When the symptoms of angina worsen, medication is 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.

Methods of intervention

Surgical treatments for coronary artery disease are aimed at restoring the normal state of the lumen of the arteries. It narrows due to cholesterol deposits on the wall of the blood vessel. Medicines in this case do not always help fix the problem. Indications for surgical treatment are mainly anatomical.

The goals of surgical treatment for coronary artery disease is to restore the lumen of the artery (revascularization), narrowed by atherosclerotic plaque

1. Stenting.
2. Aorto-coronary bypass.
3. Revascularization of the coronary vessels.
4. Indirect myocardial shunting.
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. In the normal state, it is supplied with blood from the coronary arteries extending from the aorta. Near each artery is a coronary vein, which provides blood flow from the heart. In CAD, the coronary artery is blocked by plaque. It obstructs 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 lasts 2 hours without anesthesia. The lumen of the blood vessel that conducts blood from the heart muscle to all parts of the body is restored by the introduction of a stent. This is a mesh metal tube. An x-ray is used to select the location of the stent opposite the plaque. 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 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 it is impossible to completely cure atherosclerosis, therefore, it is imperative to comply with preventive measures. A common complication after the intervention is the reappearance of the plaque. In this case, the operation is repeated. In case of coronary artery disease in a stable state, drug therapy is indicated instead of surgery.

Coronary artery bypass grafting

Ischemic heart disease is the leading cause of death in people of working age. The essence of the intervention is the complete normalization of 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 in the coronary arteries.

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

• angina pectoris unresponsive 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) is used in the legs. Its length is from 65 to 75 cm. The doctor selects it and bandages it. Then carefully cut off. Due to the high percentage of closure of venous bypasses after the end of manipulations, arteries (radial, thoracic) are more often used for material. For shunting, arterial and venous shunts are used. The effectiveness of the procedure increases 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, 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 a 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 lesion 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 bypass

In 9% of patients, atherosclerotic plaques are localized in small arteries, and 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 shunting has been created. Channels are created from the left ventricle into a network of capillaries and arteries into the thickness of the heart. Channels are created by laser. With its help, a channel with a diameter of about 1 mm is created. From the left ventricle (lat. ventriculus sinister cordis), 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 of coronary heart 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 insufficiency. But it is necessary to find a suitable donor. Therefore, less than 1% of patients receive a transplant.

Mini-invasive intervention

Using endoscopic technique, 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. At the same time, traumatization is reduced, and the device "artificial heart - lungs" is not needed. The recovery period takes less time.

Any method of surgical treatment of coronary 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, coronary artery bypass grafting and coronary angioplasty are used.

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Ischemic heart disease is the leading cause of premature death in middle-aged people.

In 1960, the first coronary bypass operation 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 a surgeon, Professor Kolesov V.I.

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 meaning 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, chest vessels. A synthetic prosthesis is rarely used.

You will find a list of drugs for the treatment of coronary heart disease.

Complications

• sudden closure of the dilated vessel during surgery or a few hours after it;
• arterial bleeding from the femoral artery;
• sudden cardiac arrest;
• acute heart attack;
• postoperative infectious complications;
• damage to blood vessels by a catheter during surgery;
• development of acute renal failure.

The above complications are quite rare. This is due to the fact that before surgical treatment, a thorough preparation of the patient is carried out. Also important is the high qualification of medical personnel, modern surgical equipment.

Possible complications are:

• people aged 65 and over;
• women;
• patients with unstable angina and 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 surgery restores normal blood flow in the heart muscle. The heart begins to receive the necessary oxygen. The risk of myocardial infarction decreases, the patient has a chance to prolong life.

Angioplasty surgery also gives the same therapeutic effects. But unlike shunting, it has a more gentle way. Large skin incisions are not made, the sternum is not disconnected. Just a puncture of the femoral artery.

But a less invasive method of angioplasty does not guarantee the complete curability of the patient. It has many complications and risks.

According to studies by American cardiologists, mortality after coronary artery bypass grafting is less compared to angioplasty.

There was an increase in life expectancy in patients with unstable angina.

For citation: Akchurin R.S., Shiryaev A.A., Vlasova E.E., Vasiliev V.P., Galyautdinov D.M. Surgical treatment of IHD // RMJ. 2014. No. 30. S. 2152

Ischemic heart disease (CHD) is the leading cause of death among the working-age population in developed countries. The search for optimal methods of its treatment is a task of vital importance. For almost half a century, the method of direct myocardial revascularization - coronary artery bypass grafting (CS) has been the mainstay of the treatment of this disease. First used in clinical practice in the late 1960s. CABG has become the most studied of the surgical interventions; today, more than half a million surgeries are performed worldwide every year, and the number continues to grow.

