Progress in the Care of the Coronary
Artery Disease Patient
P SPSA 34 th Annual C.M.E.
Seminar in Surgery
July 16-20, 2008
The Great Wolf Lodge
Traverse City , Michigan
Progress in the Care of the Coronary Artery Disease Patient
Manuel R. Estioko, M.D.
Saint John’s Health Center
Santa Monica , CA
Coronary artery disease (CAD) remains the number one killer for both men and women in the United States. It is a progressive disease and there are clinical events that require treatment interventions either medical and or surgical. Ruptured atherosclerotic plaque often initiates platelet aggregation, thrombus generation, acute coronary occlusion and myocardial infarction (MI). Much has been accomplished in the medical treatment of the patient especially with the use of beta-blockers and statins. Better control of co-existing disease conditions like hypertension and diabetes further contribute to improved results.
In the event of admission for acute MI, cardiac catheterization and coronary angiogram is recommended to be done as soon as possible. The culprit vessel is identified; angioplasty and stenting are done to limit infarct injury. There is a trend towards multi-vessel stenting as well as repeat stenting. These are some reasons why patients are referred later for surgery and many are older and sicker. However, there are complications of stenting. Bare metal stent (BMS) has significant restenosis problem of about 25 to 40%. Drug eluting stent (DES) was introduced and decreased the incidence of restenosis by about one half but recently, there is observed acute stent thrombosis with the DES and patients have to take Clopidogrel for extended period to avoid this complication. So what is the next advance in technology?
Emergency coronary bypass is indicated in unstable patients in spite of or failed percutaneous coronary interventions (PCI). Some of these patients have tight left main coronary stenosis. The complications of PCI such as coronary dissection, occlusion, perforation and tamponade are low. Other serious conditions requiring emergency surgery are post-MI ruptured ventricular septum and ruptured papillary muscle of the mitral valve with severe regurgitation and pulmonary edema.
Coronary artery bypass graft (CABG) operation has consistently good long term results with low mortality and morbidity. CABG operation volume in most institutions in the US has decreased because of the progress in non-surgical treatments. The indications, graft conduits and present surgical techniques will be discussed in the presentation. The results of On pump and Off pump CABG will be compared. MidCab and Heartport are off the radar but Robotic surgery and minimally invasive procedures are emerging.
The high incidence cardiovascular disease in women and death from it was not well appreciated in the past. Women present their cardiac condition differently. Women’s health is the next frontier which is getting more recent attention. The treatment of CAD remains a major challenge for many years to come.
STATE OF THE ART LECTURE
P SPSA 34 th Annual C.M.E.
Seminar in Surgery
July 16-20, 2008
The Great Wolf Lodge
Traverse City , Michigan
STATE OF THE ART LECTURE
Opportunities in Blood Conservation in Major Surgery
Manuel R. Estioko, M.D.
Saint John’s Health Center
Santa Monica , CA
For so long physicians adhered to traditional transfusion practices without solid scientific evidence. An example of this is the use of arbitrary transfusion trigger and following the 10/30 hemoglobin/hematocrit rule. There were no accurate data supporting the different transfusion guidelines. Transfusion was left at the discretion of the individual physician resulting in tremendous variability in the use of blood and its components.
Over the past two decades, many studies emerged in the literature that has captured the attention of the medical community. These reports covered many aspects related to blood transfusion including: the hazards of blood-borne diseases; the deleterious effects of blood to vital organs like lung injury; immunosuppresion effect of blood transfusion and the increased risk of infection and poorer survival outcomes of transfused patients. At the same time, major, complex operations and even reoperations in cardiovascular, orthopedic and other specialties were successfully performed with less blood or no blood transfusions. Other factors became evident: the high cost of blood and its management; the dwindling volunteer blood donors and crises of blood supply. All these developments lead to the focus on blood conservation in most medical centers in the country. Blood management became important in medical practice that can no longer be ignored or considered an inconsequential issue.
Blood transfusion can be avoided in surgery in the following ways:
- Increase red cell mass before surgery.
- Minimize blood loss during surgery.
- Avoid bleeding problems.
- Accept lower levels of hemoglobin and hematocrit postoperatively.
- Optimize patient's recovery.
