One-Year Follow-up of Patients with Triple Vessel

Disease (Recommended CABG) on Intense Medical

Management
Aashish Contractor, Pradnya Salgaonkar, Jigar Shah,
Sangeetha Subramanium, Siddhartha Angadi, Ramakanta Panda

Asian Heart Institute, Mumbai

Forty-eight patients who were diagnosed with triple vessel coronary heart disease
(CHD), and advised coronary artery bypass graft (CABG) surgery by their
interventional cardiologist, consulted our cardiovascular surgeon. On reviewing the
angiography, the surgeon opined that surgery could be deferred, and recommended
intense medical management, for which the patients were enrolled in the cardiac
rehabilitation program. Their risk factors were aggressively controlled both
pharmacologically and with lifestyle modification, according to international
guidelines: blood pressure (BP) below 120/80 mmHg; total cholesterol < 200 mg/dl;
triglycerides < 150 mg/dl; low-density lipoprotein (LDL) cholesterol <100 mg/dl;
high-density lipoprotein (HDL) cholesterol >40 mg/dl. Other goals included smoking
cessation, tight blood glucose control in diabetics, daily physical activity of at least
30 min, and a diet low in saturated fat and high in complex carbohydrates, fruits and
vegetables. Patients were followed-up thrice a week for an average duration of 33
sessions (~3 months). They were made to exercise under telemetry supervision for
duration of 45-60 min at an intensity of 60-80% of maximal heart rate. Their diets
were analyzed through a 3-day food recall and appropriate recommendations made,
to keep their total fat intake <30%, and saturated fat intake <7%. Their BP was
evaluated at each visit, both at rest and during exercise. Diabetics had their blood
sugar measured before and after exercise. Their anti-diabetic medications were
titrated according to their responses. Lipid profiles were measured every 3 months.
To achieve these risk reduction targets, medication changes were made in
conjunction with the patient’s cardiologist. At the time of reporting all 48 patients
were stable and had not experienced a cardiac event, including myocardial infarction
(MI) or coronary intervention. Of these, 18 patients) had completed one year from
the time of their initial angiography. With aggressive medical management and
lifestyle modification, coronary intervention can be avoided in selected cases of
patients with triple vessel CHD.

Coronary artery surgery

Pathology

• The principle blood supply to the heart is via three vessels

o Right coronary artery
o Left anterior descending artery
o Circumflex coronary artery
• Atherosclerosis occurs in the proximal portions of these vessels
 • The main treatable risk factors for coronary artery disease are
o Hypercholesterolaemia
o Hypertension
o Diabetes
o Smoking
• Depending on number of vessels involved patient is described as having
o Single-vessel disease
o Double-vessel disease
o Triple-vessel disease
• Prognosis depends on
o Number of vessels involved
o Left ventricular function

Investigations

• Left ventricular function can be assessed by assessing ejection fraction on

o Echocardiography
o Angiography
o Multiple-gated acquisition (MUGA) scan
• Coronary angiography allows
o Confirmation of diagnosis
o Preoperative planning of site of graft

Indications for surgery

• Usually requires severe stenosis (>70%) with left main stem or triple vessel
disease
• No improved survival seen in patients with single or double-vessel disease
• Improved survival seen in those with poor left ventricular function
• Similar survival seen in patients undergoing angioplasty for multi-vessel
disease

Assessment of risk

• Patients at greatest risk have the most to gain from surgical intervention
• Mortality risk can be estimated using various scoring tools
• Risk is calculated by summating individual risk factors

Parsonnet score

• Age greater than 70 years +7%

• Age greater than 75 years +12%
• Age greater than 80 years +20%
• Female sex +1%
• Hypertension +3%
• Diabetes +3%
• Obesity +3%
• Good ejection fraction Nil
• Moderate ejection fraction +2%
 • Poor ejection fraction +4%

Euroscore

• Age - for each 5 years over 60 years +1%

• Female sex +1%
• Chronic respiratory disease +1%
• Extracardiac arteriopathy +2%
• Neurological dysfunction +2%
• Creatinine greater than 200 µmol/l +2%
• Previous cardiac surgery +3%
• Unstable angina +2%
• Recent myocardial infarction +2%
• Good ejection fraction Nil
• Moderate ejection fraction +1%
• Poor ejection fraction +3%

Choice of conduit

• Conduits can be either venous or arterial

• Long saphenous vein is easy to harvest by a second surgeon
• Allows multiple grafts to be fashioned
• Has patency rate of 60% at 10 years
• Left internal mammary artery as been used to graft the left anterior descending
• Patency rate of 90% at 10 years has been reported

Surgery

• Chest is entered via a median sternotomy

• Left internal mammary artery is dissected
• Long saphenous vein can be harvested and prepared by second surgeon
• Heart is cannulated and patient is placed on bypass
• Aorta is cross clamped
• Injury to heart reduced by cardioplegic solutions
• Cardioplegia can be either warm (37 degrees) or cold (4 degrees)
• Recent advances include
o Off-pump coronary artery surgery
o Minimally invasive direct coronary artery surgery

• Both can avoid either bypass or median sternotomy

Complications

• Bleeding
• Atrial fibrillation
• Wound infection
• Poor cardiac function
• Stroke