1. ISCHEMIC HEART DISEASE
Staff Members of Cardio-thoracic Surgery Departments
Egypt

2. ISCHEMIC HEART DISEASE Anatomic Considerations
The heart is supplied by the left main coronary artery (LM) and right coronary artery (RCA). Left main coronary artery divides into left anterior descending (LAD) and circumflex (Cx) coronary arteries. The LAD gives diagonal branches; the (CX) gives obtuse marginal branches (OM). The right coronary artery (RCA) gives the posterior descending artery (PDA).

3. Anatomic Considerations, cont.
Left main (LM) disease: A significant lesion affecting the left main (LM) coronary artery.
One-vessel disease: A significant lesion (or lesions) affecting one of the three arteries (LAD, Cx, RCA).
Two-vessel disease and three-vessel disease: Significant lesions affecting two arteries or three arteries, respectively.

4. Anatomy of coronary artery

5. Angina pectoris is a symptom of myocardial ischemia
Angina pectoris is a symptom of myocardial ischemia. Lab, Lipids, uric acid, cardiac enzymes (Troponin I, CK MB). ECG, Stress test (Ergometry), Echo & Stress Echo (Doputamine), Isotope studies (myocardial scintigraphy), with thallium-201- or a technetium-99m Multislice CTA, Coronary angiography is done to diagnose the site, degree, extent and number of coronary vessels stenosed in ischemic heart disease patients. Percutaneous coronary intervention (PCI) can be done during the procedure to perform balloon dilatation of the stenosed segment of the coronary artery and insert a stent inside it.

6. Multislice CTA coronary arteries

7. Coronary angiography

8. Coronary Angiography

9. Treatment
Medical: correction of risk factors (diabetes, hyperlipidemia {statins}, hyperuricemia, smoking, obesity), Tritherapy (beta-blockers, nitrates & calcium channel blockers) and antiplatelets.
Percutaneous coronary intervention (PCI).
Coronary Artery Bypass Graft surgery (CABG)

10. Percutaneous coronary intervention (PCI).

11. Coronary artery bypass graft surgery (CABG)
Definition It is the surgical treatment of coronary artery stenosis in which one or more stenosed coronary arteries are bypassed by blood vessel graft to restore normal blood flow to the heart. Aim of CABG Complete revascularization of myocardium; to Relieve symptoms, Improve quality of life, Increase life expectancy.

12. CABG

13. Indications of CABG
Left main stem coronary stenosis (>50%). OR Left main Equivalent.
Three-vessel disease especially diabetic patients.
One or two vessel disease with extensive myocardium in risk & not suitable for PCI.
In-stent stenosis or thrombosis after PCI & for emergency complications (dissection) of PCI.
Combined CABG and valve surgery.
Surgery for complications of myocardial infarction (MI); including acute & chronic ischemic mitral regurge (MR), VSD, ventricular free-wall rupture, and ventricular aneurysm.

14. Indications for CABG Left main coronary artery stenosis :
Stenosis >50%, as annual mortality 10-15%

15. Indications for CABG, cont.
Left main equivalent:
> 70% stenosis of proximal left anterior descending (LAD) and proximal circumflex artery (Cx)

16. CABG Procedure Median sternotomy is the standard approach .
Techniques:
ON-PUMP: Extracorporeal circulation is used in most patients.
OFF-PUMP (OPCAB): grafts can be performed on a beating heart. The surgeon overcomes problem of bleeding by using intracoronary shunts. While heart movement can be overcome by using stabilizer.
MIDCAB (minimally invasive direct coronary artery bypass) is a procedure in which a small left thoracotomy is done and the procedure is performed on a beating heart.
Video assisted thoracoscopic surgery (VATS) & robotic surgery were used recently.

17. On-pump CABG Very low mortality and morbidity Excellent results.
The most widely used technique worldwide.

18. Off-pump coronary artery bypass (OPCAB)
Newer technique with the proposed benefit of lower complication rates.

19. The grafts (conduits) for CABG
Arterial: Left and right internal mammary arteries (LIMA & RIMA), radial artery, right gastroepiploic artery) or
Venous: Reversed long saphenous vein.
Saphenous vein graft is the most commonly used graft as it is lengthy, and can be used for revascularization of many diseased vessels. Internal mammary artery is the best conduit used due to long term patency.

20. CABG

21. Reversed SVG

22. Bilateral IMAs

23. Radial Harvest

24. Right gastroepiploic artery

25. Grafts are anastomosed to the coronary vessels distal to the stenotic lesion.
Saphenous vein, and free arterial grafts are anastomosed proximally to the aorta.
Internal mammary artery arising from the subclavian artery is dissected as a pedicle graft from the inner aspect of the sternum and anastomosed distally to the coronary artery.

26. Complications Perioperative infarction, Low cardiac output state,
Arrhythmias,
Bleeding,
Non-cardiac complications of other organ systems e.g. brain, lung and kidney,
Deep sternal wound infection.
Mortality ( 2-3%).