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The Problem

Terapia chirurgia della cardiopatia ischemica: la rivascolarizzazione chirurgica del miocardio a cuore battente e terapia chirurgica delle complicanze dell’infarto miocardico. The Problem.

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The Problem

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  1. Terapia chirurgia della cardiopatia ischemica: la rivascolarizzazione chirurgica del miocardio a cuore battente e terapia chirurgica delle complicanze dell’infarto miocardico

  2. The Problem • Coronary artery bypass grafting is one of the most frequently performed operations and its application increase: • 800.000 pts/year worldwide • 12.000 pts/year in Italy • 1-3% perioperative mortality • 15-20% complications (42% neurocognitive impairment) • 2-3 months period of recovery • Any improvement in the safety and efficacy of the procedure or any means to increase the rate of its application, however small, would have a major impact in absolute terms.

  3. Options for the Treatment of CAD • Medical - poor prognosis • PCA a) Standard • b) New Devices • 3) Surgical a) On-Pump • b) Off-Pump - Sternotomy • - Mini-invasive access

  4. Invasivity in Cardiac Surgery • Cardio-Pulmonary Bypass • Cardioplegic Cardiac Arrest • Surgical Entry

  5. On-pump CABG Coronary anastomosis is performed using the CPB to optimize • manipulation of the heart, • visibility of the coronary vessels, • stability of the anastomotic area, • quality of the anastomosis, • protection of the heart. Yet, CPB and CCA itself has potential adverse effects.

  6. One potential method for achieving improvement in the safety and efficacy of CABG is off-pump coronary artery bypass grafting (OPCAB) to avoid: Cardio-Pulmonary Bypass Cardioplegic Cardiac Arrest

  7. Theoretical and practical advantages of OPCAB • Total body inflammatory response • Coagulopathy • Transfusion requirement • Post-operative neuralgic sequelae • Renal dysfunction • Length of stay • Cost

  8. Application of OPCAB • Initially, the technique was reserved for young patients who had good LV function and single or double CAD affecting accessible arteries with healthy distal vessels. • The application of the technique has tended to increase dramatically since the introduction of devices for stabilizing the heart. • To date has been used largely in selected patients, with the reported use of the procedure varying widely in different centers (between 0% and 90%). The next group for which the technique was advocated was that of elderly patients with multivessels CAD and comorbid conditions that were perceived tomake them poor candidates for cardiopulmonary bypass.

  9. Sharif Al-Ruzzeh, Magdi Yacoub, et al. “Does off-pump coronary artery bypass (OPCAB) surgery improve the outcome in high-risk patients?: a comparative study of 1398 high-risk patients” European Journal of Cardio-thoracic Surgery 23 (2003) 50–55

  10. Controindications of OPCAB • Absolute: • clinical heart failure, • hemodynamic instability, • severe left ventricular dysfunction, • significant cardiac enlargement, • frequent arrhythmias • Relatives: • urgent or emergency operation, • Female sex, • small or diffusely diseased vessels • Intramyocardial coronaries • coronary calcifications

  11. In the absence of solid data to guide selection, the rate of application of OPCAB currently depends on the attitude, experience, prediction, biases of the surgical group.

  12. Deployed Stabilization Device for Off-Pump Coronary-Artery Bypass Surgery. The arms of the device are positioned on the epicardium, adjacent to the vessel intended for construction of the distal anastomosis, and dampen motion at the operative site when local suction or compression is applied.

  13. Conclusions:“In low-risk patients, there was no difference in cardiac outcome at one year between those who underwent on-pump CAB surgery and those who underwent OPCAB. OPCAB surgery was more cost effective.”

  14. Kaplan–Meier Estimates of Survival Free from Stroke, Myocardial Infarction, and Repeated Coronary Revascularization. P=0.48 by the log-rank test.

  15. “In selected patients, off-pump CABG is safe and yields a short-term cardiac outcome comparable to that of on-pump CABG.” (Circulation. 2001;104:1761-1766.)

