Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3614_Библиотеки_им_академика_М_И_Перельмана
.pdf
SECTION 7 Technical aspects ofcoronary artery bypass graft surgery398
https://t.me/medicina_free
76. Esposito ML, Zhang Y, Qiao X, Reyelt L, Paruchuri V, Schnitzler
GR, etal. Le ventricular unloading before reperfusion promotes
functional recovery aer acute myocardial infarction. J Am Coll
Cardiol. 2018;72(5):501– 14.
77. Kirklin JK, Nael DC, Pagani FD, Kormos RL, Stevenson
LW, Blume ED, etal. Seventh INTERMACS annual
report:15,000 patients and counting. J Heart Lung Transplant.
2015;34(12):1495– 504.
78. Dang NC, Topkara VK, Leacche M, John R, Byrne JG, Naka Y.
Le ventricular assist device implantation aer acute anterior
wall myocardial infarction and cardiogenic shock:a two- center
study. J orac Cardiovasc Surg. 2005;130(3):693– 8.
79. Adamo L, Nassif M, Tibrewala A, Novak E, Vader J, Silvestry SC,
etal. e Heartmate Risk Score predicts morbidity and mortality in
unselected le ventricular assist device recipients and risk straties
INTERMACS class 1 patients. JACC Heart Fail. 2015;3(4):283– 90.
80. Mehra MR, Goldstein DJ, Uriel N, Cleveland JC, Yuzefpolskaya
M, Salerno CT, etal. Two- year outcomes with a magnetically
levitated cardiac pump in heart failure. N Engl J Med.
2019;378(15):1386– 95.
81. Mehta P, Imamura T, Juricek C, Sarswat N, Kim G, Raikhelkar J,
etal. Combined le ventricular assist device and coronary artery
bypass graing surgery:should we bypass the bypass? ASAIO J.
2020;66(1):32– 7.
https://t.me/medicina_free
57
Prevention ofmediastinitis
Harold L. Lazar
Introduction
not possible to eliminate these risk factors. However, by instituting a
series of interventions in the preoperative, intraoperative, and post-
Sternal wound infections resulting in mediastinitis occur in 1– 4%
of patients undergoing coronary artery bypass gra (CABG) sur-
operative periods, the incidence of sternal wound infection can be
signicantly decreased and mediastinitis virtually eliminated.
gery. Although the incidence of mediastinitis has decreased, it is still
associated with increased morbidity and mortality and decreased
long- term survival. Sternal infections prolong hospital stay, increase
hospital readmissions, raise hospital costs, and are now publicly reported. In the United States, the Centers for Medicare & Medicaid
Services will no longer reimburse the extra hospital costs for treating
deep sternal wound infections (DSWIs) following CABG surgery.
Although bilateral internal thoracic artery (BITA) graing has
been shown to prolong survival, its use has been curtailed, especially
in diabetic patients, because of the concern of the increased risk for
sternal wound infections and mediastinitis.
is chapter will review the preoperative, intraoperative, and
postoperative principles to prevent sternal wound infections and
mediastinitis following CABG surgery.
Interventions toprevent sternal wound
infections andmediastinitis
Preoperativeprevention
Nasaldisinfectants
Twenty to thirty per cent of the general population are Staphylococcus
species carriers. e predominant organism found in cardiac wound
infections is Staphylococcus that originates from the patient’s own
nasal ora. erefore, all CABG patients should have nasal swab
testing prior to surgery. However, the results of nasal swab cultures
may not be available in those patients who require urgent or emergent surgery. Polymerase chain reaction (PCR) assays provide a more
rapid screening (<12 hours) for Staphylococcus carriers; although
Definitions
Sternal wound infections may be supercial (SSWIs) or deep
(DSWIs). ASSWI involves the skin, subcutaneous tissue, and may
extend to the pectoralis fascia, but not to the bone. ADSWI involves
the bone and mediastinal space and is associated with fever, sternal
instability, purulent mediastinal drainage, and positive deep tissue
and, possibly, blood cultures.
they add to medical costs and are not available in all hospitals.
