Surgical treatment of ischemic heart disease indications and contraindications. Surgical treatment of coronary heart disease: history and modernity

Question: Hello!

My grandmother is 86 years old, in good health, cheerful, but a year ago she was diagnosed with coronary artery disease. She has an inguinal hernia; previously, the surgeons who looked at her told her to “be patient, do nothing, or take your responsibility” - because of her age and heart. But the hernia is growing... I would like a “second opinion” from the Internet: is everything right, surgery is impossible? and in the event of a strangulated hernia, a critical condition, what to do?

Thanks for your answer in advance.

Answer: Good afternoon. Coronary heart disease (CHD) is a fairly common disease; according to statistics, it affects about 14% of the population of the Russian Federation, and in the age group over 70 years old the total is more - about 50%. One of the results of such a high prevalence of IHD is the constant readiness of doctors to treat various types of problems (complications) of this disease. That is, IHD itself is not a big problem for doctors, and is also a contraindication to surgery and anesthesia. The specific form of this disease is important, so elective surgery will be contraindicated if your grandmother has angina of a high functional class (FC 3-4).

Elderly and senile age are certainly not a contraindication to surgical treatment; for example, in Europe, patients of this age are the rule rather than the exception. Thus, most likely, there are no objective obstacles to performing the necessary operation (provided that the grandmother does not have other diseases that you forgot to report).

What to do? If the doctors at your hospital doubt the final outcome of the operation and anesthesia, then I would not perform the operation in such a place, since, most likely, the doctors’ doubts are an indicator of their low professional level rather than the severity of your grandmother’s health condition. Therefore, try seeking advice from a higher level clinic.

As for the risks, they always exist, whether in a young absolutely healthy person or in an elderly sick patient. Only in the first case they are smaller, in the second – larger, but they are still present in both. Based on the description you gave (“health is not bad, cheerful...”), it seems that your grandmother’s health is actually not that bad, therefore, she has an average statistical risk. All the best!

Question: Dear doctor, thank you very much for your detailed and prompt answer! Thank you for not ignoring our problems and helping with valuable advice! I wrote to you about shortness of breath, if you remember (I’m preparing for rhinoplasty). I wrote that I suffer from frequent headaches. As it turned out, this was low blood pressure. It was always 90/60 and didn’t seem to bother me, but apparently, with age, the normal pressure for the body also changes... When the pressure drops, a terrible piercing pain begins in the area of ​​the left temple and covers the lower part, I drink coffee - it goes away instantly. 100/70, I already feel good. After it turned out that the cause of the headache is low blood pressure - I drink coffee every morning at work, otherwise it starts again... Doctor, please tell me, in this case, can I perform an operation and give anesthesia? Very scary. Moreover, you go into surgery with an empty stomach, and I have no headache without coffee. Can blood pressure drop significantly during anesthesia? Is it all controlled? I'm very scared, I think I'm going to die :(

Answer: Hello again. Habitually low blood pressure is not a contraindication to surgery. Any anesthesia can indeed cause a decrease in blood pressure, but when such a tendency appears, the anesthesiologist immediately administers special drugs intravenously that instantly increase and stabilize the functioning of the cardiovascular system. Therefore, you should not worry about this either. Out of curiosity, I looked through my database of outpatients (mostly young women), and it turned out that 5.5% of them had a systolic (“upper”) blood pressure of no more than 90-95 mmHg. Art. In general, low blood pressure is not such a rare situation. All the best.

Question: Good afternoon, dear doctor! Please advise: is it possible to perform a cholecystectomy on my mother, she is 63 years old, according to the results of ultrasound and MRI, the gallbladder does not function, it is completely clogged with stones, without gaps, concomitant diseases: ischemic heart disease, arrhythmic variant, NRS of the type of constant normo-tachysystolic form, fibrillation atria, CHF 1 FC 2. Mitral valve insufficiency grade 1-2, IDC grade 1-2. There is also a cyst on the tailbone, i.e. She cannot lie on her back for a long time. What should we do??? Do a surgery? Will her heart withstand anesthesia and how will she feel after the operation? Will anesthesia affect the state of health and in particular the flicker, how will it work?

Answer: Hello. The concomitant diseases you described are not contraindications to anesthesia and surgery, the only exception being atrial fibrillation, or rather its form. It is safe to perform a planned operation at a heart rate of less than 100 per minute, that is, with a normosystolic form of arrhythmia. The normo-tachysystolic form indicates that the pulse varies in the direction of periodically exceeding the limit of 100 beats per minute. That is, before going for surgery, you need to treat the arrhythmia well - to achieve a normal heart rate (normosystolic form). This issue should be resolved by your local physician or cardiologist.

Carrying out anesthesia against the background of heart disease is, of course, a certain risk. According to the cardiac risk index, your mother belongs to the second class, meaning the probability of developing life-threatening complications is about 2.5%. What are these possible complications? Acute heart failure, severe arrhythmia, myocardial infarction. 2.5% - the probability does not seem to be great, but it is quite real. What needs to be done to avoid this risk? First of all, adequately prepare for the operation (the main role here should belong to the cardiologist, that is, you need to try to find a good specialist). And, secondly, the anesthesiologist who will perform anesthesia must be a truly experienced and professional doctor (he will do everything possible to ensure that the heart endures and withstands the planned operation).

As for the cyst, you need to consult with surgeons. It will not affect the anesthesia in any way, but it may affect the course of the postoperative period. It is important to know whether the mother will be able to remain on her side after the operation: is this possible after the planned operation; will it cause pain; that if there is a need to transfer to the intensive care unit, where all patients are lying on their backs, all these questions need to be asked to the surgeon. If something is not possible, then surgery to eliminate the cyst should be considered.

All the best!

Question: Does anesthesia affect potency?

Answer: Good night. No, anesthesia does not affect potency in any way; dozens of studies have been devoted to this topic in the West, none of which have revealed any negative aspects of general anesthesia on potency. As for regional anesthesia techniques (in particular), yes, there is an opinion that after it is performed, men may experience some problems in the sexual sphere.

All the best!

