It is known that ischemic heart disease is a growing and irreversible process, no matter what medications it is treated with. Today IHD is recognized as the most common cause of sudden deaths, as well as one of the leading causes of death in the population in terms of overall rates (30%).
Considering the fact that this disease is more and more often diagnosed in working citizens (45-50 years old), surgical treatment of coronary artery disease can be called a truly life-saving method of restoring a person's working capacity.
Since it is impossible to restore the lumen of the artery narrowed by an atherosclerotic (cholesterol) plaque with drugs, surgical treatment of ischemic heart disease, in theory, should be recommended to all patients without exception with such a diagnosis.
However, cardiac surgery requires a number of conditions. When determining the indications for surgical treatment, the following main factors must be considered:
- the severity of angina pectoris and its resistance (immunity) to drug treatment methods, that is, the clinical picture of ischemia;
- anatomical data on the damaged coronary bed - localization and degree of damage to the coronary arteries, the type of their blood supply, the number of damaged vessels;
- contractile function of the heart muscle;
- the patient's age.
Among these conditions, the last 3 are of the greatest importance, since the probability of operational risk and the prognosis of the disease without surgery depend on these factors. Evaluation of these factors makes it possible to determine the feasibility or uselessness of surgical methods for the treatment of coronary artery disease. Indications for surgical treatment are:
- multiple damage to the coronary arteries;
- the presence of stem stenosis in one of the arteries;
- the presence of narrowing of the openings of the right and left coronary arteries.
Surgical treatment of ischemic heart disease is not performed if the following contraindications are present:
- less than 4 months after a heart attack;
- with weakening of the myocardium with severe heart failure;
- with reduced contractile function of the heart muscle (with ejection fractions< 0,3);
- with multiple diffuse damage to the peripheral coronary arteries.
Let's consider the surgical methods of treatment of coronary artery disease in more detail.
Indications for surgical treatment of coronary artery disease
Angioplasty and stenting of coronary arteries
Until recently, one of the most frequently used methods of surgical treatment for coronary artery disease was the minimally invasive technique of percutaneous balloon angioplasty, which has lost its relevance today. The reason is too short-term, unstable effect. Later, this technique was supplemented with a procedure that allows for many years to maintain the effect of expanding the lumen of the vessel - stenting, and has become one of the most popular ways to restore the arterial lumen.
Method description
The technique of stenting coronary arteries is almost identical to balloon angioplasty, with the only difference that at the end of the balloon, which is introduced to the patient through a vein, there is a small transforming frame made of metal mesh, called a stent.
- The patient is first given a sedative or local anesthetic.
- Then, through the patient's femoral vein, a special guide - a catheter - is inserted through which a radiopaque contrast agent and a stent are delivered to the narrowed artery.
- The entire operation is carried out under the control of X-ray equipment. When the stent is in front of the atherosclerotic plaque, it is expanded with an inflatable balloon to the size of the vessel.
- The design of the stent rests against the walls of the vessel and keeps them in an expanded state.
Efficiency
To enhance the effectiveness of the procedure, more and more modern types of frames are being developed from high-quality materials - stainless steel or special alloys. A wide variety of stents are produced today:
- not requiring balloon expansion (self-expanding);
- with a special polymer coating, dosed-out drug release for the prevention of restenosis (re-narrowing);
- innovative models of stents - scaffolds, characterized by biological solubility and a low probability of restenosis, which completely dissolve 2 years after the operation.
The latest types of stents are somewhat more expensive in price, but they are more effective.
Possible complications
Surgical treatment by stenting successfully restores normal arterial blood flow in 90% of cases without causing any complications. But in rare cases, negative consequences are still possible. They can manifest themselves:
- bleeding;
- violation of the integrity of the arterial walls (vessel dissection);
- problems with kidney function;
- the occurrence of hematomas at the puncture site;
- thrombosis or restenosis of the stent area;
- seldom (< 0,05%) - летальным исходом.
It is extremely rare that an artery blockage occurs, as a result of which the patient requires urgent coronary artery bypass grafting (5 cases per 1000).