Topical intranasal therapies are the best method to eradicate
Staphylococcus colonization; mupirocin ointment (Bactroban®,
GlaxoSmithKline, Brentford, UK) appears to have great ecacy in
treating Staphylococcus nasal carriers. It has been shown in retrospective, single- centre studies to decrease the incidence of sternal
wound infections. Nasal mupirocin has no eect in patients who
are not nasal staphylococcal carriers and in patients with a negative
PCR assay. Furthermore, it only decolonizes 45– 50% of methicillinresistant Staphylococcus aureus (MRSA) carriers. erefore,
Risk factors fordeveloping sternal wound
infection andmediastinitis
mupirocin nasal ointment should only be used in those patients who
have a positive nasal culture for staphylococcal species or a positive PCR assay and in those patients in whom culture results are not
available or cannot be obtained at the time of surgery. It should be
Patients with obesity, chronic renal failure, chronic obstructive pulmonary disease, diabetes mellitus, peripheral vascular disease, and
those who require hospitalization prior to their CABG surgery are
at higher risk for developing a postoperative wound infection and
mediastinitis. Unfortunately, these risk factors are found in the
majority of patients undergoing CABG surgery today. Since most
CABG patients require surgery on an urgent or emergent basis, it is
administered within 24 hours of surgery and continued for 5days.
Topical intranasal use of iodine- based polymicrobial disinfectant
(povidone- iodine, Betadine®, 3M, St. Paul, MN, USA) solution has
also been proposed and adopted by many centres as a more convenient intranasal therapy. is treatment has the advantage of
being eective against all nasal ora, regardless of the patient’s carrier status, and being almost immediately eective aer a single
SECTION 7 Technical aspects ofcoronary artery bypass graft surgery400
https://t.me/medicina_free
application, even if administered only in the preoperative holding
area just prior to surgery. is simple, one- time application reduces
nasal bacteria, including S. aureus, by 99.5% in just 1 hour and
maintains this reduction for at least 12 hours. In direct comparison
against mupirocin, intranasal povidone- iodine solution was more
eective in reducing nasal ora.
Presurgicalbathing
Preoperative showering with chlorhexidine gluconate is recommended to reduce surgical site infections and has been shown to
decrease bacterial skin counts to a greater extent than other agents.
However, randomized controlled trials showed no dierence in the
postoperative wound infection rates between patients who showered
with chlorhexidine gluconate, povidone- iodine soap and water,
or placebo. While presurgical bathing reduces the skin microbial
burden that can contribute to wound infections and mediastinitis, it
alone cannot prevent skin ora organisms from contaminating the
surgical wound during CABG surgery.
Preoperative hairremoval
Preoperative hair removal should be performed with clippers, and
not razors, to minimize skin abrasions that can colonize with organisms from the patient’s own skin ora. It should not be performed
in the operating room to minimize the risk of contaminating the
sterile eld.
Poor nutritionalstatus
Patients with poor nutritional status and those with hypoalbuminaemia
(serum albumen concentration <2.5 g/ mL) prior to cardiac surgery
have a signicantly higher incidence of DSWIs, mediastinitis, and
mortality. Elderly patients and those patients with a serum albumen
concentration less than 2.5g/ mL and a weight loss of greater than 10%
of total body weight within 6months of surgery appear to be the most
vulnerable. Preoperative nutritional support should be instituted in
those patients in whom surgery can be safely delayed for 7– 10days.
is approach has been shown to decrease wound infections and
sepsis following major abdominal surgery. e enteral route is preferred since it avoids volume overload, metabolic derangements, and
line sepsis, and is more cost- eective.
Preoperative extrathoracicinfections
Infections which are present at a site remote from the planned cardiac incision, especially those involving the urinary tract, lungs,
abdominal organs, and so tissues, signicantly increase the incidence of postoperative wound infections. In non- urgent/ emergent
situations, the organisms involved should be identied and appropriate antibiotics promptly instituted until the infection has totally
resolved.
Optimizing preoperative glycaemiccontrol
Increased serum glucose levels (>200 mg/ dL) prior to cardiac surgical
procedures have been shown to signicantly increase the incidence
of sternal wound infections, especially in those diabetic patients in
whom glycated haemoglobin levels exceed 7.5%. Reducing serum
glucose to less than 200 mg/ dL signicantly decreases the incidence
of sternal wound infections in patients with diabetes mellitus. In
those CABG patients who require urgent or emergent surgery with
glucose levels greater than 200 mg/ dL, optimizing glycaemic control
is best accomplished by using intravenous insulin infusions. is is
now a classIrecommendation in the Society of oracic Surgeons
(STS) guidelines for blood glucose management during adult cardiac surgery.