Indications
For almost 30 years, CABG remained the only method of coronary revascularization; during this period, indications for CABG were formed based on the possibilities of drug therapy of that time and comparison of its results with the results of CABG in different clinical groups. However, with the development of scientific and technological progress and the introduction of percutaneous coronary interventions (PCI) into practice, a choice has appeared among the methods of revascularization; endovascular methods have firmly taken their place in the treatment of coronary artery disease and have become an alternative to surgery. In addition, over the past decade, drug therapy for coronary artery disease has undergone significant transformation and has shown improvement in outcomes, especially in cases of stable disease. This led to a rethinking of the indications for surgical revascularization (in the direction of their narrowing), especially when taking into account possible cerebral complications. Nevertheless, based on the latest randomized clinical trials (RCTs), which involved the most seriously ill patients and studied a wider range of clinical outcomes, it can be argued that CABG remains the "gold standard" for managing patients with stenosis of the left coronary artery and three-vessel lesion of the coronary bed.
Coronary revascularization has 2 goals: to alleviate clinical manifestations, or improve the quality of life, and improve prognosis - both immediate and long-term. It follows that indications for revascularization (both PCI and CABG) can be classified into clinical and anatomical (or prognostic) ones.
Clinical indications for coronary revascularization are considered to be:
- the presence of severe angina pectoris that persists despite optimal drug therapy; in other words - the lack of effect of drug therapy;
- circulatory failure against the background of proven ischemia;
- acute coronary syndrome.
Anatomical, or prognostic, indications for revascularization prioritize CABG over PCI in cases such as:
- stenosis of the trunk of the left coronary artery (LCA) >50%;
- equivalent of SLCA (proximal stenoses of the anterior descending artery and circumflex artery) >70%;
- three-vessel lesion of the coronary bed in combination with dysfunction of the left ventricle (LV) of the heart (LV ejection fraction<50%);
- three-vessel lesion of the coronary bed with a proven large volume of ischemic myocardium;
- a two-vessel lesion with obligatory involvement of the proximal anterior descending artery in combination with LV dysfunction (LV ejection fraction<50%).
The formation of indications for revascularization was based on a comparison of the results of medical, endovascular and surgical treatment of patients from different clinical groups, reflected in numerous RCTs, meta-analyses and large observational registries of the last decade. The most convincing comparison of PCI and CABG was performed in the randomized subgroup (n=705) of the SYNTAX study: CABG was characterized by a significantly higher risk of cerebral complications (2.7% vs. 0.3%), but a significantly lower frequency of repeated revascularizations (6.7% vs. 12.0%, p<0,02) .
It should be emphasized that today the formulation of indications for the use of one or another method of revascularization in each specific case is not based on dogma, but is formed taking into account the analysis of the effectiveness and side effects of ongoing drug therapy, coronary anatomy, confirmed ischemia, and the available results of comparisons of PCI and CABG in such situations, assessing the technical capabilities and experience of operators, as well as choosing the patient himself. With any choice of revascularization, the patient's treatment will be combined (revascularization + optimal drug therapy).

Risk stratification
The Parsonnet, Society of Thoracic Surgeons (STS), Mayo Clinic Risk Score, ACEF score, Euroscore, Euroscore II scales are designed to predict the risk of surgical mortality; some of them include not only age and LV ejection fraction, but also creatinine level as determinants. Each surgeon before the operation is aware that the scales are only advisory in nature and the final decision regarding tactics is made by the team of doctors. CABG becomes appropriate and indicated if its expected benefit outweighs the potential dangers and life-threatening risks. Today, in daily clinical practice, the most used system is Euroscore II.

Preparation for KSh
Preoperative examination of the patient involves detailing the clinical situation in order to formulate indications for CABG and risk stratification. Concomitant diseases (diabetes mellitus (DM), obesity, chronic obstructive pulmonary disease, thyroid pathology) should be diagnosed and maximally compensated at the prehospital stage. A likely complication of surgery using a heart-lung machine (EC) and systemic heparinization is gastrointestinal bleeding in the presence of its potential sources. We insist on 100% preoperative gastroscopy even in the absence of a peptic ulcer clinic - to identify "silent" erosive and ulcerative lesions; if detected, CABG should be delayed until endoscopic remission is achieved. There is no doubt that there is an increased risk of infectious postoperative complications in the presence of foci of infection that were not sanitized before surgery. Therefore, the search and treatment of foci of infection in the presence of markers of inflammation is mandatory. Sanitation of the oral cavity, even without visible signs of inflammation, is indicated for all candidates for CABG without exception.

In preparing for CABG, we assign an important role to the diagnosis and specification of neurological deficit: both in patients with stenoses in the carotid system, and without them. To assess and effectively reduce the risk of neurological complications, patients should be additionally examined (Doppleroscopy of the branches of the aortic arch, magnetic resonance imaging of the brain in the angiographic mode), if necessary, consulted by a neurologist for the purpose of differentiated preoperative preparation and appropriate treatment starting from the first day of the postoperative period.

