SURGERY SUBSPEC: THORACIC AND CARDIOVASCULAR

SURGERY
Dr. De Asis

CASE  Coronary artery disease – main diagnosis

 A 62-year-old woman, current smoker, diabetic, hypertensive and o Basis: The left heart catheterization showed 90% stenosis in the
hyperlipidemic, presented to the E.R with a 2-day history of intermittent proximal third of LAD, 80% stenosis in the proximal RCA, with a
chest pain. On examination, she was tachycardia with a heart rate of 30% disease in the middle circumflex artery.
101 beats/min, and hypertensive with a blood pressure of 160/100 o We have Two general classification:
mmHg. The patient does not have any signs of heart failure. An
electrocardiogram showed 2-mm depression in V2-V6.
 The patient was started on heparin and given IV metoprolol, as well as
nitroglycerin. In addition, she was started on Eptifibatide infusion. The
patient remained symptomatic until her coronary angiogram. The left
heart catheterization showed 90% stenosis in the proximal third of
LAD, 80% stenosis in the proximal RCA, with a 30% disease in the
middle circumflex artery.
QUESTIONS
 What is the best plan of treatment for this patient
A. Percutaneous Coronary Intervention to both the LAD and RCA now
B. Referral for two-vessel Coronary Bypass Graft Surgery (CABG)
C. PCI to the LAD with staged intervention to the RCA
[Reference: google image]
D. Medical management with no PCI or CABG
 Complete diagnosis of the case: CAD Acute coronary syndrome with
CASE DISSECTION
NSTEMI
General data  62 years old, woman  OTHER TWO DIAGNOSIS OF THE PATIENT ARE:
Chief  Chest pain o Diabetes
complaint o Hypertension
2 days PTI patient experience intermittent chest
HPI CORONARY ANATOMY
 pain
Personal Current smoker, diabetic, hypertensive and
History  hyperlipidemic
Physical  HR – 101/min (Tachycardic)
Examination  BP – 160/100 mmHg (Hypertensive)
 Started on heparin and given IV Metoprolol, as well
Course in the as nitroglycerin
ER/Ward  She was also started on Eptifibatide Infusion
 Remained symptomatic until her coronary angiogram
 ECG
o Showed 2 mm depression in V2-V6 (sign of acute
coronary syndrome)
 NSTEMI
On ECG, the result is highly suggestive of ST
depression. If it is an acute
coronary syndrome, you label it as ST elevation
or non-ST elevation. So, in the
case, it is a non-ST elevation MI. The diagnosis
is acute coronary syndrome, non-ST elevation
MI. Then usually in the diagnosis, the functional
class of the patient is added. Recall the NYHA
classification and the Canadian Cardiovascular
Society Angina classification. The complete
Diagnostic diagnosis is acute coronary syndrome,
Interpretation NSTEMI, NYHA class II, CCSA class II in sinus
rhythm. As a clerk, you will be given a task to
attach the drug indices in your patient’s chart.
The table is the example of drug index*The [Reference: google image]
other way to give diagnosis is coronary artery Course Branches Territorial
disease, free vessel Supply
involvement NYHA class II in sinus rhythm Transverse LAD, LAX
between the
pulmonary
 On Coronary Angiogram LM artery and
o Left heart catheterization showed 90% stenosis in
(LAA) left
the proximal third of LAD
atrial
o 80% stenosis in the proximal RCA
appendage
o 30% disease in the middle circumflex artery
Transverse the Diagonal branches, Anterior LV
o > 50% - significant LAD interventricula septal branches mass and
 Nitroglycerin – vasodilator, to relieve the ischemia. r groove septum
So that blood will flow in the coronary arteries. Passes Obtuse Marginal Lateral LV
Oxygen can be delivered at the myocardium to posteriorly (OM) mass
improve the chest pain. LCx
Medications close to the
 Heparin – anti-coagulant, same function as to mitral valve
nitroglycerin. To improve blood flow Transverse the -Right posterior RV and
 Metoprolol – beta1 selective blocker, to control Right AV descending artery septum
the heart rate. Decreases the heart rate groove (RPDA)
 Anti-platelet drug of the glycoprotein IIb/IIIa RCA -Right posterolateral
inhibitor, reversibly binds to platelet artery (RPL)
Eptifibatide
-Conus artery
-SA Nodal artery
DIAGNOSIS OF THE CASE LM: Left Main Coronary Artery, LAD: Left Anterior Descending