Smoking cessation and aggressive pulmonarytoilet
Active smoking at the time of cardiac surgery is an independent risk
factor for sternal infections and mediastinitis, especially in patients
greater than 70years of age. Although the exact time for cessation
of smoking prior to surgery is unknown, it is recommended that,
whenever possible, patients should stop smoking for at least 30days
prior to surgery. In those patients who either cannot quit smoking
or who require urgent/ emergent CABG and are actively smoking,
preoperative pulmonary physiotherapy can help to loosen secretions and minimize mucus plugging which results in prolonged ventilation, increased coughing, and respiratory infections, all of which
contribute to sternal instability, wound dehiscence, and ultimately
mediastinitis.
Preoperativeantibiotics
Preoperative antibiotics are essential to decrease the incidence
of wound infections and mediastinitis following cardiac surgical
procedures. In 2006– 2007, the STS Workforce on Evidence- Based
Medicine published a series of guidelines for the duration and choice
of antibiotics during cardiac surgical procedures., e following is
a summary of their recommendations:
• Acephalosporin, either cefazolin or cefuroxime, should be given
within 60 minutes prior to the skin incision (classIrecommendation, level of evidence A).
• Vancomycin should be reserved for patients with type Iallergic
reactions to a beta- lactam agent or in cases where MRSA is of
concern. ese include patients hospitalized for more than 3days,
patients transferred from another inpatient facility, procedures
involving a prosthetic valve or a vascular gra, and institutions
with a high prevalence of MRSA (classII recommendation, level
of evidence B).
• Since vancomycin is less active against S. aureus strains, the most
common organisms found in DSWIs, vancomycin is not recommended as the sole prophylactic antibiotic for cardiac surgery
procedures (classIII recommendation, level of evidence B).
• An aminoglycoside should be added preoperatively for Gram-
negative coverage when vancomycin is the primary prophylactic
antibiotic since vancomycin’s activity is limited to Gram- positive
bacteria; specically MRSA and methicillin- resistant S. epidermidis
(classIIB recommendation, level of evidence C).
Intraoperativeprevention
Antibiotics
Since cardiac surgery procedures usually last longer than 4 hours
and antibiotic levels may be altered during cardiopulmonary bypass,
the STS guidelines recommend that cephalosporins be re- dosed for
procedures lasting longer than 4 hours. Weight- based dosing is recommended (classIrecommendation, level of evidence A).
57 Prevention ofmediastinitis 401
https://t.me/medicina_free
Instruments
Flashing instruments, especially larger instruments such as sternal
retractors and retractors used for the dissection of the internal
thoracic artery (ITA), should be avoided. Instruments used for
harvesting saphenous veins and those used for groin cannulation
should not be used in the mediastinum. is increases the risk for
cross- contamination of surgical wounds and ultimately sternal
wound infections and mediastinitis.
Glycaemiccontrol
Elevated glucose levels (>200 mg/ dL) during surgery are an independent risk factor for postoperative sternal wound infections,
while maintaining serum glucose less than 180 mg/ dL decreases the
incidence of sternal wound infections. STS guidelines recommend
that patients with persistently elevated serum glucose levels greater
than 180 mg/ dL during surgery should receive a continuous intravenous insulin infusion to maintain serum glucose levels at less than
180 mg/ dL.
Topicalantibiotics
Topical antibiotics applied to the cut edges of the sternum in either
a dry or powdered form achieve much higher local wound concentrations than are possible with systemic antibiotics and these high
Vander Salm et al., in a prospective randomized trial of patients
undergoing a median sternotomy, found that vancomycin applied
topically to the edges of the sternum reduced the rate of sternal wound
infections from 3.6% to 0.5% (P=0.02). Lazar et al., in a retrospective, non- randomized study involving over 3000 sternotomy
patients, found that topical vancomycin applied as a slurry to both
edges of the sternum in conjunction with perioperative antibiotics
and tight glycaemic control (<180 mg/ dL), totally eliminated supercial (0% vs 1.6%; P <0.001), deep (0% vs 0.7%; P=0.005), or any type
of wound infection in both non- diabetic (0% vs 2.2%; P <0.0001)
and diabetic patients (0% vs 3.3%; P=0.0004). Furthermore, in a
dierent study, Lazar etal. found that when applied topically to the
sternum, serum levels of vancomycin returned to baseline by the
sixth postoperative day, and there was no increase in drug- resistant
infections or postoperative renal toxicity. Gentamycin– collagen
sponges have also been shown to reduce the incidence of both supercial and DSWIs by 40%. It is, however, important to limit the exposure of the gentamycin sponges in saline prior to implantation to
avoid decreasing the concentration of the gentamycin in the sponges.