  16. Octopus Study Group

  17. OPCAB and The Future • Current evidence suggests that OPCAB is gradually establishing • its position in practice, but it should continue to be subjected to scrutiny in the foreseeable future. • In the future, randomized trials and outcome data from large registres will make it possible to explore the potential risks and benefits in the latter, substantially larger cohort of surgical patients. • “Until such data are available, we will not know wheter off-pump by-pass surgery is a step forward, backward or sideways” • Eric A. Rose

  18. Minimally invasive OPCABG • MIDCAB • Video assisted CAB(± Port Access System) • Robotic assisted • Hybrid Strategy

  19. The Goal of Surgical Revascularization

  20. MIDCAB

  21. MIDCAB

  22. MIDCAB • Smaller incision (minithoracotomy) • Off-pump • Beating heart Largely abandoned because of the high incidence of graft occlusion and instances of fatal graft avulsion.

  23. MIDCAB is a safe and effective procedure. • When compared to PTCA, the freedom from angina and the need for redo procedures after 6 months is statistically better for MIDCAB. • MIDCAB is a valuable alternative for isolated proximal LAD lesions.

  24. Robotic Surgery

  25. Robotic Surgery

  26. Hybrid Strategies in Myocardial Revascularization MIDCAB (graftingLIMA to LAD ) + PCA (of the otheraffected vessels) • the goal: to achieve a completerevascularization • to take advantageof the best that both surgical and interventional approacheshave to offer for the revascularization of the ischemic myocardium, while at the same time minimizing trauma and morbidityto the patient. [M. Zenati 1999]

  27. Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia. Karagoz HY, Sonmez B, Bakkaloglu B, Kurtoglu M, Erdinc M, Turkeli A, Bayazit K. Department of Cardiovascular Surgery, Guven Hospital, Ankara, Turkey. karagoz@tr-net.net.tr “Our initial experience confirms the feasibility of performing coronary bypass grafting in the conscious patient without endotracheal general anesthesia. “ Ann Thorac Surg 2000 Jul;70(1):91-6

  28. Chirurgia delle Complicanze Meccaniche dell’ Infarto Miocardico

  29. Complicanze chirurgiche dell’infarto miocardico • Acute • Difetto interventricolare • Rottura di parete libera • Rottura di muscolo papillare (IM ischemica acuta) • Croniche • Aneurisma ventricolare • Pseudoaneurisma • Alterazioni anatomiche di muscolo papillare (IM cronica)

  30. Rottura di SIV (1) • Caratteristiche morfologiche • Localizzazione: • anteriore (60%) posteriore(40%) • Associato a: • occlusione coronarica totale, spesso malattia monovasale (insufficiente circolo collaterale), spesso + Aneurisma ventricolare (30-70%) • Può essere multiplo (5-11%) • 2. Clinica e Diagnostica • Improvvisa comparsa di soffio pansisolico con irradiazione a destra associato a scadimento repentino delle condizioni emodinamiche (scompenso ventricolare dx). • Radiografia torace: segni di ipertesione polmonare e congestione piccolo circolo • Gradiente di SO2(a-p) 9% conferma shunt sx-dx • Ecocardiogramma: localizzazione e dimensioni, coesistenza di IM ed AnVsx • Coronarografia e Ventricolografia

  31. Rottura di SIV (2) 3. Storia Naturale Incidenza: 1-2% di IMA (diminuita dall’introduzione della terapia trombolitica, modificati i tempi di insorgenza) Si può verificare da 2-3 gg fino a 2 sett. da IMA Donne/Uomini= 3:2 La morte nella prima ora è comune (5%) A dispetto delle più moderne tecniche di trattamento dell’insufficienza cardiaca, la sopravvivenza senza intervento riparativivo è di solo il 7% ad un anno:

  32. Rottura di SIV (3) • Cause di morte: • 60% CHF, acuto • 20% morte improvvisa aritmica • 15% CHF, cronico, intrattabile • 5% CVA • Fattori di rischio per morte: • Stato emodinamico e funzione ventricolare pre-operatoria • SIV posteriore >> SIV anteriore • Estensione della necrosi miocardica