Coronary artery stenting result
Coronary artery bypass surgery
As noted above, there are situations when angioplasty and stenting are impossible, most often due to severe stenosis of the coronary artery. Then the surgical treatment of coronary artery disease involves a technique that has been worked out for decades - coronary artery bypass grafting (CABG), or filing to the coronary artery "bypass".
Method description
Without a doubt, the coronary artery bypass grafting method can be called the most radical way to restore blood circulation in the artery.
The essence of the method is to create an additional "tunnel" on the damaged artery for blood flow from a piece of a vein or artery of the patient himself (anastomosis).
The material is taken mainly from the large femoral vein or from the radial vein, as well as from the aorta of the forearm.
Today, 3 types of CABG are practiced:
- On a cardiac arrest of a patient with cardiopulmonary bypass.
- On the patient's active heart, without IR connection. This technique reduces the risk of complications, shortens the duration of the procedure and, as a result, accelerates postoperative recovery. This technique is only possible for surgeons with extensive experience.
- Recently, more and more often they resort to minimally invasive (with minimal dissection) technique used both on a working and on a stopped heart with an IC connection. It is distinguished by less blood loss, a decrease in the number of infectious complications, and a reduction in the period of postoperative rehabilitation.
Efficiency
If we talk about the effectiveness of this type of surgical treatment of coronary artery disease, then it can be called the most optimal method that can solve the problem of blood supply in both single and multiple damage to the arteries. CABG has the highest rates of positive outcomes of the operation and the achievement of a sustainable result.
Possible complications
Any surgical intervention, especially such radical as coronary artery bypass grafting, carries the risk of complications. Coronary artery bypass grafting can be complicated by:
- deep vein thrombosis;
- bleeding;
- development or myocardial infarction;
- disorder of cerebral circulation;
- narrowing of the shunt (bypass vessel);
- wound infection, formation of keloid scars;
- systematic pain at the site of the incision and other pathologies.
In fairness, it should be noted that such situations do not happen often.
Stages of coronary artery bypass grafting
External counterpulsation method
In situations where none of the above methods can be applied for various reasons, non-invasive therapy of ischemic disease is proposed in the form of external counterpulsation technique. This technique does not apply to the types of surgical treatment of coronary artery disease, but it is often used in the preoperative period, as well as during postoperative rehabilitation (after 1–2 weeks). And, of course, as a therapeutic agent for damage to small branches of the coronary arteries that cannot be stent or bypass.
Method description
The essence of this method consists in a forced increase in diastolic pressure in the aorta and an increase in perfusion coronary pressure, followed by unloading of the left ventricle at the time of compression (systole) of the myocardium.
The impact of counterpulsation on the myocardium leads to a decrease in its oxygen demand, increased cardiac output and coronary circulation in general.
How is the procedure performed?
- The patient is placed on a couch, electrodes of an electrocardiograph are connected to the chest, the data of which is displayed on the monitor.
- The patient's arms, legs and thighs are wrapped with pneumatic cuffs (similar to a tonometer).
- A sensor is installed on one of the fingers to measure the pulse and display blood flow in the arteries, it also measures the level of oxygen saturation in the blood.
- This whole system works synchronously with the electrocardiogram - at the time of diastole (relaxation of the myocardium and its saturation with blood), air is sequentially injected into the cuffs. This creates a wave of blood directed towards the heart.
- At the time of systole (contraction of the myocardium and the release of blood into the aorta), the cuffs are drastically released from the air, simply deflated, which increases blood flow in the vessels and facilitates the work of the heart.
Numerous studies have shown that this technique of non-surgical treatment of coronary artery disease shows the greatest efficiency with a therapeutic course of 35 hours (one hour manipulation per day for 4–7 weeks).
Cardiac shock wave therapy method
The manipulation associated with cardiac shock wave therapy (CES) also refers to the method of non-invasive, that is, non-surgical treatment of coronary heart disease. But this method has the right to be considered in our article, since it is also used to treat complications of ischemic disease after surgery. And such cases, according to various sources, account for 10-30%.
Today it is still difficult to predict the immediate and long-term prospects of coronary artery disease surgery aimed at direct revascularization (restoration of the vascular system) of the myocardium.