Bone wax should beavoided
Bone wax should not be applied to the sternum during cardiac surgery. It acts as a foreign body, prevents bone union, and has been
found to be an independent risk factor for sternal dehiscence and
infections. Furthermore, it has not been shown to limit blood loss
or the use of blood products. Vancomycin paste, applied to the
cut edges of the sternum, is helpful in reducing bleeding from the
sternum, without the deleterious eects of bone wax.
Haemostasis and adequatedrainage
All surgeons are aware of the importance of minimizing excessive intraoperative bleeding, and achieving haemostasis. Excessive
bleeding and haematoma formation result in a culture medium
that promotes bacterial growth and leads to mediastinitis. Blood
transfusions may also contribute to postoperative infections and
should be kept to a minimum. Excessive use of topical haemostatic
agents may also elicit an inammatory response which predisposes
to mediastinitis. When diuse oozing is present due to an underlying coagulopathy, adequate drainage of the mediastinum and
pleural cavities is essential. Aer the coagulopathy is treated and
clots form, proper location of drainage tubes which are appropriately ‘stripped’ will minimize the amount of retained mediastinal
blood and decrease the incidence of mediastinitis.
Intraoperative techniques tomaintain sternalstability
Minimizing postoperative sternal infections and mediastinitis starts
with performing a midline sternotomy. An inadvertent paramedian
sternotomy is oen accompanied by a sternal fracture, and increases
the risk for instability, dehiscence, and ultimately infection. When
this occurs, a ‘Robicsek weave’, in which wires are woven through the
intercostal spaces parasternally in conjunction with standard transverse wires, can decrease the incidence of sternal dehiscence.
For routine sternal closures without fractures, a gure- of- eight
technique has been found to decrease the incidence of supercial
and deep sternal infections, especially when cable wires are used.
Rigid sternal xation with bands or plates have been used in
obese, diabetic, and chronic obstructive pulmonary disease patients
to reduce the incidence of dehiscence in these high- risk patients.
e results are inconclusive; they are more expensive and have been
associated with wound seromas and haematomas. ey should not
be used in patients with osteoporosis and in the presence of active
infections.
Minimizing sternal infections inpatients withBITAgrafts
Although BITA graing has been shown to increase long- term survival in CABG patients, it is associated with a higher risk of DSWIs.
e risk appears to be signicantly higher in patients with longstanding and insulin- dependent diabetes mellitus. Skeletonization
of BITAs signicantly decreases the incidence of wound infections
in all patients, similar to the incidence observed when only a single
ITA is used. e use of a modied pedicle harvesting technique
for BITAs, in which the bifurcation of the distal ITA to the chest
wall and the pericardiophrenic artery branch are preserved, has also
been shown to decrease the incidence of sternal wound infections.
ese techniques will help to decrease BITA- related sternal wound
infections and increase the use of BITA graing in all patients. e
most recent (2018) European Society of Cardiology/ European
Association for Cardio- oracic Surgery Guidelines on myocardial
revascularization now recommend skeletonizing the ITA in patients
with a high risk for sternal wound infections (classIB).
Postoperativeprevention
Antibiotics
STS guidelines now recommend that appropriate antibiotics should
be continued for no longer than 48 hours following surgery.
Vancomycin, when used with a cephalosporin, and aminoglycosides,
when used with vancomycin, should each be given for one additional postoperative dose.
SECTION 7 Technical aspects ofcoronary artery bypass graft surgery402
https://t.me/medicina_free
Glycaemiccontrol
STS guidelines now recommend that serum glucose concentration be
less than 180 mg/ dL for the rst 24 hours in the intensive care unit
using intravenous insulin infusions. Insulin infusions should continue in those patients in whom extended periods of intensive care
unit care are necessary due to the need for inotropic support, mechanical ventilatory or circulatory assistance, or antiarrhythmic therapy.
Chest wallstabilization
Early extubation and suppression of uncontrolled coughing episodes
prevents sternal instability and dehiscence which lead to infection.
External chest support devices have also been used to prevent movement of the sternal tables. However, these vests are cumbersome to
wear and patient compliance is variable.
Drainage and indwellingcatheters
As noted previously, retained blood which develops into a coagulum
is an excellent culture medium and increases the risk for mediastinitis. Every eort should be made to maintain patency of drainage
catheters to remove any retained blood. ese catheters should be
removed as soon as the drainage decreases since they also serve as
a potential nidus for infection. In those instances where patients require re- exploration for bleeding, this should done expeditiously
3. Anderson MJ, David ML, Scholz M, Bull SJ, Morse D, HulseStevens M, etal. Ecacy of skin and nasal povidone- iodine
preparation against mupirocin- resistant methicillin- resistant
Staphylococcus aureus and S. aureus within the anterior nares.
