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.