A few basics of cardiac surgery…. Brett Sheridan, MD Assistant Professor Department of Surgery

Define the difference between congenital and acquired (adult) heart disease.

What is the incidence of congenital heart disease in the Unites States?

List the 3 most common causes of death in the US…

1) Heart Disease 2) Cancer 3) Stroke

How many people in the US died from cardiovascular disease in 2001?

Do more men or women die from cardiovascular disease?

Define “acute coronary syndrome” according to the American Heart Association

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

Describe the initial stabilizing treatment for symptomatic ischemic heart disease presenting in the ER

ECG within 10 minutes Supplemental O2 IV access continuous ECG monitoring Sublingual NTG if SBP > 90 mmHG Morphine ASA (chewed) Labs If ST elevation > 1mV or LBBB then reperfusion (fibrinolysis or PTCA)

What is AMI management in first 24 hours?

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

What is a coronary angiogram and why do we do we perform them?

Percutaneous coronary angioplasty (PTCA, PCI,…)

What is a percutaneous coronary intervention (PCI)

Percutaneous coronary angioplasty (PTCA, PCI,…)

Why are patients referred for CABG instead of undergoing a PCI approach to coronary artery disease? I.e. which patients benefit from CABG? Acute coronary Syndrome: On-going myocardial ischemia despite initial Rx ThrombolyticsRevascularization PCICABG

Cite 2 prospective randomized trials comparing PCI vs CABG for the treatment of multivessel CAD

Inclusion Criteria –Symptomatic –Multivessel CAD –LVEF > 30% Baseline Characteristics –Class III/IV angina - 66% –Previous MI - 42% –3 vessel CAD - 30% –mean LVEF = 60%

Comparison of Coronary-Artery Bypass Surgery and Stenting for the Treatment of Multivessel Disease (Arterial Revascularization Therapies Study Group) CABG PCI Patients (n) Late outcome year Death 2.8% 2.5% MI 4.0% 5.3% CVA 2.0% 1.5% Revascularization * 4 % 17% Event-free survival * 88% 74% Symptom-free * 90% 79% Cost * $13,638 $10,665

14% benefit w/ CABG! Event –free Survival: CABG vs PCIS

16 % benefit w/ CABG! Risk of Repeat Revascularization

Risk of Death 3.7 % SURVIVAL benefit w/ CABG!

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

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

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

Advantages - Traditional CABG Still Heart Exposure and access Visualization The most intensely scrutinized procedure in US medicine SAFETY

Disadvantages - Traditional CABG Proinflammatory response to CPB Suggestion of end-organ injury –CNS –Pulmonary –Renal Increased fluid shifts

Off-Pump Gear

Off-Pump Stabilizing Devices

Off-Pump Exposure of PDA

List 10 complications of CABG and there relative frequency

Death3% Stroke1-2% Bleeding requiring re-op3-5% Wound Problems0.5-5% Myocardial infarction2-30% Arrhythmias10-60% Pneumonia4% Pneumothorax1-2% Cardiac Tamponade3-6% Pericardial Inflammation18% Renal Insufficiency15-20%

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

Class I ASA Beta-blockers ACE inhibitor Statins

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)