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Heart Surgery – latest developments

Heart Surgery – latest developments. Dr DG Harris Vergelegen Hospital. In Africa:. No new developments outside SA Africa devoid of cardiac surgical units SA, Namibia (new), Kenya, Sudan, Egypt, Algeria, Libya, Ivory coast, Ghana, Nigeria. (previously in Zimbabwe)

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Heart Surgery – latest developments

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  1. Heart Surgery – latest developments Dr DG Harris Vergelegen Hospital

  2. In Africa: • No new developments outside SA • Africa devoid of cardiac surgical units • SA, Namibia (new), Kenya, Sudan, Egypt, Algeria, Libya, Ivory coast, Ghana, Nigeria. (previously in Zimbabwe) • Expense (disposables, expertly trained staff)

  3. Advances in Cardiac surgery 1) Technical advances (new surgical techniques, operations) – NO COST 2) Technological advances – very useful - very EXPENSIVE

  4. The Internet!! • Information about diseases • Information about treatments • Information about hospitals • Information about Doctors • www.heart-valve-surgery.com

  5. Coronary Surgery – new developments: • ‘Off Pump’ coronary bypass • Minithoracotomy coronary bypass • Total arterial grafting

  6. Traditional CABG • 1 internal mammary artery + veins • Excellent initial response, later on re-intervention is common • Gold standard, it works well..`if it ain`t broke, do`nt fix it`` • BUT: Damaging effects of INVASIVE procedure – Wounds / Mediastinitis -- Heart lung machine -- Incidence is significant Veins do not last as long as arteries

  7. What`s New in Cardiothoracic Surgery?

  8. Complications of Cardiopulmonary bypass • Neurological problems, varying from stroke to cognitive impairment (microemboli) • Bleeding due to platelet damage • Whole body inflammatory response – need for postop ventilation • Renal failure • Cardiogenic shock / failure to wean • Permanent pacemaker • Respiratory failure • Long term: cardiomyopathy

  9. `OFF PUMP CABG` (OPCAB) • NO HEART LUNG MACHINE , CORONARIES INDIVIDUALLY IMMOBILISED WITH STABILISER • SURGERY DONE ON BEATING HEART • PERSONAL EXPERIENCE SINCE 1999 • WORLDWIDE :VARIABLE FROM SURGEON TO SURGEON AND BETWEEN UNITS • USA: 20% INDIA, CHINA 80% FRANCE, BELGIUM 40-50%

  10. ADVANTAGES OF OPCAB • LESS BLEEDING - can operate 2 days after plavix • LOWER MORTALITY • LESS NEUROLOGICAL SIDE EFFECTS, INCL STROKE, CONFUSION, COGNITIVE DECLINE • LESS STERNAL INFECTIONS • LESS RENAL FAILURE • LESS RESPIRATORY COMPLICATIONS, SHORTER PERIOD OF VENTILATION AND CAN OFTEN EXTUBATE IN THEATRE • Graft patency equivalent in most studies • PROCEDURE OF CHOICE IN CERTAIN PATIENTS – elderly, renal failure, redo, Caicified aorta

  11. HOSPITAL MORTALITY unrestricted in interval, excluding acute infarctsup to 5 % predicted EuroSCORE risk45 % relative risk reduction Pred. risk 2.77 (ECC) 2.88 (OPCAB) Obs. risk 1.46 % ECC 955 pts Obs. risk 0.81 % OPCAB 1722 pts

  12. Freedom fromEarly MORTALITY (3-months interval) K.U.Leuven 1997-2006 Excluding acute infarcts OPCAB-effect Non-risk adjusted P= 0.009 Risk-adjusted P= 0.05 - Saturated prop. score (AUC 0.83) - Age - Gender - Renal failure (dialysis /creat>2) - Any vascular disease - Ejection Fraction - Unstable ST at surgery OPCAB N=2864 3 mnths 97.4±0.3 ECC N=1583 3 mnths 95.9±0.5

  13. Non-risk adjusted P= 0.05 Risk-adjusted (AUC=0.84) P= 0.23 - Saturated propensity score (AUC 0.83) - Age - Creatinine preop - Unstable ST at surgery

  14. Freedom from STROKE (8 days interval) Severe carotid stenosis ≥ 80 % stenosis K.U.Leuven 1997-2006 Excluding acute infarcts Non-risk adjusted P= 0.10 OPCAB N=395 8 days 97.7±0.7 ECC N=190 8 days 95.2±1.5

  15. PERSONAL EXPERIENCE (SINCE 2004) • STROKE = 0% • MORTALITY 0.6% • TRANSFUSION +/- 20% • BLEEDING 0.3% • RENAL FAILURE -> DIALYSIS = 0 • MEDIASTINITIS (sternal bone infection) = 0 • Prolonged ventilation = 0.6%

  16. AIMS OF OPCAB • AVOID CARDIOPULMONARY BYPASS • AVOID STOPPING THE HEART • AVOID TOUCHING AORTA • MOVE TOWARD SMALLER INCISION • PATENCY AND NUMBER OF GRAFTS MUST BE EQUIVALENT • MOVE TOWARD HYBRID PROCEDURES

  17. OPCAB: Graft patency • All large, randomised studies show equivalent patency with on pump • One smaller study showed decreased patency • Over 2000 articles published • Decrease of Major Adverse Cardiac Events is proportional to number of arterial grafts, as well as completeness of revasc

  18. Mini-thoracotomy CABG • Next logical step • Clutter from bypass tubing no longer an issue • Established procedure since 1980`s – the origin of OPCAB • LIMA to LAD – relatively easy, both lie just under skin incision

  19. MINITHORACOTOMY OPCAB

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