Operation technique
CABG surgery is performed to form a new blood flow pathway bypassing the affected areas of the coronary arteries, usually in its epicardial part. The most commonly used shunts are the left internal thoracic (mammary) artery (LIMA) and fragments of the great saphenous vein (GSV) of the leg and thigh. The use of the right internal thoracic (RIMA), radial (LA), right gastroepiploic arteries (RGA) and the small saphenous vein is considered an alternative and has its limitations.

Most often, myocardial revascularization is performed using EC. The operation begins with the simultaneous exposure of vascular grafts and the performance of a median sternotomy. The veins of the lower extremities are isolated from separate incisions, mainly in both legs. LA is isolated in combination with accompanying veins, using measures to prevent arterial spasm - external irrigation with papaverine solution.

The arterial branches of the LA are clipped.
After performing a standard median sternotomy, the internal mammary arteries are isolated until the pericardium is opened, mobilizing the graft leg with the surrounding tissues.
After breeding the edges of the sternum with a retractor, the pericardium is opened in a T-shape and sutured to the edges of the wound. After complete heparinization (300-400 Units/kg of weight), the aortic cannula is placed somewhat proximal to the origin of the brachiocephalic trunk; for venous drainage, one double-lumen cannula is most often used, passed through the right atrial appendage into the inferior vena cava. Complete IR is performed with moderate hypothermia up to 28-32oC. A cardioplegic cannula is inserted into the ascending aorta. After stabilization of hemodynamic parameters in the calculated mode, transverse clamping of the aorta distal to the cardioplegic cannula is performed and cardioplegia is performed by introducing 400-500 ml of cold potassium solution. A saline solution frozen to a mushy consistency is placed in the pericardial cavity.
The choice of vessels for shunting and approximate localization of anastomoses is determined by the topography of the lesion of the coronary bed. Under optical magnification with a sharp scalpel, the epicardium is opened above the outer surface of the artery in the anastomosis zone, then the lumen of the artery. High-quality optical control during this manipulation allows you to choose the place of opening of the artery outside the zone of atherosclerotic plaque and prevent possible injury to the posterior wall of the artery. Further, the incision of the artery is expanded longitudinally with specialized scissors curved along the edge to 4-8 mm. An anastomosis of an autovenous or arterial graft is formed, corresponding in size to the arteriotomy. For a vascular suture of an autovenous-coronary anastomosis, a 7/0 or 8/0 thread is used, for an ayo-arterial-coronary anastomosis - a 8/0 thread (prolene) with atraumatic stabbing needles. Only the walls of the vessels are sutured with a continuous suture, the surrounding tissues are involved in the anastomosis in cases of thinning of the coronary artery wall and the threat of eruption.
In case of a severe diffuse atherosclerotic process in the coronary vessels, the absence of an adequate lumen for performing an anastomosis, or severe calcification, it is necessary to use the endarterectomy technique. By removing the altered intima from the coronary artery, the entire channel, as well as the lateral and septal branches, are released in the distal direction. After performing endarterectomy, a suture with a coronary bypass graft is performed throughout the arteriotomy incision. The length of such anastomosis can be more than 3 cm.
Increasingly widespread introduction of sequential (“side-to-side”) anastomoses, multiple autoarterial CABG, the use of bimammary T- ​​and Y-shaped structures, and IAS urgently require an increase in the precision of interventions and determine the prospects for the use of microsurgical methods.

The use of microsurgical techniques and an operating microscope in coronary surgery significantly improves the quality of distal anastomoses. In our practice, we use a ceiling-mounted or floor-mounted operating microscope. Optical magnification varies in the range of 4-48 times, 6-12 times is enough for comfortable work. The advantages over conventional loupes-glasses are:
- a single field of view of the surgeon and assistant;
- variable magnification to eliminate technical errors;
- good visualization of the altered vascular wall;
- the possibility of using microsuture material (threads 8-9/0) and microsurgical instruments.
It should be noted that a feature of this technology is the indirect vision of the surgical field for the surgeon and assistant and, as a result, unusual manual coordination of distal anastomoses. The limited working field (field of view 4-5 cm) requires the ability to work with tools with minimal hand movements.
The experience of more than 6,500 operations of direct myocardial revascularization performed by us using an operating microscope allows us to recommend cardiac surgeons to use microsurgical techniques more widely in coronary surgery. Tables 1 and 2 show the results of our 10-year follow-up study of patients operated on in 1998-2001.
To form proximal anastomoses, after removing the transverse clamp from the aorta, lateral pressing of the aorta is performed, oval perforations are formed slightly larger than the diameter of autovenous shunts, oriented accordingly to the functionally advantageous position of the shunt. Autovenous grafts with aorta are anastomosed with a continuous 6/0 suture.
After myocardial revascularization and stabilization of hemodynamics, EC is stopped, the aorta and right heart are decannulated, the anterior mediastinum, the pericardial cavity and, if necessary, the opened pleural cavities are drained. Osteosynthesis of the sternum is performed mainly with wire cerclage sutures. The soft tissues of the wound are sutured in layers with synthetic suture material.
It will not be exaggerated to say that the introduction of mammary coronary bypass grafting (MCB) in the 1970s. marked a new era in coronary surgery, when it was possible to significantly improve both the immediate and long-term results of CABG. The revolution in surgery that occurred with the advent of the MCS is comparable in importance to another, more recent revolution in interventional cardiology with the advent of drug-eluting stents. Long-term patency (10-15 years) of mammary shunts exceeds 90%, which gives a significant increase in survival. Today, the use of MCS is the "gold standard" of coronary surgery.