There are many opportunities in blood conservation that include strategies before surgery, intraoperative techniques and postoperative care. Erythropoiesis stimulating agents (ESA) and iron therapy are utilized to increase red cell mass in preparation for major surgery. Sound surgical principles that have to be followed with great details will be discussed in the presentation. The main goals are to minimize blood loss and employ techniques that avoid bleeding. Meticulous hemostasis is performed in every step of the operation. Excessive intravenous fluid administration is to be avoided since it can lead to dilutional coagulopathy. The principles in blood conservation are applicable in any surgical procedure. Fewer problems are encountered in general surgical operations and non-cardiac procedures because there is no burden of large dose Heparin anticoagulation and risk of bleeding. Open heart surgery is more involved, but successful operations can be performed (including complex operations and reoperations), without the use of blood. To illustrate this, we are presenting our experience in the surgical treatment of thoracic aortic dissection and aneurysm. Usually, this group of patients have large blood loss and are always transfused. To perform these procedures without blood transfusion is indeed the ultimate surgical challenge.
The emphasis on optimum blood management is here and is gathering more attention. There are principles and strategies that are applicable in surgery to decrease blood transfusion or avoid transfusion completely. It is incumbent upon the physicians and surgeons to re-evaluate their practice to approach the state of the art. It is no longer acceptable to be using so much blood.
G. Michael Deeb, M.D.
G. Michael Deeb, M.D.
Herbert Sloan Collegiate Professor of Surgery
Director Multidisciplinary Aortic Clinic
Section of Cardiac Surgery
University of Michigan
Cardiovascular Center
Ann Arbor, Michigan
The purpose of this lecture is to discuss the surgical treatment for thoracic aortic disease. We will discuss the various sites and locations of thoracic pathology in relationship to its specific needs for repair. We will talk about the indications for intervention for each type of pathology depending on their location and the underlying etiology of the disease.
We will look at the aortic root, the ascending aorta, the aortic arch and the descending thoracic aorta separately. We will discuss the indications for operation and the various types of operations at each site. We will go into explicit detail as to the various interventional techniques which are available for each site. We will then discuss results which include both short-term and long-term data.
We first begin with the aortic root and ascending aorta and discuss the various indications for intervention. We will then divide intervention into valve sparing roots versus root conduit replacement with a valve.
We will then discuss aortic arch surgery and the evolution of aortic arch surgery as well as the techniques of hyperthermic circulatory arrest with both retrograde and antigrade cerebral perfusion. We will talk about the progression and present status of this type of surgery.
We will then end the lecture discussing descending thoracic aortic and thoracoabdominal aortic aneurysms and discuss the differences between invasive interventional and less invasive intervention with percutaneous stents.
At the end of this lecture you should have a broad idea of the various types of pathology for thoracic aortic disease as well as the particular sites and each of their specific nuances for repair. You will be familiar with the major invasive techniques as well as the new endovascular techniques.
"Asanguinous" Open-Heart Surgery
Philip S. Chua, MD, FACS, FPCS, Victor K. O' Yek , MD, FACS, FRCS, Cris J. Carlos, MD, Felix R. Gozo, MD, Cardiovascular Surgery Associates, 8684 Connecticut Street, Merrillville, Indiana 46410
"Asanguinous" open-heart surgery was initially performed by our team at our institution in January 1982 for mitral valve replacement in a Jehovah's Witness, whose religious beliefs precluded blood transfusion. Since then, we have applied this principle to all of our open-heart cases, with excellent results. Using an IBM 2991 blood cell processor and Sorensen Autologous Transfusion System, our institution has salvaged an average of 92.1 units of blood per month, from January 1982 to December of 1983, with a total of 650 units for 1982 and 1105 units for 1983. From January to August of 1984, a total of 645 units were saved, with an average of 80 units per month. This protocol involved 1121 patients with coronary bypass surgery, 32 of which had concommitant repair of LV aneurysm, and 27 with unilateral carotid endarterectomy. One hundred and sixty-eight underwent cardiac valve replacement, 109 mitral, 57 aortic, and 2 combined MVR-AYR. Eighty-six percent of our entire series did not require homologous, transfusion, other than their own, individual salvaged packed cells. "Asanguinous" open-heart surgery is not only possible and safe, but also a medically prudent technique that is cost-efficient and devoid of the usual hazards associated with homologous transfusion.