Knowledge sharing slideshows to increase general awareness about common medical procedures and good health guidelines Crea...
Coronary Artery Bypass Graft
<ul><li>Prior to 1930’s, heart surgery seen as impossible, with high morbidity and mortality </li></ul><ul><ul><li>“ Surge...
<ul><li>Chronic angina </li></ul><ul><li>Unstable angina </li></ul><ul><li>Acute myocardial infarction </li></ul><ul><li>A...
<ul><li>Most common arteries bypassed: </li></ul><ul><ul><li>Right coronary artery </li></ul></ul><ul><ul><li>Left anterio...
<ul><li>Saphenous vein used for bypassing right coronary artery and circumflex coronary artery </li></ul><ul><li>Internal ...
<ul><li>Conduit removed </li></ul><ul><li>Median sternotomy </li></ul><ul><ul><li>Sternum divided using electric saw </li>...
<ul><li>Bypass of arteries: </li></ul><ul><ul><li>Incision in target artery: </li></ul></ul><ul><ul><li>Anastamosis of gra...
<ul><li>Positive: </li></ul><ul><ul><li>Relief of angina in 90% of patients </li></ul></ul><ul><ul><li>80% angina free aft...
<ul><li>Minimally invasive surgery does not use CPB </li></ul><ul><li>Smaller incision </li></ul><ul><li>Emerging as a rep...
<ul><li>Additionally, MIDCAB: </li></ul><ul><ul><li>Reduced need for blood transfusions, if any </li></ul></ul><ul><ul><li...
Small incisions for video-assisted LIMA harvest Thoracotomy incision (~10 cm) RG Cohen, et al;  Minimally Invasive Cardiac...
<ul><li>Small portion of front of 4 th  rib removed </li></ul><ul><li>LIMA clipped and dissected  </li></ul><ul><li>MIDCAB...
<ul><li>LAD exposed </li></ul><ul><li>Anastamosis preformed with assistance of mechanical stabilizer </li></ul>RG Cohen, e...
<ul><li>MIDCAB in-hospital and 1 year results (n=174) </li></ul><ul><ul><li>This study conducted at Washington Hospital Ce...
<ul><li>New instruments must be developed </li></ul><ul><li>Requires highly skilled surgeon and learning curve for surgeon...
<ul><li>Uses CPB </li></ul><ul><li>Balloon catheter system for aortic occlusion and cardioplegic arrest </li></ul><ul><li>...
<ul><li>LIMA harvested using specialized retractor </li></ul><ul><li>Aorta drawn into operating field </li></ul>RG Cohen, ...
<ul><li>Aorta clamped, anastamosis performed </li></ul>RG Cohen, et al;  Minimally Invasive Cardiac Surgery Port-Access CABG
<ul><li>Benefits: </li></ul><ul><ul><li>Bloodless field </li></ul></ul><ul><ul><li>Heart arrested </li></ul></ul><ul><ul><...
<ul><li>Arterial Revascularization Therapy Study (ARTS) 2001 </li></ul><ul><ul><li>Percentage requiring second revasculari...
<ul><li>Stent or Surgery Study (SOS) 2001 </li></ul><ul><ul><li>Death rate for CABG in this study unusually low </li></ul>...
<ul><li>ERACI II (2001): </li></ul><ul><ul><li>Percutaneous Transluminal Coronary Revascularization (PTCR) compared to CAB...
<ul><li>CABG results in a lower restenosis rate as compared with stenting </li></ul><ul><ul><li>Drug-eluting stents will n...
<ul><li>Currently, stenting is recommended over surgery for one-vessel disease </li></ul><ul><ul><li>In the future, drug-e...
<ul><li>References: </li></ul><ul><ul><li>Cohen, Robbin G, et al.  Minimally Invasive Cardiac Surgery .  St. Louis: Qualit...
Upcoming SlideShare
Loading in …5
×

Coronary Artery Bypass Graft (CABG) - Desun Hospital Health Insight

10,073 views
9,589 views

Published on

Desun Hospital Health Insights : An introduction to Coronary Artery Bypass Graft (CABG) for treatment of cardiac problems

Published in: Health & Medicine
0 Comments
19 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
10,073
On SlideShare
0
From Embeds
0
Number of Embeds
19
Actions
Shares
0
Downloads
627
Comments
0
Likes
19
Embeds 0
No embeds

No notes for slide
  • Cover Page
  • Go over history, summarize slide, don’t read
  • Indications for surgery
  • Coronary Artery Bypass Graft (CABG) - Desun Hospital Health Insight