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 Artery, LCx: Left Circumflex Artery, RCA: Right Coronary Artery o Heart failure should be suspected in patients who present with
dyspnea, orthopnea, fatigue, and edema
PATHOPHYSIOLOGY
 Arrhythmias may also be sequelae of CAD. Ischemic etiologies should
be investigated in patients who present with new arrhythmias.
o CAD may result in arrhythmias following an acute MI or as the result
of ultrastructural and electrophysiologic remodeling secondary to
chronic ischemic heart disease.
o Ischemia of the electrical conduction system may be present in the
form of new onset complete or partial atrioventricular conduction
blocks.
DIFFEERENTIALS OF THE CASE
 Coronary artery disease – main diagnosis
ETIOLOGY & PATHOLOGY (Swartz)
 GERD
 Atherosclerotic stenoses are the primary mechanism of CAD.
o Usually complains of epigastric pain, which is an atypical symptom
 Pathophysiologic process is initiated with vascular endothelial injury
of CAD
and is potentiated by inflammatory mechanisms, circulating lipids,
 Esophageal spasm
toxins, and other vasoactive agents in the blood
 Musculoskeletal pain
 Macrophages and platelets are attracted to this area of endothelial
dysfunction inciting a local inflammatory response. During this process,  PUD
macrophages infiltrate into the intimal layers and accumulate o Same as GERD, patient complains of epigastric pain
cholesterol-containing low-density lipoproteins.  Pulmonary embolus
 The growth factors secreted promote proliferation of smooth muscle  Costochondritis (Tietze’s syndrome)
cells within the intima and media of the arteries. Together with the  Biliary tract disease
accumulation of the lipid-laden macrophages, the smooth muscle  Pulmonary hypertension
hyperplasia results in an atheroma and subsequent stenosis of the  Pleuritic
vessel.  Pericarditis
 These atheromas have a fibrous cap that may rupture, exposing the  Aortic dissection
underlying cells and extracellular matrix, which are very prothrombotic.  In 80% of patients present with typical symptoms, such as classic
 Acute plaque rupture and thrombus formation is thought to be the angina, chest pain, or chest heaviness. 20% of patients present with
main pathophysiologic mechanism responsible for acute coronary atypical symptoms. Included there is epigastric pain. Another atypical
syndromes presentation is dyspnea or shortness of breath. If this is present, there is
RISK FACTORS AND PREVENTION LV dysfunction already, the heart failure is severe.
 Risk factor modification, percutaneous and surgical revascularization  Another differential diagnosis is aortic stenosis. These patients also
 Use of medication, Aspirin; HMG-CoA reductase inhibitors [statins], present chest pain due to insufficient blood that reach the coronary
and β-blockers), has decreased mortality from coronary artery disease arteries. Part of the diagnostic work up of aortic stenosis is to perform
by 74% coronary angiography to rule out CAD.
 Major Risk Factors: atherosclerosis includes advanced age, cigarette LABORATORY AND DIAGNOSTIC PROCEDURE
smoking, hypertension, dyslipidemias, sedentary lifestyle, obesity, and NON-INVASIVE
diabetes  Lipid profile
Current guidelines outlined in AHA/ACC o Triglycerides levels
 Consensus statement summarize the secondary prevention  Normal =500 mg/dL
