A few basics of cardiac surgery

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A few basics of cardiac surgery.
Brett Sheridan, MD Assistant Professor Department
of Surgery
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Define the difference between congenital and
acquired (adult) heart disease.
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What is the incidence of congenital heart disease
in the Unites States?
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List the 3 most common causes of death in the US
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1) Heart Disease2) Cancer3) Stroke
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How many people in the US died from
cardiovascular disease in 2001?
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Do more men or women die from cardiovascular
disease?
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Define acute coronary syndrome according to the
American Heart Association
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Acute coronary syndrome (ACS) is defined by
EITHER acute myocardial infarction or unstable
angina.These patients are divided into 3
subsets ST elevation myocardial infarction
(STEMI) non-ST elevation MI Unstable angina
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Describe the initial stabilizing treatment for
symptomatic ischemic heart disease presenting in
the ER
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• ECG within 10 minutes
• Supplemental O2
• IV access continuous ECG monitoring
• Sublingual NTG if SBP gt 90 mmHG
• Morphine
• ASA (chewed)
• Labs
• If ST elevation gt 1mV or LBBB then reperfusion
  (fibrinolysis or PTCA)

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What is AMI management in first 24 hours?
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• Limited activity 12 hrs and monitor 24 hrs
• No prophylactic antiarrythmics
• IV heparin if
• large anterior MI,
• PTCA, LV thrombus or
• thrombolytics administered
• SQ heparin for all others
• ASA indefinitely
• IV NTG x 24 hrs
• IV beta-blocker if stable
• ACE inhibitor if BP permits
• Statin therapy

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What is a coronary angiogram and why do we do we
perform them?
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Percutaneous coronary angioplasty (PTCA, PCI,)
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What is a percutaneous coronary intervention (PCI)
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Percutaneous coronary angioplasty (PTCA, PCI,)
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Percutaneous coronary angioplasty (PTCA, PCI,)
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Why are patients referred for CABG instead of
undergoing a PCI approach to coronary artery
disease?I.e. which patients benefit from CABG?
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Cite 2 prospective randomized trials comparing
PCI vs CABG for the treatment of multivessel CAD
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• Inclusion Criteria
• Symptomatic
• Multivessel CAD
• LVEF gt 30
• Baseline Characteristics
• Class III/IV angina - 66
• Previous MI - 42
• 3 vessel CAD - 30
• mean LVEF 60

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Comparison of Coronary-Artery Bypass Surgery and
Stenting for the Treatment of Multivessel
Disease(Arterial Revascularization Therapies
Study Group)

• CABG PCI
• Patients (n)                                   
  605                                      600
• Late outcome                             
  ---------------------1 year-----------------Death
                                            2.8
                                   2.5MI
                                                
  4.0                                   5.3
  CVA 2.0 1.5
• Revascularization                     4
                                17Event-free
  survival                   88
                                
  74Symptom-free                           90
                                     79
• Cost                             13,638
                               10,665

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Event free Survival CABG vs PCIS
14 benefit w/ CABG!
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Risk of Repeat Revascularization
16 benefit w/ CABG!
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Risk of Death
3.7 SURVIVAL benefit w/ CABG!
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Conclusions-SoS Trial

• Again, repeat revascularization remains more
  common after PCI (with or without a stent) in
  multivessel CAD.
• In this study, higher rate of all cause mortality
  with PCI

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Contrast the difference between off-pump CABG
versus the typical cardiopulmonary bypass
supported CABG.
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Traditional CABG

• General anesthetic
• Median sternotomy
• Conduit harvest (LITA, radial, vein)
• Institution of cardiopulmonary bypass (CPB)
• Cardiac arrest
• Placement of aortocoronary grafts
• Separation from CPB
• Close

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Advantages - Traditional CABG

• Still Heart
• Exposure and access
• Visualization
• The most intensely scrutinized procedure in US
  medicine
• SAFETY

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Disadvantages - Traditional CABG

• Proinflammatory response to CPB
• Suggestion of end-organ injury
• CNS
• Pulmonary
• Renal
• Increased fluid shifts

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Off-Pump Gear
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Off-Pump Stabilizing Devices
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Off-Pump Exposure of PDA
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List 10 complications of CABG and there relative
frequency
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• Death 3
• Stroke 1-2
• Bleeding requiring re-op 3-5
• Wound Problems 0.5-5
• Myocardial infarction 2-30
• Arrhythmias 10-60
• Pneumonia 4
• Pneumothorax 1-2
• Cardiac Tamponade 3-6
• Pericardial Inflammation 18
• Renal Insufficiency 15-20

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What four medications prevent MI and death
following a myocardial infarction?
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Class I

• ASA
• Beta-blockers
• ACE inhibitor
• Statins

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A prospective randomized trial comparing
stenting with off-pump coronary surgery for
high-grade stenosis in the proximal left anterior
descending coronary artery three-year follow-up
JACC, 2002, 40(11) 1955-1960