Bimammary shunting undoubtedly increases the potential benefit of the operation, however, it cannot always be used in patients with diabetes and obesity, since it is associated with a higher risk of wound infection due to devascularization of the sternum. PVHA can be used on a stalk, i.e., with the preservation of its anatomical source, or it can be used as a free arterial graft. Unfortunately, a sufficient number of RCTs proving the advantage of bimammary shunting over the use of LVHA alone are not yet available. The long-term results of both interventions will be analyzed in the Arterial Revascularization Trial in the near future.

The initial experience of using the left LA as a bypass showed worse results than with venous bypass and caused pessimism. However, with the improvement of isolation techniques and the use of methods to combat spasm, the situation has changed, and the results of a number of RCTs have confirmed this. Many clinics have studied the possibility of using HSA, the prospects for its routine use are still being explored.
Clinical practice shows that in young patients who do not suffer from DM and obesity, multi-arterial bypass surgery is highly justified and gives hope for a good long-term result.
In order to minimize blood loss, autotransfusion of concentrated washed erythrocytes is used before, during and after CPB using Cell Saver technology. This reduces the need for donated blood, reduces the frequency of transfusion, pulmonary, renal and brain complications, as well as reduces the time of patients' stay in the hospital by 25-30%.

KSh without IR (off-pump)
The intervention is performed without the use of EC on the beating heart, while local stabilization of the myocardium in the area of ​​the distal anastomosis is achieved using specially designed devices (Fig. 1).
Initially, this technique was proposed as a surgical intervention with a lower risk of perioperative stroke. In our study (it was carried out in 2007-2008), this was confirmed. We compared the incidence of cerebral complications in CABG with CPB and without CPB among patients older than 70 years. In this group, where the choice of surgical technique without CPB is especially justified, stroke developed in 3 times, and encephalopathy - 2 times less often than in "traditional" CABG. Some RCTs, however, did not show a significant reduction in the incidence of neurological complications during CABG on a beating heart. The advantage of this technology is still waiting for its convincing confirmation or refutation. It is accepted that off-pump CABG is technologically not a routine, but a complex intervention, and is recommended for implementation only in highly specialized centers.

Results and complications
Mortality in specialized clinics is<2%. В неосложненной группе пациентов моложе 65 лет, без нарушения функции ЛЖ и клинических признаков недостаточности кровообращения 30-дневная летальность не превышает 1%. Необходимо заметить, что такой уровень летальности сохраняется уже длительное время, несмотря на то, что контингент оперированных стал значительно тяжелее и старше. Это объясняется накоплением опыта и прогрессом в анестезиологии, перфузиологии, хирургической технике, послеоперационном наблюдении и медикаментозном ведении.
Bleeding after CABG is an infrequent but serious complication and develops against the background of massive heparinization due to impaired hemostasis and platelet function during CPB. The average volume of blood loss in uncomplicated CABG is 400-600 ml, which is usually compensated with the help of blood-saving technologies (Cell Saver and its domestic analogues) and transfusions; resternotomy and surgical hemostasis are needed in 0.5-2% of cases.
The most common clinically significant and prognostic early complications of CABG are cerebral disorders, wound infection, and renal dysfunction; perioperative infarction and deep vein thrombosis develop less frequently.

The adverse neurological outcomes of CABG include stroke, delirium, and the so-called cognitive impairment. Despite advances in technology, their frequency, unfortunately, remains quite high and stable. For illustration, we compared the results of our annual activity in different periods of work - for 1995 and 2010. (Table 3). Comparison of only the results of CABG showed that over 15 years the number of operations has almost tripled, and we have managed to achieve a significant reduction in hospital mortality, the incidence of perioperative infarction, mediastinitis, and even renal failure. However, in the fight against cerebral complications, our successes were much more modest. The most significant causes of cerebral complications are a decrease in cerebral perfusion and embolism, and these causes are realized as a result of 3 main points: the EC itself, manipulations on the aorta, and heart rhythm disturbances. We consider the combined lesion of the main arteries of the head as an extremely unfavorable background against which the action of these mechanisms is realized.