Question: Hello! I would like to get an answer to my question. My mother is undergoing surgery to remove a nodular goiter (4 cm), can the operation be performed under local anesthesia? Because a month ago she suffered clinical death due to coronary angiography; she had persistent asystole when contrast was administered. In the post-resuscitation period, the presence of 5 fractures was revealed: 4 rib fractures, 1 sternum fracture, pneumonia, infiltrates from the subclavian, bursitis from a contusion of the shoulder joint, for resuscitation measures. Psychologically, she is afraid to undergo general anesthesia. Please tell me when, judging by the indications, I can go for the next operation, and what anesthesia is indicated?

Answer: Good evening. Typically, nodular goiter is operated on under general anesthesia, although some surgeons also use local anesthesia. Basically, the choice of anesthesia method depends on three things: the standards accepted in the hospital (in other words, traditions), the experience of the surgeon (not every surgeon can perform high-quality local anesthesia), and the anatomy of the goiter (size, relationship with nearby tissues and organs). Therefore, only the surgeon who will perform the operation on your mother can tell you whether it is possible to perform the operation under local anesthesia.

As for possible anesthesia. Asystole due to the administration of contrast is not a rare situation, and is one of the known and always expected complications of coronary angiography, that is, it is a complication of coronary angiography, and not anesthesia. Therefore, the asystole that has occurred, by contrast, is in no way equivalent to possible difficulties with the upcoming anesthesia. Fractures of the ribs and sternum, pneumonia are also not a contraindication to anesthesia, the only thing is that routine anesthesia will be possible only after the fractures have healed and no earlier than 1 month after complete recovery from pneumonia. “Infiltrates” after installation of a subclavian catheter and bursitis of the shoulder joint are not a contraindication to anesthesia.

What obstacles to anesthesia might there still be? Firstly, this is the condition for which coronary angiography was performed and, strictly speaking, the results of this study. You haven’t said anything about this, but this information is very important. Thus, a recent heart attack (less than 6 months), unstable angina, stable angina of functional class 3-4 will be a contraindication to elective surgery and, accordingly, to anesthesia. Secondly, it is important to know whether stenting of the coronary arteries was performed or not (if a stent is installed, it will be possible to carry out a planned operation no earlier than 3-12 months, depending on the type of stent).

What anesthesia will be indicated? Dozens of anesthesiology textbooks are devoted to the peculiarities of anesthesia for patients with coronary heart disease, so it is simply not possible to present their essence in multiples within the “Questions and Answers” ​​section. However, it is still possible to answer your question: your mother will be shown a professionally performed anesthesia (this is described in sufficient detail in the article “What is it?”).

I sincerely wish your mother health, safe anesthesia and surgery!

The operation for coronary heart disease, when the patency of the distal coronary arteries is preserved, is coronary artery bypass grafting. The operation is performed under conditions of artificial circulation. Operative access to the heart is carried out by longitudinal, median sternotomy. Simultaneously with the sternotomy, vein grafts are isolated and prepared from the great saphenous vein on the leg or thigh. Sometimes a piece of the internal mammary artery is used. The length of the vein graft depends on the number of grafts that need to be used. Hypothermic perfusion (28-30 °C) with hemodilation (hematocrit 25-28%) is performed.

The use of pharmacocold cardioplegia and drainage of the left ventricle makes it possible to provide optimal conditions when applying distal anastomoses of the autovenous vein to the coronary arteries. Based on the data of a preliminary X-ray examination (coronary angiography data), the corresponding coronary artery is isolated from the epicardial bed, its distal occlusion sites are ligated and transected.
If large coronary arteries are completely blocked, the operation can be performed without connecting a heart-lung machine. Before anastomosis of the coronary artery with the autovenous vein, the latter is reversed so that the valves do not interfere with blood flow, and the end of the vein is cut at an angle of 45°. The coronary artery is opened longitudinally distal to the site of narrowing. First, an end-to-end anastomosis is performed between the bypass and the distal segment of the transected coronary artery. This anastomosis is easier to perform using a special bougie, which is passed through a shunt into the coronary artery.

Then the ascending aorta is pressed sideways, an oval hole is cut out in its wall, and an end-to-side anastomosis is performed between the shunt and the aorta. The shunt is placed at right angles to the longitudinal axis of the aorta. The anastomosis is performed with a continuous entwining suture or other methods are used to form an anastomosis. After applying all the distal anastomoses of the shunts with the affected coronary arteries, remove the transverse clamp from the ascending aorta, restore cardiac activity and, pressing the parietal ascending aorta, perform proximal anastomoses. Two or three arteries can be bypassed at the same time.

Mammarocoronary bypass. The main feature of the technique of this operation is that after sternotomy, the internal mammary artery is mobilized from its mouth at the left subclavian artery to the diaphragm. A special retractor is used to lift the edge of the sternum, isolate the internal mammary artery along with the accompanying vein and surrounding fatty tissue, ligating and crossing the lateral branches. The distal end of the artery is ligated above the diaphragm and divided. The central end is then prepared for anastomosis. The coronary artery is opened with a linear incision up to 5 mm long and an anastomosis is performed. In case of complete occlusion of the coronary artery, the anastomosis can be performed end-to-end after crossing the artery below the site of occlusion. The left internal mammary artery is used for revascularization of one of the branches of the left coronary artery system, the right - for the anterior interventricular or right coronary artery.

Angioplasty of the coronary arteries. This is a method of mechanical dilatation of the coronary artery in the area of ​​stenosis using a special balloon catheter. The catheter is passed over a guidewire and the balloon is placed in the area of ​​the narrowed section of the artery. The Seldinger technique is used to pass the catheter through the femoral artery. The balloon is inflated under a pressure of 4-6 atm, gradually expanding the stenotic area. The entire procedure is performed under conditions of heparinization of the patient, using antianginal drugs and calcium antagonists. Dilatation can be performed in the presence of coronary artery stenosis of a length (0.5-1.5 cm). However, during dilatation, myocardial ischemia, infarction, rhythm disturbances, and even fibrillation may develop. Therefore, dilatation is carried out only in the operating room when the cardiac surgical team is ready to perform emergency surgical revascularization of the myocardium in the event of coronary artery thrombosis, intimal detachment and acute myocardial infarction.

