Coronary artery disease

Weihua Zhang

Department of Cardiovascular
Surgery
the First Affiliated Hospital
Zhengzhou University
Ⅰ. Physiology of coronary circulation
 Coronary blood flow
 delivers: O2 and metabolic substrates
 removes: CO2 and metabolic byproducts

 The volume of coronary blood flow is

250ml/min, accounts for 5% of cardiac output
under normal condition, which is a high rate of
energy use compared other organs.
 The extraction of O2 in the coronary bed is very high,
averaging 75% under normal condition and increasing to
nearly 100% during stress.
 Coronary artery blood flow occurs primarily during
diastole. (coronary perfusion pressure, CPP)
 Under a specified coronary perfusion pressure myocardial
blood flow is determined by autoregulation of regional
arteriolar resistance modulated by local metabolic
demands. Therefore, coronary flow depends on vessels
patency and arteriolar resistance . (Importance)
 Pathophysiology of the heart
 The energy demands of the heart are so great
that the entire ATP content of the heart turns
over every 4 to 5 seconds.
 Therefore, the heart cannot tolerate ischemia .
 Coronary occlusion caused commonly by
atherosclerotic plaque leads to: a. immediately
loss of heart function b. myocardial necrosis
within hours
 When an atherosclerotic plaque in a proximal
coronary artery decreased the cross-sectional area by
75% or more, the resistance caused by the plaque
becomes significant. (angina pectoris, myocardial
dysfunction and myocardial infarction after excises or
other factors )
 The mechanism of excise-induced angina (relative
ischemia) and infarction (necrosis begins after 15-
20min , irreversible, >4-6h)
 Coronary artery disease includes:
 atherosclerotic coronary artery disease
 Coronary vasospasm
 Trauma of coronary artery
 Caused by syphilis (aortitis cause the stenosis
in coronary ostia)
 Inflammation
 Congenital malformation of coronary artery
 All of them may lead to coronary occlusion and
narrow
 But coronary atherosclerosis is the most common
cause of coronary narrowing and occlusion,
atherosclerotic coronary artery disease (CAD) is
much more common than others
 Coronary artery disease discussed commonly by us
usually refers to atherosclerotic coronary artery
disease, because which is the most common cause of
death in the western countries.
Surgical management of
coronary artery disease

1. Bypass grafting for CAD

 Historical aspects
 Bypass grafting for CAD was developed between
1967 and 1968 in US.
 In the 1970s, it was widely adopted as the operation
became simpler and safer. The introduction of
potassium cardioplegia greatly facilitated both use
performance and safety of the procedure.
 Several major changes occurred in the 1980s.
the use of mammary artery (LIMA, bilateral
mammary grafts and sequential mammary grafts)
 Drug therapy and angioplasty
 Frequency and epidemiology
 In United States, CAD causes more than 600,000
deaths annually.
 The disease is more common in men in the first five
decades of life, with a male/female ratio of about 4:1.
 According to worldwide epidemiologic studies,
frequency: Finland(1), USA(2), Japan(lowest).
 The disease is seldom found in populations in which
the average cholesterol concentration is below
200mg/100ml
 The frequency of deaths from CAD increases 2-4
times with each decade of life.
 Etiology
 Coronary atherosclerosis is a disorder of lipid
metabolism of unknown origin.
 There are three major theories now :
a. the response of injury
b. the lipogenic hypothesis
c. the monoclonal hypothesis
 Several risk factors clearly had been recognized as
increasing the frequency of coronary disease.
 The major ones include cigarette smoking,
hypertension, hypercholesterolmia, diabetes, and severe
obesity.
 Additional risk factors include increasing age, male sex,
and the family history.
 Lack of physical exercise or stress are plausible factors
but they lack scientific proof.
 Among the different risk factors, tobacco
smoking has a very strong adverse effect.
 Hypertension is another strong risk factor.
 Many studies have found an association
between high blood cholesterol levels and an
increased frequency of coronary disease.
 Any cholesterol level above 200mg/dl is
associated with an increased risk, especially
levels above 240mg/dl.
 Pathology
 Coronary atherosclerosis occurs primarily in the
proximal portion of the three major coronary arteries
within 5cm of their origin from the aorta, fortunately,
the part of distal arterial segments is usually patent.
 Coronary atherosclerosis is a diffuse process, the
severity of which is easily underestimated by the
arteriogram.
 The terminology of single-, double-, triple- vessel
disease is usually used to designate the number of
major coronary arteries involved.
 Many patients with severe disease have triple-
vessel involvement. A common pattern is
stenosis or occlusion of the proximal portion
of RCA, LAD and LCX, however, which are
usually patent in the distal parts of them.
 The fortunate segmental variation is the basis
for bypass grafting.
 A 50% decrease in the diameter of coronary artery,
corresponding to a 75% reduction in cross-sectional
area, decreases blood flow a moderate amount.
 A reduction of two-thirds in diameter , corresponding
to a reduction in cross –sectional area of about 90%
represents severe stenosis.
 Generally, 50% diameter=75% area;75% D=95%
area; 88% D=98% area
 The two dominant factors the determine
prognosis are the number of vessels involved
and the function of the left ventricle.
 Left ventricular function is expressed as
ejection fraction.
normal: 60-75%
mild to moderate depression of LV function :
40-60%
moderate depression: below 40%
severe depression: below 30%
 The influence of ventricular function
on prognosis is striking.
 With ventricular dysfunction before
operation, the 5-year survival rate
after operation decreased to 40%.
 Clinical considerations
 Progressive myocardial ischemia can cause three
serious events: angina pectoris, myocardial infarction
and sudden death.
 Angina typically appears when myocardial O2
consumption is increased from exercise, eating or
emotional stress.
 80% of patients angina is “typical”. In at least 15-
20% of cases, angina is “atypical” can mimic many
diseases commonly including esophagitis,
esophageal hiatal hernia, cholecystitis, bursitis.
 Unfortunately, a number of patients,
probably 10 to 20%, do not have
angina despite continuing myocardial
ischemia.
 Such silent ischemia has been
recognized with increasing
frequency, primarily by 24-hour
monitoring with an ECG.
 Unstable angina is an important clinical
syndrome that is intermediate between classic
angina and myocardial infarction.
 This syndrome probably comes from acutely
decreased regional myocardial flow produced
by rupture of an atherosclerotic plaque with
subsequent thrombosis.
 Therefore, it is an acute medical emergency.
 Myocardial infarction is the most common
serious life-threatening complication.
 Infarction is usually results from acute
thrombosis of the diseased coronary artery.
 The significance of the infarction depends on
how much the myocardium is injured.
 Sudden death is the most common form of
death from coronary disease.
 Laboratory evaluation
 CAD usually produces no abnormalities on physical
examination. Therefore, the diagnosis of CAD
depends on eliciting a history of angina or previous
infarction. Unless angina is present, CAD can be
detected only by lab studies.
 A heart of normal size on chest film
 ECG, exercise ECG
 Radionuclide angiography to measure myocardial
contractility, EF value
 Observe the LV wall movement with echocardiography.
 Coronary angiography
 It is the crucial diagnostic study for CAD. (the
best method , golden standard)