Mediastinitis develops in 1-2% of cases, risk factors are severe diabetes, high body mass index, steroid use, and resternotomy. Modern antibiotic therapy and the use of preparations containing immunoglobulins often make it possible to cope with the infection in the so-called closed management.
Renal dysfunction requiring replacement therapy occurs in 1-5% of patients and can be predicted in most cases; its most common substrate is diabetic nephropathy and hypoperfusion. The development of acute renal failure significantly affects the prognosis, lengthens the patient's stay in the intensive care unit and department, and increases the cost of treatment.
The most common postoperative problems include cardiac arrhythmias (atrial fibrillation), pulmonary complications (pleurisy, atelectasis, pneumonia), postpericardiotomy syndrome, anemia, and impaired wound healing.

Postoperative rehabilitation
The activation of the patient begins on the 1st day of the postoperative period (half-recumbent and passive sitting position - on the 1st day, active sitting position in bed, transferring to a chair, transition to a vertical position and walking around the ward - from the 2nd day). Particular attention is paid to the early start of breathing exercises.
In order to prevent rhythm and conduction disturbances during the first 5-7 days after surgery, constant monitoring of electrolyte disturbances is necessary; maintaining a normal serum electrolyte concentration in most cases ensures the retention of sinus rhythm. The most common variant of rhythm disturbance in the postoperative period is atrial fibrillation.
In the standard case, drug therapy in the recovery period includes:
a) basic drugs, the use of which is mandatory and 100% (low molecular weight heparin, acetylsalicylic acid, antibiotic, antifungal antibiotic, antiulcer drug);
b) drugs that are not mandatory, but much in demand in the postoperative period (β-blockers and potassium preparations);
c) various drugs for symptomatic treatment (analgesics, muco- and bronchodilators, antiarrhythmics, iron, epoetin β).
The results of our implementation of the "accelerated rehabilitation program" showed that a significant shortening of the hospital postoperative period - up to 7-8 days - is possible. However, with the current composition of patients, only 15-20% of patients (uncomplicated cases of CABG) can actually enter this program; the rest require a longer recovery in the department and continued rehabilitation outside the surgery department. Our experience shows that for the success of the surgical treatment of today's contingent of patients, it is necessary to provide for a period of stay in a rehabilitation institution, preferably a specialized one, lasting at least 14-20 days. The goals of such post-treatment are: the final restoration of physical activity and adaptation to life, the acquisition of self-confidence and knowledge of one’s condition, and the final selection of drug therapy before discharge (if necessary, anticoagulant therapy, severe diabetes and switching from insulin to oral drugs, for after-treatment of neurological complications, anemia, etc.). Already at this stage of rehabilitation, the patient begins secondary prevention of the disease, which will continue further. In most Western countries, this phase of rehabilitation is defined as a time interval - from 3 to 6 weeks. after discharge.

The pathogenesis of changes in the body with regular physical activity has been studied, their benefits are not in doubt. In our opinion and experience, it is necessary to comply with the following most important requirements for planning physical training: regularity, discreteness, i.e., a smooth stepwise increase in load, and mandatory consideration of the state of the myocardium and the presence of arrhythmias when choosing a model of physical training (moderate or intense).

Usually, an individual physical training program is determined based on the results of the stress test. In studies of the effectiveness of KSh back in the 1980-1990s. it became obvious that the majority of patients are able to perform a stress test on the 12th-14th day of the postoperative period, and in the vast majority of cases with a significant increase in the double product in comparison with the preoperative result. In the vast majority of cases, the criterion for terminating the exercise test after surgery is the patient's physical fatigue, less often, the achievement of a submaximal heart rate. The results of the stress test become the starting point for increasing the volume of physical activity and determining the need for drug support for this process. Repeated tests with physical activity are carried out as an adaptation control. Physical training can take the form of individual and group sessions with a mentor, walking (i.e. dosed walking), cycling, swimming in the pool and training on simulators. We consider walking, including climbing stairs, and an exercise bike to be the most acceptable types of physical training. We adhere to the classical principles of activation: first increase the volume of the load, and only then - its intensity. When applied to walking, this means: first increase the distance, and then, with a confident overcoming of 4-5 km without rest, the pace of walking.