Patients suffering from various forms of conduction and rhythm disturbances, myocardial contractile dysfunction, infarction and postinfarction aneurysm of the left ventricle, widespread cardiosclerosis and other complications are forced to resort to reoperation.
Another option is to take advantage of the opportunities that doom the patient to a painful existence in the confined space of a home or hospital.
The CUVP technique can significantly improve the quality of life of a patient who underwent surgical treatment of coronary artery disease, and is considered the most promising and dynamically developing method of conservative therapy.
Procedure for the procedure
The CUVP procedure is painless, performed on an outpatient basis and does not require the use of anesthesia.
- The patient is laid down on a couch, a machine with a cardio sensor is pressed against his chest, which works on the principle of ultrasound equipment.
- The shock waves are generated in the water-filled container of the therapy head and are transmitted to the patient through a flexible membrane.
- The emission of shock waves is performed synchronized with the ECG in the refractory phase of the cardiac cycle with a targeted effect on the ischemic area.
- The impact of acoustic shock waves stimulates local factors of angiogenesis, which is manifested by the formation of new vascular branches in the coronary blood flow system.
- The total duration of the CUVP course is about 12 weeks. The frequency and duration of each procedure is agreed with the doctor, usually 10 sessions, 30 minutes each, with breaks of several days.
After the CUVP procedure, the patient goes home and goes about his usual business.
What is the best surgical method?
Despite the likelihood of complications, all the options for surgical treatment of coronary heart disease discussed above are highly effective and significantly improve the patient's quality of life. The most radical and effective method is considered to be coronary artery bypass grafting (CABG).
To carry out a particular operation, a number of indications are required, as well as the absence of contraindications.
Therefore, the choice of the method of surgical treatment of coronary artery disease, be it angioplasty, stenting or coronary artery bypass grafting, should be carried out taking into account the individual indicators of each patient separately.
Useful video
You can learn more about the indications for surgery in patients with coronary artery disease, methods of examination before surgery and types of operations in this video:
Conclusion
- Modern therapeutic methods for ischemia include medical and surgical treatment of ischemic heart disease.
- The most popular methods of surgical treatment of ischemia at present are stenting and coronary artery bypass grafting.
- In the intermediate period (before or after surgery), it is advisable to use non-invasive methods - external counterpulsation and cardiological shock wave therapy.
Definition of ischemic heart disease.
Ischemic heart disease, as defined by the WHO Commission, is an acute or chronic dysfunction resulting from an absolute or relative decrease in the supply of arterial blood to the myocardium. This dysfunction is most often associated with a pathological process in the coronary artery system.
For the first time, the syndrome of coronary insufficiency was described in England by Heberden in 1768, who called it “angina pectoris”; 20 years later, his compatriots Jenner end Parry explained the pain behind the sternum with angina pectoris by “ossification of the coronary vessels”. In Russia V.P. Obraztsov and N.D. Strazhesko \\ 1909 \\ described the clinical picture of acute myocardial infarction. Subsequent observations have shown that angina pectoris and myocardial infarction are different stages of the same disease - ischemic heart disease, which is based on coronary artery insufficiency, most often due to atherosclerosis.
IHD is now so common and causes so many deaths that it is called an epidemic disease. Atherosclerosis of the coronary arteries is the leading cause of death in the adult population, especially in highly developed countries. Taking into account the tendency towards “rejuvenation” of atherosclerosis, the problem of IHD treatment is acquiring social significance, since this disease affects the segment of the population that provides scientific, technical and financial progress in most countries.
For a long time, the treatment of ischemic heart disease was considered a therapeutic problem, and indeed, the development of new drugs that significantly improve coronary blood flow and reduce myocardial oxygen demand, which is the basis of the tactics of conservative treatment of ischemic heart disease, has improved the quality of life for many patients. It should be noted that the success of the therapeutic treatment of coronary heart disease depends on the range of drugs used, however, they are mostly expensive, and the patient has to take them constantly for many years, and this also becomes an economic problem. However, with stenosing, and especially occlusive lesions of the coronary arteries, conservative treatment is ineffective. According to the well-known English resuscitator McIntosh \\ 1976 \\, with the conservative treatment of coronary artery disease, the seven-year survival rate of patients with stenosis of 1 coronary artery was 78%, stenosis of 2 coronary arteries - 51.5%, if there is stenosis of 2 coronary arteries with stenosis of the interventricular or circumflex branches, survival rate is only 37.0%.