 Moderate stenosis is present with a diameter

reduction of 50%; severe stenosis 70%.
 Treatment
 Medical therapy
 Angioplasty
 Bypass surgery
 Medical therapy
 It should be performed individually.
 The most important three measures:
 Cessation of smoking
 Control of hypertension
 Dietary modification to lower blood cholesterol below 200mg/dl

Additionally, Treatment of diabetes, Weight reduction and physical

exercises
 Drug therapy includes aspirin, nitrates, beta-
adrenergic blockers and calcium channel blockers.
 Details of medical therapy is beyond the scope of this
lecture.
 Angioplasty
 PTCA, dilate the vessels with the balloon
 For the patients with Single-, double –vessel
lesions, it has usually been done.
 Interventional cardiologists work

3-4% myocardial infarction, a small

percentage require emergency bypass.
Long term results are uncertain
 Coronary artery bypass
1. Indication
 The patients with frequent attack of angina or without
angina relief during medical therapy.
 The patients with left-sided main disease or severe
triple-vessel disease confirmed by CAG .
 The patients with severe single or double-vessel
disease, which couldn’t be treated by intervention as
diffuse lesion or lesion’s position.
 Failure of PTCA or restenosis after PTCA.
 The patients with unstable angina
and triple-vessel disease,
unavailability of medical therapy,
myocardial ischemia indicated by
ECG need emergency bypass.
 50%, distal patent, 1.5mm, EF.30%
 Contraindications to
operation
 Contraindications to operation
diffuse lesion, distal lesion
the area of infarcted myocardium is too
large
the significant enlargement of the heart
EF<20%
right ventricular failure or renal or
hepatic dysfunction .
 High risk factors for
operation
 Age, weight, female, EF, PAH,
hypertension, diabetes, stoke history,
AMI history, combined with valve
disease and ventricular aneurysm,
unstabele angina, LIMA as graft,
shock
 Grafts: IMA, GSV, radial artery, right
gastroepiploic artery , inferior epigastric artery
, subscapular artery.
 Technique of graft procurement
 Technique of coronary grafting
 Coronary grafting techniques
 The distal anastomosis
From heel to toe
 The aortic anastomosis
 Sequential anastomoses
 Off-pump CABG
 endarterectomy
 Postoperative care
 In the first 12 to 24 hours after operation, Bp,
ventilation, bleeding, cardiac output,
arrhythmias should be considered.
 Complications
 Stroke
 Myocardial infarction
 Renal failure
 Wound infection