La rivascolarizzazione Miocardica

Presentazione sul tema: "La rivascolarizzazione Miocardica"— Transcript della presentazione:

1 La rivascolarizzazione Miocardica

2 ETA’ MEDIA RISCHIO MEDIO
COM’E’ (E COME SARA’) IL PAZIENTE CANDIDATO A CHIRURGIA CORONARICA CORONARICA OGGI PERCHE’ Età media della popolazione generale Procedure non invasive (PTCA, ICD, PM biv…) ETA’ MEDIA Diabetici Dializzati/IRC Mal. Coronarica periferica e vasi tortuosi e/o di piccolo calibro Scompenso cardiaco RISCHIO MEDIO

3 Epidemiologia ed impatto sociale
(Price AE. Heart 2004, 90: Jones JR et al. HSE Epidemiology and medical statistics Unit,2002) Malattie CardioVascolari (CVD) Malattia coronarica e Stroke Morte prematura (prima dell’età pensionabile) Giorni lavorativi persi/anno per CVD lavoro-correlata 1,84 milioni 36% Uomini 27% Donne Costo economico-industriale 180 milioni Euro/anno

4 DELLA RIVASCOLARIZZAZIONE MIOCARDICA
OBIETTIVI DELLA RIVASCOLARIZZAZIONE MIOCARDICA RIPRISTINO/MIGLIORAMENTO ASPETTATIVA DI VITA RIPRISTINO/MIGLIORAMENTO QUALITA’ DI VITA RESTITUZIONE AD UNA VITA SOCIALMENTE PRODUTTIVA

5 Hlatky MA et al. Employment after coronary angioplasty or CABG in patients employed at the time of revascularisation. Ann Int Med 1998; 129:543.

6

7 Cleveland Clinic Foundation
70 65 60 55 50 45 40 30 20 10 % pts. Età dei pazienti chirurgici Età media % di > 70 anni % di > 80 Age yrs 2002 1972 1977 1982 1987 1992 1997 Cleveland Clinic Foundation

8 From birth From Age 20 From Age 45 From Age 75

9 Settantenni ed ottantenni sottoposti a cardiochirurgia
50 40 30 20 10 % % Età 70 % Età 80 1970 1980 1990 2000

10 DIAGNOSTICA

11 CORONAROGRAFIA

12 CORO-TC

13 Esami complementari Prova da sforzo (Treadmill Test)
Stratificazione del rischio Prova da sforzo (Treadmill Test) Scintigrafia miocardica Ecocardiogramma A riposo Sotto sforzo (stress)

14 L’INTERVENTO

15 2004 Guidelines for Coronary Artery Bypass Graft Surgery
ACC/AHA PRACTICE GUIDELINES—FULL TEXT Eagle and Guyton et al 2004 Guidelines for Coronary Artery Bypass Graft Surgery A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery) Developed in Collaboration With the American Association for Thoracic Surgery and the Society of Thoracic Surgeons Circulation August 31, 2004 JACC September 1, 2004, issue Indicazioni convenzionali…

16 Asymptomatic or Mild Angina
Class I 1. CABG should be performed in patients with asymptomatic or mild angina who have significant left main coronary artery stenosis. (Level of Evidence: A) 2. CABG should be performed in patients with asymptomatic or mild angina who have left main equivalent: significant (greater than or equal to 70%) stenosis of the proximal LAD and proximal left circumflex artery. (Level of Evidence: A) 3. CABG is useful in patients with asymptomatic ischemia or mild angina who have 3-vessel disease. (Survival benefit is greater in patients with abnormal LV function; e.g., EF less than 0.50 and/or large areas of demonstrable myocardial ischemia.) (Level of Evidence: C) Class IIa CABG can be beneficial for patients with asymptomatic or mild angina who have proximal LAD stenosis with 1- or 2-vessel disease. (This recommendation becomes a Class I if extensive ischemia is documented by noninvasive study and/or LVEF is less than 0.50.) (Level of Evidence: A) Class IIb CABG may be considered for patients with asymptomatic or mild angina who have 1- or 2-vessel disease not involving the proximal LAD (If a large area of viable myocardium and high-risk criteria are met on non invasive testing, this recommendation becomes Class I). (Level of Evidence: B) Class III Indications for CABG in Asymptomatic or Mild Angina: See text.