Antimicrob Agents Chemother. 2015;59(5):2765– 73.
4. Phillips M, Rosenberg A, Shopsin B, Cu G, Skeete F, Foti A, etal.
Preventing surgical site infections:a randomized, open- label trial
of nasal mupirocin ointment and nasal povidone- iodine solution.
Infect Control Hosp Epidemiol. 2014;35(7):826– 32.
5. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR.
Guideline for prevention of surgical site infections. Infect Control
Hosp Epidemiol. 1999;20(4):250– 78.
6. Jie B, Jiang ZM, Nolan MT, Zhu SN, Yu K, Kondrup J. Impact
of preoperative nutritional support on clinical outcome in
abdominal surgical patients at nutritional risk. Nutrition.
2012;28(10):1022– 7.
7. Lazar HL, Chipkin SR, Fitzgerald CA, Bao Y, Cabral H, Apstein
CS. Tight glycemic control in diabetic coronary artery bypass
gra patients improves perioperative outcomes and decreases
recurrent ischemic events. Circulation. 2004;109(12):1497– 502.
8. Lazar HL, McDonnell M, Chipkin SR, Furnary AP, Engelman
RM, Sadhu AR, etal. e Society of oracic Surgeons Practice
Guideline Series:blood glucose management during adult
cardiac surgery. Ann orac Surg. 2009;87(2):663– 9.
9. Edwards FH, Engelman RM, Houck P, Shahian DM, Bridges CR,
Society of oracic Surgeons. e Society of oracic Surgeons
to minimize the need for blood transfusions which contribute to
sternal wound infections. When patients are returned to the operating room for re- exploration, appropriate antibiotics should be redosed and topical antibiotics should be reapplied to the sternal edges.
Finally, indwelling urinary, central venous, and peripheral arterial catheters should be removed as soon as the patients are clinically stable and invasive haemodynamic monitoring is no longer
necessary.
Practice Guideline Series:antibiotic prophylaxis in cardiac
surgery, part i:duration. Ann orac Surg. 2006;81(1):397– 404.
10. Engelman RM, Shahian D, Shemin R, Guy TS, Bratzler D,
Edwards F, etal. e Society of oracic Surgeons practice
guideline series:antibiotic prophylaxis in cardiac surgery, part
II:antibiotic choice. Ann orac Surg. 2007;83(4):1569– 76.
11. Halasz NA. Wound infection and topical antibiotics:the surgeon’s
dilemma. Arch Surg. 1977;112(10):1240– 4.
12. Vander Salm TJ, Okike ON, Pasque MK, Pezzella AT, Lew R,
Traina V, etal. Reduction of sternal infection by application of
Conclusion
topical vancomycin. J orac Cardiovasc Surg. 1989;98(4):618– 22.
13. Lazar HL, Ketchedjian A, Haime M, Karlson K, Cabral H. Topical
vancomycin in combination with perioperative antibiotics
e prevention of sternal wound infections and mediastinitis is
multifactorial and requires a team eort among surgeons, referring physicians, nurses, and operating room and intensive care unit
personnel. Implementing the recommendations described in this
chapter has the potential to decrease the incidence of sternal infections and mediastinitis to less than 0.5% in all patients undergoing
CABG surgery. is will encourage the increased use of BITA gras,
decrease postoperative morbidity and mortality, decrease hospital
costs, and ultimately increase long- term survival.
and tight glycemic control helps to eliminate sternal wound
infections. J orac Cardiovasc Surg. 2014;148(3):1035– 8.
14. Lazar HL, Barlam T, Cabral H. e eect of topical vancomycin
applied to sternotomy incisions on postoperative serum
vancomycin levels. J Card Surg. 2011;26(5):461– 5.
15. Kowalewski M, Pawliszak W, Zaborowska K, Navarese EP,
Szwed KA, Kowalkowska ME, etal. Gentamicin- collagen
sponge reduces the risk of sternal wound infections aer
heart surgery:meta- analysis. J orac Cardiovasc Surg.
2015;149(6):1631– 40.
16. Deo SV, Shah IK, Dunlay SM, Erwin PJ, Locker C, Altarabsheh
SE, etal. Bilateral internal thoracic artery harvest and deep
REFERENCES
1. Huang SS, Rifas- Shiman SL, Warren DK, Fraser VJ, Climo MW,
Wong ES, etal. Improving methicillin- resistant staphylococcus
aureus surveillance and reporting in intensive care units. J Infect
Dis. 2007;195(3):330– 8.