Endovascular methods of treatment of arrhythmias, coronary artery disease (balloon angioplasty, stenting), heart defects (closure of VSD, ASD, PDA), surgical (coronary artery bypass grafting, mini-coronary artery bypass grafting, correction of congenital heart defects, arterial prosthetics, aorta are carried out at the Scientific Center for Cardiovascular Surgery named after A.N. Bakulev (Moscow).

Surgical technique for percutaneous arterialization of the coronary vein. This is a unique method of restoring blood supply to the heart, which can replace coronary artery bypass surgery and save the lives of many people with heart disease. Normally, blood flows to the heart muscle through the coronary arteries, which arise from the aorta. Next to each artery there is a coronary vein, through which blood flows away from the heart muscle. In coronary artery disease, a plaque forms in the coronary artery, blocking the flow of blood to the heart. Plaques do not form in veins. The essence of this operation is that, using a special catheter, a channel is created between the narrowed artery and a normal coronary vein.

Technique of surgical intervention. The operation is performed without anesthesia and opening the chest and lasts about 2 hours. To perform this procedure, the femoral artery is catheterized or exposed under local infiltration anesthesia. Next, a catheter with an ultrasound sensor and a special needle is inserted through the femoral artery into the coronary artery, after which the wall of the artery and the adjacent vein are pierced.

This hole is then expanded with a balloon and a tube is inserted, creating a channel between the coronary artery and vein. The vein above the canal is blocked. The loss of one vein does not seriously affect blood circulation in the heart. As a result of the operation, blood begins to bypass the narrowed section of the artery and enters the affected areas of the heart muscle through the vein. It turns out that the direction of blood flow in the vein is reversed and the vein begins to perform the function of an artery.

After this procedure, the patient is under the supervision of doctors for one day, after which he can be discharged from the hospital.

This method will help tens of thousands of patients in whom, due to pronounced changes in the coronary vessels, it is impossible to undergo angioplasty (expansion of a narrowed section of the artery with a special balloon) and coronary bypass surgery.

Drug therapy for coronary heart disease (CHD) does not always produce results. If this happens, they decide to treat coronary heart disease through surgery. Surgical treatment of coronary artery disease is the best option for people of working age, because such treatment helps to get rid of the problem quickly. This means that a person diagnosed with coronary artery disease will be able to restore functionality in a short time.

Angioplasty – a balloon compresses plaques

In what cases is surgery necessary?

If the cause of the development of coronary heart disease is atherosclerotic plaques, it is impossible to remove them with medications, in which case surgical treatment of coronary heart disease is recommended, but this is not the only reason. To carry out such therapy, a number of conditions must be met:

1. The severity of angina pectoris, its resistance. Angina pectoris is not affected by medications that were used previously. This means that there must be a pronounced clinical picture of ischemia.
2. Availability of anatomical information regarding coronary injury. The attending physician must have information about the degree of damage, the type of blood supply, and the number of damaged vessels.
3. The indication for surgical treatment may be the age of the patient.
4. Contractile function of the heart.

Note! Determining the method of treating the disease is based on the last three factors. They will help you understand the risk of surgery and the prognosis for recovery.

Indications for surgical treatment:

• Numerous injuries to the coronary arteries.
• The presence of stenosis in the stem arteries.
• Narrowing of the mouth of the coronary arteries - on the right or left.

Contraindications

When treating IHD, surgery is not used in the following cases:

1. If less than 4 months have passed since myocardial infarction.
2. If the myocardium is weakened by severe heart failure.
3. When the contractile function of the heart decreases.
4. In cases where there are numerous diffuse lesions of the peripheral cardiac arteries.

Treatment methods

There are a number of ways to cure such a disease using a radical method, including:

• Angioplasty and stenting.
• Shunting.
• External counterpulsation and cardiac shock wave therapy are non-invasive techniques that can become an alternative to drug treatment.

Each technique has its own specifics and effectiveness; everything should be considered in detail.

Angioplasty and stenting

Not long ago, the method was popular and often used. This minimally invasive technique is losing its relevance today. The reasons are quite objective - the result does not last for a long period.

But modern techniques make it possible to prolong the effect due to the stenting technique. This technique is similar to balloon angioplasty, but there is a significant difference - at the end of the balloon, which is inserted into the patient’s vessel, there is a frame that has the ability to transform. It is made of a metal mesh, which, when inflated, keeps the vessel in an expanded state. Both procedures are interventional, performed through the vessels without opening the chest or open heart surgery.

Installation of a metal stent in a vessel

Indications for surgery:

1. Unstable angina.
2. Atherosclerotic vascular lesions.
3. Myocardial infarction, including acute.
4. Pathologies of the carotid arteries.

Operation order:

1. The patient is given a sedative or local anesthesia.
2. A catheter is inserted through the thigh vein to the site of narrowing, through which contrast is delivered to the target area, which can be seen by x-ray, and a stent.
3. The operation is performed under X-ray control.
4. When the catheter reaches the target vessel, the stent is expanded using a balloon until it reaches the size of the vessel. As a result, the structure rests against the walls and fixes them in a normal state.

Efficacy and complications

To enhance the effect, the design of frames made from different materials is constantly being improved. Stainless steel and alloys are often used. Today there are stents that do not require balloon expansion - they expand on their own. There are stents with a treatment function, since they have a polymer shell that releases a certain dose of a restorative drug. The latest development is biologically soluble stents, which dissolve after 2 years.

Possible complications:

• Bleeding.
• Vessel dissection.
• Kidney pathologies.
• Hematomas at puncture sites.
• Myocardial infarction.
• Thrombosis or restenosis.
• In less than 0.5% of cases, death.

Bypass surgery

This technique is a real salvation if other surgical methods cannot be used. The most common situation is when the stenosis of the cardiac artery is too severe. The technique has been worked out over decades and many generations of doctors.

The operation contributes to:

• Reducing or decreasing signs of pathology.
• Restoring blood circulation in the heart.
• Improving the quality of life.