recommendations. Class I recommendations includes:  Borderline high 150-199 mg/dL
o smoking cessation and avoidance of environmental tobacco exposure LABORATORY  High 200-499 mg/dL
o Blood pressure control to under 140/90 mmHg (under 130/80 mmHg EXAM  Very High >=500 mg/dL
in those with diabetes or chronic kidney disease)  Glucose
o LDL cholesterol levels less than 100 mg/dL, aspirin therapy in all  HbA1c
patients without contraindications  Creatinine
o A BMI target of less than 25 kg/m2  CBC
o Diabetes management with target HbA1c <7%, and encouragement  Myoglobin
of daily moderate-intensity aerobic exercise o Cannot distinguish tissue of origin
o β-Blockers should be used in all patients with LV dysfunction and  Troponin I
following MI, ACS, or revascularization, unless a specific o Specific for the cardiac form
contraindication is present. CARDIAC o MOST sensitive
o Renin-angiotensin-aldosterone system blockade in patients with MARKERS o Elevated 4-8 hours after onset, peaks at 12-
hypertension, LV dysfunction, diabetes, or chronic kidney disease 16 hours and remains elevated for 5-9 days
should also be considered. o Values above 1.5 is suggestive of MI
CLINICAL MANIFESTATION  CK-MB
 Angina pectoris, myocardial infarction (most common serious o High sensitivity and specificity in MI
complication), ischemic heart failure, arrhythmias, and sudden death  Between 0 and 3 mg/dL, is an independent risk
 Angina pectoris is the pain or discomfort caused by myocardial CRP factor for IHD and useful in therapeutic
ischemia and is typically substernal and may radiate to the left decision making
upper extremity, neck, or epigastrium.  Expected to increase when there is already heart
o Characteristics of chest pain that make myocardial ischemia less PRO-BNP
failure
likely include pleuritic chest pain, pain reproducible by movement or  Cardiac silhouette, pulmonary congestion,
palpation, or brief episodes lasting only seconds CHEST X- RAY
associated pulmonary pathology
o Typical angina is relieved by rest and/or use of sublingual
12- LEAD  Rate, rhythm, ventricular hypertrophy, blocks,
nitroglycerin. ELECTROCARD ischemia.
 Myocardial infarction is a serious consequence of CAD occurring IOGRAM (12-L
when ischemia results in myocardial necrosis. ECG)
 This may be silent and need not be preceded by angina. 2-  Just like the ultrasound
 Necrosis may result in disruption of the myocardial integrity leading to DIMENSIONAL  Chamber size, wall motion, shunts, valve
devastating conditions such as intracardiac shunts from ventricular ECHOCARDIOG pathology, LV function, effusion
septal defects, acute valvular regurgitation from rupture of necrotic RAPHY WITH  Coronary Artery results in LV dysfunction
papillary muscles, and cardiac aneurysms, which have the potential for DOPPLER o 2D- Echocardiography shows Left ventricular
fatal rupture (2DED) Ejection fraction (LVEF); Categories in:
 Ischemic insults from CAD may lead to congestive heart failure.
 NORMAL: 50% to 70%
o The initial myocardial damage sets off a cascade of both local and
 MILD DYSFUNCTION: 40% to 49%
systemic responses.  MODERETE DYSFUNCTION: 30% to
o Over time, these changes can cause deleterious myocardial loading 39%
and abnormal neurohumoral responses that result in pathologic  SEVERE DYSFUNCTION: LVEF <
remodeling of the heart.

