Alfa Ferry FRCS Cardiac Surgeon OPERATIVE MANAGEMENT IN CORONARY ARTERY DISEASE

Alfa Ferry FRCS Cardiac Surgeon OPERATIVE MANAGEMENT IN CORONARY ARTERY DISEASE

Management in CHD Medical (medikamentosa) Intervensi 1. Percutaneous ( PTCA & stenting ) 2. Surgical ( CABG, CABG & mitral valve procedure, CABG & LV aneurysm resection, etc )

CABG Penanganansecarapembedahanuntukpenyak itjantungkoroner. Padaprinsipnyamemberikanalirandarah dg jaluralternatifuntukmensupplyototjantungdi manasebelumnyapembuluhdarah yang mensupply area tersebuttersumbat (occlusion) ataumenyempit (stenosis).

Surgical Intervension Coronary artery bypass surgery ( CABG ) Aim : restore blood flow to the coronary vessels hence improve coronary circulation and treat ischaemic myocardium.

CABG CABG merupakansalahsatualternatifpenangananpe nyakitjantungkoroner. CABG bukanmerupakanjalanterakhirapabilacara lain gagal. Dalambeberapajenispenyakitjantungkoroner CABG merupakan first choice karenahasilakhir yang lebihbaikdibandingkanpemasanganstent.

Jenisjenispenyakitjantungkoronerdimana CABG lebihbaikdaristenting: Left Main Artery disease Diabetic with triple vessel disease. Chronic total occlusion daripembuluhdarahkoroner. Failed PTCA

CABG CABG is like 2 operation : Median Sternotomy CABG

CABG 1.Median Sternotomy Operasipembukaantulang dada (median sternotomy) Menakutkantetapirisikokematian : 0% 2.Operasi bypass koroner (CABG) Mempunyairesoikokematian 1% padapenderitadenganfungsijantung yang masihbaik. ( resikokematianstent 0.5% )

Perbandingan CABG danstenting CABG PTCA (stenting) resiko 1% 0.5% Mortalitas(kematian) 2% 2% Stroke 10% 2% Perdarahan 2% 0.5% Infeksi 1% 1% GagalGinjal*

Preoperative assessment Establish diagnosis ( done by cardiologist ) History of angina or angina equivalent Is it unstable or stable angina? ECG, Treadmill, Echo results Coronary Angiography is the gold standard on assessing coronary flow and degree of stenosis. MSCT

Preoperative preparation Antiplatelet should be stopped at least 5-7 days before operation if possile to reduce risk of bleeding. Dental clearance need to be sought if time allowed to reduce risk of infection. Blood and blood product are crossmatched and prepared.

CABG On Pump Off Pump On Pump Beating heart Minimally Invasive CABG ( MIDCAB ) Robotic CABG Hybrid

Conduits / Grafts in CABG Grafts used can be Internal Mammary artery ( IMA ), Saphenous vein, Radial artery, gartroepiploic artery. LIMA to LAD grafts has been established to have prolonged survival in CAD patients. ( 95 % LIMA to LAD anastomosis is still patent in 15 years, paper by cleveland clinic groups )

On Pump CABG CABG traditionally done on pump. Pump = Cardiopulmonary bypass machine = Heart Lung machine. The Pump is used to replace function of the heart to pump blood to the whole body at the time of CABG. The heart is stopped from beating by means of infusing cardioplegia solution to the coronary artery.

Off Pump CABG CABG is done without the use of the Pump. The heart is continously beating normally during the procedure. Anastomosis of grafts were done with help of a stabilizer ( octopus system ) to stabilize the target vessel for grafting. Heart is not stopped at all.

Off Pump Beating heart Combination Off and On Pump. CABG is done with circulation supported by CPB/Pump, but heart is left beating and anastomosis is done with help of stabilizer just like off pump. Useful in certain cases.

Minimally Invasive CABG CABG done via small incision Lateral anterior thoracotomy Ministernotomy Subxyphoid approach Usually done for single LIMA to LAD graft anastomosis. Done Off-Pump.

Robotic CABG CABG done via small holes in the chest to put robotic arm inside pericardial cavity. On Pump technique, heart is stopped. Only done in small percentage of CABG

Hybrid CABG CABG is done at the same time as PTCA/Stenting, or shortly thereafter in the same operating theatre. Hybrid operating theatre Selected cases

Posoperative management ICU Ventilator management Close monitoring Interpretasi profil hemodynamic When to extubate/ weaning ventilator Rehabilitation Moving to the wards Discharge.

ICU, close monitoring, ventilator management. All patients will be transferred to ICU after a CABG operation Almost all will require temporary artificial ventilation and sedation with or without muscle relaxant All will have continous invasive monitoring such as arterial line, Central venous pressure line, Pulmonary artery line by which of swanganz catheter.

When to wean from ventilator/ extubate Criteria for weaning: Stable Haemodynamic on low inotropic support Able to breath on their own Awake/ conscious

Rehabilitation Started from preop with assessment of breathing capability, briefing on post op sequence Include breathing exercise, passive and active limb exercise Encourage early ambulation, usually 2 days post op

Discharge Hospital discharge usually at day 6 to day 8 postop Need to be able to walk on their own Relatively pain free except when coughing Follow up 1 week post op.

Summary CABG merupakansalahsatualternatifdaripenangananp enyakitjantungkoroner. CABG merupakanprosedur yang amandilakukandenganresikokematian/mortalita s yang hampirsamadengan PTCA/Stenting. Padajenisjenispenyakitjantungkoronerseperti Left Main disease, Diabetic dg 3 vessel disease, CABG mempunyai long term prognosis lebihbaik.