Indications:

1. Acute phase of angina, if not treated with medication.
2. Heart attack.
3. Acute heart failure.
4. Atherosclerosis of the arteries of the heart.
5. Narrowing of the lumen by more than 50%.

The bypass technique is currently the most radical method of restoring blood circulation. An additional path for blood is created on the damaged artery. Moreover, such a road is made not from artificial materials, but from the patient’s own veins or arteries. The material is taken from the femoral, radial vein, and aorta of the forearm.

Bypass surgery

There are the following types of bypass:

1. The patient's heart stops and artificial blood circulation is connected to it.
2. On a functioning heart. This method will allow you to recover faster and minimize complications. But it requires a huge amount of surgeon experience to operate.
3. A minimally invasive technique that is used on a beating and stopped heart. In this case, it is possible to achieve less blood loss, reduce various types of complications, and shorten the rehabilitation period.

This technique is considered optimal in the treatment of coronary artery disease. A positive outcome of the operation is observed in the majority of patients. Complications are rare, but they are possible in the following form:

• Deep vein thrombosis.
• Bleeding.
• Arrhythmia, heart attack.
• Cerebrovascular disorder.
• Wound infection.
• Constant pain at the incision sites.

Which is more effective?

It is impossible to answer unequivocally; one or another technique can be used if there are clear indications for it and there are no contraindications. Bypass surgery provides the best result with fewer complications, but it is not a universal solution. The doctor chooses one method or another based on data about the patient’s health status.

The operation will help restore functionality faster

Conclusion

Surgical treatment is considered a radical method of restoring normal heart function. Two effective methods have proven themselves to be positive, but they are used only if drug treatment does not produce results.

More:

Types of heart surgeries and features of the rehabilitation period after them

Over the past 10 years, surgery for coronary heart disease (CHD) has undergone major qualitative and quantitative changes. Against the backdrop of significant advances in drug treatment of coronary artery disease and its complications, surgical methods not only have not lost their importance, but have become even more widely used in everyday clinical practice.

The history of surgery for coronary heart disease goes back about 100 years. It began with operations on the sympathetic nervous system and various types of indirect myocardial revascularization. In the second half of the 20th century, the period of development of direct myocardial revascularization operations began. The priority in creating such methods belongs to V. Demikhov, who in 1952 proposed anastomosing the internal mammary artery with the coronary arteries of the heart. And in 1964, V. Kolesov, for the first time in world practice, successfully performed mammarocoronary anastomosis on a beating heart, thereby marking the beginning of minimally invasive surgery of the coronary arteries. In 1969, R. Favoloro proposed a new direction - the operation of autovenous coronary artery bypass grafting (CABG).

After the widespread introduction of coronary angiography into clinical practice, which allows for accurate diagnosis of lesions of the coronary arteries, methods of direct myocardial revascularization began to develop unusually widely. In some countries, the number of direct myocardial revascularization operations reaches more than 600 per 1 million population. The World Health Organization has established that the need for such operations, taking into account the mortality rate from coronary artery disease, should be at least 400 per 1 million population per year.

Today there is no longer a need to prove the effectiveness of surgical treatment of coronary artery disease using direct myocardial revascularization methods. Currently, operations are accompanied by low mortality (0.8-3.5 percent), lead to an improvement in the quality of life, prevent the occurrence of myocardial infarction (MI), and increase life expectancy in many seriously ill patients.

The most important branch of surgery for coronary artery disease is the method of endovascular (x-ray surgery) treatment of patients with stenotic process of the coronary arteries.

In 1977, Grünzig proposed a balloon catheter, which, by puncturing the common femoral artery, is inserted into the coronary bed and, when inflated, expands the lumen of the narrowed sections of the coronary arteries. This method, called transluminal balloon angioplasty (TLBA), quickly became widespread in the treatment of chronic ischemic heart disease, unstable angina, and acute coronary artery disease. In addition, it is widely used for diseases of the main arteries, aorta and its branches. In recent years, the TLBA procedure has been supplemented by the introduction of a stent into the area of ​​the dilated artery - a frame that holds the lumen of the artery in a dilated state.

Methods of endovascular treatment and surgery for coronary artery disease do not compete, but complement each other. The number of angioplasties using a stent in economically developed countries is steadily increasing. Each of these methods has its own indications and contraindications. Progress in the development of new methods of surgical treatment of coronary artery disease constantly leads to the development of new directions and technologies.

Multifocal atherosclerosis

In this direction, single- and multi-stage operations are used. For example, before direct myocardial revascularization surgery, balloon dilatation of the affected great artery can be done, and then CABG can be performed.

The number of patients with multifocal atherosclerosis is huge. In each specific case, modern diagnostic tools make it possible to identify the arterial basin, the narrowing of which is most dangerous for the patient’s life. Cardiologists and surgeons must determine the sequence of surgical interventions in each of the pools.

Undoubtedly, the most important part of the problem of multifocal atherosclerosis is the combination of ischemic heart disease with narrowing of the arteries supplying the brain.

Ischemic stroke (IS) ranks second as a cause of death in many countries around the world. Together, MI and AI account for about 50 percent. of all deaths in the world. Thus, patients with damage to both the coronary and brachiocephalic arteries (BCA) have a double increased risk of death - from MI and from IS.

According to our data, the frequency of hemodynamically significant lesions of the BCA among patients with coronary artery disease is about 16 percent. We conducted a study of more than 3000 patients with coronary artery disease using non-invasive screening. Along with neurological examination and auscultation of the BCA, the program includes Doppler ultrasound as the main non-invasive method for studying BCA lesions. It is important to note that screening revealed a higher frequency of BCA lesions in asymptomatic groups of patients.

When identifying hemodynamically significant stenoses of the BCA in these patients, including the asymptomatic group, the main role in diagnosis, along with coronary angiography, is played by the angiographic study of the BCA. As a result of the study, we found that damage to the internal carotid artery (ICA) is in first place - 73.4 percent. A fairly significant group consists of patients with coronary artery disease with intrathoracic lesions of the BCA (9.9 percent).

