neurocognitive dysfunction varies from 30% to 80% depending on the timing of assessment of cognitive function after cardiac surgery, study design, and the statistical definition used to define neurocognitive decline Neurocognitive dysfunction after CABG can have an important bearing on long-term quality of life
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Coronary Artery Bypass Graft Fate of internal thoracic artery 90% are patent 10 years after operation Due in part good function of endotheilial cells - EDRF, prostacyclin etc. Its native position and resistance to arteriosclerosis and anastomosis to LAD with large run off through diagonal & septal branches cause good patency Bilateral IMA has been favored Wound complications may be more prevalent
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Coronary Artery Bypass Graft Fate of saphenous vein Begins with intimal hyperplasia for more than 1 month & this process is not progressive but remodeling process Development of areas in vein indistinguishable morphologically from fibrous plaque of arteriosclerosis 20% of vein grafts have been proximal suture line stenosis within 1 year 50% of patients have some narrowing of distal anastomosis within 1 year , but not progressed by 5 years Thrombosis is still another process and 10% close within few weeks without antiplatelet therapy
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Coronary Aretry Bypass Graft Progression of coronary disease Most important native vessel coronary artery stenoses proximal to a vein graft become more severe within 5 years of CABG The incidence and rate of progression of lesser stenoses proximal to a vein graft remains uncertain Lesser stenoses in ungrafted arteries progress in severity with lesser frequency than do important stenoses, but 25% to 50% of such lesions progress within 5 years. Important stenoses in ungrafted vessels progress after operation , presumably at about the same rate as in natural history of coronary artery disease New stenoses do appear in apparently nonstenotic arteries that were not grafted
Slide 34 :
Coronary Arytery Bypass Graft Fate & results The primary predictors of long-term mortality were older age, prior myocardial infarction, hypertension, diabetes, and prior coronary artery bypass grafting. Atherosclerosis is a diffuse disease affecting all beds Revascularization must thus be considered in the context of appropriate lipid-lowering and antiplatelet therapies, renin-angiotensin-aldosteronism system blockade, and ß-blocker therapy. All of these therapies have been shown to be life saving and to prevent events in appropriate patients.
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Stenotic Coronary Arytery Disease Indications for operation Chronic stable angina Number of systems with important stenoses Left main stenosis Three-system disease Two-system disease with severe angina Single-system disease with proximal LAD stenosis Effect of LV function on indication Unstable angina Myocardial infarction Acute complications during PTCA Unfavorable events after previous CABG
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Stenotic Coronary Artery Disease CABG versus PTCA PTCA is sufficiently effective in single- & two- vessel disease that is advisable initial therapy The limitations of PTCA relate primarily to the difficulty in obtaining and maintaining complete revascularization for reasonable period time CABG is preferable in left main disease and 3 vessel disease.
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Stenotic Coronary Artery Disease Endarterectomy Some surgeons use endarterecomy frequently, particularly in the distal RCA and report good results Some surgeons report lower graft patency rates through endarterectmized arteries, Yeh et al. ; graft patency rate of 64% in endarterectomy group, 92% in not used group 3. Controversial in incidence of perioperative infarct and patency rate
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Stenotic Coronary Artery Disease Surgical angioplasty Surgical angioplasty was abandoned years ago for major coronary artery branches , but has been successfully used by some for LMCA Anterior approach is preferable Contraindication ; extensive calcification and older age
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Stenotic Coronary Artery Disease Combined carotid artery disease Combination of severe coronary & carotid disease has in the past unfavorably affected long term prognosis One stage procedure ; 3-4% mortality Staged operation is advantageous because of low mortality and morbidity Protocol (JHStL) for those over 65 years 1) Duplex sono is negative - cardiac procedure alone 2) Duplex sono is positive & hemodynamic state is stable – staged carotid angioplasty rather than one stage 3) If hemodynamic state is unstable – carotid procedure may omitted
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Coronary Arytery Bypass Graft Mechanisms of statins Statins enhance endothelial function by decreasing superoxide formation, upregulating the expression of endothelial nitric oxide synthase, and inhibiting the release of angiotensin II and endothelin. They reduce inflammation by decreasing levels of CRP and reducing cytokine and adhesion molecule expression. Thrombosis is suppressed and fibrinolysis is enhanced by reducing platelet aggregation and adhesion and thromboxane formation and promoting fibrinolysis by enhancing tissue plasminogen activator synthesis and reducing tissue plasminogen activator inhibitor levels
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Coronary Arytery Bypass Graft Statin therapy Patients undergoing elective operations should receive dosages of statins targeted to achieve LDL levels of less than 100 mg/dL and even lower (<70 mg/dL) for high-risk cases. Patients requiring urgent or emergency CABG should have high-dose statin therapy initiated as soon as the decision is made to proceed with the operation. Atorvastatin at 80 mg would appear to be the statin of choice for these patients on the basis of its superior results in trials involving patients with ACSs.
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