The modalities of treatment for coronary artery disease iuc: (1) nlcdical,(2) angioplasty and stenting, ;lnd (3) coronary artery bypass surgely.
The patient's symptoms, nature and number of blocks, suitability of distal vessels for grafting and lcft ventricular function have to be taken into account before deciding on surgical treatment. Assessment of viability of n1yoc:udiunl will help in identifying patients who will benel'it from surgery.
Left Main Coronary Artery Disease (LMCAD)
Stenosis of 50 per cent or lllore of the left main coron;lry urtery is :un indicatio~l for surgery. Results of nledical management are vely poor and angioplasty is hazardous in thesc patients. Even if patient is asymptomatic or when angina is well co~ltrolled with medication, early surgery is indicated. The operation has to be done urgently if' there is critical left main lcsion.
Triple Vessel Disease (TVD)
Patients with triple vessel disease and impaired left ventricular fitnction do badly on ~lkedical treatment. They are canclidates for CABG. Operation is a better choice colnpared to Iriple vessel angioplnsty and stcnting. 11' a triple vessel disease patient has significant block in proxinlal LAD (plaximal to first septa1 and first diagonal) and proximal circu111flcx it will itmount to left main equivalent disease. They will have. to undergo CABG. In spite of triplc vessel disease if' the symptoms are mild, blocks arc less than 70 per cent and IeTt ventricular [unction good; they can be put on rncdicnl treatmcnt wit11 close follow up.
Double Vesscl Disease (DVD)
Percutaneous intervention with stenting is usually advised for these pntieuts.However if it is left main equivalent disease or when block is close to a inajor branch or if left ventricle is impaired, surgery is a better choice.
Single Vessel Disease (SVD)
They do well on medical treatment or with angioplasty. However if proximal LAD is significantly blocked and LIMA can be used as a conduit, surgery gives excellent results. In a patient with proximal LAD lesion if the ejection fraction (EF) is less than 50 per cent and non-invasive tests show extensive reversible ischaemia, surgery is the best choice.
Unstable Angina
It is indicative of imnportant reversible myocardial ischaernia that needs urgent evaluation and treatment. Medical management usually relieves symptoms and if the patient settles down, further investigations can be done electively.Urgent intervention is required in patients with left main coronary artery disease (LMCAD) and severe triple vessel disease. Angina at rest suggests ongoing ischaemia, which might lead to myocardial iilfarction (MI).
Acute Myocardial Infarction
Patients with acute non-Q myocardial infarction may need urgent interventioll as indicated for cases of unstable angina.Uncomplicated Q Wave MI CABG has very little place in cases of uncomplicated Q wave myocardial infarction. However the place of urgent surgeiy has to be comnpared to thrombolytic therapy and primary PTCA. The risk of surgery educes with passage of time. If it is safe it is better to postpoiie the surgely for 48 hours,Acute Myocardial Infarction with Haemodynamic Deterioration
These patients may require urgent insertion of intra aortic balloon pump (IABP) followed by PTCA or surgery. 50 per cent of them can be salvaged by surgery or angioplasty. Single most important factor for successful surgery is myocardial protection at the time of surgery. Repel-fusion injury has to be avoided at the end of re-vasculmisation. Cold or warm cardioplegic arrest, controlled aortic repelfusion with warm blood (Hot shot) and allowing an empty beating heart time for full recovely of nlyocardium have improved surgical results.
Acute Complicatiolls of PTCA
The incideilce of complications after PTCA that require emergency surgely has reduced considerably in the present era. Intro,duction of stents, perfusion calheters and excellel~t medical management have all contributed to this. In the initial periods of angioplasty surgical team and operating room used to be stand-by when angioplasty is done. If there is haemodynamic collapse after angioplasty, insertion of IABP, percutaneous cardiopulmonary bypass and emergency CABG may be required.
Influence of LV Futlction
LV function, whether normal or impaired is important while selecting a patient for CABG and for long-term results of surgical revascularisation. If left ventiicula function is normal even in the presence of less than critical blocks in all three coronay arteries, medical treatment gives good results.Depressed LV funct!lon is an indication for surgery. If the ejection fraction (El?) is more than 0.3, surgical results cue good. However when ejection fraction is less than that risk of surgery becomes greater with poor long-term benefits. Exercise or resting Thallium 201 scintigraphy, dobutanline stress echocardiography or positron emission tomographic (PET) scaniling will help in distinguishing ischaemic viable myocardium lrom a scar.
Influence of Diabetes Mellitus
Diabetes causes micro vascular obstructive disease in heart, kidney, retina and peripheral nerves. Scrupulous rather than casual co~ltrol of diabetes helps in protecting these organs. Coronary artery and cardiovascular disease are more prevalent in diabetic patients. In diabetics coronary artery diseaseis more diffuse and the target vessels for grafting usudly snialler in these patients. Patient's perception of angina is modified in diabetes and they usually come for treatment in more advanced condition. Statistics shows that 25 to 30 per cent of patients coming up for CABG are diabetic.Wyperglycemia has to be well controlled before 'and after coronary artery bypass surgery.