17 Stable Angina -1 Class I 1. CABG is recommended for patients with stable angina who have significant left main coronary artery stenosis. (Level of Evidence: A) 2. CABG is recommended for patients with stable angina who have left main equivalent: Significant (greater than or equal to 70%) stenosis of the proximal LAD and proximal left circumflex artery. (Level of Evidence: A) 3. CABG is recommended for patients with stable angina who have 3-vessel disease. (Survival benefit is greater when LVEF is less than 0.50.) (Level of Evidence: A) 4. CABG is recommended in patients with stable angina who have 2-vessel disease with significant proximal LAD stenosis and either EF less than 0.50 or demonstrable ischemia on noninvasive testing. (Level of Evidence: A) 5. CABG is beneficial for patients with stable angina who have 1- or 2-vessel CAD without significant proximal LAD stenosis but with a large area of viable myocardium and high-risk criteria on noninvasive testing. (Level of Evidence: B) 6. CABG is beneficial for patients with stable angina who have developed disabling angina despite maximal noninvasive therapy, when surgery can be performed with acceptable risk. If angina is not typical, objective evidence of ischemia should be obtained. (Level of Evidence: B)

18 Stable Angina -2 Class IIa Class III
1. CABG is reasonable in patients with stable angina who have proximal LAD stenosis with 1-vessel disease. (This recommendation becomes Class I if extensive ischemia is documented by noninvasive study and/or LVEF is less than 0.50). (Level of Evidence: A) 2. CABG may be useful for patients with stable angina who have 1- or 2-vessel CAD without significant proximal LAD stenosis but who have a moderate area of viable myocardium and demonstrable ischemia on noninvasive testing. (Level of Evidence: B) Class III 1. CABG is not recommended for patients with stable angina who have 1- or 2-vessel disease not involving significant proximal LAD stenosis, patients who have mild symptoms that are unlikely due to myocardial ischemia, or patients who have not received an adequate trial of medical therapy and a. have only a small area of viable myocardium or (Level of Evidence: B) b. have no demonstrable ischemia on noninvasive testing. (Level of Evidence: B) 2. CABG is not recommended for patients with stable angina who have borderline coronary stenoses (50% to 60% diameter in locations other than the left main coronary artery) and no demonstrable ischemia on noninvasive testing. (Level of Evidence: B) 3. CABG is not recommended for patients with stable angina who have insignificant coronary stenosis (less than 50% diameter reduction). (Level of Evidence: B)

19 Unstable Angina/Non–ST-Segment
Elevation MI (NSTEMI) Class I 1. CABG should be performed for patients with unstable angina/NSTEMI with significant left main coronary artery stenosis. (Level of Evidence: A) 2. CABG should be performed for patients with unstable angina/NSTEMI who have left main equivalent: significant (greater than or equal to 70%) stenosis of the proximal LAD and proximal left circumflex artery. (Level of Evidence: A) 3. CABG is recommended for unstable angina/NSTEMI in patients in whom revascularization is not optimal or possible, and who have ongoing ischemia not responsive to maximal nonsurgical therapy. (Level of Evidence: B) Class IIa CABG is probably indicated for patients with unstable angina/NSTEMI who have proximal LAD stenosis with 1- or 2-vessel disease. (Level of Evidence: A) Class IIb CABG may be considered in patients with unstable angina/NSTEMI who have 1- or 2-vessel disease not involving the proximal LAD when percutaneous revascularization is not optimal or possible. (If there is a large area of viable myocardium and high-risk criteria are met on noninvasive testing, this recommendation becomes Class I.) (Level of Evidence: B) Class III Indications for CABG in Unstable Angina/Non–QWave MI: See text.

20 ST-Segment Elevation MI (STEMI)-1
Class I Indications for CABG in ST-Segment Elevation (QWave) MI: None. Emergency or urgent CABG in patients with STEMI should be undertaken in the following circumstances: a. Failed angioplasty with persistent pain or hemodynamic instability in patients with coronary anatomy suitable for surgery. (Level of Evidence: B) b. Persistent or recurrent ischemia refractory to medical therapy in patients who have coronary anatomy suitable for surgery, who have a significant area of myocardium at risk, and who are not candidates for PCI. (Level of Evidence: B) c. At the time of surgical repair of postinfarction ventricular septal rupture or mitral valve insufficiency. (Level of Evidence: B) d. Cardiogenic shock in patients less than 75 years old with ST-segment elevation or left bundlebranch block or posterior MI who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock, unless further support is futile because of patient’s wishes or contraindications/unsuitability for further invasive care (Level of Evidence: A) e. Life-threatening ventricular arrhythmias in the presence of greater than or equal to 50% left main stenosis and/or triple-vessel disease (Level of Evidence: B)