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 30%
CARDIAC ENZYMES/ BIOMARKERS
MYOGLO TROP I & CK-MB LDH
BIN T
N. V 0-85 ng/Ml <0.04 5-25 IU/L 140-280
ng/Ml (3-5% of U/L
total CK)
After injury 30 min 3-4 h 3-4 h 24-72 h
Remains 10 days 3-4 days 8-14 days
Detectable
MM & BB Non-specific
are specific marker for MI,
and its
to skeletal
concentration
muscle and can be
brain tissue elevated
in hemolytic
anemia, stroke,
pancreatitis
INVASIVE
 Gold standard  Figure 1A. the coronary arteries and their relation to the ECG leads.
 The significant finding in angiography is when Localization of myocardial infarction/ischemia is done by using ECG
the stenosis is more than 50%. Post autopsy changes to determine the affected area and subsequently the occluded
findings, 50% stenosis is 75% reduction in coronary artery (culprit)
 In relation to ECG, this shows how different chest leads are positioned.
Limb lead, I-III, and Chest leads, V1-V6. Usually at ST elevation, it is
at II III and aVF, and as you can see it is at anterior location. Meaning
the chance that will be affected is left anterior descending artery

CORONARY
ANGIORAPHY
cross sectional diameter of the arteries
 Access from femoral or Radial artery
Figure 7-1. Diagrammatic representation of
relationship between two methods of estimating
severity of coronary artery stenosis.
 [NOTE] "Refer to the 'Terminologies Table'
below for the significant findings observed
during coronary angiography."
 Figure 2. The arterial supply of the conduction system. As seen, the
sinoatrial node is supplied by the right coronary artery in 60% of
individuals, and by the left circumflex artery in the remainder. The
atrioventricular node is supplied by the right coronary artery in 90%
(right dominant system) of individuals, whereas the in the remaining
TERMINOLOGIES 10% the supply comes from the left circumflex artery (left dominant
system).
 This just shows the different blood supply in the conduction systems of
the heart. The SA node is supplied 60% by the right coronary artery and
40% from the left circumflex artery. If the AV node is supplied by the
right coronary artery, it is called the right dominant system, which is
seen in 90% of the patients. The remaining 10% is supplied by the left
circumflex, which is called left dominant system
Table 1: Localization of ischemic are in ST Elevation Myocardial
Infarction (STEMI/ STE- ACS)

 Interpretation  Interpretation
o Left main coronary artery o (upper arrow) LAD 50%
50% blockage. occlusion with
o LCx 75-90 % occlusion
Consideration to say it’s an LME:
o At least 70% involvement of
LAD & LCx
o Location of occlusion should
be PROXIMAL  We take a look at ST elevation. If you are looking at V1 to V2, usually
 You always start with a non-invasive test. These are the blood test. the affected area is the septal region. When we say the culprit lesion, it
Such is the artery that is involved. So, when it comes to V1-V2, the culprit
as lipid profile and cardiac markers. lesion is the proximal LAD. If it is V3-V4, it is usually anteriorly
 On chest X-ray, we can see heart failure symptoms such as enlargement located, still the LAD. V5-V6, the apical region, the culprit lesion is at
of different chambers. distal LAD, LCx or RCA. Leads I and aVL is at the lateral side of the
heart which is supplied by the LCx. And leads II, AVF and III is
 On ECG, we can see the ST elevation. 2D-ECHO and then angiogram
inferiorly located, supplied by 90% RCA, 10% LCx. V7, V8 and V9 is
posterolateraly located and supplied by RCA or LCx

