2 NY Heart Association Classification Class I: Patients with cardiac disease but without resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or angina pain.Class II: Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or angina pain.Class III: Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain.Class IV: Patients with cardiac disease resulting in an inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.
3 Preop Risk Assessment Major predictors: Intermediate predictors: unstable coronary syndrome (recent MI)decompensated heart failure (NYHA class IV),significant arrhythmias and severe valvular disease.Intermediate predictors:mild angina (old MI)compensated heart failure (NYHA class II and III),Diabetesrenal insufficiency.Mild predictors:advanced ageuncontrolled systemic hypertension,irregular rhythmprior strokeabnormal EKG
4 High-risk procedures : Specific surgical risk factors or procedures expose the patient to greater or lesser risk of a cardiovascular event.High-risk procedures :emergent, major procedures in the elderlymajor vascular procedureslong general surgical procedures with anticipated large fluid shifts and/or blood loss (e.g., pancreatectomy, hepatic resection, or abdominoperineal resection).Intermediate-risk procedures:any intraperitoneal or intrathoracic operationcarotid endarterectomyOrthopedichead and neck proceduresLow-risk procedures:Endoscopicbreastsuperficial operations.
5 Assign a class High, Intermediate, Low risk Do noninvasive testing based on riskIf positive, pursue coronary angiography if possibleRemember, CAD has same risk factors as PVD (major vascular surgery)
6 Studies EKG CXR ECHO -- see flow pattern and valvular insufficiency Dobutamine stress echocardiographPPV for cardiac event is 20-40%A negative test is 93 to 100% predictive that no cardiac event will occur.Radionuclide Studies – thallium scan – uptake dependent on myocardial perfusionPET good for looking at viability of underperfused areas determine if capable to responding to reperfusion
7 Cardiac Catheterization Measures pressures and cardiac outputShuntsDetermines anatomyCoronary Angiography – measures the degree of diseaseCan determine area of a cardiac valve
8 CAD 1946 IMA to myocardial tunnel flow low and abandoned 1950’s coronary endarterectomy attempted1960’s first CABG with SVG at Cleveland ClinicPrimarily ATH being multifactorial with segmental plaqueSx: angina, MI, CHF, arrhythmias, sudden deathMI is the most common serious complication of CADModern therapy: early reperfusion with either thrombolytic therapy or emergent angioplastylowered the mortality to <5CHF may develop after MIIf late scarring, bypass grafting may not be beneficial
9 CABGCABG may be indicated in patients with chronic angina, unstable angina, or postinfarction angina, and in asymptomatic patients with severe proximal lesions or patients with atypical symptoms who have easily provoked ischemia during stress testing.In general, patients with more severe angina (CCS class III or IV symptoms) are most likely to benefit from bypassThe Veterans Administration Cooperative Study.demonstrated improved long-term survival in patients with left main disease treated with surgicalThe European Coronary Surgery Study Group.Surgery was found to be associated with improved survival in patients with triple-vessel disease and in patients with double-vessel disease with proximal left anterior descending and circumflex artery lesions.Coronary Artery Surgery Study.improved survival with surgery in patients with triple-vessel disease and depressed cardiac function.Unstable AnginaMost patients require urgent revascularization with either percutaneous coronary intervention (PCI) or CABG.Acute Myocardial InfarctionCABG generally does not have a primary role in the treatment of uncompoccurlicated acute MIPCI or thrombolysis is the preferred method of emergent revascularizationThe primary indication for surgery after acute transmural MI is in patients who develop mechanical complicationsUsually occurs 4 to 5 days after MI,Need intra-aortic balloon pump (IABP) placed and undergo emergent repairHigh mortality rates
10 The left IMA has a 10-year patency rate of approximately 95% when used as an in situ graft to the LAD.Right IMA may be used to provide a second arterial conduit as either an in situ or a free --patency rates are approximately 70 to 80% at 10 years.