The Heart Institute \\ Cleveland, USA \\ in 1985 published the statistics of the US Department of Health spending on conservative treatment of coronary artery disease, comparing with the items of expenditure on cancer. Expenses for drugs, hospital expenses, industrial losses, disability costs and funeral costs were included. It turned out that the amount of expenses for the treatment of coronary artery disease was 3 times higher than the cost of cancer.
Thus, the need for surgical care in these patients is clear.
Etiopathogenesis of ischemic heart disease.
The cause of coronary artery disease in most patients is progressive atherosclerosis of the coronary arteries, this is confirmed by studies of pathomorphologists who detect stenosing atherosclerosis of the coronary arteries in 92 - 96.8% of patients who died from myocardial infarction.
However, the role of impaired coronary atherosclerosis in the pathogenesis of ischemic heart disease is ambiguous and it should be considered as a background process that can disrupt the functional capabilities of the coronary system in relation to its adaptation to changing modes of work of the heart / MOS at rest 4 - 5 l / min., For a sprinter at the finish to 40 l / min. Speaking about the role of functional factors in the pathogenesis of myocardial infarction, they usually mean the spasm of the coronary arteries, which alters the ability to regulate blood flow in the myocardium and lead to pronounced metabolic abnormalities, the production of catecholamines, which increase myocardial oxygen demand. Thus, even with unchanged blood flow in the coronary vessels, acute myocardial hypoxia may occur.
Risk factors for the development of coronary artery disease:
- age and gender \\ men over 40 years old \\;
- burdened heredity;
- limited physical activity;
- hypertonic disease;
- obesity;
- smoking;
- chronic infections;
The clinical picture of angina pectoris and acute infarction was examined in detail at the departments of the therapeutic profile, we will be interested in the problems of anatomy, diagnosis and surgical directions in the treatment of coronary artery disease.
The blood supply system of the heart.
1. System of coronary arteries
- right coronary artery - has 3 branches or segments;
- left coronary artery - has 7 branches or segments;
2. Type of blood supply
- left \\ optimal \\;
- right \\ most dangerous \\;
- balanced \\ moderately dangerous \\;
Upon admission to the deck aviation department of the Air Force Higher Academy - West Point, USA, officers undergo coronary angiography to determine the state of the coronary arteries and the type of blood supply. Pilots are admitted only with the left type of blood circulation, which provides the best blood flow in the myocardium during stressful situations.
3. Collateral blood supply to the heart
- from small branches that supply blood to the aortic wall,
lung tissue, bronchial branches;
- from the arteries of the pericardium;
- directly from the chambers of the heart;
Thus, it is possible to improve the blood supply to the heart only by direct revascularization of the coronary arteries or by increasing collateral blood flow.
Diagnosis of ischemic heart disease in a surgical clinic is based mainly on the use of instrumental research methods and analysis of general clinical data.
Instrumental research methods
- Ultrasound of the pericardium and heart chambers \\ zones of akinesia, aneurysmal enlargements \\
- MRI of the heart chambers in combination with the vascular program;
- Selective angiography \\ with refractoriness to conservative
treatment methods to assess blood flow disorders; rhythm disturbances not associated with valve pathology; determination of the patency of shunts after direct revascularization; acute myocardial infarction \\
A clear understanding of the localization of the lesion, the degree of narrowing and the state of the peripheral bed of the coronary arteries allow planning surgery for myocardial revascularization.
Surgical treatment of ischemic heart disease.
The lack of sufficiently effective methods of conservative treatment of coronary sclerosis necessitates the development of various methods of surgical treatment of this disease. An important role in the development of various methods of revascularization was played by the emergence of artificial circulation and coronary angiography. Currently, there is no doubt that conservative therapy is ineffective in case of sharp stenosing and occlusive lesions of the arteries. Surgical treatment is shown to create new sources of myocardial revascularization. All surgical methods are divided into indirect and direct myocardial revascularization.
