Ebook Coronary artery bypasses: Part 2
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Ebook Coronary artery bypasses: Part 2
In: Coronary Artery BypassesEditors: Russell T Hammond and James B AltonISBN: 978-1-60741-064-5 ©2009 Nova Science Publishers, Inc.Chapter I/Coronary Ebook Coronary artery bypasses: Part 2 Artery Bypass Grafting for Chronic and Acute Heart FailureMarco Pocar, Andrea Moneta, Davide Passolunghi, Alessandra Di Mauro, Alda Bregasi, Roberto Mattioli and Francesco DonatelliUnit of Cardiac Surgery and Echo-Lab;Scientific Institute MultiMedica Hospital;University of Milan; Milan. ItalyAbstra Ebook Coronary artery bypasses: Part 2ctThe techniques and reproducibility of surgical coronary revascularization rely on over forty-year experience However, surgery for ischemic heart disEbook Coronary artery bypasses: Part 2
ease with associated left ventricular dysfunction carried high if not prohibitive operative risk during the pioneering and early era of coronary surgeIn: Coronary Artery BypassesEditors: Russell T Hammond and James B AltonISBN: 978-1-60741-064-5 ©2009 Nova Science Publishers, Inc.Chapter I/Coronary Ebook Coronary artery bypasses: Part 2l often relies on concurrent anginal symptoms. Similarly, many surgeons are reluctant to offer surgery aimed to reverse low cardiac output during acute or evolving myocardial infarction.The purpose of this chapter is to depict up-to-date strategies and attitudes toward coronary operations in chronic Ebook Coronary artery bypasses: Part 2 or acute heart failure, focusing on personal experience with ischemic cardiomyopathy and acute coronary syndromes complicated by pump dysfunction orEbook Coronary artery bypasses: Part 2
shock. Emphasis will be given to the selection of patients, evolving technology. technical strategies, and ultimately to the limitations of isolated cIn: Coronary Artery BypassesEditors: Russell T Hammond and James B AltonISBN: 978-1-60741-064-5 ©2009 Nova Science Publishers, Inc.Chapter I/Coronary Ebook Coronary artery bypasses: Part 2assolunghi et al.Coronary artery bypass grafting (CABG) relies on worldwide experience gained during over torn- years since the first clinical successful senes of patients [1J- In spite of technical reproducibility, low risks and predictable results, patients with associated left ventricular (LV) dy Ebook Coronary artery bypasses: Part 2sfunction carried a high if not prohibitive operative risk during the pioneering and early era of coronary surgery. Indications for CABG have broadeneEbook Coronary artery bypasses: Part 2
d during the last two decades, but many institutions arc still reluctant to offer surgery in higher-risk settings, namely, severely depressed systolicIn: Coronary Artery BypassesEditors: Russell T Hammond and James B AltonISBN: 978-1-60741-064-5 ©2009 Nova Science Publishers, Inc.Chapter I/Coronary Ebook Coronary artery bypasses: Part 2reThe most common modality of cardiovascular death is refractory heart failure secondary’ to coronary artery disease. Although patients undergoing isolated CABG represent a lower-risk population among cardiac surgical candidates. LV dysfunction represents an independent risk factor for hospital and Ebook Coronary artery bypasses: Part 230-day mortality. This IS most often depicted by a poor I.v ejection fraction (LVEF). particularly when lower than 30-35%. a higher New’ York Heart AsEbook Coronary artery bypasses: Part 2
sociation functional class or. even more dramatically, a low output state and the requirement for inotropic support, which all represent typical variaIn: Coronary Artery BypassesEditors: Russell T Hammond and James B AltonISBN: 978-1-60741-064-5 ©2009 Nova Science Publishers, Inc.Chapter I/Coronary Ebook Coronary artery bypasses: Part 2ysfunction and concurrent angina pectoris, which traditionally underlies a potential for viability and thus for contractile recovery' [4]. Conversely, indications for CABG in case of prevalent heart failure symptoms have been outlined more recently [5-7].Indications for RevascularizationSelection of Ebook Coronary artery bypasses: Part 2 patients remains controversial, and is even more complex in the younger age group with advanced heart failure, which might be potentially consideredEbook Coronary artery bypasses: Part 2
for transplantation. However, good long-term survival. as late as 10-to-15 years after CADG. can be anticipated in selected subgroups of patients [7],In: Coronary Artery BypassesEditors: Russell T Hammond and James B AltonISBN: 978-1-60741-064-5 ©2009 Nova Science Publishers, Inc.Chapter I/Coronary Ebook Coronary artery bypasses: Part 2n of coronary atherosclerosis well correlates with I.v dysfunction. The quality of distal coronary territories is an obvious issue and diffuse distal disease W'ith poor peripheral run-off. which is worsened by higher intraventricular diastolic pressures, has been outlined as a strong pedictor of a p Ebook Coronary artery bypasses: Part 2oor outcome in these patients [6J. How’ever. the definition of an unfavourable surgical anatomy cannot be standardized and must be judged on an indiviEbook Coronary artery bypasses: Part 2