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 after the procedure.  The artery may develop a hole
 The procedure is usually (artery perforation).
performed using local anesthesia,
which involves fewer risks than
general anesthesia (putting you
under")
Stent placement
 A stent is a tiny tube that a doctor places in an artery or duct to help
keep it open and restore the flow of bodily fluids in the area.
 Stents help relieve blockages and treat narrow or weakened arteries.
Doctors may also insert stems in other areas of the body to support
 Here is a typical ECG reading. The 2nd and 3rd is non ST elevation, blood
while the 4th one shows ST elevation. vessels in the brain or ducts that carry urine and bile.
 For the 2D-ECHO, you can almost see everything that you want to see  A stent is usually a mesh-like metal tube, although fabric stents arc also
available Sometimes, doctors will use dissoluble stents coated in
medication as a temporary solution.
 In some cases, restenosis may occur. Restenosis is when too much
tissue grows around the stem. This could narrow or block the artery
again.
 Doctors may recommend forms radiation therapy or opt to insert a
medication coated stent to slow the growth of the tissue.
 When is PCI chosen over CABG? It is when the stenosis is single
discrete lesion. Then the recommendation is balloon angioplasty or
stenting. If the obstruction is long or more than two coronary arteries
are affected, then the guidelines recommend CABG surgery
THROMBOLYSIS- 6 HOURS GOLDEN PERIOD
 Drugs such as streptokinase, urokinase, RT-PA
 It is very important 6 hours from the onset of chest pain. If it is more
than 6 hours, the risk: benefit ratio is not good anymore. Drugs are not
PARASTERNAL LONG AXIS (PLAX) readily available in the hospital and a bit expensive
 Transducer position: left PREOP ASSESSMENT/ EVALUATION/ RISK STRATIFICATION
sternal edge; 2nd — 4th  Anesthesia rounds
intercostal space o Discuss the associated risk
 Marker dot direction: points o At least 1 hour to prepare the patient
towards right shoulder  Surgery rounds
 Most echo studies begin with o Discuss procedure
this view o Associated risks
 It sets the stage for subsequent o Obtain consent
echo views PRE-OP/
WARD o Checklist – prophylactic antibiotics, blood
 Many structures seen from this
view ROUNDS  If it is confirmed that the surgery will proceed,
the anesthesiologist will discuss to the patient the
risk associated with giving of medications and
TREATMENT OPTIONS intubation. The surgical team will also make
CORONARY ARTERY BYPASS GRAFT (CABG) SURGERY rounds. The patient will then ask what will be
 CABG surgery is advised for selected groups of patients with significant done in the operating room, the procedure itself,
narrowing and blockages of the heart arteries (coronary artery disease). the risk associated. Then consent is obtained
 CABG surgery creates new routes around narrowed and blocked 
arteries, allowing sufficient blood flow to deliver oxygen and nutrients RISK  1.) American Heart Association (AHA) Guideline
to the heart muscle. STRATIFICATI Circulation Journal
 Great saphenous veins – harvested ON  2.) European Society of Cardiology (ESC)
 CABG surgery is performed to relieve angina in patients who have Guidelines
tailed medical therapy and are not good candidates for angioplasty  3.) New York Heart Association (NYHA)
(PCI). Functional
 CABG surgery is ideal for patients with multiple narrowing in multiple o Classification Class I - Patients with cardiac
coronary artery Inanities. such as is often seen in patients with diabetes. disease, but without resulting limitation of
 CABG surgery has been shown to improve long-term survival in physical activity. Ordinary physical activity
patients with significant narrowing of the kit main coronary artery, and does not cause undue fatigue, palpitation,
in patients with significant narrowing of multiple arteries, especially in dyspnea, or angina pain.
those with decreased heart musk pump function o Class II - Patients with cardiac disease
 Indications (AHA Guidelines) resulting in slight limitation of physical activity.
o Chronic angina They are comfortable at rest. Ordinary
o Unstable angina o Postinfarction angina o Asymptomatic patients physical activity results in fatigue, palpitation,
with atypical symptoms developing ischemia during stress test ▪ 1-3% dyspnea, or angina pain.
O.R. mortality rate o Class III - Patients with cardiac disease
PERCUTANEOUS CORONARY INTERVENTION (PCI)/ resulting in marked limitation of physical
PERCUTANEOUS TRANSLUMINAL CORONARY activity. They are comfortable at rest. Less
ANGIOPLASTY (PTCA) than ordinary physical activity results in
Ballon Angioplasty fatigue, palpitation, dyspnea or anginal pain.
 A specially designed catheter with a tinv balloon is carefully guided o Class IV - Patients with cardiac disease
through the Artery to the blockage, then inflated to widen the opening resulting in an inability to carry on any physical
and increase blood flow to the heart. A stent is often placed during the activity without discomfort. Symptoms of
procedure, to keep the Artery open after the balloon is deflated and cardiac insufficiency or of anginal syndrome
removed. may be present even at rest. If any physical
Benefits Risk activity is undertaken, discomfort is increased
 The narrowing in the artery may  The insertion site may bleed or  4.) Canadian Cardiovascular Society (CCS)
be reduced, resulting in improved become infected. Angina Classification
blood flow.  The artery may become blocked o Class I - Ordinary physical activity such as
 Main complications are again (restenosis). walking or climbing stairs, does not cause
uncommon o You may be able to  The artery may tear (artery angina. Angina may occur with strenuous,
return to normal activities shortly dissection). rapid, or prolonged exertion at work or
recreation.