Indirect methods of revascularization.
They appeared at the dawn of coronary surgery and were associated with the lack of artificial circulation, which could protect the body and myocardium from ischemia. At the same time, a number of techniques are still used at present when it is impossible for any reason to carry out direct revascularization or in order to prepare for planned coronary artery bypass grafting. The first operations were aimed at eliminating pain impulses, reducing the basal metabolic rate or fixing organs and tissues rich in blood vessels and collaterals to the myocardium.
Jonesco (1916), Hoffer (1923) and others - cervicothoracic sympathectomy
Blumgart, Levine (1933) and others - thyroidectomy
O. Shaugnessi (1936), P.I. Tofilo (1955), Kay (1954) and others sutured the omentum, rectus abdominis muscle, pectoralis major muscle, jejunal loop, stomach, diaphragmatic flap, spleen and lung tissue to the heart to enhance roundabout blood circulation.
Hudson (1932), Beck (1935), Thompson (1935) - used notches on the pericardium, its scarification and the introduction of talc into the pericardial cavity to create artificial pericarditis and indirectly improve blood circulation.
Fieschi in 1939 proposed ligation of the internal thoracic artery on both sides to increase blood flow along aa. pericardiophrenica, supplying the pericardium and myocardium.
Weinberg in 1946 recommended "tunneling" in the thickness of the wall of the left and, if possible, right ventricle with implantation in the tunnels of both internal thoracic arteries. This operation was used for a long time in Europe and the USA as an alternative to the first attempts at coronary artery bypass grafting \\ Heart Institute, Cleveland 1971 - 3000 operations were performed with 8.5% mortality \\.
Mouse \\ Tomsk, 1980 \\ - the creation of artificial exoendopericarditis without thoracotomy and pericardiotomy, chest fenestration and treatment of the mediastinum outside with talc, is used by the author when coronary artery bypass grafting is impossible due to diffuse coronary artery disease.
The method of laser fenestration of the myocardium (1982 - 1985, Israel) - the creation of a huge number of micro-holes \\ diameter 18 - 24 mmk \\ in the thickness of the myocardium in the region of the left ventricular wall after catheterization of the left ventricle through the interventricular septum, then conducting the fiber and connecting the laser - blood flows directly into the heart muscle, the method is used independently and as a way to prepare for coronary artery bypass grafting.
Direct revascularization methods.
There are two main types of operations that are currently used - this is the imposition of a coronary artery bypass graft with an autovein or a prosthesis bypassing the affected area in conditions of extracorporeal circulation \\ IC \\ with cardioplegia and mammary-coronary bypass, which can be performed without IC.
Bailey (1957), Senning (1962), Effler (1964) - direct endarterectomy from the orifice of the coronary arteries with subsequent autovenous plasty - did not become widespread due to the high mortality due to intraoperative myocardial infarction due to the lack of high-quality coronary angiography.
Sabiston (1962) - Coronary artery bypass grafting with autovenous vein - unsuccessful, death on 2 days after surgery due to stroke
Michael de Beycky (1964), Favoloro (1967) - Coronary artery bypass grafting with a prosthesis and autovein with a successful outcome under cardiopulmonary bypass.
M.D.Knyazev (1971), V.I.Burakovsky, A.V. Pokrovsky (1971) - the first coronary artery bypass grafts in Russia with a successful outcome, performed at the I.S. A.N.Bakulev in the conditions of the IR.
V.I.Kolesov (1964) - operation of mammary-coronary bypass grafting under endotracheal anesthesia in the 1st LMI named after V.I. acad. I.P. Pavlova
Postoperative mortality after CABG according to summary statistics (USA, Germany, the Baltic states, Russia) ranges from 2 to 11.2% and depends on the duration of the operation, the state of the myocardium and the number of shunts applied.
In the group of special risk - operations against the background of acute myocardial infarction, mortality rises to 32 - 52% \\ Review of the Heart Institute, Cleveland. 1980, VI Burakovsky 1997 \\.
Angioplasty.
