Principles of surgical treatment of coronary heart disease. Surgical treatment of coronary heart disease

In developed countries, coronary heart disease is one of the main causes of death among people of working age. Coronary heart disease is a cardiac disease characterized by complete or partial disruption of the blood supply to the myocardium due to damage to the heart arteries. Coronary artery disease occurs when the need of the heart muscle for oxygen significantly exceeds the ability of the coronary arteries to transport it.

Therefore, the success of therapeutic treatment of coronary artery disease primarily depends on whether it is possible to change the balance between the delivery of oxygen to the necessary organs and the need for it. The main treatment for coronary heart disease is coronary artery bypass surgery

. Despite the radical nature of the method, which involves surgical intervention, it is the most effective, since if the outcome of the operation is favorable, the patient returns to his previous lifestyle, forever forgetting about heart pain.

What is the essence of coronary bypass surgery? The point of surgery for coronary heart disease is to create a new pathway for blood flow through shunt

, which is superimposed between the coronary artery and the ascending aorta. The result of the operation is the normal movement of blood flow, bypassing the blocked area of ​​the arteries or vessels. The surgeon most often uses the large saphenous vein from the patient’s lower extremities as shunts. It is believed that arterial shunts are more reliable and durable in use, unlike their venous counterparts. According to statistics, approximately 95% of arterial bypasses can function normally another 15 years after surgery.

2. Types of coronary bypass surgery

• The following types of coronary bypass surgery are distinguished: Without the use of artificial blood circulation.
• With a person connected to a heart-lung machine. In this case, the patient's heart is stopped.
• Minimally invasive method with or without artificial circulation. This relatively new technique of coronary bypass surgery is characterized by reduced blood loss as a result of the operation, a decrease in the number of infectious complications and, as a result, a faster recovery.

Coronary artery bypass surgery is quite lengthy and expensive. Its duration depends primarily on how many shunts the patient needs to install, as well as on its type. Typically, the operation lasts from 4 to 6 hours.

After bypass surgery for coronary heart disease, the patient will require special care and treatment to fully recover - about 8 more days in the hospital, and then 4 to 6 weeks at home. The rehabilitation period at home is based on a gradual return to your previous life and includes breathing therapy, therapeutic exercise, and a special diet. In most cases, a person returns to a normal lifestyle within 1 to 2 months after surgery. It is important to remember that the more carefully you follow all of your doctor's instructions regarding the recovery period, the faster it will be completed.

3. When is bypass surgery necessary?

Not every person with coronary heart disease needs coronary artery bypass surgery, since this operation is prescribed only when all medications and other treatments, including stenting and angioplasty, have been unsuccessful. We list the main indications for surgical intervention for coronary artery disease:

• narrowing of the lumen of the left artery;
• deterioration of the heart muscle due to valve damage;
• damage to all or individual coronary arteries.

Remember that the decision on surgical intervention is made by the doctor based on an analysis of the individual clinical picture of your disease. If the doctor sees the need for surgery, do not be alarmed. Patients who have undergone bypass surgery have a very good prognosis. By creating a new section of the vessel and normalizing blood flow to the myocardium, the patient’s life after coronary bypass surgery changes for the better:

• the likelihood of developing a heart attack is reduced;
• angina attacks disappear;
• previous performance is restored;
• the physical condition of a person improves;
• the risk of sudden death is reduced and, consequently, life expectancy is increased;
• resistance to physical activity appears;
• the need for medications is minimized.

4. Life after bypass surgery

You can consolidate the positive result after bypass surgery for coronary heart disease yourself! The main thing to remember is that you will get the most benefit from bypass surgery if you adhere to a healthy lifestyle: eat right and exercise regularly. These changes will allow you to ensure that your shunts last longer. If you were prescribed preventive medications during the rehabilitation period, do not miss a single pill! Consistent and systemic drug treatment will bring more benefits to your body than scattered use of drugs.

Coronary artery bypass surgery- in many cases, a vital operation, thanks to which a person with coronary heart disease can forget about chest pain and return to a full life. Despite the fact that this type of surgery gives the patient a chance to start his life again, this unique opportunity should be used correctly. Under no circumstances should you return to bad habits after bypass surgery and the end of the rehabilitation period: smoking and drinking alcoholic beverages, as you may again hear the diagnosis of “coronary heart disease” and go on the operating table.

This cannot be achieved with medications. There are several options for performing the operation:

Stenting operation

Stenting (percutaneous coronaryplasty)

Restoring the lumen of the artery is achieved by introducing a stent into it, which is a mesh metal tube. Under X-ray guidance, a stent is placed directly against the plaque and expanded using an inflatable balloon (which is why the procedure is sometimes called balloon angioplasty). The entire operation is performed through the thigh vein using a special guide (catheter) under local anesthesia, so that the patient is conscious during the operation, can speak and follow the doctor’s commands.

The outcome of the operation largely depends on the quality of the stent and its material. There are many types of stents, including those that can deploy themselves, without the help of a balloon, and stents that, after insertion, themselves release medicinal substances.

Stenting ensures the restoration of the lumen of the vessel, normalization of blood flow and the disappearance of symptoms (pain). But it cannot stop the global process of atherosclerosis, and the patient needs to take preventive medications. A frequent complication of stenting is the re-growth of the plaque in the same or another place, which requires repeated surgery.

