EHR519 Week 6: Revascularization Part 1 PDF

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Warning This material has been produced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the copyright act (Act). The material in this communication may by subject to copyright under the act. Any further reproduction or communication of this material by you may be the subject of copyright protection under this act. Do not remove this notice EHR519 Week 6 Pathophysiology, medications, considerations and contraindications for: Revascularisation & Chronic Heart Failure 2 Learning Outcomes be able to explain the pathophysiology of coronary artery disease; be able to explain common revascularisation procedures used to restore blood flow to the myocardium; be able to explain the pathophysiology of chronic heart failure be able to outline the risk factors, complications and co-morbidities that must be accounted for when applying exercise interventions to individuals with heart failure; be able to explain the diagnostic techniques and treatment procedures used in the treatment of chronic heart failure; 3  Revascularisation 4  Revascularisation Refers to a surgical procedure to provide new or additional blood supply to a body part or organ Including (but not limited to) heart, lungs, kidney, liver, muscles Diagnostic testing includes MRI, CT scan or X-ray fluoroscopy Identify the need for revascularisation or guide procedure Procedures include Percutaneous transluminal coronary angioplasty (PTCA), OR Percutaneous coronary intervention (PCI), with or without stenting Coronary artery bypass surgery (CABS) 5  Australian statistics (AIHW) Coronary angiography Provides medical professionals with the information to decide on treatment options 146,000 coronary angiography procedures 2020–21: 67% men 33% women – Increased from 2000-2001 by 14% in men and 12% in women Percutaneous coronary interventions Coronary angioplasty – catheter inserted with a small balloon, inflated to clear the blockage Stenting is similar, but a stent (an expandable mesh tube) inserted into the affected coronary arteries 48,000 PCIs performed 2020-21. 75% men and 25% women – Increased from 2000-2001 by 37% in men and 26% in women Coronary artery bypass grafting Attaching a harvested vessels on the outside of the heart to bypass a blocked artery 12,700 CABG procedures performed 2020–21: 83% men 17% women – DECREASED from 2000-2001 by 51% in men and 67% in women 6  Pathophysiology Coronary artery disease Build up of macrophages, platelets, calcium, fibrous connection tissue and lipids in the coronary arteries Leads to an obstruction of blood flow Mindful that ECG changes (even during a GXT) may be not present until a coronary artery has a 75% stenosis, lesions that compromise 50% or more of the lumen can be clinically significant. Lesion location, stability of plaque, symptoms, prognosis and quality of life may influence decisions associated with revascularisation procedures. 7 Tuttolomondo, A., Di Raimondo, D., Pecoraro, R., Arnao, V., Pinto, A., & Licata, G. (2012). Atherosclerosis as an inflammatory disease. Current pharmaceutical design, 18(28), 4266-4288.  Coronary intervention Coronary angioplasty and PTCA are minimally invasive procedures Involves opening in the blocked vessel via Returning blood flow to the myocardium Patients present with exertional chest pain or dyspnoea Acute myocardial infarction (MI) Plaque rupture + platelet aggregation Acute thrombus formation (sudden occlusion) Acute chest heaviness, diaphoresis, and nausea Urgent PTCA required to limit the myocardial damage 12  Percutaneous Transluminal Coronary Angioplasty (PTCA) or Percutaneous Coronary Intervention (PCI) Coronary angioplasty is less invasive that CABG Involves opening in the blocked vessel via Balloon dilation (often with stent replacement) Rotational atherectomy (rotational device to remove plaque) Directional atherectomy and laser (large lesions) Lower risk than CABG however, complications include Rebound vasoconstriction Chronic restenosis Embolism MI Arrhythmias Dissection of a coronary artery 13  Stent Stents are used to reduce the risk of an acute closure during a PTCA and restenosis Guide wire and sheath inserted through femoral artery to aorta Replaced by diagnostic catheter, drugs can be administered, images taken If PTCA required, catheter replaced by guide wire and balloon Stainless steel mesh tube which passes over the lesion and then expanded. Catheter is removed