21 ST-Segment Elevation MI (STEMI)-1
Class IIa 1. Indications for CABG in ST-Segment Elevation (QWave) MI: Ongoing ischemia/infarction not responsive to maximal nonsurgical therapy. 2.CABG may be performed as primary reperfusion in patients who have suitable anatomy and who are not candidates for or who have had failed fibrinolysis/PCI and who are in the early hours (6 to 12 hours) of evolving STEMI. (Level of Evidence: B) 3.In patients who have had an STEMI or NSTEMI, CABG mortality is elevated for the first 3 to 7 days after infarction, and the benefit of revascularization must be balanced against this increased risk. Beyond 7 days after infarction, the criteria for revascularization described in previous sections are applicable. (Level of Evidence: B) Class IIb 1. Indications for CABG in ST-Segment Elevation (QWave) MI: Progressive LV pump failure with coronary stenosis compromising viable myocardium outside the initial infarct area. 2. Indications for CABG in ST-Segment Elevation (QWave) MI: Primary reperfusion in the early hours (less or equal to 6 to 12 hours) of an evolving ST-segment elevation MI. Class III 1. Indications for CABG in ST-Segment Elevation (QWave) MI: Primary reperfusion late (greater or equal to 12 hours) in an evolving ST-segment elevation MI without ongoing ischemia. 2.Emergency CABG should not be performed in patients with persistent angina and a small area of myocardium at risk who are hemodynamically stable. (Level of Evidence: C) 3.Emergency CABG should not be performed in patients with successful epicardial reperfusion but unsuccessful microvascular reperfusion. (Level ofEvidence: C)

22 Poor LV Function Class I Class IIa Class III
1. CABG should be performed in patients with poor LV function who have significant left main coronary artery stenosis. (Level of Evidence: B) 2. CABG should be performed in patients with poor LV function who have left main equivalent: significant (greater than or equal to 70%) stenosis of the proximal LAD and proximal left circumflex artery. (Level of Evidence: B) 3. CABG should be performed in patients with poor LV function who have proximal LAD stenosis with 2- or 3-vessel disease. (Level of Evidence: B) Class IIa CABG may be performed in patients with poor LV function with significant viable noncontracting, revascularizable myocardium and without any of the above anatomic patterns. (Level of Evidence: B) Class III CABG should not be performed in patients with poor LV function without evidence of intermittent ischemia and without evidence of significant revascularizable viable myocardium. (Level of Evidence: B)

23 2004 Guidelines for Coronary Artery Bypass Graft Surgery
Eagle and Guyton et al 2004 Guidelines for Coronary Artery Bypass Graft Surgery Circulation August 31, 2004 JACC September 1, 2004, issue 5.7. Reoperation 5.11. CABG in Acute Coronary Syndromes 6.1. Less-Invasive CABG Robotics 6.2. Arterial and Alternate Conduits 6.4. Transmyocardial Revascularization

24 Mortalità nei coronarici isolati
3.6 3.4 3.2 3.0 2.8 2.6 2.4 2.2 Mortalità nei coronarici isolati 6 4 2 % Mort Grado di severità 1995 1996 1997 1998 1999 2000 2001 2002 D. Cosgrove, MD

25 RIVASCOLARIZZAZIONE MIOCARDICA Circolazione extra-corporea (CEC)
Opzioni Chirurgiche Circolazione extra-corporea (CEC) Cuore battente

26 RIVASCOLARIZZAZIONE MIOCARDICA
Opzioni Chirurgiche Circolazione ExtraCorporea MiniCEC (MECC) Convenzionale Assistenza per BH Sternotomia mediana Miniaccessi Totalmente Endoscopica (MIDCAB) (TECAB)

27 RIVASCOLARIZZAZIONE MIOCARDICA
Opzioni Chirurgiche Cuore Battente Convenzionale Assistito con CEC Sternotomia mediana Miniaccessi Totalmente Endoscopica (MIDCAB) (TECAB)

28 Percentuale Cuore Battente
40 30 20 10 %

29 I principali condotti per bypass aortocoronarico - 1
Vena Safena Autologa Arteria Mammaria

30

31 I principali condotti per bypass aortocoronarico - 2
Arteria Radiale I principali condotti per bypass aortocoronarico - 2 Arteria Gastroepiploica

32 Intervento di ByPass AortoCoronarico

33 Cuore Battente Stabilizzatore Esposizione (Lima stitch)
Shunts intraluminali

34 Hospital mortality after cardiac surgery with ageing. U. S
Hospital mortality after cardiac surgery with ageing. U.S. National Cardiovascular Network Alexander K.P. et al: JACC 2000; 35:731-8 64467 pts (4743 > 80 years)

35 Actuarial survival of elderly pts after cardiac surgery
Khan J.H. et al: Ann Thorac Surg 2000; 69:

36 650,000 450,000 250,000 50,000 CABG negli USA 1990 1992 1994 1996 1998 2000 2002 2004 2006 D. Cosgrove, MD

37 Ri-stenosi 50 40 30 20 % Angioplastica Stent Stent medicati

38

39 Nuova rivascolarizazzione
30 Angioplastica 25 p<0.001 20 15 Porcentaje acumulativo Hazard ratio (2.58 to 5.91) 10 Chirurgia 5 1 2 3 Tempo dalla randomizzazione in anni

