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Treatment of coronary heart disease

Treatment of coronary heart disease

The heart muscle needs constant supply of blood and oxygen. In coronary heart disease, the coronary arteries are obstructed by a build-up of fatty deposits (atheroma). The build-up of atheroma narrows the arteries, restricts the flow of blood to the heart muscle and causes loss of oxygen. Coronary heart disease may cause chest pain, especially during stress, and sometimes even during rest. Severe arterial plaque may cause myocardial infarction. Other symptoms may include fatigue, dyspnoea, arrhythmia and heart failure. We treat coronary heart disease with CAGs, balloon ablation (PCI) with modern metal stent (BMS) and drug-eluting stent (DES). We also make use of specialty technologies, such as IVUS, OCT, FFR, rotablation.

Choosing a treatment

Sometimes just medication is not enough. Coronary angiography is always required before the patient is given invasive treatments. Often, as a first-stage treatment and in less severe cases, a good therapeutic outcome is achieved with coronary angioplasty and stent. In more severe forms of the disease, a coronary bypass operation may be performed. Choosing the right treatment is based on international treatment recommendations and experience. Surgical treatment is always preceded by a professional care meeting between the cardiologist and the cardiac surgeon to discuss the case. The choice of treatment type is influenced by the findings of the angiograph, as well as any underlying disease (most commonly, diabetes, renal failure and pulmonary disease), possible ancillary conditions, the patient’s age and living will.

What happens during coronary bypass?

The patient is prepared for the operating room and anesthetised. Bypass surgery is usually performed through an incision down the middle of the breastbone, which keeps the cutting area blood-free and still. The heart is stopped with the aid of a heart-lung machine, in which the blood is oxidised before being returned to the body. The heart-lung machine replaces these organs for about 1 hour. Particularly aortic stenosis can be treated with transcatheter aortic valve replacement through blood vessels in joints. In this case, the patient’s own heart takes care of the blood circulation during the fitting. The doctor evaluates the patient for the safest and most appropriate surgical option and provides them the necessary information on the selected option.

During coronary artery bypass grafting, the blockage in the artery is bypassed using a grafted vein. Healthy arteries or veins are harvested to create bypass grafts that channel the needed blood flow around the blocked portions of the coronary arteries. The new section of vessel can come from the mammary artery in the chest, the radial artery in the forearm, or the saphenous vein in the leg. The saphenous vein is commonly used for grafts. The end of the vein is sewn to the aorta (the large artery that carries blood from the heart), and the other end is attached to the coronary artery below the point at which it’s blocked. The new channel allows blood to flow to the heart and relieve symptoms.

A less invasive coronary artery bypass grafting procedure is called beating-heart surgery and it is performed without the use of the heart-lung bypass machine. This means that the patient’s own heart will continue pumping blood throughout the surgery. The coronary arteries on the heart’s surface are stabilised so that the artery graft can be in stitched to the coronary artery. In beating-heart surgery, the aorta can be left alone, which reduces the risk of cerebral haemorrhage if the patient has atherosclerosis, plaques or possible earlier transient ischaemic attack. The beating-heart technique may also be used if the patient has lung disease or kidney failure.

What happens after the operation?

The patient’s post-surgery treatment in Heart Hospital lasts an average of 4-6 days and continues in a hospital of the patient’s choosing for a similar number of days. The thorax usually heals in about 6-8 weeks and any sick leave will last for 2-3 months. The aim of the surgery is to improve the patient’s quality of life and performance, and sometimes also to them getting prevent serious illness. To achieve a good long-term outcome, it is important to treat the risk factors that have led to coronary heart disease, such as high blood pressure, high cholesterol and diabetes also affect the capacity of the transplanted graft. Regular monitoring is required.

What is echocardiography?

Echocardiogram confirms whether the patient has coronary heart disease or not. The echocardiogram looks at the structure of the heart and gives information on the function and pumping action of the heart. It records the grooves on the surface of the heart; the coronary sulcus (or atrioventricular groove) runs transversely around the heart – it represents the wall dividing the atria from the ventricles. There are two coronary arteries, the right and left coronary arteries. In addition, both coronary arteries have several branches, all of which show up on the echocardiogram. If the coronary arteries show significant narrowing, the patient has cardiac heart disease.

When should echocardiogram be performed?

Echocardiogram must be performed if the chest pain is severe or the symptoms are impacting the patient of impairing the patient’s quality of life despite proper medical intervention. An echocardiogram should also be performed on the findings of certain clinical stress tests that indicate the presence of severe coronary artery disease. If the cause of chest pain is left open after a clinical stress test and other studies, it is justified to perform a diagnostic echocardiogram on the coronary artery.

How is echocardiogram performed?

The echocardiogram of coronary arteries is performed under local anaesthetic, so the patient is constantly awake.
The heart doctor may perform the procedure through the patient’s wrist or thigh valves. A contrast agent is injected through a catheter placed on the coronary arteries and at the same time, X-ray is used to image the coronary arteries filled by the contrast agent. Most procedures can be performed at the outpatient clinic, so the patient enters via Tays Heart Hospital in the morning and is discharged the same day after the echocardiogram. Occasionally, the patient may stay in Heart Hospital for one night, if they example instance use blood thinning medication or suffers from renal impairment.

What does coronary ablation mean?

Coronary heart disease develops when the coronary artery entering the myocardium becomes congested. This can be treated by balloon angioplasty and by insertion of a stent. At first the congested coronary artery is expanded by a balloon catheter. The procedure is called a balloon angioplasty. Thereafter, a stent is applied to the stenosis to ensure that the blood vessel remains open.

Today, most of the stents are drug-eluting (DES). The drug prevents the coronary artery from getting blocked again after the procedure. The doctor will determine on a case-by-case which kind of tent to use, a drug-eluting or balloon

When would the patient be offered balloon ablation and stent?

Balloon ablation is suggested for significant blocking of arteries shown in the echocardiogram. The patient’s description of their symptoms is considered when determining the need for balloon ablation and stent in their case.

In unclear situations, the status of the arteries can be determined by the findings of clinical stress test and the extra examinations carried out at the time of the angiogram. These are echocardiogram (IVUS) and optical coherence tomography (OCT). They give a good idea of the extent of the arterial congestion. The impact of the arterial congestion on heart muscle blood circulation can also be studied with the echocardiogram (FFR test). Based on these, the best treatment will be selected, whether it be optimal medical intervention, balloon ablation and stent or bypass surgery.

How will the procedure proceed in practice?

Balloon ablation and stent are carried out under local anaesthetic, with the patient awake throughout. The cardiologist may use the patient’s wrist or leg artery for the procedure.

A thin wire is inserted into the artery past the congestion via a catheter that is placed at the entrance of the hole. Afterwards, the wire is used for the ablation and then the stent.

Most balloon ablations and stents are performed in the polyclinic, with the patient arriving in Tays Heart Hospital in the morning and is discharged the same day after the procedure. Sometimes the patient spends the night in hospital after their procedure if they use blood thinning medications or the patient has a serious kidney failure. Nowadays the majority of balloon ablations are performed together with an echocardiogram, cutting the need to see a cardiologist twice about balloon ablations.