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Surgery for IHD. pathophysiology. results from progressive blockage of the coronary arteries by atherothrombotic disease . Progressive compromise in luminal diameter producing supply/demand imbalance usually produces a pattern of chronic stable angina. - PowerPoint PPT Presentation
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Surgery for IHD
results from progressive blockage of the coronary arteries by atherothrombotic disease.
Progressive compromise in luminal diameter producing supply/demand imbalance usually produces a pattern of chronic stable angina.
Plaque rupture with superimposed thrombosis is responsible for most acute coronary syndromes
(ACS), which include classic “unstable angina”, non-ST-elevation myocardial infarctions(NSTEMI), and ST-elevation infarctions (STEMI).
pathophysiology
Clinical Blood tests ECG Treadmill Echo CT angio Coronary angio
DX
1. Medical Aspirin,B-blockers,nitrates,CCB if BB
contraindicated Statins for plaque stabilization ACE inhibitors Clopidogrel ?
MX
PCI (90 minute door to balloon) Thrombolytic (alternative) TIME IS MYOCARDIUM Studies(6 hr )
STEMI
Aspirin,heparin Clopidogrel(30 days post CABG outcome
better) (ACC/AHA prohibition befor 2007 if surgery
is an option) Prasugrel shoud be stopped for 7 days
preop.
ACS
IfContinuing ischemiaRest painHD unstabilityHFElivated troponinRest ECG changes
platelet glycoprotein IIb/IIIainhibitors, such as tirofiban or eptifibatide
PCI BMS vs DES
Interventional
Studies have shown that surgery is very effective in relieving angina, in many cases is able to delay infarction, and in most cases can improve survival compared with continued medical management or PCI
Surgery
Class III or IV angina Ischaemic pul.edema Failed PCI Patient undergoing major vascular surgery
Clinical scenarios
Lt main > 50% 3VD EF<50 3VD EF>50 if significant inducible
myocardial ischemia by stress test Lesions not amenable to PCI
Anatomic indications
These patients should undergo CABG if have >50% stenosis in branch coronary arts.
Pt undergoing valve surgery Complications of MI Coronary art. Anomalies with risk of sudden
death
Other conditions
Venous conduit Arterial conduit Which is superior?
Choice of conduits
Traditional CABG OPCAB MIDCAB TECAB Robotic Laser trans myocardial revascularization
Surgical procedure
BB Aspirin Statins ACE inhibitors
Post op.cosiderations
Septal wall rupture Free wall rupture Ischaemic MR LV aneurysm
complications