and stent remains in the vessel permanently, covered by the endothelium in time Fast recovery (day-surgery in some cases) 14  Coronary Artery Bypass Surgery Revascularisation of a venous graft from the arm or leg or arterial graft (mammary) to provide blood flow to the myocardium beyond the site of occlusion or nearly occluded area. CABG isn't used for everyone with CAD. Many with CAD are treated by lifestyle changes, medicines and another revascularization procedures (angioplasty). CABG may be an option for severe blockages for large coronary arteries -especially if the heart's pumping action has already been weakened. CABG may also be an option if blockages in the heart that can't be treated with angioplasty. 15  Procedure An incision is made down the centre of the chest where the sternum is cut and the ribcage is opened. Medications are administered to stop the heart and bypass commences (not completed for off-pump CABG) An artery or vein is taken from a different part the body (chest, leg or arm) and prepared to be used as a graft for the bypass. In surgery with several bypasses, a combination of both artery and vein grafts is commonly used. Artery grafts are less like to become blocked over time, however vein grafts are more commonly used Once grafting is complete, the heart is restarted and taken off by-pass 16 Special considerations for Sternotomy No current evidence-based precautions or restrictions on arm movements Majority can initiate arm movements immediately after surgery with little risk of dehiscence (reopening the wound) Considerations: – Keep early movements close to the body – Avoid activities that put stress on the sternum – Activities should be progressive in intensity/complexity – Dehiscence risk between 1.5 & 3% Highest risk = coughing, osteoporosis or infection – Outpatient rehab can include light hand ergo or cross trainer – Notify the surgeon of any meaningful sternal complications 18  Minimally invasive and robotic coronary artery bypass grafting Introduced in mid-1990s (Benetti from Buenos Aires) Various variations sine then, performed mainly in Central Europe and USA (MIDCAB) minimally invasive direct coronary artery bypass, (MICS-CABG) minimally invasive cardiac surgery-CABG and (RACAB) robotically assisted coronary artery bypass Typical procedure: Incision below areolar in men and breast fold in women (4th intercostal space) The LIMA or RIMA is harvested under direct vision Pericardium opened; and target vessels are accessed using specifically designed positioners and stabilisers Anastomoses performed on the beating heart using standard instrumentation and standard anastomotic techniques (sometimes additional intraluminal shunts) Some early programs, stopped, but current 5-year survival similar to open CABG Video assisted only used for IMA Advantages; allows harvesting full length of the IMA, and direct lateral view on the graft (not available in MIDCAB); and close ups enable a detailed view of the graft harvesting process and magnification of Internal Mammary Artery side branches RACAB performed similar to the MIDCAB Camera port is placed in the 4th intercostal space and instrument ports in the 2nd & 6th intercostal space Ports are docked to arms surgical robot and controlled by surgeon then controls using joy sticks and 3D binoculars: = better visualisation and camera control, 3D vision, magnification, better surgical dexterity 19  Minimally invasive and robotic coronary artery bypass grafting Introduced in mid-1990s (Benetti from Buenos Aires) Various variations sine then, performed mainly in Central Europe and USA (MIDCAB) minimally invasive direct coronary artery bypass, (MICS-CABG) minimally invasive cardiac surgery-CABG and (RACAB) robotically assisted coronary artery bypass Typical procedure: Incision below areolar in men and breast fold in women (4th intercostal space) The LIMA or RIMA is harvested under direct vision Pericardium opened; and target vessels are accessed using specifically designed positioners and stabilisers Anastomoses performed on the beating heart using standard instrumentation and standard anastomotic techniques (sometimes additional intraluminal shunts) Some early programs, stopped, but current 5-year survival similar to open CABG Video assisted only used for IMA Advantages; allows harvesting full length of the IMA, and direct lateral view on the graft (not available in MIDCAB); and close ups enable a detailed view of the graft harvesting process and