Drug therapy in the rehabilitation phase, secondary prevention of coronary artery disease after CABG
A well-organized rehabilitation stage in patients after CABG becomes the beginning of secondary prevention of atherosclerosis. Secondary prevention, or cardioprotective strategy, or phase 3 cardiac rehabilitation is not only a program to continue physical training. This includes control of risk factors for atherosclerosis (dyslipidemia, smoking, hyperglycemia, arterial hypertension (AH), obesity), adequate outpatient medical monitoring and psychosocial support (Fig. 2).
Adequate outpatient medical monitoring involves the appointment of antithrombotic therapy, appropriate to the situation and the requirements of the time; effective and safe lipid-lowering therapy (statins, statins + ezetimibe, fibrates) with the obligatory achievement of target levels of cholesterol, low-density lipoprotein cholesterol and triglycerides recommended for high-risk patients; according to indications - plasmapheresis, early detection of stenosis and / or thrombosis of shunts and progression of coronary atherosclerosis based on regular non-invasive examination; timely decision on repeat angiography and PCI.

The organization of specialized medical rehabilitation of patients with coronary artery disease after CABG operations is a new direction in the health care of the Russian Federation. The importance of this problem, which has not only medical, but also great socio-economic significance, is noted in the order of the Ministry of Health and Social Development of the Russian Federation No. 44 of 2006 “On the aftercare (rehabilitation) of patients in a sanatorium”. The document refers to the need to form a concept for the rehabilitation of this category of patients in specialized centers for rehabilitation medicine. Unfortunately, today the issue of interaction between cardiac surgery centers and outpatient medical institutions remains far from being finally resolved.

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Surgical treatment of coronary heart disease consists in myocardial revascularization - restoration of impaired blood supply to myocardial areas, as well as in the treatment of complications of coronary artery disease: heart aneurysms, thrombosis, valve insufficiency, etc. Myocardial revascularization, like the pharmacotherapy of coronary heart disease, has three main goals : improving the prognosis of the disease, reducing the symptoms of the disease and improving the quality of life of the patient.

Myocardial revascularization methods:

direct (direct revascularization) - restoration of blood flow through natural, already existing paths (that is, coronary arteries);

indirect (indirect revascularization) - the creation of additional blood flow pathways bypassing the affected arteries.

The most common method of direct revascularization is percutaneous intervention on the coronary arteries, indirect - coronary artery bypass grafting. Each method of revascularization has its own advantages and disadvantages, as well as indications and contraindications. The main factors determining the choice of one or another method are the severity of symptoms, the nature of the lesion and the individual cardiovascular risk. From a surgical point of view, an important factor is the technical feasibility of performing an intervention, which implies not only the required equipment, but also the nature of the coronary artery lesion. In addition, when choosing a revascularization method, concomitant diseases are taken into account, as well as the desire of the patient himself. The decision on the need and method of surgical treatment of coronary artery disease is usually taken jointly by cardiologists and cardiac surgeons.

Main indications for myocardial revascularization:

the equivalent of stenosis of the trunk of the left coronary artery - hemodynamically significant stenosis of the anterior interventricular artery and circumflex artery;

hemodynamically significant stenoses of the main vessels.

The main contraindications for myocardial revascularization:

stenosis of one or two coronary arteries without pronounced proximal narrowing of the anterior interventricular artery, in the presence of mild symptoms of angina pectoris or in the absence of adequate drug therapy;

borderline stenoses of the coronary arteries (except for the trunk of the left coronary artery) and the absence of signs of myocardial ischemia in a non-invasive study;

hemodynamically insignificant stenoses; high risk of perioperative complications and death;

oncological diseases (contraindications are evaluated individually, taking into account the chosen method of revascularization).

Note

The contraindications listed above are taken into account, as a rule, for percutaneous interventions on the coronary arteries and for coronary bypass surgery. But for other methods of revascularization, such as laser, some of the contraindications, on the contrary, become indications.

Percutaneous interventions on the coronary arteries

The introduction of percutaneous interventions on the coronary arteries into practice has opened a new branch of medicine - invasive cardiology. Since 1977, when A. Gruentzig first performed catheter dilatation of the coronary arteries, the number of such operations has been growing, reaching, according to the latest data, over 1 million per year. This method of treatment of coronary artery disease does not require long-term hospitalization, it is performed under local anesthesia, which significantly reduces the cost of treatment and rehabilitation time.

The development of new technologies in this area has made it possible to perform manipulations on the coronary arteries under the control of intravascular ultrasound, which significantly improves the quality of the intervention and reduces the possibility of perioperative complications.

Percutaneous interventions on the coronary arteries include the following basic manipulations that restore blood flow through the affected arteries:

balloon angioplasty of the coronary arteries;

endoprosthesis replacement (stenting) of coronary arteries;

direct intravascular effect on atherosclerotic plaque.

Balloon angioplasty of the coronary arteries

The method consists in inflating a catheter balloon in the area of ​​coronary artery stenosis.

Endoprosthetics (stenting) of coronary arteries

After angioplasty of the affected area of ​​the artery, an endoprosthesis is installed in this area - a stent, which is a metal perforated tube (cylinder), inserted into the lumen of the vessel in a folded form and deployed at the target site. The stent owes its name to the English dentist C. Stent, who first created and put it into practice.