    1. 1. Knowledge sharing slideshows to increase general awareness about common medical procedures and good health guidelines Created and Distributed by All Rights Reserved Coronary Artery Bypass Graft (CABG) Public Awareness Program
    2. 2. Coronary Artery Bypass Graft
    3. 3. <ul><li>Prior to 1930’s, heart surgery seen as impossible, with high morbidity and mortality </li></ul><ul><ul><li>“ Surgery of the heart has probably reached the limits set by nature to all surgery”   </li></ul></ul><ul><ul><li> – Stephen Paget, 1896, Surgery of the Chest </li></ul></ul><ul><li>1937: Dr. John Gibbon designs heart-lung machine, which enables cardiopulmonary bypass (CPB) </li></ul><ul><li>1955: Vineburg and Buller implant internal mammary artery into myocardium to treat cardiac ischemia and angina </li></ul><ul><li>1958: Longmire, Cannon and Kattus at UCLA perform first open coronary artery endarterectomy without CPB </li></ul><ul><li>During 1960’s and 1970’s, CPB and cardioplegic arrest are adopted, allowing Coronary Artery Bypass Graft (CABG) to emerge as a viable surgical treatment </li></ul>RG Cohen, et al; Minimally Invasive Cardiac Surgery History of Heart Surgery
    4. 4. <ul><li>Chronic angina </li></ul><ul><li>Unstable angina </li></ul><ul><li>Acute myocardial infarction </li></ul><ul><li>Acute failure of percutaneous transluminal coronary angioplasty (PTCA) </li></ul><ul><li>Severe coronary artery disease </li></ul>BJ Harlan, et al; Manual of Cardiac Surgery Indications for Surgery
    5. 5. <ul><li>Most common arteries bypassed: </li></ul><ul><ul><li>Right coronary artery </li></ul></ul><ul><ul><li>Left anterior descending coronary artery </li></ul></ul><ul><ul><li>Circumflex coronary artery </li></ul></ul>Adapted from BJ Harlan, et al; Manual of Cardiac Surgery Conventional CABG
    6. 6. <ul><li>Saphenous vein used for bypassing right coronary artery and circumflex coronary artery </li></ul><ul><li>Internal mammary artery (IMA) used for bypassing left anterior descending coronary artery </li></ul><ul><ul><li>Patency rate over 90% after 10 years </li></ul></ul><ul><li>If more veins are needed, alternative sites such as upper extremity veins can be used </li></ul><ul><ul><li>Patency rate as low as 47% after 4.6 years </li></ul></ul>BJ Harlan, et al; Manual of Cardiac Surgery Conduits Used for Bypass
    7. 7. <ul><li>Conduit removed </li></ul><ul><li>Median sternotomy </li></ul><ul><ul><li>Sternum divided using electric saw </li></ul></ul><ul><li>Cold potassium cardioplegia </li></ul><ul><li>Cardiopulmonary bypass </li></ul><ul><ul><li>Cannulation of: </li></ul></ul><ul><ul><ul><li>Ascending aorta </li></ul></ul></ul><ul><ul><ul><li>Femoral artery </li></ul></ul></ul><ul><ul><ul><li>Right atrium </li></ul></ul></ul><ul><ul><li>Heparin administered to minimize clotting </li></ul></ul>GP Gravlee, et al; Cardiopulmonary Bypass: Principles and Practice Conventional CABG Procedure
    8. 8. <ul><li>Bypass of arteries: </li></ul><ul><ul><li>Incision in target artery: </li></ul></ul><ul><ul><li>Anastamosis of graft with artery: </li></ul></ul>BJ Harlan, et al; Manual of Cardiac Surgery Conventional CABG Procedure
    9. 9. <ul><li>Positive: </li></ul><ul><ul><li>Relief of angina in 90% of patients </li></ul></ul><ul><ul><li>80% angina free after 5 years </li></ul></ul><ul><ul><li>Survival about 95% after 1 year </li></ul></ul><ul><ul><li>Low chance of restenosis </li></ul></ul><ul><li>Negative: </li></ul><ul><ul><li>2-3 days in ICU, 7-10 day total hospital stay </li></ul></ul><ul><ul><li>3-6 month full recovery time </li></ul></ul><ul><ul><li>5-10% have post-op complications </li></ul></ul><ul><ul><li>Long time on CPB </li></ul></ul><ul><ul><ul><li>Depression of the patient's immune system </li></ul></ul></ul><ul><ul><ul><li>Postoperative bleeding from inactivation of the blood clotting system </li></ul></ul></ul><ul><ul><ul><li>Hypotension </li></ul></ul></ul>BJ Harlan, et al; Manual of Cardiac Surgery, WebMD.com, American College of Cardiology Foundation Conventional CABG