dual basis. Furthermore, vascular wallCoronary Artery Bypass Grafting for Chronic and Acute Heart Failure 113remodeling has been outlined in experimenIn: Coronary Artery BypassesEditors: Russell T Hammond and James B AltonISBN: 978-1-60741-064-5 ©2009 Nova Science Publishers, Inc.Chapter I/Coronary Ebook Coronary artery bypasses: Part 2more severe and proximal coronary stenoses as a pre-requisite to render CABG equally appealing. The best candidates are those presenting with left main or triplevessel disease, severe and proximally-located stenoses, and undiseased distal branchesMyocardial ViabilityDifferent imaging techniques may Ebook Coronary artery bypasses: Part 2be employed for the detection and quantification of myocardial viability. These include single photon emission tomography, positron emission tomographEbook Coronary artery bypasses: Part 2
y, magnetic resonance imaging techniques, and echocardiography [9-13]. Stresstests are often performed following inotrope infusion. typically dobutamiIn: Coronary Artery BypassesEditors: Russell T Hammond and James B AltonISBN: 978-1-60741-064-5 ©2009 Nova Science Publishers, Inc.Chapter I/Coronary Ebook Coronary artery bypasses: Part 2n-viable myocardium may not always be clear-cut. The degree of segmental viability is derived measuring respective uptake of specific tracers, which indicate a metabolic shift toward glucose consumption (positron emission tomography), the integrity of cellular and mitochondrial membranes (nuclear sc Ebook Coronary artery bypasses: Part 2intigraphy), or the amount of tissue fibrosis (magnetic resonance). Wall motion segmental assessment can also be performed with various techniques, buEbook Coronary artery bypasses: Part 2
t IS more straightforward with echocardiography. The latter and magnetic resonance also allow the analysis of ventricular wall thickening during the cIn: Coronary Artery BypassesEditors: Russell T Hammond and James B AltonISBN: 978-1-60741-064-5 ©2009 Nova Science Publishers, Inc.Chapter I/Coronary Ebook Coronary artery bypasses: Part 2n of the probability of reverse LV remodeling, irrespective of associated angina [14], Some institutions indicate CABG without preoperative viability testing [6]. but the absence of akinetic and viable segments, commonly termed hibernating myocardium, correlates with a worse outcome. Particular effo Ebook Coronary artery bypasses: Part 2rts have been devoted to quantify the amount of hibernating myocardium to predict a successftil operation and thus to sen e as a reference for approprEbook Coronary artery bypasses: Part 2
iate selection of patients. At the beginning of our experience in the late Eighties, screening for myocardial viability in angina-free patients was unIn: Coronary Artery BypassesEditors: Russell T Hammond and James B AltonISBN: 978-1-60741-064-5 ©2009 Nova Science Publishers, Inc.Chapter I/Coronary Ebook Coronary artery bypasses: Part 2nts (anterior, septal, apical, lateral, inferior) with critically stenotic coronary tributaries [7] Nowadays, the LV is subdivided into the 16 segments which abitually sene for regional wall motion analysis at echocardiography, and the presence of a minimum of 4 akinetic and viable segments has been Ebook Coronary artery bypasses: Part 2 identified as a predictor of reverse LV remodeling after CABG. During decision making, however, the surgeon should keep in mind the limitations of isEbook Coronary artery bypasses: Part 2
olated CABG in patients with more advanced cardiomyopathy This point is discussed in a separate sectionSurgical TechniqueBasic principles of CABG techIn: Coronary Artery BypassesEditors: Russell T Hammond and James B AltonISBN: 978-1-60741-064-5 ©2009 Nova Science Publishers, Inc.Chapter I/Coronary Ebook Coronary artery bypasses: Part 2the114Marco Pocar, Andrea Moneta. Davide Passolunghi et al.decision whether to employ or not cardiopulmonary bypass are of utmost importance in case of LV dysfunction.Cardiopulmonary Bypass and Myocardial ProtectionAlthough off-pump operations have been reported in patients with poor I.VKF [15]. dis Ebook Coronary artery bypasses: Part 2placement maneuvers or prolonged exposure of the lateral and posterior LV are undoubtedly less tolerated in case of dilated hearts. During off-pump opEbook Coronary artery bypasses: Part 2
erations patients arc more prone to inttaoperative hypotension or electrical instabilization, which may be as detrimental as ischemia-reperfusion injuIn: Coronary Artery BypassesEditors: Russell T Hammond and James B AltonISBN: 978-1-60741-064-5 ©2009 Nova Science Publishers, Inc.Chapter I/Coronary Ebook Coronary artery bypasses: Part 2grafts-pcr-palicnt have been reported after off-pump operations when compared to conventional (’AB(i [16], and this is likely to represent an even more critical issue in case of LV dysfunction. Thus, traditional CABG with extracorporeal circulation is the favored strategy at our institution Operatio Ebook Coronary artery bypasses: Part 2ns arc performed on moderately hypothermic (32-33 °C core temperature) cardiopulmonary bypass with blood antegrade and retrograde cardioplegia, normotEbook Coronary artery bypasses: Part 2
hermic induction, cold maintaining doses every 20 minutes, and substrate-enriched controlled reperfusion, following Buckberg’s protocols for energy-deGọi ngay
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