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 o Class II - There is slight limitation of ordinary
activity. Angina may occur with walking or
climbing stairs rapidly, walking uphill, walking
or stair climbing after meals or in the cold, in
the wind, or under emotional stress, or walking
1 >2 blocks on the level, or climbing >1 flight
of stairs under normal conditions at a normal
pace
o Class III - There is marked limitation of
ordinary physical activity. Angina may occur
after walking ≥1 block on the level, or climbing
1 flight of stairs under normal conditions at a
normal pace
o Class IV - There is inability to carry on
physical activity without discomfort; angina  The surgery consists of at least 3 surgeons
may be present at rest [Note]: inaudible, di ko alam role ni 3rd surgeon.
 NYHA describes the severity of disability, while o 1.) Main surgeon – opens the chest; the one who do the sternotomy;
the CCS describes the severity of the angina harvest internal mammary artery
o 2.) Assistant surgeon- harvest the veins on the lower extremities;
1. EuroScore II – there is a downloadable app o Connecting patient to CPB
2. Society of Thoracic Surgeons (STS) Adult  Once the veins are harvested and the
Cardiac Surgery Risk Calculator o It is more chest is open, we now proceed in
detailed than Euroscore. Because it will give connecting the vein.
you the percent of stroke rate, prolonged o “Upon opening the pericardium (image
ventilation and sternum wound infection. In on the right), the chamber that can be
the clinical practice, both scores are easily visualized first is the right
included in the patient chart ventricle. The right ventricle (RV) is the
 Euro score Example part of the heart that is most likely to be
affected during instances of stabbing
near the heart."
 Distal Anastomosis- Coronary artery

 Proximal Anastomosis- Ascending aorta

o We do not remove the valves found in the vein’. The orientation of

blood flow is from Proximal anastomosis to the distal anastomosis
(see image above)

[Note]: Inaudible part. Baker’s notes in different blood vessels use in

 Euro SCORE = 1.16% CABG
 Here is an application of Euroscore. You will just fill up all the risk  Saphenous Vein:
involved. This app will give you the exact percentage of risk that you o Location: Superficial vein in the leg.
will o Use: Commonly employed as a graft in CABG.
encounter in doing CABG procedure o Procedure: Surgeon extracts a segment, creating a bypass around
*INTRA-OP (ANESTHESIA) the blocked coronary artery.
 After verifying, getting consent,  Internal Mammary Artery (IMA):
documentation of the patient and assessing o Location: Found in the chest, a branch of the subclavian artery.
the risk, you must do the ff: o Use: Left Internal Mammary Artery (LIMA) is frequently chosen for
o Place an arterial line grafting.
o Swanz Ganz catheter/Pulmonary artery o Advantage: Demonstrates excellent long-term patency rates
catheter compared to other options.
o Continuous Arterial monitoring  Radial Artery:
o Location: Situated in the forearm.
o Use: Increasingly popular, especially as a second or third graft.
o Advantage: Notable for being an artery, potentially offering
favorable long-term outcomes.
SURGERY PROPER
SURGICAL CONSIDERATIONS
o Continuous Arterial  Mid sternotomy; thigh & legs [island
monitoring INCISION
incisions or endovascular harvest (EVH)]
 Arterial grafts – internal mammary/ thoracic
artery (IMA/ITA), right gastroepiploic artery,
o Swanz Ganz catheter/Pulmonary artery GRAFTS/
free inferior epigastric artery, splenic artery
CONDUITS
catheter  Venous grafts – greater saphenous vein,
*INTRA-OP (SURGERY) lesser saphenous vein
 Sterility- prepping; draping CARDIO-  Components: venous drainage line &
 Set-up the heart and lung machine (CPB) PULMONARY reservoir, pump, oxygenator-heat exchanger,
o Serves as the heart and lungs of the patient during operations BYPASS (CPB) arterial filter, arterial inflow line
MACHINE-HEART-  Give 3000 units/kg of systemic heparin 3
LUNG MACHINE minutes before connecting this tubing to the