The patient's symptoms, nature and number of blocks, suitability of distal vessels for grafting and lcft ventricular function have to be taken into account before deciding on surgical treatment. Assessment of viability of n1yoc:udiunl will help in identifying patients who will benel'it from surgery.
Left Main Coronary Artery Disease (LMCAD)
Stenosis of 50 per cent or lllore of the left main coron;lry urtery is :un indicatio~l for surgery. Results of nledical management are vely poor and angioplasty is hazardous in thesc patients. Even if patient is asymptomatic or when angina is well co~ltrolled with medication, early surgery is indicated. The operation has to be done urgently if' there is critical left main lcsion.
Triple Vessel Disease (TVD)
Patients with triple vessel disease and impaired left ventricular fitnction do badly on ~lkedical treatment. They are canclidates for CABG. Operation is a better choice colnpared to Iriple vessel angioplnsty and stcnting. 11' a triple vessel disease patient has significant block in proxinlal LAD (plaximal to first septa1 and first diagonal) and proximal circu111flcx it will itmount to left main equivalent disease. They will have. to undergo CABG. In spite of triplc vessel disease if' the symptoms are mild, blocks arc less than 70 per cent and IeTt ventricular [unction good; they can be put on rncdicnl treatmcnt wit11 close follow up.
Double Vesscl Disease (DVD)
Percutaneous intervention with stenting is usually advised for these pntieuts.However if it is left main equivalent disease or when block is close to a inajor branch or if left ventricle is impaired, surgery is a better choice.
Single Vessel Disease (SVD)
They do well on medical treatment or with angioplasty. However if proximal LAD is significantly blocked and LIMA can be used as a conduit, surgery gives excellent results. In a patient with proximal LAD lesion if the ejection fraction (EF) is less than 50 per cent and non-invasive tests show extensive reversible ischaemia, surgery is the best choice.
Unstable Angina
It is indicative of imnportant reversible myocardial ischaernia that needs urgent evaluation and treatment. Medical management usually relieves symptoms and if the patient settles down, further investigations can be done electively.Urgent intervention is required in patients with left main coronary artery disease (LMCAD) and severe triple vessel disease. Angina at rest suggests ongoing ischaemia, which might lead to myocardial iilfarction (MI).
Acute Myocardial Infarction
Patients with acute non-Q myocardial infarction may need urgent interventioll as indicated for cases of unstable angina.Uncomplicated Q Wave MI CABG has very little place in cases of uncomplicated Q wave myocardial infarction. However the place of urgent surgeiy has to be comnpared to thrombolytic therapy and primary PTCA. The risk of surgery educes with passage of time. If it is safe it is better to postpoiie the surgely for 48 hours,Acute Myocardial Infarction with Haemodynamic Deterioration
These patients may require urgent insertion of intra aortic balloon pump (IABP) followed by PTCA or surgery. 50 per cent of them can be salvaged by surgery or angioplasty. Single most important factor for successful surgery is myocardial protection at the time of surgery. Repel-fusion injury has to be avoided at the end of re-vasculmisation. Cold or warm cardioplegic arrest, controlled aortic repelfusion with warm blood (Hot shot) and allowing an empty beating heart time for full recovely of nlyocardium have improved surgical results.
Acute Complicatiolls of PTCA
The incideilce of complications after PTCA that require emergency surgely has reduced considerably in the present era. Intro,duction of stents, perfusion calheters and excellel~t medical management have all contributed to this. In the initial periods of angioplasty surgical team and operating room used to be stand-by when angioplasty is done. If there is haemodynamic collapse after angioplasty, insertion of IABP, percutaneous cardiopulmonary bypass and emergency CABG may be required.
Influence of LV Futlction
LV function, whether normal or impaired is important while selecting a patient for CABG and for long-term results of surgical revascularisation. If left ventiicula function is normal even in the presence of less than critical blocks in all three coronay arteries, medical treatment gives good results.Depressed LV funct!lon is an indication for surgery. If the ejection fraction (El?) is more than 0.3, surgical results cue good. However when ejection fraction is less than that risk of surgery becomes greater with poor long-term benefits. Exercise or resting Thallium 201 scintigraphy, dobutanline stress echocardiography or positron emission tomographic (PET) scaniling will help in distinguishing ischaemic viable myocardium lrom a scar.
Influence of Diabetes Mellitus
Diabetes causes micro vascular obstructive disease in heart, kidney, retina and peripheral nerves. Scrupulous rather than casual co~ltrol of diabetes helps in protecting these organs. Coronary artery and cardiovascular disease are more prevalent in diabetic patients. In diabetics coronary artery diseaseis more diffuse and the target vessels for grafting usudly snialler in these patients. Patient's perception of angina is modified in diabetes and they usually come for treatment in more advanced condition. Statistics shows that 25 to 30 per cent of patients coming up for CABG are diabetic.Wyperglycemia has to be well controlled before 'and after coronary artery bypass surgery.
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