40 Percentuale cumulativa
Mortalità Percentuale cumulativa Angioplastica 1 2 3 1% 2% 3% 4% 5% 6% p=0.007 Chirurgia Hazard ratio (1.40 to 8.70) Tempo dalla randomizzazione in anni

41 TRATTAMENTO ISCHEMIA CORONARICA
Terapia Medica 1960 BPAC 1970 Biologia molecolare 2000 1980 PTCA 1990 Nuove Tecnologie

42 PREVENZIONE SECONDARIA
DOPO L’INTERVENTO PREVENZIONE SECONDARIA Terapia Medica FANS β – bloccanti Statine 2. Controllo dei fattori di rischio Ipertensione Ipercolesterolemia Fumo Obesità Diabete

43 DOPO L’INTERVENTO PREVENZIONE SECONDARIA
Eagle and Guyton et al 2004 Guidelines for Coronary Artery Bypass Graft Surgery Circulation August 31, 2004 JACC September 1, 2004, issue Antiplatelet Therapy for SVG Patency Class I 1. Aspirin is the drug of choice for prophylaxis against early saphenous vein graft (SVG) closure. It is the standard of care and should be continued indefinitely given its benefit in preventing subsequent clinical events. (Level of Evidence: A)

44 Circulation 2003; 107: e21-e22

45 DOPO L’INTERVENTO RIPRESA DELL’ATTIVITA’ LAVORATIVA NB
DOPO LA DIMISSIONE Guidare: 3 settimane Sesso: 3-4 settimane Guarigione dello sterno: 12 settimane NB Il bypass non cura la malattia coronarica: ne cura solo le conseguenze RIPRESA DEL LAVORO Lavoro sedentario: 4-6 settimane Lavoro pesante: 12 settimane (vd.sterno) RIABILITAZIONE Non necessaria, ma utile per: monitoraggio dei progressi > timing ripresa attività Controllo di stile di vita; riduzione di peso; dieta; tolleranza allo sforzo FOLLOW UP Controlli periodici dei fattori di rischio Prova da sforzo

46 IMPATTO DEL LAVORO SULLE MALATTIE CARDIOVASCOLARI
CONDIZIONI ACCERTATE DI RISCHIO FISICI Estremi di temperatura Rumore Vibrazioni CHIMICI Disolfuro di Carbonio (CS2) Nitroglicerina Monossido di Carbonio Solventi Piombo Cobalto Arsenico BIOLOGICI Bioprodotti umani/animali PSICOSOCIALI

47 CONDIZIONI ESSENZIALI PER IL RIENTRO AL LAVORO
Valutare: Riserva coronarica sotto sforzo Rischio di aritmie Funzione ventricolare sinistra

48 OPCAB Hospital Mortality
Definition: Hospital mortality is defined as mortality before discharge home, including the interval in a secundary hospital, rehab centre or coma centre

49 Cumulative Risk-adjusted Mortality (CRAM or CUSUM) OPCAB vs ECC
This is the cram plot of our patients on the ecc and opcab. We have excluded for honesty versus the ecc (and therefore against the opcab) all patients in cardiogenic shock and cardiac massage. These are very badly scored in the euroscore and are all in the ecc group. It is clear that the opcab is better versus ecc, certainly not worse, and this after correction for risk. Later it will be identified that this difference is not yet (jan 2002 and 1200 patients opcab) statistically significant for mathematical reasons. The sample sizes are not large enough for detection of 50 % reduction of risk with only 1000 patients and around 3 % mortality.

50 OPCAB and ECC versus EuroSCORE
This graphic is valid for comparing ECC and OPCAB together versus EuroSCORE, only for the patients of paul sergeant. It is clear that the EuroSCORE risk has become totally invalid for OPCAB prediction of risk in the hands of an experienced OPCAB and CABG surgeon. It is now possible to do cabg without any risk (nearly).

51 n engl j med 350;1 www.nejm.org january 1, 2004

52 SPINAL CORD STIMULATION SCS

53 SCS IN REFRACTORY ANGINA indications
PATIENTS IN III OR IV CCS CLASS INEFFECTIVE TRADITIONAL THERAPIES UNDEFINED MYOCARDIAL ISCHEMIC AREA MULTIPLE SITES OF ISCHEMIA (ALL UNTREATABLE BY CONVENTIONAL METHODS) LOW E.F. ISCHEMIA IN THE SEPTUM HIGH SURGICAL RISK IN CASE OF REDO BAD GENERAL CLINCAL CONDITIONS

54 University of Bologna M-CM-LXXXVIII Alma Mater Studiorum