Lesion of the main left coronary artery (LMCA) or multiple lesions of the coronary arteries in severe and unstable course of coronary artery disease in combination with damage to the BCA necessitates a simultaneous operation. For this, the following criteria are available: a single access (sternotomy), from which both reconstruction of the BCA and bypass grafting of the coronary arteries can be performed. We used this approach for the first time, since it makes it possible to avoid serious complications - MI and IS.

When the ICA is affected in patients with coronary artery disease with severe angina and multiple lesions of the coronary bed and/or lesions of the LMCA, we first perform ICA reconstruction to avoid the development of stroke, and then myocardial revascularization. To protect the brain, we have developed a hypothermic perfusion technique in combination with other medicinal methods. Hypothermic perfusion with cooling of the patient to 30 C is protection not only for the brain, but also for the myocardium. During a single-stage operation, careful monitoring of the blood circulation of the brain and myocardium is necessary. The use of this tactic has given good results in preventing the development of stroke.

Another approach is to divide reconstructive operations on the coronary arteries and BCA into two stages. The choice of the first stage depends on the severity of damage to the coronary and carotid areas. In case of severe narrowing of the carotid artery and moderate damage to the coronary bed, the first stage is reconstruction of the carotid arteries, and then after some time, myocardial revascularization. This approach to the selection of indications opens up great prospects in the treatment of this severe group of patients.

Minimally invasive surgery for coronary artery disease

This is a new branch of coronary surgery. It is based on performing operations on the beating heart without the use of artificial circulation (CPB) and using minimal access.

A limited thoracotomy, up to 5 cm in length, or partial sternotomy is performed to maintain stability of the sternum. Both in many clinics around the world and in our center, this method has been used for the past three years. Academician of the Russian Academy of Medical Sciences L. Bokeria introduced this method into the practice of the Scientific Center for Agricultural Sciences. The operation has undoubted advantages due to its low morbidity and the use of minimal approaches. On the 2-3rd day, patients leave the clinic, having spent less than a day in the intensive care unit. The patient is extubated in the first hours after surgery. The indications for this type of surgical treatment are still quite limited: in the leading clinics of the world, the method is used in 10-20 percent. all operations for ischemic heart disease. Typically, the internal mammary artery (IMA) is used as an arterial graft, primarily for bypassing the anterior descending artery. To perform operations and more accurately perform anastomosis on a beating heart, stabilization of the myocardium is necessary.

These operations are indicated in elderly, debilitated patients who cannot use IR due to the presence of kidney disease or other parenchymal organs. Minimally invasive surgery can be performed on the right coronary artery or two branches of the left coronary artery from the left or right approach. After more than 50 operations performed in our center using a minimally invasive technique, there were no complications or deaths. The economic factor is also important, since there is no need to use an oxygenator.

Other minimally invasive surgery methods include robotic surgery. Recently, in our center, with the help of specialists from the USA, 4 myocardial revascularization operations were performed. The robot, controlled by a surgeon, performs the formation of an anastomosis between the coronary artery and the internal mammary artery. But for now this technique is in the development stage.

Transmyocardial laser revascularization of the myocardium

The method is based on the idea of ​​improving blood supply to the myocardium due to blood flow directly from the cavity of the left ventricle. Various attempts have been made to carry out such an intervention. But only with the use of laser technology it became possible to realize this idea.

The fact is that the myocardium has a spongy structure and if multiple holes are formed in it, communicating with the cavity of the left ventricle, then blood will flow into the myocardium and improve its blood supply. In our center, L. Bockeria, after experimental developments and the creation of a domestic laser, together with institutes of the Russian Academy of Sciences, performed a series of transmyocardial laser revascularization (TMLR) operations of the myocardium.

More than 10-15 percent. patients with coronary artery disease have such severe damage to the coronary arteries and especially their distal parts that it is not possible to perform revascularization by bypass. In this large group of patients, the only method to improve myocardial blood supply is transmyocardial laser revascularization. We will not dwell on technical details, but we will point out that transmyocardial laser revascularization is carried out from a lateral thoracotomy without connecting artificial circulation. In areas of the myocardium with a low level of blood supply, many pinpoint channels are applied, through which blood then flows into the ischemic area of ​​the myocardium. These operations can be performed either independently or in combination with bypass surgery of other coronary arteries. In a large group of operated patients, good results were obtained, allowing us to consider the method close in its role to direct myocardial revascularization.

In addition to isolated TMLR, the combination of TMLR with CABG exists and is attracting increasing attention. In a significant proportion of patients with coronary artery disease, complete revascularization cannot be performed due to the presence of diffuse damage to one of the coronary arteries. In these cases, a combined approach can be used - bypassing vessels with a patent distal bed and laser exposure in the myocardial zone supplied by a diffusely altered vessel. This approach is becoming more and more popular because it allows for the most complete revascularization of the myocardium.

The long-term results of TMLR still need to be studied.

Autoarterial myocardial revascularization

Autoarterial grafts have been widely used in coronary surgery since the early 80s, when it was shown that the long-term patency of mammarocoronary anastomosis is significantly higher than the patency of autovenous grafts. Currently, mammarocoronary anastomosis is used both in world practice and in our center in almost all myocardial revascularization operations. Recently, surgeons have shown increasing interest in other arterial grafts, such as the right internal mammary artery, the right ventricular-epiploic artery, and the radial artery. A number of options for complete autoarterial revascularization have been developed, many of which are used in our clinic.

It should be emphasized that there is currently no optimal scheme for complete autoarterial revascularization. Each of the procedures has its own indications and contraindications, and a comparative assessment of the results of revascularization using various autoarteries is being carried out around the world. The general trend today is to increase the proportion of complete arterial revascularization.