The stent is a mechanical obstacle to stenosis, it presses the intima of the artery that has stratified during angioplasty, expanding the lumen of the artery more than with angioplasty.

The use of stents significantly improves the results of treatment, reduces the risk of adverse outcomes of the operation: restenosis of the coronary arteries is observed 30% less frequently than with angioplasty, therefore, the need for repeated revascularization of the target artery decreases.

Direct effect on atherosclerotic plaque

A variety of intravascular methods are used to directly affect an atherosclerotic plaque: laser burning, destruction with special drills, plaque cutting with an atherotomy catheter, etc.

Indications for percutaneous interventions on the coronary arteries:

hemodynamically significant stenoses in one or more coronary arteries available for catheter technologies;

occlusion of the coronary arteries of a short prescription (up to 3–6 months);

impaired patency of coronary bypass grafts;

acute coronary syndrome (after unsuccessful thrombolysis or instead of it).

Contraindications for percutaneous interventions:

damage to the trunk of the left coronary artery, in which coronary bypass grafting is preferable (however, in a number of clinical situations, angioplasty and stenting of the trunk are possible);

limited technical capabilities, for example, the absence of stents with the potential need for their use;

anatomical features of the lesion - extended occlusions, severe calcification, diffuse lesions of the coronary arteries;

left ventricular aneurysm requiring surgical treatment, especially in combination with intracardiac thrombosis; contraindications for coronary angiography.

Benefits of percutaneous coronary artery interventions

A shorter rehabilitation period compared to coronary bypass grafting, due to the absence of abdominal surgery and the need for artificial circulation, as a result, the complications associated with them.

With successful interventions, their immediate clinical effectiveness is high: the frequency of seizures decreases, up to their complete disappearance, the functional class of angina pectoris decreases, the contractile function of the myocardium improves, which in combination leads to a decrease in the volume of drug treatment, increased tolerance to physical activity and improved quality of life of patients .

Disadvantages of percutaneous coronary interventions

The issue of preventing recurrence of coronary artery disease after percutaneous interventions remains unresolved at the moment. According to various sources, the recurrence rate ranges from 32 to 40% within 6 months after surgery. Restenosis occurs due to the proliferation of smooth muscle cells in the area of ​​angioplasty and/or vascular thrombosis. The frequency of relapses (restenosis and reocclusion of the target coronary arteries) is significantly reduced by endoprosthetics (stenting) of the coronary arteries, especially drug-eluting stents (paclitaxel, sirolimus, everolimus, etc.), which prevents proliferation and thrombus formation.

Remains the need for a sufficiently long antiplatelet therapy.

Long-term results of percutaneous coronary artery interventions: percutaneous interventions have an advantage over the pharmacotherapy of coronary artery disease for several years after the intervention. As time goes on, the differences disappear.

coronary artery bypass surgery

The method consists in creating new blood flow paths (shunts) bypassing the stenotic section of the coronary artery. The distal end of the shunt is sutured to the coronary artery below the stenotic area (distal anastomosis), the proximal end - directly to the aorta (proximal anastomosis).

For shunting, venous grafts (autoveins) and arterial (internal mammary arteries, radial arteries, gastroepiploic, lower epigastric) are used. At the same time, for some arterial grafts (for example, the internal mammary artery), most often it is not required to create a proximal anastomosis - the blood flow is carried out directly from the artery bed. Arterial grafts have advantages over venous grafts: they are practically not at risk of dysfunction for many years after surgery.

The volume of coronary artery bypass grafting is determined by the number of affected arteries supplying viable myocardium with blood. Each ischemic area should be revascularized. The main arteries and their large branches of the first order with a diameter of at least 1.5 mm are subject to shunting. Restoration of blood supply in the area of ​​post-infarction cardiosclerosis in most cases is considered inappropriate.

Coronary artery bypass grafting can currently be performed both under cardiopulmonary bypass and without it, on a beating heart. In recent years, the so-called mini-invasive bypass grafting using small accesses and special surgical techniques has become increasingly widespread, which can significantly reduce the patient's rehabilitation time and reduce the number of complications.

Indications for coronary bypass surgery:

with angina pectoris FC I-II

stenosis of the trunk of the left coronary artery;

the equivalent of stenosis of the left coronary artery: hemodynamically significant stenosis of the anterior interventricular artery and circumflex artery;

three-vessel lesion;

proximal stenosis of the anterior interventricular artery over 70%, isolated or in combination with stenosis of any major branch (right coronary artery or circumflex branch of the left coronary artery);

with angina pectoris FC III–IV

stenosis of the trunk of the left coronary artery;

the equivalent of stenosis of the left coronary artery - hemodynamically significant stenosis of the anterior interventricular artery and circumflex artery;

three-vessel lesion;

dual-vessel disease with an ejection fraction of less than 50% or obvious myocardial ischemia;

single-vessel lesion with a large area of ​​ischemic myocardium;

drug-refractory angina pectoris;

additional indications

drug therapy does not provide control of angina pectoris;

non-invasive methods demonstrate the wide prevalence of the ischemic zone;

high probability of success with an acceptable risk of perioperative complications;

consent of the patient (if medically indicated) to this method of revascularization after receiving comprehensive information about the risk of complications.

