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Surgery for IHD

Surgery for IHD. pathophysiology. results from progressive blockage of the coronary arteries by atherothrombotic disease . Progressive compromise in luminal diameter producing supply/demand imbalance usually produces a pattern of chronic stable angina.

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Surgery for IHD

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  1. Surgery for IHD

  2. pathophysiology results from progressive blockage of the coronary arteries by atherothrombotic disease. Progressive compromise in luminal diameter producing supply/demand imbalance usually produces a pattern of chronic stable angina. Plaque rupture with superimposed thrombosis is responsible for most acute coronary syndromes (ACS), which include classic “unstable angina”, non-ST-elevation myocardial infarctions (NSTEMI), and ST-elevation infarctions (STEMI).

  3. DX Clinical Blood tests ECG Treadmill Echo CT angio Coronary angio

  4. MX 1. Medical Aspirin,B-blockers,nitrates,CCB if BB contraindicated Statins for plaque stabilization ACE inhibitors Clopidogrel ?

  5. STEMI PCI (90 minute door to balloon) Thrombolytic (alternative) TIME IS MYOCARDIUM Studies(6 hr )

  6. ACS Aspirin,heparin Clopidogrel(30 days post CABG outcome better) (ACC/AHA prohibition befor 2007 if surgery is an option) Prasugrelshoud be stopped for 7 days preop.

  7. platelet glycoprotein IIb/IIIainhibitors, such as tirofiban or eptifibatide If Continuing ischemia Rest pain HD unstability HF Elivated troponin Rest ECG changes

  8. Interventional PCI BMS vs DES

  9. Surgery Studies have shown that surgery is very effective in relieving angina, in many cases is able to delay infarction, and in most cases can improve survival compared with continued medical management or PCI

  10. Clinical scenarios Class III or IV angina Ischaemicpul.edema Failed PCI Patient undergoing major vascular surgery

  11. Anatomic indications Lt main > 50% 3VD EF<50 3VD EF>50 if significant inducible myocardial ischemia by stress test Lesions not amenable to PCI

  12. Other conditions These patients should undergo CABG if have >50% stenosis in branch coronary arts. Pt undergoing valve surgery Complications of MI Coronary art. Anomalies with risk of sudden death

  13. Choice of conduits Venous conduit Arterial conduit Which is superior?

  14. Surgical procedure Traditional CABG OPCAB MIDCAB TECAB Robotic Laser trans myocardial revascularization

  15. Post op.cosiderations BB Aspirin Statins ACE inhibitors

  16. complications Septal wall rupture Free wall rupture Ischaemic MR LV aneurysm

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