2. Cimochowski GE, Harostock MD, Brown R, Bernardi M, Alonzo
N, Coyle K. Intranasal mupirocin reduces sternal wound infection
aer open heart surgery in diabetics and nondiabetics. Ann
orac Surg. 2001;71(5):1572– 8.
sternal wound infection in diabetic patients. Ann orac Surg.
2013;95(3):862– 9.
17. Sajja LR, Mannam G, Dandu SBR, Sompalli S. Reduction of
sternal wound infections in diabetic patients undergoing opump coronary artery bypass surgery using modied pedicle
bilateral internal thoracic artery harvest technique. J orac
Cardiovasc Surg. 2012;144(2):480– 5.
18. Neuman FJ, Sousa- Uva M, Ahlsson A, Alfonso F, Banning
AP, Benedetto U, etal. ESC/ EACTS Guidelines on myocardial
revascularization. Eur Heart J. 2019;40(2):87– 165.
https://t.me/medicina_free
SECTION 8
Coronary artery bypass gra
surgery inspecial situations
Section editors:Naresh Trehan and Yasir Abu-Omar
58. Coronary artery bypass grafting in women 405
Jessica Yu Rove and Jennifer S.Lawton
59. Coronary artery bypass grafting in
octogenarians 411
Derrick Y.Tam, Reena Karkhanis, and Stephen E.Fremes
60. Coronary artery bypass graft surgery in the setting
of acute myocardial infarction 415
Babatunde A.Yerokun and Peter K.Smith
61. Coronary artery bypass grafting in patients with
ventricular dysfunction:indications, techniques,
and outcomes 419
Andrea Garatti, Serenella Castelvecchio, Alessandro Parolari,
and Lorenzo Menicanti
62. Coronary artery bypass grafting:diabetes and
kidney disease 423
Michael E.Farkouh and Valentin Fuster
63. Coronary artery bypass grafting with surgical
ventricular reconstruction 431
Serenella Castelvecchio, Raffaella Molfetta, Andrea Garatti,
and Lorenzo Menicanti
64. Coronary anomalies:indications and technique,
including anomalous coronary arteries and
coronary artery fistulas 435
Anita Nguyen, Ramachandra C.Reddy, and Hartzell V.Schaff
https://t.me/medicina_free
https://t.me/medicina_free
58
Coronary artery bypass graing
inwomen
Jessica Yu Rove and Jennifer S. Lawton
Introduction
is chapter acknowledges perceived and actual dierences in
the manifestation of coronary artery disease between women and
men. Further, it summarizes data on the modern performance and
outcomes of coronary artery bypass surgery in women compared
to men.
Epidemiology ofcoronary artery disease
inwomen
Cardiovascular disease is the number one cause of death for adult
women in the United States and every major developed country of
the world. Between 1984 and 2013 in the United States, more women
than men died annually of cardiovascular disease. In 2016, 412,244
American women died from cardiovascular diseases, accounting for
almost a quarter of female deaths that year., is disease burden
is not simply due to women’s longevity as compared with men.
Ischaemic heart disease is the leading killer of women, with annual
mortality rates that aect more women under the age of 55years
than breast cancer (Fig. 58.1).,
In addition to traditional risk factors for atherosclerotic coronary
disease, such as diabetes, smoking, obesity, inactivity, hypertension, and dyslipidaemia, there are non-traditional risk factors for
coronary disease in women such as preterm delivery, hypertensive disorders of pregnancy, gestational diabetes, autoimmune disease (rheumatoid arthritis and lupus), breast cancer radiation and
chemotherapy, and depression (Fig. 58.2)., Furthermore, we now
know that a diagnosis of diabetes puts women at 50% greater risk of
coronary artery disease compared to the same diagnosis in men.,
In 2011, the American Heart Association released an update on
‘Eectiveness-based guidelines for the prevention of coronary artery
disease in women’ and recommended risk-stratifying women based
on their risk scores in three categories:(1) high risk, (2)at risk, and
(3)optimal risk (Fig. 58.3).
Evaluation ofcoronary artery disease inwomen
Physician evaluation of coronary artery disease in women is predicated on recognizing the risk of heart disease in female patients. It
is striking that only 8% of primary care providers and 17% of cardiologists in 2005 knew that heart disease killed more women every
year than men. Despite the American Heart Association’s release
of ‘Evidence-based guidelines for cardiovascular disease prevention in women’ in 2004, the risk of heart disease in women is still
under-recognized by physicians. Women are more likely than men
to be assigned a lower Framingham risk category despite a similar
calculated risk., Furthermore, when presenting with symptoms
of myocardial ischaemia, women are less likely than men to be referred for cardiac catheterization., When women undergo cardiac
catheterization for evidence of myocardial ischaemia, they are less
likely than men to be diagnosed with obstructive coronary artery
disease.,, With increased utilization of fractional ow reserve to
objectively assess coronary lesions, one propensity-matched study
showed that female patients referred for catheterization have lower
fractional ow reserve values compared to men for a given angiographic appearance of coronary stenosis.