In addition to the described methods of revascularization in IHD, the method of angioplasty or balloon dilatation of the lumen of the coronary artery is used with vascular thrombolysis or stenting / installation of a metal frame-prosthesis inside the lumen of the vessel (Grunzig, 1977). This method is used as an independent method of treatment, as well as preparation for CABG. The positive effect is achieved in 65% of cases.
Any method of surgical treatment of coronary artery disease is highly effective.
The severity of shortness of breath decreases, angina pectoris decreases or completely disappears. Each method of surgical treatment has its own indications and contraindications.
For the treatment of coronary artery disease are used: coronary artery bypass grafting and coronary angioplasty.
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Ischemic heart disease is the leading cause of premature death in middle-aged people.
In 1960, the first coronary bypass surgery in the history of medicine was performed in the United States by surgeon Robert Hans Goetz.
In Russia, the first bypass surgery was performed in 1964 by the surgeon Professor V.I. Kolesov.
The operation is aimed at:
- reduction or elimination of clinical symptoms in a patient;
- restoration of blood circulation in the heart muscle;
- improving the quality of life.
The essence of the operation is that a new normal blood flow is formed in the place where the coronary arteries are affected. Shunts are used to create new arteries. This helps to prevent irreversible changes in the myocardium, and improves its contractility.
A shunt is a part of a healthy artery or vein that is taken from another part of the patient's body. The shunt can be the radial artery, the vessels of the chest. A synthetic prosthesis is rarely used.
You will find a list of drugs for the treatment of coronary heart disease.
Complications
- sudden closure of an enlarged vessel during surgery or a few hours after it;
- arterial bleeding from the femoral artery;
- sudden cardiac arrest;
- acute heart attack;
- postoperative infectious complications;
- vascular damage by a catheter during surgery;
- the development of acute renal failure.
The above complications are rare. This is due to the fact that thorough preparation of the patient is carried out before the surgical treatment. High qualification of medical personnel and modern surgical equipment are also important.
The following are susceptible to possible complications:
- people aged 65 and over;
- women;
- patients with unstable angina pectoris and those who have had myocardial infarction.
The choice of the method of surgical treatment of coronary artery disease
Methods of surgical treatment of coronary heart disease have found their place in cardiac surgery.
Coronary artery bypass grafting restores normal blood flow to the heart muscle. The heart begins to receive the oxygen it needs. The risk of myocardial infarction decreases, the patient has a chance to prolong life.
Angioplasty surgery gives the same therapeutic effects. But unlike bypass surgery, it has a more gentle method. No large skin incisions are made, the sternum does not come apart. Only the femoral artery is punctured.
But a less invasive method of angioplasty does not guarantee the complete recovery of the patient. Has many complications and risks.
According to research by American cardiologists, mortality after coronary artery bypass grafting is less than that of angioplasty.
There was an increase in life expectancy in patients with unstable angina pectoris.
Atherosclerotic coronary artery disease leads to the development of coronary insufficiency. A characteristic feature of coronary sclerosis is the presence of stenotic narrowing in the proximal part of the main coronary arteries and their large branches. As a result of the obstacle, blood flow to the myocardium in the area of \u200b\u200bdistribution of the affected artery decreases and myocardial ischemia occurs. As a result, a mismatch arises between the need for oxygen in the heart muscle and the ability to deliver it to the heart.
Clinically this discrepancy is manifested by a stenocarditis symptom complex, a characteristic feature of which is pain syndrome. Pain occurs during exercise (exertional angina) or at rest (rest angina) and is localized behind the sternum or in the region of the heart. The clinical manifestations of coronary insufficiency are very diverse and mainly depend on the severity and nature of the spread of coronary sclerosis and the degree of narrowing of the coronary arteries. Currently, along with conservative therapy for coronary heart disease, which is described in detail in the course of internal diseases, surgical methods of treating this disease are widely used.
For myocardial revascularization, indirect and direct operations are proposed.
Among indirect interventions For a long time, Weinberg's operation was widespread: implantation of the internal thoracic artery into the myocardium in the area of \u200b\u200bthe affected coronary artery. Due to the structural features of the myocardium, a network of collaterals develops between the implanted and coronary arteries, through which blood flows into the pool of the stenotic coronary artery, and thus myocardial ischemia decreases. In recent goals, this operation has been abandoned due to injury ethics and comparatively low efficiency.