Ischemic myocardial dysfunction

Among patients with coronary artery disease, there is a fairly large group of patients with sharply reduced myocardial contractility. Reduced left ventricular ejection fraction (LVEF) has traditionally been considered a major risk factor for CABG surgery. At the same time, adequate revascularization can lead to reversal of myocardial dysfunction in cases where it is caused by ischemia. This is the basis for the increasingly widespread use of direct myocardial revascularization operations in patients with depression of its contractile function. The most important point when selecting patients for surgery is the differentiation of cicatricial and ischemic dysfunction. For this purpose, a number of techniques are used, including radioisotope methods, but today the stress echocardiography method is considered the most informative. As the accumulated experience of surgical treatment of patients with sharply reduced myocardial contractility shows (and more than 300 such operations have already been performed in our center), with correctly established indications, the risk of CABG in this group is not much higher than the risk of surgery in the group of ordinary patients with coronary artery disease. It is important to note that with successful surgical treatment of these patients, long-term survival significantly exceeds survival with conservative treatment.

Transluminal balloon angioplasty and stenting

Endovascular treatment methods are a separate huge section of the problem of treating coronary artery disease. The results of endovascular methods are less stable than the results of CABG, but their advantage is that they do not require thoracotomy and cardiopulmonary bypass. Endovascular methods are constantly being improved, more and more new types of stents are appearing, and a so-called atherectomy technique has been developed, which allows expanding the lumen of the vessel by resection of part of the atherosclerotic plaque before implanting a stent. All these methods will undoubtedly evolve.

One of the new directions is the combination of surgical and endovascular myocardial revascularization. This approach has become especially relevant in connection with the development of minimally invasive surgery. During interventions without artificial circulation, it is not always possible to bypass the vessels located on the posterior surface of the heart. In such cases, in addition to CABG, transluminal angioplasty and stenting of other affected coronary arteries are subsequently performed. The method certainly has good prospects.

It is necessary to attract the attention of a wide range of doctors to the new possibilities of coronary surgery, which has become a powerful social factor in the life of any society. It has enormous potential and leads to the prevention of myocardial infarction and its complications. In the future, its prospects are obvious, and the role of our center as a leading institution in Russia will invariably grow, subject to clear organization, financing and timely referral of patients for surgical treatment.

Professor Vladimir RABOTNIKOV,
Cardiovascular Research Center
surgery named after A.N.Bakuleva RAMS.

The surgical method has become widespread and has become firmly established in the arsenal of means in the complex treatment of patients with coronary artery disease. The idea of ​​creating a bypass shunt between the aorta and the coronary vessel, bypassing the area affected and narrowed by atherosclerosis, was clinically implemented in 1962 by David Sabiston, using the great saphenous vein as a vascular prosthesis, placing a shunt between the aorta and the coronary artery. In 1964, Leningrad surgeon V.I. Kolesov was the first to create an anastomosis between the internal mammary artery and the left coronary artery. Previously proposed numerous operations aimed at eliminating angina pectoris are now of historical interest (removal of sympathetic nodes, transection of the dorsal roots of the spinal cord, periarterial sympathectomy of the coronary arteries, thyroidectomy in combination with cervical sympathectomy, scarification of the epicardium, cardiopericardiopexy, suturing an omental flap to the epicardium leg, ligation of the internal mammary arteries). In coronary surgery, at the diagnostic stage, the entire arsenal of diagnostic methods traditionally used in cardiological practice is widely used (ECG, including exercise testing and drug tests; radiological methods: chest X-ray; radionuclide methods; echocardiography, stress echocardiography). Left heart catheterization allows measurement of end-diastolic pressure in the left ventricle, which is important for assessing its functional capacity, especially if this study is combined with measurement of cardiac output. Left ventriculography allows you to study the movement of the walls and their kinetics, as well as calculate the volumes and thickness of the walls of the left ventricle, evaluate contractile function, and calculate the ejection fraction. Selective coronary angiography, developed and introduced into clinical practice by F. Sones in 1959, is intended for objective visualization of the coronary arteries and main branches, studying their anatomical and functional state, the degree and nature of damage by the atherosclerotic process, compensatory collateral circulation, the distal bed of the coronary arteries, etc. e. Selective coronary angiography in 90-95% of cases objectively and accurately reflects the anatomical state of the coronary bed. Indications for coronary angiography and left ventriculography:

1. Myocardial ischemia detected using non-invasive diagnostic methods
2. The presence of any type of angina, confirmed by non-invasive research methods (changes in the ECG at rest, a test with dosed physical activity, 24-hour ECG monitoring)
3. History of myocardial infarction followed by post-infarction angina
4. Myocardial infarction in any phase
5. Routine monitoring of the condition of the coronary bed of a transplanted heart
6. Preoperative assessment of the coronary artery in patients over 40 years of age with valve diseases.

In recent decades, myocardial revascularization by transluminal balloon dilatation (angioplasty) of stenotic coronary arteries has been used in the treatment of coronary artery disease. The method was introduced into cardiological practice in 1977 by A. Gruntzig. The indication for angioplasty is a hemodynamically significant lesion of the coronary artery in its proximal sections (except for ostial stenoses), provided there is no significant calcification and damage to the distal bed of this artery. To reduce the frequency of relapses, balloon angioplasty is supplemented by implantation of special atrombogenic frame structures - stents - into the site of stenosis (Fig. 1). A necessary condition for performing angioplasty of the coronary arteries is the availability of a ready operating room and surgical team to perform emergency coronary artery bypass surgery in the event of complications.

2015 NMHC named after. N.I. Pirogov.

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SURGICAL TREATMENT OF IHD

Drug treatment for chronic ischemic heart disease is mainly carried out in two ways: 1) increasing blood flow in the coronary arteries to improve the perfusion of ischemic myocardium; 2) a decrease in oxygen demand by ischemic myocardium. Nitrates are strong coronary vasodilators; the vasodilatory effect is predominantly on the venous bed. A decrease in venous blood return helps reduce the myocardial oxygen demand. Beta blockers reduce the frequency and strength of heart contractions, which also helps reduce metabolism in the myocardium. Calcium antagonists are potent coronary vasodilators and are primarily effective in treating coronary artery spasm. In addition, the above groups of drugs reduce blood pressure, thereby reducing afterload. The introduction of drugs that block beta-adrenergic receptors, long-acting nitrates and calcium antagonists into the practice of treating coronary artery disease has significantly improved treatment results. However, there is a large group of patients who require surgical treatment. The development of direct revascularization operations was facilitated by the introduction of coronary angiography. The method of selective coronary angiography was first used at the Cleveland Clinic (USA) by cardiologist F. Sounes in 1959. Currently, coronary angiography is mainly performed using the Seldinger approach through the femoral artery. A special catheter is inserted into the mouth of the coronary artery. Due to the side holes, the catheter does not obstruct the coronary arteries and does not stop the blood flow in them during the study. Then a radiopaque contrast agent is injected, and the systems of the left and right coronary arteries are visualized alternately. The studies are carried out on special angiographic units (Siemens and others). During this procedure, a number of different parameters indicating the state of cardiac activity are also determined (ejection fraction, cardiac index, myocardial contractility, of course, diastolic pressure in the left ventricle and others), and left ventriculography is also performed. During the latter, the presence of a left ventricular aneurysm or areas of thrombosis can be diagnosed.