  33. Trattamento Preoperatorio • Riduzione delle resistenze vascolari Riduzione dello Shunt (vasodilatatori) • Mantenimento di gittata cardiaca e PA per garantire un’adeguata perfusione agli organi (inotropi e diuretici) • Mantenimento o incremento di flusso miocardico (IABP! Beneficio max in 24h con successivo plateau) • ECMO

  34. Indicazioni chirurgiche Indicazione = sintomatologia e/o Qp/Qs 2 Tempi: - Urgente: emodinamica instabile o MOF - Ritardato (2-3 sett.) se stabile emodinamicamente (5%) Considerazioni chirurgiche Approccio attraverso Vs, Vd, Vs/Vd, Adx Tecnica chirurgica (chiusura diretta o patch) Procedure concomitanti (CABG, sostituzione/riparazione valvolare mitralica, ventricoloplastica, chiusura di rottura parete libera)

  35. CASO CLINICO A 52 year male was admitted with acute anterior wall myocardial infarction. The patient had recurrent postinfarct angina and one episode of ventricular fibrillation that required electrical defibrillation. A new systolic murmur was noted after the procedure. Bedside echocardiogram revealed basal ventricular septal rupture. Three days post rupture - the ventricular septal defect size is small and the flow is turbulent in nature. Three weeks post rupture - the defect size has increased to 2.9 cm. The defect edges are regular. Color flow shows a laminar flow pattern with predominant left to right shunt.

  36. DIV anteriore e sua riparazione

  37. Rottura posteriore del setto

  38. Long-term survival curves for patients younger and older than 70 years. (Reproduced with permission from Muehrcke DD et al: J Cardiac Surg 1992; 7:290.)

  39. Long-term survival of bypassed patients, non-bypassed patients, and patients with single-vessel disease. Patient survivals between the three groups are different (p = 0.0062). There is no difference in survival at 10 and 15 years between the bypassed group and the group with single-vessel disease (p = 0.053). However, there is a significant difference between the bypassed and the unbypassed groups (p = 0.0015). (Reproduced with permission from Muehrcke DD et al: Ann Thorac Surg 1992; 54:876.) Long-term survival of bypassed and nonbypassed patients broken down by location of ventricular septal defect. Operative deaths are included in determinations. (Reproduced with permission from Muehrcke DD et al: Ann Thorac Surg 1992; 54:876.)

  40. DIV Recidivo • 10–25% dei pazienti sottoposti ad intervento • Precoce (entro 30 gg) 75% Tardivo 25% • Diagnosi con Ecocolor doppler • Cause: • Nuove perforazioni nell’immediato postoperatorio • Leaks periprotesici • Difetti “satelliti” non individuati durante il 1° intervento • Indicazione al re-intervento: • Sintomatici • Compromissione emodinamica *Shunt calcolato Qp:Qs > 2.0. • Quando il DIV è piccolo (Qp:Qs < 2.0), asintomatico o controllato con minima terapia diuretica, è ragionevole mantenerlo in terapia medica ed è possibile una chiusura spontanea nel tempo

  41. Percutaneous transaortic closure of postinfarctional ventricular septal rupture. Hachida M, Nakano H, Hirai M, Shi CY. Department of Cardiovascular Surgery, Tokyo Womens' Medical College. “We report a case of successful closure of a postinfarctional ventricular septal defect by means of the transaortic approach with a balloon catheter. This method brought about substantial improvement in cardiopulmonary function before an elective operation and made it possible to successfully perform the operation on the patient, an 81-year-old woman, on the 22nd day of admission”. PMID: 2012427 [PubMed - indexed for MEDLINE] Ann Thorac Surg 1991 Apr;51(4):655-7 Transcatheter closure of a residual postmyocardial infarction ventricular septal defect with the Amplatzer septal occluder D H Roberts,K P Walsh Blackpool Victoria Hospital, Whinney Heys Road, Blackpool, Lancashire FY3 8NR, UK, b Alder Hey Children's Hospital, Eaton Road, Liverpool L2 2AP, UKHeart 1998;80:522-524 ( November )