Currently, the most widespread is coronary artery bypass surgery: Connecting the affected coronary artery below the narrowing site to the ascending aorta using a vascular graft. At the same time, there is an immediate restoration of coronary circulation in the zone of myocardial ischemia, the symptoms of angina pectoris disappear to a large extent, the development of myocardial infarction is prevented, and in many cases the ability to work of patients is also restored. The indication for coronary artery bypass surgery is severe angina pectoris caused by isolated stenosing atherosclerotic lesions of one or more major coronary arteries with a narrowing of the vessel lumen by 70% or more.
Greatest effect this operation gives in patients with preserved and viable myocardium. A special place in the selection of patients for surgery is occupied by selective coronary angiography and ventriculography. With the help of these methods, the anatomy of the coronary circulation, the degree of spread of coronary sclerosis, the nature of the damage to the coronary arteries, the zone of damage to the heart muscle are studied, the ways and mechanisms of compensation for the violation of the coronary circulation are determined.
Coronary artery bypass grafting performed from a median longitudinal sternotomy in conditions of extracorporeal circulation and cardioplegia with active drainage of the left ventricular cavity. The right coronary, anterior interventricular, left circumflex arteries, as well as their largest branches can be shunted. Up to four coronary arteries are shunted at the same time. When coronary insufficiency is combined with an aneurysm of the heart, a defect of the interventricular septum, or a lesion of the valve apparatus of the heart, a simultaneous operation of bypassing the coronary artery and correction of intracardiac pathology is performed.
As a vascular graft in most cases, segments of the great saphenous vein of the thigh are used. Along with them, the internal mammary arteries can be used for shunting. The first successful operations of creating a mammary-corneal anastomosis in our country were performed in 1964 by V.I.Kolesov. In addition, segments of the deep artery of the thigh or the radial artery can serve as a vascular graft.
The adequacy of the restoration of blood circulation in the affected coronary artery depends on the amount of blood flow through the shunt. The mean blood flow through the shunt is 65 ml / min. Restoration of blood circulation in the ischemic myocardium significantly improves its contractile ability: the end diastolic pressure in the left ventricle decreases, the diastolic volume of the left ventricle decreases, and the ejection fraction increases. After the operation, the symptoms of angina pectoris completely disappear or significantly decrease in patients, tolerance to physical activity increases, the patients return to work.
Surgical treatment of acute coronary insufficiency (myocardial infarction) is aimed primarily at the speedy restoration of blood flow in a blocked coronary artery using coronary artery bypass grafting. The most effective operation is performed in the first 4-6 hours after the onset of the development of a heart attack. In cases where acute myocardial infarction is accompanied by cardiogenic shock, an auxiliary circulation can be performed using a counterpulsator. The use of circulatory support makes it possible to perform diagnostic selective coronary angiography and determine the possibility of surgical intervention, as well as to prepare for the operation and the operation itself with a lower degree of risk.
If the symptoms of angina pectoris worsen, medications are ineffective. There is a need for surgery. But modern drug treatment has become much more effective due to a decrease in myocardial oxygen consumption. The main indication for surgery in a pathological condition is the anatomical parameters of the patient. These include the location and number of affected vessels.
Intervention methods
Surgical methods for the treatment of coronary artery disease are aimed at restoring the normal state of the lumen of the arteries. It narrows due to deposits of cholesterol on the blood vessel wall. Medicines in this case do not always help eliminate the problem. The indications for surgical treatment are mainly anatomical.
The goals of surgical treatment in IHD is to restore the lumen of an artery (revascularization) narrowed by an atherosclerotic plaque
- Stenting.
- Coronary artery bypass grafting.
- Revascularization of the coronary vessels.
- Indirect myocardial bypass grafting.
- Heart transplant.
The operation for ischemic stroke is carried out depending on the indications at the discretion of the doctor.
