1. Ischemic heart disease. Indications and methods of surgical treatment. Surgery department №2

2. IHD classification (WHPO) 1. Acute blood flow arrest 2. Stenocardia 3. Myocardial infarction 4. Heart failure 5. Cardiac rhythm disorders

3. IHD clinical picture Angina pectoris: (chest pain on exertion, in cold weather or emotional situations) Angina pectoris: (chest pain on exertion, in cold weather or emotional situations) Acute chest pain: acute coronary syndrome, unstable angina or myocardial infarction("heart attack", severe chest pain unrelieved by rest associated with evidence of acute heart damage) Acute chest pain: acute coronary syndrome, unstable angina or myocardial infarction("heart attack", severe chest pain unrelieved by rest associated with evidence of acute heart damage) Heart failure: (difficulty in breathing or swelling of the extremities due to weakness of the heart muscle) Heart failure: (difficulty in breathing or swelling of the extremities due to weakness of the heart muscle)

4. IHD diagnostics ECG ECG Echocardigraphy Echocardigraphy Coronarography Coronarography Ventriculography Ventriculography

5. IHD treatment Non-invasive surgical treatment Non-invasive surgical treatment (could help to turn up the heart on working in conditions of decreased coronary circulation) Percutaneus coronary intervention (PCI) (balloon angioplasty or coronary stenting) Percutaneus coronary intervention (PCI) (balloon angioplasty or coronary stenting) Open heart operation Open heart operation

6. IHD invasive treatment The best revascularization – is full revascularization is full revascularization

7. Indications for IHD surgery treatment Both PCI and CABG are more effective than medical management at relieving symptoms Rihal C, Raco D, Gersh B, Yusuf S (2003) Both PCI and CABG are more effective than medical management at relieving symptoms Rihal C, Raco D, Gersh B, Yusuf S (2003) CABG is superior to PCI in multivessel coronary disease (SoS trial) CABG is superior to PCI in multivessel coronary disease (SoS trial) Patients treated with CABG had lower rates of death and of death or myocardial infarction than treatment with a coronary stent Patients treated with CABG had lower rates of death and of death or myocardial infarction than treatment with a coronary stent

8. IHD surgery treatment Coronary-aortic bypass grafting (CABG) Coronary-aortic bypass grafting (CABG) LIMA –to - LAD grafts LIMA –to - LAD grafts

9. Indications for CABG ( Guidelines for CABG Surgery the American College of Cardiology and the American Heart Association, 1999 ) 1. Significant left main coronary artery stenosis. 2. Left main equivalent: significant (70 %) stenosis of the proximal LAD and proximal left circumflex arteries. 3. Three-vessel disease. 4. Two-vessel disease with significant proximal LAD stenosis and either ejection fraction <0.50 or demonstrable ischemia on noninvasive testing.

10. Indications for CABG ( Guidelines for CABG Surgery the American College of Cardiology and the American Heart Association, 1999 ) 5. One- or 2-vessel stenosis without significant proximal LAD stenosis, but with a large area of viable myocardium and high-risk criteria on noninvasive testing. 6. Disabling angina despite maximal noninvasive therapy, when surgery can be performed with acceptable risk.

11. 2004 ACC/AHA CABG guidelines Disease of the left main coronary artery (LMCA) Disease of the left main coronary artery (LMCA) Disease of all three coronary vessels (LAD,LCX and RCA). Disease of all three coronary vessels (LAD,LCX and RCA). Diffuse disease not amenable to treatment with a PCI. Diffuse disease not amenable to treatment with a PCI.

12. CABG history In 1952, Demikhov pioneered surgical myocardial revascularization with the internal mammary artery in canines. In 1952, Demikhov pioneered surgical myocardial revascularization with the internal mammary artery in canines. However, the invention of beating-heart or off-pump CABG surgery is often attributed to Kolessov, who, in 1967, used a minithoracotomy incision, anastomosing the left internal mammary artery (LIMA) to the left anterior descending artery (LAD). However, the invention of beating-heart or off-pump CABG surgery is often attributed to Kolessov, who, in 1967, used a minithoracotomy incision, anastomosing the left internal mammary artery (LIMA) to the left anterior descending artery (LAD). Later pioneers of the off-pump technique include Favoloro, Garrett, and associates (in the United States); Trapp and Bisarya (in Canada); and Ankeney (in the United States)—all of whom performed off-pump CABG surgery from 1968 to 1975. Later pioneers of the off-pump technique include Favoloro, Garrett, and associates (in the United States); Trapp and Bisarya (in Canada); and Ankeney (in the United States)—all of whom performed off-pump CABG surgery from 1968 to 1975.

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18. Thanks for your attention