Coronary Artery Disease Flashcards
What are the indications for surgical intervention in AAOCA
Symptomatic or history of aborted SCD - Class 1 B
Asymptomatic left coronary from the right sinus of valsalva - Class 1 B
Symptomatic and if surgical risk high - Class IIa B for PCI
Asymptomatic right coronary from left sinus of valsalva - Class IIa C for stress testing for inducible ischemia
If stress testing negative in AAORCA, patient can participate in competitive sports - Class IIa C
In surgically treated patients where the operation was successful, if patients are asymptomatic and stress test is negative, they can participate in competitive sports 3 months post-operatively - Class IIb C
What are the treatments for AAOCA
Unroofing - done via aortotomy from inside the aorta, it involves incising the common wall between the aorta and the intramural coronary from the inside, then creating a neo-ostium in the sinus that it was supposed to originate from. This technique is the most commonly used (70% of cases), is the easiest to perform but works best in intramural lesions
Re-implantation - detaching the artery from its intramural course and re-implanting it into the correct sinus - easier to do in AAORCA, can be done with a saphenous vein graft as an interposition graft
Ostioplasty -
PA translocation - detaching the PA and re-attaching the distal PA so that the interarterial course of the coronary is eliminated
Bypass - better in older patients, problems with early graft failure due to ischemia occuring during exercise
What is the incidence of coronary artery fistulas? What are the common coronary fistulas? What are the consequences?
Coronary fistulas occur in 0.3% of routine angiograms
Most commonly they drain to the right sided circulation, the PA (15-40%) RV (14-40%), RA (19-26%), coronary sinus 7%, SVC 1%. Left sided drainage is less common (LV 2-19%, LA 5-6%)
Heart failure - long term coronary artery fistulas can cause overloading of the left heart and dilation and heart failure
Coronary issues - dilation of the proximal part of the coronary, coronary steal syndrome, chronic myocardial ischemia, premature atherosclerosis
Endocarditis - increased risk of endocarditis occurs with coronary artery fistulas
Hemopericardium - can occur with rupture of an aneurysmal coronary
What is the treatment for symptomatic coronary artery fistulas?
Treatment of fistulas can be surgical or transcatheter with coils. The requirements for safe and satisfactory closure include the ability to cannulate the coronary artery supplying the fistula, absence of large branches that might be inadvertently embolized, and a single, narrow fistula site.
The major contraindications to catheter occlusion include very young age (size of the catheter is not sufficiently small to be introduced in small coronary arteries), a large and wide fistula, a fistula with multiple communications, a distal fistula, an adjacent vessel at risk, and the need for other concomitant surgical repair.
Surgical options include tying off the fistula, if distal, opening the artery with an arteriotomy and oversewing the fistula from the inside of the vessel or using pledgeted mattresses around the coronary to occlude the fistula from the outside.
How many Americans die of CAD each year?
Half a million
Who developed coronary angiography?
Who is credited with developing coronary artery bypass grafting?
Mason Sones in 1957
Rene Favaloro 1967
What is the CCS angina classification?
0 = No angina 1 = Angina only with strenuous or prolonged exertion 2 = Angina with walking at a rapid pace on the level, on a grade, or upstairs 3 = Angina with walking at a normal pace less than two blocks or one flight of stairs 4 = Angina with even mild activity
What are the criteria for ECG stress testing in CAD?
60-70% sensitive and specific
1mm of ST segment depression has a 90% PPV, a 2mm shift with accompanying angina is virtually diagnostic
Early onset of ST segment depression and prolonged depression after the discontinuation of exercise are strongly associated with significant multivessel disease.
How do surgeons interpret myocardial perfusion imaging?
Reversible defects indicate ischemia and viability
Irreversible defects indicate scar
Sensitivity is around 90% and specificity 75%
How do surgeons interpret stress echo?
An initial augmentation of contractility followed by loss or “drop out” is diagnostic of ischemia and viability, whereas failure to augment contractility at low dose or exercise suggests scar.
What is the definition of a “protected” left main?
A left main is considered “protected” if there is at least one patent bypass graft to the LAD or LCX circulation
What are the class 1 indications for CABG for survival?
ACC/AHA 2011
Unprotected LM disease (B)
Triple vessel disease (B)
Two vessel disease with proximal LAD disease (B)
Survivors of sudden cardiac death with presumed ischemia mediated VT
What are the class 1 indications for CABG for symptoms?
ACC/AHA 2011
1 or more significant stenoses amenable to revascularization and unacceptable angina despite GDMT (A)
What are the class IIa indications for CABG for survival?
ACC/AHA 2011
Two vessel disease without proximal LAD disease with extensive ischemia (B)
One vessel proximal LAD disease with LIMA (B)
LVEF 35-50% (B)
What are the class IIa indications for CABG for symptoms?
1 or more significant stenosis in whom GDMT cannot be implemented (C)
Previous CABG with 1 or more significant stenosis associated with ischemia and unacceptable angina despite GDMT (C)
Complex 3VD (Syntax >22) and a good candidate for CABG (B)
What are the major early trials that showed benefit in CABG?
CASS, Veterans and ECSS
What is the STICH trial?
A trial of 1212 patients with LVEF <35% and CAD amenable to CABG, mortality was 36% in the CABG arm and 41% in the medical arm at 56 months mean followup, however 17% of the medical arm crossed over to the CABG arm. At 10 years, CABG showed significantly less mortality than medical arm (58.9 vs 66.1% from any cause, p=0.02 and 40.5 vs 49.3% from CV causes, p=0.006)
