1. Surgical Treatment of Ischaemic Heart Disease Division of Cardiothoracic Surgery UWI Mona

2. Coronary Arterial Disease Atherosclerosis in native coronary vessels (multi- factorial) Atherosclerosis in native coronary vessels (multi- factorial) Blocks develop Blocks develop Partial blocks prone to platelet clots Partial blocks prone to platelet clots Large plaques prone to fracture  clots form Large plaques prone to fracture  clots form  Myocardial Infarction(MI)

3. Angina: Chest Pain due to inadequate Blood Flow  Ischaemia Unlike MI, angina may be reversible Unlike MI, angina may be reversible Some form of intervention may alleviate symptoms Some form of intervention may alleviate symptoms (open or less-invasive surgery; angioplasty +/- stenting)

4. Coronary Bypass: Bypasses the Block

5. How is the occlusion bypassed? Most procedures are done on a non-beating heart Most procedures are done on a non-beating heart Cardiopulmonary Bypass Machine (CPB) is used to take over the pumping function of the heart, and the gas exchange function of the lungs Cardiopulmonary Bypass Machine (CPB) is used to take over the pumping function of the heart, and the gas exchange function of the lungs Cardioplegia is given to stop the electrical activity of the heart Cardioplegia is given to stop the electrical activity of the heart Therefore, the heart is still, and the delicate operation can be performed with great precision Therefore, the heart is still, and the delicate operation can be performed with great precision

6. The Cardiopulmonary Bypass Machine

7. The CPB Circuitry

9. The Appearance of the Heart on Opening the Sternum

12. Anastomosing the Internal Mammary Artery to the Left Anterior Descending Coronary Artery

13. The Completed LIMA-LAD Anastomosis

15. Saphenous Vein(green arrow) being anastomosed to Coronary Artery(red arrow)

16. Completed SV-Coronary Anastomosis

17. CABG can be done on a BEATING HEART:

18. What are the results? Best results are for open surgery using cardiac arrest (30 yrs experience) Best results are for open surgery using cardiac arrest (30 yrs experience) Newer techniques such as Beating Heart Surgery, Minimal Access CABG, Robot-assisted CABG, are all in early stages Newer techniques such as Beating Heart Surgery, Minimal Access CABG, Robot-assisted CABG, are all in early stages For multivessel disease, surgery still superior to angioplasty/stenting For multivessel disease, surgery still superior to angioplasty/stenting

19. A Late Complication Patent LIMA Patent LIMA Graft with distally blocked native coronary artery

20. Angioplasty and Stenting A catheter-based procedure performed by cardiologists in the CATH LAB which can dilate and maintain the lumen of a partially blocked coronary artery through the insertion of a tiny metallic mesh tube A catheter-based procedure performed by cardiologists in the CATH LAB which can dilate and maintain the lumen of a partially blocked coronary artery through the insertion of a tiny metallic mesh tube Very good short-term (< 5 yrs) results, but poor longer term results when compared to traditional surgical therapy Very good short-term (< 5 yrs) results, but poor longer term results when compared to traditional surgical therapy

21. Pre- and Post- Angioplasty

22. Stent is left inside coronary artery and holds lumen open

23. Conclusions CABG is one of the most successful operations ever devised CABG is one of the most successful operations ever devised Hundreds of thousands of procedures worldwide yearly Hundreds of thousands of procedures worldwide yearly Surgery has best long-term results, although angioplasty techniques are improving long- term outlooks Surgery has best long-term results, although angioplasty techniques are improving long- term outlooks All of these interventions are PALLIATIVE THERAPIES, ie. The underlying disease may continue to cause problems post-op All of these interventions are PALLIATIVE THERAPIES, ie. The underlying disease may continue to cause problems post-op