OPERATIVE MANAGEMENT IN CORONARY ARTERY DISEASE
Alfa Ferry FRCS Cardiac Surgeon
Management in CHD
Medical (medikamentosa)
Intervensi
1. Percutaneous ( PTCA & stenting )
2. Surgical ( CABG, CABG & mitral valve procedure, CABG & LV aneurysm resection, etc )
CABG
Penanganansecarapembedahanuntukpenyakitjantungkoroner.
Padaprinsipnyamemberikanalirandarah dg jaluralternatifuntukmensupplyototjantungdimanasebelumnyapembuluhdarah yang mensupply area tersebuttersumbat (occlusion) ataumenyempit (stenosis).
Surgical Intervension
Coronary artery bypass surgery ( CABG )
Aim : restore blood flow to the coronary vessels hence improve coronary circulation and treat ischaemic myocardium.
CABG
CABG merupakansalahsatualternatifpenangananpenyakitjantungkoroner. CABG bukanmerupakanjalanterakhirapabilacara lain gagal.
Dalambeberapajenispenyakitjantungkoroner CABG merupakan first choice karenahasilakhir yang lebihbaikdibandingkanpemasanganstent.
Jenisjenispenyakitjantungkoronerdimana CABG lebihbaikdaristenting:
Left Main Artery disease
Diabetic with triple vessel disease.
Chronic total occlusion daripembuluhdarahkoroner.
Failed PTCA
CABG
CABG is like 2 operation :
Median Sternotomy
CABG
CABG
1.Median Sternotomy
Operasipembukaantulang dada (median sternotomy)
Menakutkantetapirisikokematian : 0%
2.Operasi bypass koroner (CABG)
Mempunyairesoikokematian 1% padapenderitadenganfungsijantung yang masihbaik. ( resikokematianstent 0.5% )
Perbandingan CABG danStenting
CABG PTCA (stenting) resiko
1% 0.5% Mortalitas(kematian)
2% 2% Stroke
10% 2% Perdarahan
2% 0.5% Infeksi
1% 1% GagalGinjal*
Preoperative assessment
Establish diagnosis ( done by cardiologist )
History of angina or angina equivalent
Is it unstable or stable angina?
ECG, Treadmill, Echo results
Coronary Angiography is the gold standard on assessing coronary flow and degree of stenosis.
MSCT
Preoperative preparation
Antiplatelet should be stopped at least 5 - 7 days before operation if possile to reduce risk of bleeding.
Dental clearance need to be sought if time allowed to reduce risk of infection.
Blood and blood product are crossmatched and prepared.
CABG
On Pump
Off Pump
On Pump Beating heart
Minimally Invasive CABG ( MIDCAB )
Robotic CABG
Hybrid
Conduits / Grafts in CABG
Grafts used can be Internal Mammary artery ( IMA ), Saphenous vein, Radial artery, gartroepiploic artery.
LIMA to LAD grafts has been established to have prolonged survival in CAD patients. ( 95 % LIMA to LAD anastomosis is still patent in 15 years, paper by cleveland clinic groups )
On Pump CABG
CABG traditionally done on pump.
Pump = Cardiopulmonary bypass machine = Heart Lung machine.
The Pump is used to replace function of the heart to pump blood to the whole body at the time of CABG.
The heart is stopped from beating by means of infusing cardioplegia solution to the coronary artery.
Off Pump CABG
CABG is done without the use of the Pump. The heart is continously beating normally during the procedure.
Anastomosis of grafts were done with help of a stabilizer ( octopus system ) to stabilize the target vessel for grafting.
Heart is not stopped at all.
Off Pump Beating heart
Combination Off and On Pump.
CABG is done with circulation supported by CPB/Pump, but heart is left beating and anastomosis is done with help of stabilizer just like off pump.
Useful in certain cases.
Minimally Invasive CABG
CABG done via small incision
Lateral anterior thoracotomy
Ministernotomy
Subxyphoid approach
Usually done for single LIMA to LAD graft anastomosis.
Done Off-Pump.
Robotic CABG
CABG done via small holes in the chest to put robotic arm inside pericardial cavity.
On Pump technique, heart is stopped.
Only done in small percentage of CABG
Hybrid CABG
CABG is done at the same time as PTCA/Stenting, or shortly thereafter in the same operating theatre.
Hybrid operating theatre
Selected cases
Posoperative management
ICU
Ventilator management
Close monitoring
Interpretasi profil hemodynamic
When to extubate/ weaning ventilator
Rehabilitation
Moving to the wards
Discharge.
ICU, close monitoring, ventilator management.
All patients will be transferred to ICU after a CABG operation
Almost all will require temporary artificial ventilation and sedation with or without muscle relaxant
All will have continous invasive monitoring such as arterial line, Central venous pressure line, Pulmonary artery line by which of swan-ganz catheter.
When to wean from ventilator/ extubate
Criteria for weaning:
Stable Haemodynamic on low inotropic support
Able to breath on their own
Awake/ conscious
Rehabilitation
Started from preop with assessment of breathing capability, briefing on post op sequence
Include breathing exercise, passive and active limb exercise
Encourage early ambulation, usually 2 days post op
Discharge
Hospital discharge usually at day 6 to day 8 postop
Need to be able to walk on their own
Relatively pain free except when coughing
Follow up 1 week post op.
Summary
CABG merupakansalahsatualternatifdaripenangananpenyakitjantungkoroner.
CABG merupakanprosedur yang amandilakukandenganresikokematian/mortalitas yang hampirsamadengan PTCA/Stenting.
Padajenisjenispenyakitjantungkoronerseperti Left Main disease, Diabetic dg 3 vessel disease, CABG mempunyai long term prognosis lebihbaik.