    10. 10. <ul><li>Minimally invasive surgery does not use CPB </li></ul><ul><li>Smaller incision </li></ul><ul><li>Emerging as a replacement for conventional CABG </li></ul><ul><li>Starting in 1990’s, MIDCAB has gained popularity </li></ul><ul><li>Usually conducted for LIMA to LDA grafts </li></ul>RG Cohen, et al; Minimally Invasive Cardiac Surgery Minimally Invasive Direct CABG
    11. 11. <ul><li>Additionally, MIDCAB: </li></ul><ul><ul><li>Reduced need for blood transfusions, if any </li></ul></ul><ul><ul><li>Less time under anesthesia: patients are moved out of intensive care more quickly </li></ul></ul><ul><ul><li>Less pain and discomfort </li></ul></ul><ul><ul><li>Up to 40% savings over conventional CABG (under $20,000 compared to over $30,000) </li></ul></ul>TA Salerno, et al. Beating Heart Coronary Artery Surgery Advantages of MIDCAB Over CABG MIDCAB CABG Full sternotomy No Yes CPB No Yes Operating time 2-3 hrs 3-6 hrs Recovery time 1-2 weeks 3-6 months Effectiveness 90% 90% Incision length 10 cm 30 cm
    12. 12. Small incisions for video-assisted LIMA harvest Thoracotomy incision (~10 cm) RG Cohen, et al; Minimally Invasive Cardiac Surgery MIDCAB Procedure
    13. 13. <ul><li>Small portion of front of 4 th rib removed </li></ul><ul><li>LIMA clipped and dissected </li></ul><ul><li>MIDCAB retractor and </li></ul><ul><li>LIMA stabilizer </li></ul><ul><li>facilitates grafting </li></ul>RG Cohen, et al; Minimally Invasive Cardiac Surgery MIDCAB Procedure
    14. 14. <ul><li>LAD exposed </li></ul><ul><li>Anastamosis preformed with assistance of mechanical stabilizer </li></ul>RG Cohen, et al; Minimally Invasive Cardiac Surgery Completed graft MIDCAB Procedure
    15. 15. <ul><li>MIDCAB in-hospital and 1 year results (n=174) </li></ul><ul><ul><li>This study conducted at Washington Hospital Center by a single surgical team </li></ul></ul><ul><li>Clinical results improved with each operation performed </li></ul>Clinical Results Using MIDCAB Mehran R, et al; Circulation In-hospital MACE 1% Procedure time 132±20 minutes Time to extubation 6±3 hours Hospital stay 2.1±1.9 days Mortality (one year) 1% MACE (one year) 6%
    16. 16. <ul><li>New instruments must be developed </li></ul><ul><li>Requires highly skilled surgeon and learning curve for surgeons limits number performed </li></ul><ul><ul><li>Small incision </li></ul></ul><ul><ul><li>Beating heart </li></ul></ul><ul><ul><li>Blood in field </li></ul></ul><ul><li>Can only be used with patients having blockages in one or two coronary arteries on the front of the heart </li></ul><ul><ul><li>Attempts at operating on other arteries have been moderately successful, but requires even greater skill and practice </li></ul></ul>RG Cohen, et al; Minimally Invasive Cardiac Surgery Drawbacks of MIDCAB
    17. 17. <ul><li>Uses CPB </li></ul><ul><li>Balloon catheter system for aortic occlusion and cardioplegic arrest </li></ul><ul><li>5-8 cm left anterior thoracotomy incision </li></ul><ul><ul><li>No sternotomy!!! </li></ul></ul>RG Cohen, et al; Minimally Invasive Cardiac Surgery Port-Access CABG
    18. 18. <ul><li>LIMA harvested using specialized retractor </li></ul><ul><li>Aorta drawn into operating field </li></ul>RG Cohen, et al; Minimally Invasive Cardiac Surgery Port-Access CABG
    19. 19. <ul><li>Aorta clamped, anastamosis performed </li></ul>RG Cohen, et al; Minimally Invasive Cardiac Surgery Port-Access CABG
    20. 20. <ul><li>Benefits: </li></ul><ul><ul><li>Bloodless field </li></ul></ul><ul><ul><li>Heart arrested </li></ul></ul><ul><ul><ul><li>allows more accurate anastomoses than MIDCAB </li></ul></ul></ul><ul><ul><li>Smaller incision than CABG </li></ul></ul><ul><ul><li>No sternotomy </li></ul></ul><ul><li>Drawbacks </li></ul><ul><ul><li>Uses CPB </li></ul></ul><ul><ul><li>Technically very difficult </li></ul></ul>RG Cohen, et al; Minimally Invasive Cardiac Surgery Port-Access CABG
    21. 21. <ul><li>Arterial Revascularization Therapy Study (ARTS) 2001 </li></ul><ul><ul><li>Percentage requiring second revascularization: </li></ul></ul><ul><ul><ul><li>16.8% in stenting group </li></ul></ul></ul><ul><ul><ul><li>3.5% in CABG group </li></ul></ul></ul><ul><ul><li>Event-free survival at one year: </li></ul></ul><ul><ul><ul><li>73.8% of stent group </li></ul></ul></ul><ul><ul><ul><li>87.8% of CABG </li></ul></ul></ul><ul><ul><li>Costs for the initial procedure $4,212 less for stenting </li></ul></ul><ul><ul><li>Difference reduced during follow-up because of the increased need for repeated revascularization </li></ul></ul><ul><ul><ul><li>After one year, the net difference in favor of stenting was $2,973 per patient. </li></ul></ul></ul>New England Journal of Medicine Stent or Surgery?