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 patient to prevent malfunctioning of the
machine due to the presence of clot
 Agents of Damage/ Side Effects
o Shear stress
o Incorporation of foreign substances
o Heparin and protamine side effects
o Trauma to the blood - RBC hemolysis
o Low-grade coagulopathy
o Systemic inflammatory response
o End-organ dysfunction
 Chemical cardioplegia (antegrade; retrograde)
– solution with high K+ content
MYOCARDIAL  Hypothermia – decreases O2 requirement and
PROTECTION allows lower flow rates without producing
lactic acidosis; metabolic activity decreases
with lower body temperature.
OFF-PUMP CORONARY ARTERY BYPASS (OPCAB)
SURGERY
 Beating heart  Less myocardial injury
 Mortality rate (6.5 vs 11.4%)  Fewer blood transfusions
 Stroke (1.6 vs 5.7%)  Earlier postoperative
 Decreased perioperative complications extubation
 Earlier hospital discharge
OTHER TREATMENT OPTIONS
MINIMALLY INVASIVE DIRECT CORONARY ARTERY
BYPASS (MIDCAB)
 L anterior Mini thoracotomy  Single-vessel disease: LAD or
 Beating heart diagonal
 Late results better than PCI
TRANSMYOCARDIAL LASER REVASCULARIZATION (TMR)
 Carbon dioxide, holmium; yttrium-aluminum-garnet laser
 Drill multiple holes through the myocardium into ventricular cavity
which
 Stimulates angiogenesis in the area of injury for patients with refractory
angina who are unsuitable candidates for standard CABG due to poor
distal coronary artery anatomy
POST-OP CARE/ MONITORING
 SICU
 Intensivist
CABG OUTCOME
 Mortality rate
o Elective CABG for stable angina w/ good LV function <1%
o Unstable angina (UA), post infarction angina, moderate LV
dysfunction, failed PTCA 3-5%
o Severely depressed LV function requiring urgent operation 10-20%
o Post infarction cardiogenic shock w/ MR or VSD >40%
 Saphenous vein graft
o Patency rate 65-75% in 10 years
o 10-15% occlude within the 1st year c. 2-5%/yr. occlude thereafter
 IMA graft - in-situ patency rate 90-95% in 10 yrs; 70-80% if free graft
 Recurrent angina occurs in 35% 2o to vein graft occlusion &
progression of disease in non-bypassed vessels or in bypassed vessels
beyond the site of distal anastomosis.
 Angina symptoms treated medically w/ only 10% requiring reop at 10
yrs
 Peri-op M
o 2-3% instable angina
o 5-10% UA
o 30-50% in “E’ CABG after a failed PTCA
o Thereafter, late MI rate is 1-3%/yr
 Mortality rate in reop 2-3x higher
 Long-term survival rate a. all vein graft 80% & 65% (5 & 10 yrs
respectively) b. IMA 90% & 75%
 The most important predictor adversely predicting long-term prognosis
is LV dysfunction

REFERENCES:
 Doc De Asis ppt and audio recording
 Swartz principle edition 11th edition
 Google Photos

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