Revascularization inwomen
Acknowledging the substantial burden of coronary artery disease
in women, it is surprising that less than a third of patients enrolled
in studies on the management of acute coronary syndrome and coronary artery bypass graing (CABG) are women.– e numbers
in these studies mirror statistics that show bypass graing is oered
to women at a lower rate than to men. In a contemporary analysis
of a coronary artery disease registry, male sex was signicantly associated with referral for CABG versus percutaneous coronary intervention (odds ratio 2.27; P <0.001). According to the National
Center for Health Statistics in the United States, approximately
450,000 bypass operations are performed per year and roughly 30%
SECTION 8 Coronary artery bypass graft surgery inspecial situations406
450,000
Deaths
Traditional ASCVD Risk Factors
Emerging, Nontraditional ASCVD Risk Factors
https://t.me/medicina_free
400,000
350,000
300,000
250,000
200,000
150,000
100,000
50,000
Males
Females
0
CVD
428,434
412,244
Cancer Accidents CLRDDiabetes
314,571
283,467
103,864
57,510
Causes of Deaths
Males Females
73,045
81,551
43,763
36,295
Alzheimer’s
Disease
35,372
80,731
Fig.58.1 Bar graph showing cardiovascular disease and other major causes of death for all males and females in the United States:2016. CLRD,
chronic lower respiratory disease; CVD, cardiovascular disease.
Source data from National Center for Health Statistics and National Heart, Lung, and Blood Institute.
are performed for women. Interestingly, more women than men
undergo emergent CABG.,
Unique perioperative recommendations for women undergoing surgical revascularization have been described. e Society
of oracic Surgeons (STS) Workforce on Evidence-Based Surgery
has issued guidelines for the perioperative management of women
undergoing coronary artery bypass surgery. In addition, there are
Diabetes
noteworthy technical considerations specic to revascularization in
women.,
Complete revascularization and target coronarysize
ere is angiographic and intraoperative evidence that women
have smaller coronary arteries compared to men., When adjusted for body surface area, women have coronaries that are,
Preterm delivery
Obesity and overweight
Fig.58.2 Traditional and non-traditional atherosclerotic cardiovascular disease (ASCVD) risk factors in women. Increasing among women and more
impactful traditional ASCVD risk factors include diabetes mellitus, hypertension, dyslipidaemia, smoking, obesity, and physical inactivity. Emerging,
non-traditional ASCVD risk factors include preterm delivery, hypertensive pregnancy disorders, gestational diabetes mellitus, breast cancer treatments,
autoimmune diseases, and depression.
Reproduced from Garcia M, Mulvagh SL, Merz CN, Buring JE, Manson JE. Cardiovascular disease in women:clinical perspectives. Circ Res 2016;118:1273–93 with permission from
Wolters Kluwer.
Smoking
Physical inactivity
Hypertension
Dyslipidemia
Hypertensive disorders of pregnancy
Gestational diabetes
Autoimmune disease
Breast cancer treatment
Depression
58 Coronary artery bypass grafting inwomen 407
Risk status
High risk (≥1
high-risk states)
At risk (≥1 major
risk factor[s])
Ideal cardiovascular
health (all of these)
Systemic autoimmune collagen-vascular diseases
https://t.me/medicina_free
Fig.58.3 Classification of cardiovascular disease risk in women. BP,
blood pressure; CHD, coronary heart disease; DASH, dietary approaches
to stop hypertension; DBP, diastolic blood pressure; HDL-C, high-density
lipoprotein cholesterol; IMT, intima–media thickness; SBP, systolic blood
pressure; wk, weeks; y, years.