CABG surgery is performed using extracorporeal cardiopulmonary bypass and cardioplegia on a switched-off (“dry”) heart. Access to the heart is a longitudinal full median sternotomy. Then the ascending aorta, vena cava (or the right atrium with a console) are cannulated, and a cardiopulmonary bypass machine (ACB) is connected. At the same time, the main trunks of the saphenous veins are taken from the lower extremities of the operated patient. The ascending aorta is then clamped and cardioplegic cardiac arrest is performed. Distal anastomoses of the autovenous vein and coronary arteries are performed. The number of shunts applied (2-9, on average - 4) depends on the condition of the coronary bed. To perform a mammary-coronary anastomosis, the left internal thoracic artery is isolated together with surrounding tissues and veins in the form of a vascular-muscular flap (in situ) or by skeletonization. It is mobilized using a coagulator, and its small lateral branches are clipped or cauterized with an electrocoagulator. The right internal mammary artery is primarily isolated by skeletonization. Before completing the occlusion, measures are carefully taken to prevent the occurrence of air embolism. The clamp is then removed from the aorta. Against the background of ongoing prevention of air embolism with the help of a defibrillator, cardiac activity is restored. Next, proximal anastomoses are performed with the ascending aorta and the AIC is turned off. After decannulation, layer-by-layer suturing of the wound is performed, leaving drainage in the pericardial cavity.

IHD - indications for surgical treatment

In 1962, at Duke University (USA), D. Sabiston performed the first direct surgical revascularization of the myocardium using autovenous CABG. Unfortunately, the patient died on the 2nd day after surgery from a stroke.

In 1964 year, Dr. Garret at the M. DeBakey clinic successfully performed autovenous CABG of the right coronary artery for the first time. 7 years after surgery the shunt was patent.

February 25, 1964 year in Leningrad, Professor V.I. Kolesov was the first in the world to perform revascularization of the circumflex artery using. internal mammary artery. He and his group later used two internal mammary arteries for the first time and performed them. operations for unstable angina, acute myocardial infarction.

The massive development of autovenous coronary artery bypass grafting is associated with the name of the Argentine surgeon R. Favaloro, who worked at the Cleveland Clinic in the late 1960s. From May 1967 to January 1971, this group performed 741 CABG operations, and this experience was summarized in a book that described the basic principles and techniques of CABG operations.

In our country, a great contribution to the development of these operations was made by

M.D. Knyazev, B.V. Shabalkin, B.S. Rabotnikov, R.S. Akchurin, Yu.V. Belov.

Surgical treatment of coronary heart disease is one of the main phenomena of medicine of the 20th century. In the United States, 11% of the total healthcare budget is spent annually on surgical treatment of coronary artery disease. Considering the prevalence of IHD among the population of economically developed countries, the number of operations for IHD is growing every year. Despite the development and spread of various types of coronary angioplasty, currently 2,000 coronary artery bypass grafting (CABG) operations are performed per 1 million inhabitants per year in the United States, and 600 in Western European countries. Moreover, in Germany, Sweden, Belgium, Norway, In Switzerland, this figure exceeds 1000 per 1 million inhabitants per year, and government programs have now been adopted to increase the number of centers performing CABG operations. Thus, in Germany, 25 new cardiovascular surgery centers have been opened in the last 2 years. The smallest number of CABG operations in Europe are performed in Romania, Albania and the CIS countries. According to the Scientific Center for Cardiovascular Surgery named after. AN. Bakulev, in 1996 in Russia there were 7 million registered patients with ischemic heart disease. This gives particular relevance to various aspects of surgical treatment of coronary artery disease in Russia. Before we dwell in more detail on the indications for CABG, we present the classification of the American Heart Association, according to which indications for certain procedures are divided into the following classes:

Class I. diseases for which there is general agreement that a given procedure or treatment is useful and effective.

Class II: diseases for which there are different opinions about the usefulness or sufficiency of the operations or procedures performed.

Class II a. most opinions agree on the usefulness or sufficiency of the procedures performed.

Class II b: the futility or inadequacy of the procedure prevails in most opinions on this matter.

Class III: conditions for which there is a general consensus that the procedure will be useless or even harmful to the patient.

The purpose of performing CABG is to eliminate symptoms of coronary artery disease (angina pectoris, arrhythmia, heart failure), prevent acute myocardial infarction and increase life expectancy. The benefits of performing CABG must outweigh the risks of surgery and take into account the individual patient's potential future activity level. The variety of forms and variants of coronary artery disease in combination with many associated factors requires a more careful consideration of the issue of indications for CABG operations.

Indications for CABG surgery in asymptomatic patients or patients with exertional angina of functional class I-II are:

1. Significant stenosis (> 50%) of the trunk of the left coronary artery (LCA).

2. Equivalent to LMCA trunk stenosis - > 70% stenosis of the proximal part of the anterior interventricular branch (LAD) and circumflex branch (CLB) of the LMCA.

3. Three-vessel disease (indications are further enhanced by ejection fraction - EF< 0.50).

Proximal LAD stenosis (> 70%) - isolated or in combination with stenosis of another major branch (right coronary artery - RCA - or OB). Class II b

One- or two-vessel coronary disease that does not include the LAD.