Coronary artery bypass grafting

Another method of restoring the lumen of the heart arteries, it began to be used earlier than stenting. Its essence is to create a shunt (bypass) through which blood enters the heart, bypassing the affected area of ​​the artery. This operation, more serious than stenting, is performed under general anesthesia on an open heart through an incision in the chest. Often a heart-lung machine is required. The features of the operation - which vessels are used as a shunt, whether to stop the heart or not, etc. - depend on the degree of damage to the heart.

CABG is preferable in cases of blockage of several arteries of the heart, as well as in high-risk patients - over 65 years of age, diabetics, and heart failure.

Transmyocardial laser revascularization

A rather rare surgical method for treating ischemic heart disease. It consists in the fact that with the help of a special laser installation, from 20 to 40 thin through passages are made in the heart muscle with a depth up to the cavity of the left ventricle. Through these passages, blood flows to the heart muscle directly from the left ventricle, bypassing the coronary arteries. The processes occurring in the heart muscle after such an intervention have not been fully studied, however, patients experience improved well-being, increased performance, and a decrease in pain. Recently, there has been a tendency to perform TMLR simultaneously with stenting or CABG.

Heart transplant

An extreme measure resorted to in case of severe heart damage accompanied by severe heart failure. The operation is complicated by the need to find a suitable donor, and therefore less than 1% of patients who meet the criteria for a heart transplant receive it.

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 complemented 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 coronary lesions 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 last three years. Academician of the Russian Academy of Medical Sciences L. Bockeria introduced this method into the practice of the Scientific Center for Agricultural Sciences. The operation has undoubted advantages due to low trauma 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 scar 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 an 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 large 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.

If angina symptoms worsen, medications are not effective. 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.

Methods of intervention

Surgical methods for treating coronary artery disease are aimed at restoring the normal state of the lumen of the arteries. It narrows due to cholesterol deposits on the blood vessel wall. In this case, medications do not always help eliminate the problem. Indications for surgical treatment are mainly anatomical.

The goals of surgical treatment for ischemic heart disease are to restore the lumen of the artery (revascularization) narrowed by an atherosclerotic plaque

1. Stenting.
2. Coronary artery bypass grafting.
3. Revascularization of coronary vessels.
4. Indirect myocardial bypass.
5. Heart transplant.

Surgery 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. Under normal conditions, it is supplied with blood from the coronary arteries arising from the aorta. Not far from each artery is a coronary vein, which drains blood from the heart. With coronary artery disease, the coronary artery is blocked by plaque. It obstructs blood flow 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 pumping is usually performed through the femoral artery

The operation lasts 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 inserting a stent. This is a mesh tube made of metal. X-rays are used to determine the location of the stent opposite the plaque. An inflatable balloon expands the tube. 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 expand on their own, and some even release drugs themselves after insertion. The operation restores the lumen of the blood vessel, normalizes blood flow and eliminates pain. But atherosclerosis cannot be completely cured, so it is imperative to follow preventive measures. A common complication after surgery is the reappearance of the plaque. In this case, the operation is repeated. For stable IHD, drug therapy is indicated instead of surgery.

Coronary artery bypass grafting

Coronary heart disease is the main cause of death in people of working age. The essence of the intervention is to completely normalize the process of blood supply to the heart and the movement of blood through arteries with a narrowed lumen. The coronary arteries and the main artery are connected by shunts.

This is a standard operation for blockages of the coronary arteries.

If IHD is diagnosed, indications for intervention are as follows:

• angina pectoris refractory to drug therapy;
• complications from myocardial infarction;
• heart failure;
• ventricular arrhythmias;
• atherosclerosis.

Surgery is performed on 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.

For bypass surgery, the great saphenous vein (GSV), located in the legs, is used. Its length ranges from 65 to 75 cm. The doctor isolates it and bandages it. Then he carefully cuts it off. Due to the high percentage of closure of venous shunts after the end of manipulation, arteries (radial, thoracic) are more often used for the material. Arterial and venous shunts are used for bypass surgery. The effectiveness of the procedure increases with the use of anterior shunts. But such an operation must be performed by a highly qualified specialist and is expensive, and the recovery period takes a long time.

During surgery, your heart is temporarily stopped and your body is connected to a machine called a heart-lung machine.

Revascularization of coronary vessels

The intervention is performed on the working heart muscle. With the help of special medications, the heart rate slows down. The doctor performs an anastomosis using the internal thoracic arteries (a. thoracica interna). The operation is performed if severe heart damage is detected; due to this condition, even a slight stop in the patient’s heart function can provoke a worsening of the situation.

Indirect myocardial bypass

In 9% of patients, atherosclerotic plaques are localized in small arteries, and 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 has been created. From the left ventricle, channels are created into a network of capillaries and arteries into the thickness of the heart. The channels are created with a laser. With its help, a channel with a diameter of about 1 mm is created. From the left ventricle (lat. ventriculus sinister cordis), blood carrying oxygen penetrates the network of cardiac capillaries. At the end of 3–4 months, the channels close. But the results of the operation last for more than 2 years. Such surgical treatment of coronary heart disease is not very common.

Heart transplant

This method is used as a last resort if the heart is severely affected by a pathological process. And also in cases of severe cardiovascular insufficiency. But it is necessary to find a suitable donor. Therefore, less than 1% of patients receive a transplant.

Minimally invasive intervention

Using endoscopic technology, the doctor connects the branches of the right (right coronary artery) or left (left coronary artery) coronary artery with the blood vessel that carries blood from the heart muscle to the mammary gland. In this case, trauma is reduced, and an artificial heart-lung device is not needed. The recovery period takes less time.