Surgery for IHD

results from progressive blockage of the coronary arteries by atherothrombotic disease.

Progressive compromise in luminal diameter producing supply/demand imbalance usually produces a pattern of chronic stable angina.

Plaque rupture with superimposed thrombosis is responsible for most acute coronary syndromes

(ACS), which include classic “unstable angina”, non-ST-elevation myocardial infarctions(NSTEMI), and ST-elevation infarctions (STEMI).

pathophysiology

Clinical Blood tests ECG Treadmill Echo CT angio Coronary angio

DX

1. Medical Aspirin,B-blockers,nitrates,CCB if BB

contraindicated Statins for plaque stabilization ACE inhibitors Clopidogrel ?

MX

PCI (90 minute door to balloon) Thrombolytic (alternative) TIME IS MYOCARDIUM Studies(6 hr )

STEMI

Aspirin,heparin Clopidogrel(30 days post CABG outcome

better) (ACC/AHA prohibition befor 2007 if surgery

is an option) Prasugrel shoud be stopped for 7 days

preop.

ACS

IfContinuing ischemiaRest painHD unstabilityHFElivated troponinRest ECG changes

platelet glycoprotein IIb/IIIainhibitors, such as tirofiban or eptifibatide

PCI BMS vs DES

Interventional

Studies have shown that surgery is very effective in relieving angina, in many cases is able to delay infarction, and in most cases can improve survival compared with continued medical management or PCI

Surgery

Class III or IV angina Ischaemic pul.edema Failed PCI Patient undergoing major vascular surgery

Clinical scenarios

Lt main > 50% 3VD EF<50 3VD EF>50 if significant inducible

myocardial ischemia by stress test Lesions not amenable to PCI

Anatomic indications

These patients should undergo CABG if have >50% stenosis in branch coronary arts.

Pt undergoing valve surgery Complications of MI Coronary art. Anomalies with risk of sudden

death

Other conditions

Venous conduit Arterial conduit Which is superior?

Choice of conduits

Traditional CABG OPCAB MIDCAB TECAB Robotic Laser trans myocardial revascularization

Surgical procedure

BB Aspirin Statins ACE inhibitors

Post op.cosiderations

Septal wall rupture Free wall rupture Ischaemic MR LV aneurysm

complications