magnification of Internal Mammary Artery side branches RACAB performed similar to the MIDCAB Camera port is placed in the 4th intercostal space and instrument ports in the 2nd & 6th intercostal space Ports are docked to arms surgical robot and controlled by surgeon then controls using joy sticks and 3D binoculars: = better visualisation and camera control, 3D vision, magnification, better surgical dexterity 20  Minimally invasive and robotic coronary artery bypass grafting Introduced in mid-1990s (Benetti from Buenos Aires) Various variations sine then, performed mainly in Central Europe and USA (MIDCAB) minimally invasive direct coronary artery bypass, (MICS-CABG) minimally invasive cardiac surgery-CABG and (RACAB) robotically assisted coronary artery bypass Typical procedure: Incision below areolar in men and breast fold in women (4th intercostal space) The LIMA or RIMA is harvested under direct vision Pericardium opened; and target vessels are accessed using specifically designed positioners and stabilisers Anastomoses performed on the beating heart using standard instrumentation and standard anastomotic techniques (sometimes additional intraluminal shunts) Some early programs, stopped, but current 5-year survival similar to open CABG Video assisted only used for IMA Advantages; allows harvesting full length of the IMA, and direct lateral view on the graft (not available in MIDCAB); and close ups enable a detailed view of the graft harvesting process and magnification of Internal Mammary Artery side branches RACAB performed similar to the MIDCAB Camera port is placed in the 4th intercostal space and instrument ports in the 2nd & 6th intercostal space Ports are docked to arms surgical robot and controlled by surgeon then controls using joy sticks and 3D binoculars: = better visualisation and camera control, 3D vision, magnification, better surgical dexterity 21  Minimally invasive and robotic coronary artery bypass grafting Introduced in mid-1990s (Benetti from Buenos Aires) Various variations sine then, performed mainly in Central Europe and USA (MIDCAB) minimally invasive direct coronary artery bypass, (MICS-CABG) minimally invasive cardiac surgery-CABG and (RACAB) robotically assisted coronary artery bypass Typical procedure: Incision below areolar in men and breast fold in women (4th intercostal space) The LIMA or RIMA is harvested under direct vision Pericardium opened; and target vessels are accessed using specifically designed positioners and stabilisers Anastomoses performed on the beating heart using standard instrumentation and standard anastomotic techniques (sometimes additional intraluminal shunts) Some early programs, stopped, but current 5-year survival similar to open CABG Video assisted only used for IMA Advantages; allows harvesting full length of the IMA, and direct lateral view on the graft (not available in MIDCAB); and close ups enable a detailed view of the graft harvesting process and magnification of Internal Mammary Artery side branches RACAB performed similar to the MIDCAB Camera port is placed in the 4th intercostal space and instrument ports in the 2nd & 6th intercostal space Ports are docked to arms surgical robot and controlled by surgeon then controls using joy sticks and 3D binoculars: = better visualisation and camera control, 3D vision, magnification, better surgical dexterity 22 Minimally invasive and robotic coronary artery bypass grafting 23  Clinical Considerations Dependent on the revascularisation procedure undertaken Success if dependent on the patient’s age, co-morbidities, severity, number and location of lesion. CABG PTCA (PCI) Stent therapy Improves long-term survival Success rate of 84% in 95% success rate Relief of angina pectoris patients with unstable angina 1-2% risk of thrombosis and Improves QOL acute closures Restenosis in approx. 25% Occlusion rates are 20% of cases, usually in the first Restenosis rates (25-40% after 5 years and 40 % after 6 months metal stents and 10% with 11 years drug-eluting stents) are dependent on co- morbidities, and intervention 24  Five year outcomes PCI + drug-eluting stent v’s CABG Primary findings Majors adverse cardiac or cerebrovascular events reduced following CABG compared to PCI with DES (12 months to 5 years) Additional analysis showed similar outcomes in those with low-to- intermediate blockages Another finding = for secondary surgery in high risk patients, PCI is safer Zhang et al. 2020. Atherosclerosis 308, 50-56 25 Medications 26