11 Saphenous vein grafts Radial Artery Graft Targets on the lateral and posterior walls of the heart.The 10-year patency of saphenous vein grafts is only approximately 65%patency is limited by the development of progressive intimal hyperplasia and late vein graft atherosclerosis.Radial Artery GraftAllen testExcellent results
12 CABG Results Mortality 1-3% Variables that have been identified as influencing operative risk according to STS risk modeling include:female gender, age, race, body surface area, NYHA class IV status, low ejection fraction, hypertension, PVD, prior stroke, diabetes, renal failure, chronic obstructive pulmonary disease, immunosuppressive therapy, prior cardiac surgery, recent MI, urgent or emergent presentation, cardiogenic shock, left main coronary disease, and concomitant valvular disease. Perioperative complications include MI, bleeding, stroke, arrhythmias, tamponade, wound infection, aortic dissection, pneumonia, respiratory failure, renal failure, GI complications, and multiorgan failure.Angina completely relieved or markedly decreased in >98% of patients,.Exercise capacity with most patients demonstrating a markedly improved functional response to exercise secondary to improved blood flow.Late survival is similarly excellent after CABG, with a 5-year survival of >90% and a 10-year survival of 75 to 90Again depends on risk factors present
13 CABG versus StentThe Bypass Angioplasty Revascularization Investigation Trial.There was no significant difference in 5-year survivalPCI group required more repeat interventions, with 54% within 5 years vs. only 8% for CABG.In diabetic patients with triple-vessel disease, CABG offered a clear survival advantage at 5 years, 80.6 vs. 65.5% with PCI (P = .003).Arterial Revascularization Therapies Study Group.At 1 year, death, stroke, and MI rates were similarPCI patients had more recurrent symptoms, 16.8 vs. 3.5% in CABG patients.The 1-year event-free survival rate was 73.8% with PCI compared with 87.8% with CABG.New York State Study Group.Long-term patient survival was superior with CABG rather than stenting in patients with two or more diseased coronary arteries.17SummaryWhen comparing CABG to PCI for the treatment of patients with CAD, results demonstrate that with appropriate patient selection both procedures are safe and effective, with little difference in mortality. PCI is associated with less short-term morbidity, decreased cost, and shorter hospital stay, but requires more late reinterventions. CABG provides more complete relief of angina, requires fewer reinterventions, and is more durable. Additionally, CABG appears to offer a survival advantage in diabetic patients with multivessel disease.
14 Valvular Heart Disease Surgical rate increased as CABG rate declinesSurgical therapy is now recommended at a much earlier stage of the disease process in an attempt to maintain normal cardiac function long after valve surgery.Surgical OptionsReplacementRepair
15 Valves Mechanical Valves Tissue Valves Homografts Autografts excellent flow characteristicsan acceptably low risk of late valve-related complicationsextremely low risk of mechanical valve failureMust anticoagulateTissue ValvesPorcine or bovineLow thromboembolism rateHomograftsUncertain durablityDifficulty with preservationAutograftsPulmonary Valve as Aortic Valve and homograft for PV (Ross procedure)
16 Mitral Disease Mitral Valve Disease Valve Repair Mitral Stenosis almost always caused by rheumatic heart diseaseMitral stenosis usually has a prolonged course after the initial rheumatic infection, and symptoms may not appear for 10 to 20 years.Pulmonary congestionCan develop mural thrombiECHO diagnosticBalloon valvuloplasty if uncomplicated stenosisCommissurotomy has advantage of addressing nonpliable or calcified valvesValve Repairprocedure of choice for most patients with MV insufficiency,the primary advance in MV repair resulted from work by Carpentier in the 1970s.15-year freedom from valve repair failure is >90% in patients with degenerative mitral insufficiency.lower risks of thromboembolic- and anticoagulant-related complications
17 Mitral Disease Mitral Insufficiency . Degenerative disease is the most common cause of mitral insufficiency in the United States,The basic physiologic abnormality in patients with mitral insufficiency is regurgitation of a portion of the LV stroke volume into the left atrium.This results in decreased forward blood flow and an elevated left atrial pressure, producing pulmonary congestion and volume overload of the left ventricle.findings of mitral insufficiency are an apical holosystolic murmur and a forceful apical impulseSurgery for any NYHA II (SOB on exertion).OptionsRepairReplacementAnnuloplasty deviceCommissurotomy.
