Description
Patients with multi-vessel coronary artery disease represent a high-risk subset requiring meticulous surgical planning and intraoperative care. This session will explore case-based approaches to optimize outcomes in patients with complex anatomy, impaired ventricular function, or coexisting comorbidities. Strategies such as complete revascularization, graft selection, and perioperative hemodynamic support will be discussed. The session will also highlight multidisciplinary decision-making in managing these challenging cases.
Summary Listen
- High-risk coronary artery bypass grafting (CABG) is defined by significant pre-operative morbidity risks, including diffuse multi-vessel disease, severely decreased left ventricular function, redo-operations, and urgent/emergency surgery needs. Malnutrition, frailty, advanced renal disease, CVS, and COPD are also contributing factors.
- Pre-operative evaluation involves imaging like coronary angiography, cardiac MRI or CT, and risk quantification tools like the EuroSCORE II or STS risk calculator. Nutritional status, frailty, and lung function are also assessed to build a holistic risk profile.
- CABG is strongly recommended for patients with left main disease, three-vessel disease (especially with left ventricular dysfunction), and diabetic patients. It's also considered when PCI fails or is not feasible due to complex anatomy. A heart-team approach is vital for choosing the most appropriate treatment.
- Intraoperative strategies include off-pump CABG (OPCAB), which minimizes systemic inflammatory response, stroke, and neuro-cognitive decline, but is technically demanding. On-pump CABG offers better exposure and hemodynamic management, but has a higher risk of neurological complications. Total arterial grafting (TAG) with arterial conduits like the internal mammary artery is favored for long-term patency, especially in diabetics and younger patients.
- Surgical approaches include median sternotomy for complex diversification and complete revascularization. Minimally invasive approaches are useful for specific patients, but limited for high-risk multi-vessel patients. Anesthetic and monitoring considerations are critical for hemodynamic stability, minimizing myocardial depression, and early weaning from ventilation.
- The left internal mammary artery (LIMA) to the LAD remains the gold standard. The radial artery is a preferred second graft, particularly for high-grade stenosis, while saphenous vein grafts have lower long-term patency.
- Energy sources and detection techniques used in graft harvesting minimize trauma and optimize graft quality. Open harvesting allows full vessel inspection, but carries risks of wound complications. Endoscopic vessel harvesting is minimally invasive, but requires specialized training. Graft testing and patency is assessed intraoperatively.
- Post-operative management involves early extubation, fluid balance, and monitoring renal function. Graft flow can be assessed using transient time flow measurement and ICG. Goal is to keep the patient pain-free and breathing independently.
- Special considerations include meticulous management in diabetic patients, patients with CKD, and those undergoing redo CABG. Complete revascularization has shown clear survival benefits.
- Recent advances include hybrid revascularization (PCI and CABG), minimally invasive CABG, mechanical circulatory support (ECMO, IABP), enhanced recovery after surgery (ERAS) protocols, and artificial intelligence for risk assessment and surgical planning.
- Challenges may include low cardiac output, arrhythmia, renal failure, and stroke, requiring interventions like IABP, ECMO, antiarrhythmics, and dialysis. Cases like coronary dissection or VSR often require urgent surgical intervention.
Sample Certificate
About the Speakers
Dr. Md. Abir Tazim Chowdhury
Senior Specialist, Cardiothoracic and Vascular Surgery, Evercare Hospital, Bangladesh
Financial Disclosure
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