Reproduced from Mosca L, Benjamin EJ, Berra K etal. Effectiveness-based guidelines
for the prevention of cardiovascular disease in women—2011 update:a guideline from
the American Heart Association. Circulation 2011;123:1243–62 with permission from
Wolters Kluwer.
angiographically, 0.3 mm on average smaller than those of men
of the same body size. In another study that measured coronary
arteries intraoperatively, women more frequently had coronaries
smaller than 1.25 mm. In particular, women had signicantly
smaller le anterior descending arteries compared to men. In
Criteria
Clinically manifest CHD
Clinically manifest cerebrovascular disease
Clinically manifest peripheral arterial disease
Abdominal aortic aneurysm
End-stage or chronic kidney disease
Diabetes mellitus
10-y predicted CVD risk ≥10%
Cigarette smoking
SBP ≥120 mmHg, DBP ≥80 mmHg, or treated
hypertension
Total cholesterol ≥200 mg/dL, HDL-C <50
mg/dL, or treated for dyslipidemia
Obesity, particularly central adiposity
Poor diet
Physical inactivity
Family history of premature CVD occurring in
first-degree relatives in men <55 y of age or
in women <65 y of age
Metabolic syndrome
Evidence of advanced subclinical atherosclerosis
(e.g. coronary calcification, carotid plaque, or
thickened IMT)
Poor exercise capacity on treadmill test and/or
abnormal heart rate recovery after stopping
exercise
(e.g. lupus or rheumatoid arthritis)
History or preeclampsia, gestational diabetes, or
pregnancy-induced hypertension
Total cholesterol <200 mg/dL (untreated)
BP <120/<80 mmHg (untreated)
Fasting blood glucose <100 mg/dL (untreated)
Body mass index <25 kg/m
Abstinence from smoking
Physical activity at goal for adults >20 y of age:
≥150 min/wk moderate intensity, ≥75
min/wk vigorous intensity, or combination
Healthy (DASH-like) diet
2
this study, the incidence of incomplete revascularization was also
signicantly higher in women. Performing bypass surgery on
smaller coronaries is understandably more technically challenging.
Although graing small coronaries has not been associated with increased morbidity or mortality, the technical challenge of graing
small coronaries may contribute to observed lower rates of complete
revascularization. Complete revascularization to each suitable region has been associated with reduced mortality.– In addition,
incomplete revascularization has been associated with increased
postoperative myocardial infarction, reintervention for early gra
failure, and postoperative shock requiring mechanical support.
Graftchoice
Internal thoracic artery (ITA) utilization for CABG has been
shown to improve both in-hospital and long-term survival and it is
undisputedly the recommended conduit to bypass the le anterior
descending artery.– e STS guidelines for CABG in women
make a classI(level of evidence B) recommendation to use at least
one ITA gra to bypass a stenotic coronary in every CABG case.
e use of an ITA is a quality measure for CABG endorsed by the
National Quality Forum and the STS. ITA use is reported to the
Centers for Medicare & Medicaid Services in the United States as
a quality measure and a justication must be provided if it is not
used. e le ITA use in men is 80–95%. In stark contrast, le ITA
use in women has been only 50–75%. In fact, the STS National
Cardiac Database identies female sex as an independent predictor
for non-use of an ITA gra. Clearly a more concerted eort must
be made to use an ITA conduit in women.
Multiple arterial graing using bilateral internal thoracic arteries
(BITAs) and radial arteries is supported by American, European, and
STS guidelines.– ere is strong evidence supporting superior patency and improved survival with the use of BITA gras compared
to saphenous vein gras in CABG., In addition, there are data
demonstrating equivalent survival and postoperative complications
between propensity-matched cohorts of men and women receiving
BITA gras. Despite this evidence, only 5–10% of patients receive
BITA gras and the utilization of BITA gras in women is half the
rate of utilization in men.,
Although not as underutilized as the right ITA, the utilization of
radial arteries in women is a paltry 10–20%., ere is growing
evidence that radial artery graing in women not only yields superior patency to vein gras, but positively impacts survival., In
a study including more than 300 women undergoing CABG with radial artery gras who were propensity matched to over 1000 women
undergoing CABG with saphenous vein gras, the use of radial
artery conduit exhibited a signicant protective eect on survival
from 5years out to 15years. is protective eect was associated
with radial artery patency (80%) that was comparable to the le
ITA (84%), at 15years and much superior to saphenous vein gras
(56%). In another study that matched women undergoing CABG
with saphenous vein gras to women who also received radial artery
gras, survival at 5years was 82% in those receiving radial artery
graing compared to 74% in the saphenous vein gra group. In another recent analysis of pooled patients from the randomized trials
of radial artery utilization followed out to 5years, females who had
radial artery conduits had fewer major adverse cardiac events and
female sex was associated with a lower risk of radial artery conduit
occlusion and a higher risk of saphenous vein gra occlusion.
Соседние файлы в папке Библиотека им академика М.И. Перельмана