Stenting
It is a unique way to normalize blood circulation to and from the heart. Normally, it is supplied with blood from the coronary arteries that extend from the aorta. Near each artery is a coronary vein, which provides blood flow from the heart. In coronary artery disease, the coronary artery is blocked by a plaque. It interferes with the flow of blood, but does not affect the veins. The essence of the intervention is to create a channel between the coronary blood vessel and the narrowed lumen of the artery with a special catheter.
Intra-aortic balloon counterpulsation is usually performed through the femoral artery
The operation takes 2 hours without anesthesia. The lumen of the blood vessel that carries blood from the heart muscle to all parts of the body is restored by the introduction of a stent. It is a metal mesh tube. Using X-ray, the location of the stent opposite the plaque is selected. The tube expands with an inflatable balloon. All manipulations are carried out through the femoral vein using a catheter. Local anesthesia is used, so the patient is aware of what is happening to him and follows the doctor's commands. The success of the intervention is related to the quality of the tube materials. There are stents that open on their own, and some, after insertion, even release medicinal substances themselves. The operation restores the lumen of the blood vessel, normalizes blood flow and relieves pain. But it is impossible to completely cure atherosclerosis, therefore, it is imperative to observe preventive measures. A common complication after surgery is plaque reappearance. In this case, the operation is repeated. With ischemic heart disease in a stable condition, drug therapy is indicated instead of surgery.
Coronary artery bypass grafting
Ischemic heart disease is the main cause of death in people of working age. The essence of the intervention lies in the complete normalization of the process of blood supply to the heart and the movement of blood through the arteries with a narrowed lumen. The coronary arteries and the main artery are connected by shunts.
This is the standard surgery for blockages in the coronary arteries.
If ischemic heart disease is diagnosed, indications for intervention are as follows:
- angina pectoris refractory to drug therapy;
- complications from myocardial infarction;
- heart failure;
- ventricular arrhythmias;
- atherosclerosis.
Surgical intervention is performed for patients aged 30 to 55 years. In older people, atherosclerosis also affects other arteries. Usually the number of shunts does not exceed five. An artificial heart-lung device is used.
A large saphenous vein (GSV) located in the legs is used for bypass surgery. Its length is from 65 to 75 cm. The doctor selects it and makes a dressing. Then he cuts it off carefully. Due to the high percentage of closure of venous grafts after the end of manipulations, arteries (radial, thoracic) are more often used for the material. Arterial and venous shunts are used for shunting. The effectiveness of the procedure is increased with the use of anterior shunts. But such an operation must be carried out by a highly qualified specialist and is expensive, and the recovery period takes a long time.
During surgery, the heart is temporarily stopped and your body is connected to a machine called a heart-lung machine.
Revascularization of the coronary vessels
The intervention is performed on the working heart muscle. With the help of special medications, the heart rate slows down. The doctor imposes an anastomosis using the thoracic internal arteries (a.thoracica interna). The operation is performed if a pronounced heart disease is detected, in connection with this condition, even a slight stop in the patient's heart can provoke an aggravation of the situation.
Indirect myocardial shunting
In 9% of patients, atherosclerotic plaques are localized in small arteries, while their multiple lesions are observed. Balloon angioplasty cannot be used due to the large number of vessels. Other manipulations are also ineffective. For such patients, indirect myocardial bypass grafting has been created. From the left ventricle, channels are created into the network of capillaries and arteries into the heart. The channels are created by a laser. It creates a channel with a diameter of about 1 mm. From the left ventricle (Latin ventriculus sinister cordis), the oxygen-carrying blood enters the network of cardiac capillaries. At the end of 3-4 months, the channels are closed. But the result of the operation lasts more than 2 years. Such surgical treatment for coronary artery disease is not very common.
Heart transplant
This method is resorted to as a last resort if the heart is severely affected by the pathological process. And also with severe cardiovascular failure. But you need to find a suitable donor. Therefore, less than 1% of patients receive a transplant.
Mini-invasive intervention
Using endoscopic techniques, the doctor connects the branches of the right (right coronary artery) or left (left coronary artery) coronary artery with a blood vessel that conducts blood from the heart muscle to the mammary gland. In this case, trauma is reduced, and the device "artificial heart - lungs" is not needed. The recovery period takes less time.