18 Aortic Disease Aortic Stenosis Aortic Insufficiency Primary causes of aortic stenosis include acquired calcific disease, bicuspid aortic valve, and rheumatic disease.Must be reduced to one third its normal cross-sectional area before significant hemodynamic changes occur.Moderate aortic stenosis is defined as an aortic valve area between 1.0 and 1.5 cm2Severe stenosis is defined as a valve area <1.0 cm2Aortic stenosis results in increased myocardial work and progressive concentric LV hypertrophy with little ventricular dilatation.The classic symptoms of aortic stenosis include exertional dyspnea, decreased exercise capacity, heart failure, angina, and syncope.Once the patient becomes symptomatic, prompt operation is indicated.Operative IndicationsAortic valve replacement is indicated for virtually all symptomatic patients with aortic stenosis.Surgery also may be recommended for asymptomatic patients with aortic stenosis who have a progressive increase in the transvalvular gradient on serial echocardiographic studies, a rapid rise in diastolic dimensions, a valve area <0.80 cm2, progressive pulmonary hypertension, or right ventricular dysfunction during exercise testing.Aortic InsufficiencyMultiple causes: degenerative, inflammatory, infectious etiology, etcProduces volume loading strain on the LVRepair for any NYHA II or above may be irreversible once symptoms occur
19 IHSS Idiopathic Hypertrophic Subaortic Stenosis Varying degrees of subaortic LV outflow tract obstructionDynamic component usually be provoked with volume depletion, vasodilators, or inotropes.Operative TechniquesSurgical septal myotomy and myectomy (Morrow technique)
20 Heart Failure Transplant the gold standard for end-stage heart disease CABG for ischemic cardiomyopathyMyocardial viability is the pivotal
21 Assist Devices Balloon Pump Ventricular Assist Devices balloon is inflated during diastole and deflated during systole.Coronary blood flow is increased by improved diastolic perfusion, and afterload is reduced.Generally, the IABP is used for a few days with minimal morbidity.Ventricular Assist Devicesanytime the heart can no longer support the oxygen delivery demands of the bodyBridge to recovery or transplantMay be “destination” for non transplant candidates
22 Atrial Fibrillation Cox Maze procedures Interventional EP Lab Series of surgical incisions and reconstruction of the atria such that the sinus mechanism is preserved98% success rate, an extremely low follow-up neurologic event rateInterventional EP LabAblation
23 PacemakersPacemakers were first developed in the 1950s, patients attached with power cordNow done with transvenous leads that require only a subcutaneous access procedure and fluoroscopic control.Defibrillators1990s: ICDs createdDetect and treat ventricular tachyarrhythmias.Battery charges a capacitor and delivers jolt of energy to myocardiuma
24 Myxoma Myxomas Clinical Manifestations Treatment Sixty to 75% of cardiac myxomas develop in the left atriumThere is no tendency to invade other areas of the heart, and distant metastases are rarely reportedMay be completely asymptomatic until it grows large enough to obstruct the MV or TV or fragments to produce embolispecimen. The neck of the mass that was obstructing the mitral orifice is clearly delineated.Clinical ManifestationsSymptoms may include those of MV obstruction; peripheral embolization; or generalized autoimmune symptoms.TreatmentSurgery should be performed as soon as possible after the diagnosis has been established due to the inherent risk of a disabling or fatal cerebral embolus
25 Endocarditis AV MC site of prosthetic valve complications MV MC site of native valveTV MC site of IV drug usersS. aureus for 50%
26 Anticoagulation?ABX Prophylaxis?Best conduit for CABG?CABG versus Stent?A-fib management?