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Surgical Treatment of Ischaemic Heart Disease Division of Cardiothoracic Surgery UWI Mona Coronary Arterial Disease Atherosclerosis in native coronary vessels (multifactorial) Blocks develop Partial blocks prone to platelet clots Large plaques prone to fracture clots form Myocardial Infarction(MI) Angina: Chest Pain due to inadequate Blood Flow Ischaemia angina may be reversible Unlike MI, Some form of intervention may alleviate symptoms (open or less-invasive surgery; angioplasty +/- stenting) Coronary Bypass: Bypasses the Block How is the occlusion bypassed? 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 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 The Cardiopulmonary Bypass Machine The CPB Circuitry The Appearance of the Heart on Opening the Sternum Anastomosing the Internal Mammary Artery to the Left Anterior Descending Coronary Artery The Completed LIMA-LAD Anastomosis Saphenous Vein(green arrow) being anastomosed to Coronary Artery(red arrow) Completed SV-Coronary Anastomosis CABG can be done on a BEATING HEART: What are the results? 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 For multivessel disease, surgery still superior to angioplasty/stenting A Late Complication Patent LIMA Graft with distally blocked native coronary artery 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 Very good short-term (< 5 yrs) results, but poor longer term results when compared to traditional surgical therapy Pre- and Post- Angioplasty Stent is left inside coronary artery and holds lumen open Conclusions CABG is one of the most successful operations ever devised Hundreds of thousands of procedures worldwide yearly Surgery has best long-term results, although angioplasty techniques are improving longterm outlooks All of these interventions are PALLIATIVE THERAPIES, ie. The underlying disease may continue to cause problems post-op