    22. 22. <ul><li>Stent or Surgery Study (SOS) 2001 </li></ul><ul><ul><li>Death rate for CABG in this study unusually low </li></ul></ul>The Lancet, Journal of the American College of Cardiology Stent or Surgery? PCI and Stenting n=480 CABG n=487 Mortality at 1 year 2.5% 0.8% Need for additional PCI 13% 4.8% Need for additional CABG 9% 1% Overall adverse effects 22.1% 12.2%
    23. 23. <ul><li>ERACI II (2001): </li></ul><ul><ul><li>Percutaneous Transluminal Coronary Revascularization (PTCR) compared to CABG </li></ul></ul>Journal of the American College of Cardiology Stent or Surgery? Costs Medical Status After 1 Year In patients with 3-vessel disease All Patients Enrolled PTCR n=225 CABG n=225 MACE 30 days 3.6% 12.3% Death 30 days 0.9% 5.7% Survival 1 year 96.9% 92.5% Freedom for MI 97.7% 93.4% Need for revascularization 16.8% 4.8%
    24. 24. <ul><li>CABG results in a lower restenosis rate as compared with stenting </li></ul><ul><ul><li>Drug-eluting stents will narrow this difference </li></ul></ul><ul><li>Due to repeat treatment, costs for stents and surgery are approximately equal after 2 years </li></ul><ul><li>Minimally invasive surgeries (MIDCAB and port-access) will result in fewer complications from surgery and a shorter hospital stay </li></ul><ul><ul><li>This leads to lower costs for surgery, essentially removing the cost advantage of stenting </li></ul></ul><ul><li>Diabetics have a substantially better response to CABG than to angioplasty and stenting </li></ul>Current Controlled Trials in Cardiovascular Medicine Summary: Stent or Surgery?
    25. 25. <ul><li>Currently, stenting is recommended over surgery for one-vessel disease </li></ul><ul><ul><li>In the future, drug-eluting stents will probably be used </li></ul></ul><ul><ul><li>Minimally invasive surgeries could be used in place of stents in diabetic, and other high-risk patients </li></ul></ul><ul><li>For more than one-vessel disease, surgery is substantially better at preventing restenosis and so will likely continue to be used in the future </li></ul><ul><ul><li>Minimally invasive surgeries will expand and replace most conventional CABG procedures </li></ul></ul>In The Future...
    26. 26. <ul><li>References: </li></ul><ul><ul><li>Cohen, Robbin G, et al. Minimally Invasive Cardiac Surgery . St. Louis: Quality Medical Publishing, Inc, 1999. </li></ul></ul><ul><ul><li>Gravlee, Glenn P, at al. Cardiopulmonary Bypass: Principles and Practice . Philadelphia: Lippincott Williams & Wilkins, 2000. </li></ul></ul><ul><ul><li>Holmes Jr, David R. “Debate: PCI vs CABG: a moving target, but we are gaining,” Current Controlled Trials in Cardiovascular Medicine . December 2001 Vol 2 No 6. </li></ul></ul><ul><ul><li>Harlan, Bradley J, et al. Manual of Cardiac Surgery . New York: Springer-Verlag, 1995. </li></ul></ul><ul><ul><li>Mehran, R, et al. “One-Year Clinical Outcome After Minimally Invasive Direct Coronary Artery Bypass,” Circulation . December 2000 Vol 102 Issue 23 Pages 2799-2802 </li></ul></ul><ul><ul><li>Salerno, Thomas A, at al. Beating Heart Coronary Artery Surgery . Armonk: Futura Publishing Company, Inc, 2001. </li></ul></ul><ul><ul><li>Serruys, Patrick W, et al. “Comparison of coronary-artery bypass surgery and stenting for the treatment of multivessel disease,” New England Journal of Medicine . April 12, 2001 Vol 344 No 15. </li></ul></ul><ul><ul><li>Stables, RH, et al. “Coronary artery bypass surgery versus percutaneous coronary intervention with stent implantation in patients with multivessel coronary artery disease (the Stent or Surgery trial): a randomised controlled trial,” The Lancet . September 28, 2002 Vol 360 Issue 9338 Pages 965-970. </li></ul></ul><ul><ul><li>American College of Cardiology </li></ul></ul><ul><ul><li>Medscape.com </li></ul></ul><ul><ul><li>TCTMD.com </li></ul></ul><ul><ul><li>WebMD.com </li></ul></ul>Questions???

    ×