All patients with stenosis of the main branches of the coronary bed< 50%.

Indications for CABG surgery in patients with stable angina pectoris of III-IV functional class are:

1. Significant stenosis (> 50%) of the trunk of the left coronary artery.

2. Equivalent to LMCA trunk stenosis - > 70% involvement of the proximal LAD and OB.

3. Three-vessel disease (the effect of surgery is greater in patients with EF< 0.50).

4. Two-vessel lesion with significant proximal stenosis of the LAD and EF< 0.50 или с очевидной ишемией миокарда при неинвазивных тестах.

5. One- or two-vessel disease without proximal LAD stenosis, but with a large area of ​​ischemic myocardium and symptoms of a high risk of fatal complications identified by non-invasive tests.

6. Persistent severe angina despite maximum therapy. If the symptoms of angina are not completely typical, other evidence of severe myocardial ischemia should be obtained.

1. Proximal stenosis of the LAD with single-vessel disease.

2. One- or two-vessel coronary lesion without significant proximal stenosis of the LAD, but with a middle zone of myocardial damage and ischemia, determined by non-invasive tests.

1. One- or two-vessel disease without involvement of the proximal LAD in patients with mild manifestations of coronary artery disease who have not received adequate therapy, have a small area of ​​myocardial damage or lack of confirmation of myocardial ischemia in non-invasive tests.

2. Borderline coronary stenosis (50-60% narrowing with the exception of the left artery trunk) and the absence of myocardial ischemia in non-invasive tests.

3. Coronary stenosis less than 50% in diameter.

Indications for CABG in patients with unstable angina and non-penetrating AMI are associated not only with improved survival of this category of patients, but also with a decrease in pain and an improvement in quality of life. Some researchers have reported a higher mortality rate after CABG in patients with unstable angina and non-penetrating myocardial infarction and have shown that one of the most important conditions for improving surgical results in these patients is preliminary medical stabilization of the condition of these patients. At the same time, other authors did not find such a strict dependence on preliminary drug stabilization of patients. Indications for CABG in patients with unstable angina and non-penetrating myocardial infarction are:

1. Significant stenosis of the left artery trunk.

2. Equivalent to stenosis of the left coronary artery trunk.

3. The presence of myocardial ischemia, despite maximum therapy.

Proximal LAD stenosis with one- or two-vessel disease.

One- or two-vessel disease without proximal LAD stenosis.

All other options.

In recent years, due to the success of thrombolytic therapy and primary balloon angioplasty, the indications for surgical treatment of transmural acute myocardial infarction (AMI) have been narrowed. Clear indications for surgery with transmural AMI are mechanical complications - acute mitral regurgitation, ventricular septal defect and rupture of the wall of the left ventricle of the heart.

Indications for surgical intervention in patients with transmural AMI without mechanical complications is:

Ongoing ischemia/infarction resistant to

maximum therapy.

1. Progressive heart failure with ischemic myocardium outside the infarction zone.

2. Possibility of myocardial reperfusion in the early stages (< 6 до 12 часов) от развития ОИМ.

Myocardial reperfusion within more than 12 hours from the onset of AMI.

Recently, there has been renewed attention to the treatment of patients IHD with low myocardial contractility, since a number of studies have shown that in these patients with multivessel disease, reversible myocardial ischemia is often present and CABG can lead to stabilization and improvement of the course of coronary artery disease in these patients. A condition should be distinguished when a patient with a low ejection fraction has symptoms of severe angina and ischemia and minimal manifestations of heart failure. In such cases, there are indications for myocardial revascularization. On the other hand, if the patient has severe manifestations of heart failure with a low functional class of angina, additional studies (stress echocardiography) should be performed to ensure that the patient has so-called “dormant” myocardium, the revascularization of which will improve the patient’s condition. However, it is precisely in patients with reduced myocardial function and with damage to the left artery trunk, three- and two-vessel disease (especially with the involvement of the proximal LAD) that one should expect a preferential effect of surgical treatment compared with medication. Considering that large randomized studies in the USA and Western Europe, on the basis of which the above-described indications for surgical treatment of various forms of coronary artery disease were developed, practically did not include patients with an ejection fraction less than 0.30, then we should expect even greater benefits from surgical treatment in these patients compared to therapeutic.

The positive effect of surgical myocardial revascularization has also been shown in patients with ventricular arrhythmias, who have experienced ventricular fibrillation, or who could have ventricular tachycardia or fibrillation on electrophysiological examination. In price

CABG is more effective in preventing ventricular fibrillation than ventricular tachycardia because the mechanism of the latter arrhythmia is more likely to be associated with a “reentry” mechanism in the area of ​​scarred myocardium than with ischemia of the heart muscle. In such cases, additional implantation of a defibrillator-cardioverter is usually required.

For aneurysms of the left ventricle of the heart Indications for surgical treatment are the presence of one of the following conditions:

1. Angina pectoris II-IV functional class according to the classification of the Canadian Heart Association or unstable angina.

2. Heart failure II-IV functional class according to NYHA.

3. Severe heart rhythm disturbances in the form of frequent ventricular extrasystole or ventricular tachycardia.

4. Loose thrombus in the LV cavity.

The presence of a flat, organized thrombus in the LV cavity is not in itself an indication for surgery. Coronary artery stenoses >70% accompanying the LV aneurysm serve as an indication for myocardial revascularization in addition to resection of the LV aneurysm.

Currently, the question of indications for correction of stage II mitral regurgitation in patients undergoing CABG remains debatable. This failure is based on both dysfunction of the papillary muscles as a result of myocardial infarction or transient ischemia, and dilatation of the fibrous ring of the mitral valve as a result of remodeling and expansion of the LV cavity. In cases of mitral regurgitation of III-IV degrees, the indications for intervention on the mitral valve become absolute , with mitral regurgitation of the second degree, these indications are less obvious. It has now been shown that in 70% of such patients, a significant reduction in the degree of mitral regurgitation can be achieved through isolated myocardial revascularization. And only if the degree of mitral insufficiency increases during stress tests in combination with echocardiography, patients are usually indicated for plastic surgery on the mitral valve.