OPCABG for Full Myocardial Revascularisation How we do it

Transcription

1 OPCABG for Full Myocardial Revascularisation How we do it 28 th SHA Conferance Dr.Farouk Oueida Head of Cardiac Surgery Dept. SBCC-Dammam KSA

2 The Less Invasive CABG Full Revascularisation Full Sternotomy Minimyse the CPB Adverse Effects (Minibypass) Avoid the CPB Adverse Effects (OPCAB) Endoscopic Vein Harvesting

3 Colessov 1964 OPCABG 37% world wide

4 Studies All patients Better outcome Lower Morbidity ComparableGraft Patency? Health Care Cost

5 J Thorac Cardiovasc Surg. Author manuscript; available in PMC 2010 March 11. J Thorac Cardiovasc Surg February; Effects of on- and off-pump coronary artery surgery on graft patency, survival, and health-related quality of life: Long-term follow-up of 2 randomized controlled trials Gianni D. Angelini, MCh, MD, FRCS, FETCS,a Lucy Culliford, BSc, MSc, PhD,a David K. Smith, BSc, MRCP,a Mark C. K. Hamilton, MRCP, FRCR,b Gavin J. Murphy, BSc, ChB, MD, FRCS(CTh),a Raimondo Ascione, MD, MCh, FRCS, FETCS,a Andreas Baumbach, MD, FRCP, FESC,b and Barnaby C. Reeves, BA, MSc, DPhila a Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, United Kingdom Methods: Participants in 2 randomized trials comparing off-pump coronary artery bypass and coronary artery bypass grafting with cardiopulmonary bypass were followed up for 6 to 8 years after surgical intervention to assess graft patency, major adverse cardiac-related events, and health-related quality of life. Patency was assessed by using multidetector computed tomographic coronary angiographic analysis Major adverse cardiac-related events and health-related quality of life were obtained from questionnaires given to participants and family practitioners. Results: Patency was studied in 199 and health-related quality of life was studied in 299 of 349 survivors. There was no evidence of attrition bias. The likelihood of graft occlusion was no different between off-pump coronary artery bypass (10.6%) and coronary artery bypass grafting with cardiopulmonary bypass (11.0%) groups (odds ratio, 1.00; 95% confidence interval, ; P>.99). Conclusions: Long-term Graft Patency and health outcomes with off-pump coronary artery bypass are similar to those with coronary artery bypass grafting with cardiopulmonary bypass when both operations are performed by experienced surgeons

6 Cross-Clamp Cardioplegia CPB Adverse No Conversion No Surgeon Stress No Cross-Clamp No Cardioplegia No CPB Adverse Risk of Conversion Surgeon stress Adverse

7 Adverse Effects of CPB Cause Effect Hemodilution Neutrophil activation, decrease in surfactant Platelet destruction by CPB platelet aggregation Destruction by cardiopulmonary bypass Embolus formation, bypass >2 hours Cannulation, bubble oxygenator Cannulation of femoral artery Release of catecholamines (epinephrine, norepinephrine) due to hypothermia Release of tumor necrosis Diuresis Hypothermia Glucagon release Systemic heparinization Leukocyte release Leukocyte release, microemboli activation, vasopressin release, hypothermia Fluid retention, interstitial fluid accumulati Pulmonary dysfunction Thrombocytopenia Hemoglobinemia Stroke, neurological dysfunction Air emboli Aortic dissection Hypertension Hypotension, tachycardia Hypokalemia Myocardial depression Hyperglycemia bleeding Capillary leakage Organ failure Renin- angiotensin Oliguria

8 Recently, there have been attempts to decrease these adverse effects (inflammatory reaction) caused by the use of CPB by developing better, more effective systems

9 Resting Heart or Mini By-Pass

10 Benefits of Resting 1- Closed System (no blood activation). 2- No Cardiotomy Suction. 3- Low Prime Circuit (reduce hemodilution). 4- Venous Air Removal Device (VARD)

11 New Studies should be done to find the real position of Resting Heart Technique

12 My personal opinion: Resting Heart should be located very close to the OPCAB

13 SBCC Experience First OPCABG SBCC 25/07/2003 OPCABG Today 3000 Resting Heart 350

14 How we do it?

15 Our Technique

16 Atrial Pacing

17 Mid CAB For single graft to LAD Not for multi vessel disease

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19 The Less Invasive CABG Full Revascularisation Full Sternotomy Minimyse the CPB Adverse Effects (Minibypass) Avoid the CPB Adverse Effects (OPCAB) Endoscopic Vein Harvesting

20 Introduction - BITA less than 10% of CABG have multiple arterial grafts. Increase the trend of total arterial revascularization. In 10 yrs : 95% LITA / LAD patent 50% SV occlusion / stenosis 20% SV early occlusion in 1 year Tatoulis, Ann Cardiothorac Surg, 2013;2(4):

21 BITA 2 ITAs better than 1 at 10 yrs Survival is superior - 90% Fewer recurrent cardiac event Rate of reoperation - 50% Long term patency Lytle et al, Circulation, 2001 Taggart et al, Euro Heart Journal, 2010 Pevni et al, Ann Thorac Surg, 2016

22 SBCC Experience CABG with ITAs 325 SITA ± SV (49.8%) 328 BITA ± SV (50.2%)

23 SBCC BITA 80% 70% 60% 50% 40% SITA BITA 30% 20% 10% 0%

24 BITA Configurations in SBCC 1- (LL/RL) LITA-LAD with In situ RITA to Left Coronary Tree 2- (RL/LL) RITA-LAD with In situ LITA to Left Coronary Tree 3- (Y-graft) LITA-LAD with Free RITA based on LITA 4- (LL/RR) LITA-LAD with In situ RITA to Right Coronary Tree

25 Our Technique

26 OPCAB Ygraft

27 Pre Op Angio Bilateral Mammary

28 LIMA to LAD

29 RIMA to RCA

30 Improve Mammary lenghth

31 Improve RIMA lenghth

32 Improve RIMA lenghth

33 Resting Heart

34 RIMA to LAD (post op angio)

35 RIMA to Diag( post op Angio)

36 RIMA to OM (post op angio)

37 Y Graft (post op angio)

38 LAD Endartrectomy

39 Resting Heart for Impaired LV Function 32 cases of resting heart for severely impaired left ventricle

40 Table (1): Preoperative demographic and laboratory results.

41 Table (2): Operative data of the patients. CABG: Coronary arteries bypass grafting CPB: Cardio-pulmonary bypass. Min: minute.

42 Table (3): Clinical outcome and Postoperative laboratory results. SD: standard deviation; ICU: intensive care Unit; FFP: fresh frozen Plasma; PRBCS: packed red blood cells.

43 My personal opinion: Resting Heart should be located very close to the OPCAB

44 Leg Wound The main patient Complain

45 Endoscopic Vein Harvesting

46 Vasoview System

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48 EVH Flow Sheet

49 EVH INDICATOR FROM 16/3/2013 TO 6/2/2014 %6 %15 %79 EVH EVH + Open Open

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52 EVH 1

53 EVH 2

54 EVH 3

55 Never compromise Myocardial Full Revascularization for Esthetics. The main patient complain post CABG is from the leg wound. Mid-CAB only for LIMA to LAD+ More BITA for better long term The real Minimal invasive CABG? 1 - Minimize or avoid the Adverse effects of CPB by Resting Heart or OPCAB. 2 - Avoid the complications of the Conventional Saphenous Vein Harvesting By EVH Technique

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