  42. Rottura post-IMA di parete libera • William Harvey (1647). • Morgagni (1765) descrive 11 casi autoptici. (Ironicamente, Morgagni morì per questa complicanza!) • Hatcher e coll. (1970) all’Emory University riportano la prima riparazione chirurgica di rottura ventricolo destro • Fitz Gibbon e coll (1971) descrivono la prima riparazione chirurgica di rottura post IMA del ventricolo sinistro Rottura post IMA della parete anteriore Vsx. Decesso per tamponamento cardiaco acuto

  43. IMA della parete posteo-laterale del Vsx. La freccia indica il tratto di rottura: ematoma sottoepicardico e versamento pericardico –tamponante di 200-250 cc. (Una fuoriuscita di 2 gocce/sec determina un versamento di 360 cc in una ora).

  44. Rottura post-IMA di parete libera • Incidenza dell’ 11% (dati autoptici) Più comune nelle donne con età media di 63 anni con primo IMA. • Timing: picco incidenza limite • In epoca pre-trombolisi V° giornata entro 15 gg (90%) • Con trombolisi (entro le 7h riduce incidenza, dopo le 17 h ne aumenta l’incidenza): 8 h entro 3 gg (95%) • Sede: • Parete anteriore 55% • Parete laterale 35% • Altre 10% • Morfologia: • Semplice (tragitto perpendicolare transparietale) 45% • Complessa (più tragitti serpiginosi, spesso obliqui) 55%

  45. Storia Naturale • Acuta: Morte improvvisa preceduta da crisi anginosa. Tamponamento e DEM (entro pochi minuti dall’esordio) • Subacuta: Breccia piccola temporaneamente chiusa da coagulo o adesione pericardica con lento filtraggio. Segni di tamponamento progressivo e poi shock cardiogeno. (D/d con estensione di IMA o IMA destro) Può essere compatibile con la vita per giorni. • Cronica: chiusura spontanea per adesione tra epicardio e pericardio o formazione di Pseudoaneurisma

  46. Technique to repair rupture of the free wall of the left ventricle. A. Left ventricular free wall rupture. B. A limited infarctectomy is closed with horizontal mattress sutures buttressed with two strips of felt. C. Then the whole area is covered with a Teflon patch sutured to healthy epicardium with a continuous propylene suture. Alternatively, the Teflon patch can be glued to the ventricular tear and the infarcted area using a biocompatible glue. (Adapted from David TE: Surgery for postinfarction rupture of the free wall of the ventricle. In David TE [ed]: Mechanical Complications of Myocardial Infarction. Austin, TX, R.G. Landes Company, 1993, pp 142–151.)

  47. Insufficienza Mitralica Ischemica Unadjusted (for risk factors) survival curves for 11,848 patients with and without IMR catheterized for symptomatic CAD and treated medically or by surgery [solid line, MR 3-4+; dotted line, moderate (2+) MR; dot-dashed line, mild (1+) MR; dashed line, no MR]. (From Hickey et al).

  48. Insufficienza Mitralica Post-IMA • Acuta (30-50% durante IMA) • Funzionale (“stunned heart”) Recupero • da rottura MP (0,5-1,5%) • MP Posteriore vs Anteriore: 3-6/1 • Malattia coronarica spesso Monovasale (25%) • Compare nella prima settimana • Cronica(10-15%)da disfunzione MP (reversibile “miocardio ibernato” od irreversibile) o da dilatazione Ventricolare (da dislocamento di MP). • Post IMA inferiore 3-5% • Post IMA anteriore 6-8% Malattia coronarica spesso Trivasale Compare fino a tre mesi post IM • Recidivante(2-5%) da “Claudicatio” di MP

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