Contraindications for coronary bypass surgery:

diffuse lesions of the coronary arteries;

social and psychological factors;

patient refusal to intervene.

Notes

1. The elderly age of the patient is not a contraindication, however, the risk of perioperative complications in this category of patients is higher due to comorbidities.

2. Significant dysfunction of the left ventricle (FI less than 35%, LV end-to-end pressure more than 25 mm Hg) is not a contraindication, but worsens the prognosis of the operation.

3. Past myocardial infarction is not a contraindication.

The main causes of IHD relapses after coronary artery bypass grafting: progression of atherosclerosis with damage to new (non-bypassed) coronary arteries, as well as the coronary bed located distal to the functioning bypass; shunt dysfunction (usually venous).

Results of coronary artery bypass surgery

Coronary bypass surgery improves the prognosis of the disease only in the following clinical situations:

the presence of stenosis of the trunk of the left coronary artery;

proximal stenoses of the three main coronary arteries;

stenosis of two main arteries, one of which is the anterior interventricular artery;

left ventricular dysfunction.

In other clinical situations, coronary artery bypass grafting has no advantages over pharmacotherapy in terms of its effect on the prognosis of the disease, however, it has significant advantages in improving the quality of life.

Indications for surgical treatment in the presence of left ventricular aneurysm: all of the above factors for angina pectoris in combination with severe ventricular arrhythmias; thrombosis of the left ventricle; heart failure of the second degree and above (according to NYHA).

Surgical treatment of coronary heart disease has gone through several stages of development. The first of them is on the sympathetic part of the nervous system, the purpose of which is to interrupt the pathways for the spread of pain and eliminate spasm of the coronary vessels. It is a surgical continuation of pharmacotherapy.

Also used retrosternal novocaine blockade, removal of the stellate ganglion (C8 and T1) - stelectomy.

The next stage in the development of surgical treatment of coronary heart disease is represented by indirect methods of myocardial revascularization by suturing the pericardium (Thompson), skeletal mice (Beck), and omentum (O'Shaughnessy) to it. These operations are also ineffective, since any cicatricial adhesion between organs after the vascular stage (red scar) turns into an avascular one (white scar).

Surgical treatment entered the forefront of the fight against coronary heart disease after Favalloro performed the first operations in 1958 coronary artery bypass grafting (ACS), thereby starting the stage of direct reconstructive operations on the coronary vessels. The development of this method was preceded by the introduction into practice of a complex research method - selective coronary angiography, which makes it possible to determine the places of narrowing of the coronary arteries. Thanks to coronary angiography, it was found that the lesions of these vessels are not diffuse, but segmental, and therefore they can be bypassed.

The principle of CABG is simple: a shunt is placed between the ascending aorta and the coronary vessel distal to the narrowing site. The shunt can be an autovein, an autoartery. xenograft, implant. Coronary artery bypass grafting is currently considered as an emergency operation for acute myocardial infarction. A timely operation can prevent or significantly reduce the area of ​​myocardial necrosis. Multiple shunts can be placed if needed.

Thoracic coronary bypass surgery. Professor of the Military Medical Academy of St. Petersburg Kolesov proposed an alternative CABG operation - an end-to-side anastomosis, which is applied between the internal thoracic artery and the coronary vessel. The operation is less efficient, but has its advantages. First, one anastomosis is applied instead of two. Secondly, it is possible to avoid the dangerous stage of the operation on the reflexogenic area of ​​the aorta. Thirdly, the operation prevents scarring of the shunt, as it is connected to the body.

Surgical treatment of cardiac arrhythmias. As part of the conduction system of the heart, the number of fibers that transmit impulses decreases with age. and the percentage of connective tissue increases. If the elements of the conduction system of the heart fall into unfavorable conditions (CHD, heart attack), then this process is accelerated and leads to heart rhythm disturbances. There are transverse and longitudinal atrioventricular blockade. With transverse blockade, the connection between the sinoatrial and atrioventricular parts of the conduction system is disrupted. Incomplete blockade is possible, when ventricular contractions fall out with a certain frequency (Adams-Stokes syndrome), and complete (transverse block). With transverse blockade, the atria contract in a normal rhythm - 65-80 contractions per 1 minute (sinus rhythm), and the ventricles - at a frequency of 40-50 per 1 minute due to second-order pacemakers.