Coronary Revascularization (Case 40)

Chapter 58 Coronary Revascularization (Case 40)

Sharon Ben-Or, MD, Francis D. Ferdinand, MD

Cases Considered

Patient 1 67-year-old male with acute MI

Patient 2 61-year-old female with exertional chest pain

Speaking Intelligently

By the time patients with an acute MI, exertional chest pain, or an abnormal stress test are referred to a cardiac surgeon, most have already had a workup for ischemia including a stress test and cardiac catheterization. Nonetheless, when a patient is sent to me for consideration of coronary revascularization, I take my own careful hx in order to categorize the patient’s symptoms in terms of the New York Heart Association functional class categories.

A patient’s workup must determine the location and extent of the lesions within the coronary vessels as well as any concomitant valvular lesions or arrhythmias that might need to be addressed at the time of surgery. Assessing the patient’s comorbidities is key in planning for surgery and assessing risk. I always evaluate for peripheral vascular occlusive disease, cerebrovascular disease, renal insufficiency, and diabetes.

PATIENT CARE

Clinical Thinking

• Patient 1: In the setting of acute chest pain, an EKG is key for evaluating ST segment elevation as well as localization of the lesion and determination of associated arrhythmia.
• In the acute setting, cardiac catheterization is indicated in order to demonstrate the location of the lesion and other areas of stenosis, open the diseased artery, and prevent irreversible cardiac damage.
• It is recommended to stabilize the patient for a period of 72 hr prior to operating.
• Patients 1 and 2: Cardiac catheterization defines the anatomy and enables planning for stenting or bypass.
• Echocardiography defines valvular lesions that may occur concomitantly with coronary artery disease.

History

• Determine duration and character of the symptoms: location, radiation, and characteristic of pain; associated nausea and vomiting; diaphoresis; and palpitations.
• What worsens the pain? Consider exercise and stress. What alleviates the symptoms? Consider rest, nitroglycerin, and anxiolytics.
• Have symptoms worsened over time?
• Determine if there is a previous hx of coronary artery disease, peripheral vascular disease, renal insufficiency, and cerebrovascular disease.
• A family hx of cardiac disease should also be elicited.

Physical Examination

• Auscultate the carotid arteries for bruits.
• Auscultate the lungs for rales.
• Cardiac examination should be focused on whether the rate and rhythm are regular; determine presence of murmurs, rubs, or gallops.
• Examine for peripheral pulses.
• Particular attention should be paid to the Allen’s test on both arms as the radial artery is a potential conduit for bypass. The Allen’s test involves occluding both the radial and ulnar arteries while the patient is making a fist and then releasing the ulnar artery to see if it is adequate as the only blood supply to the hand.

Tests for Consideration

• CBC: Platelets, hemoglobin, and white count.
 $35
• Lipid profile: Total cholesterol, HDL, LDL, and triglycerides. Higher LDL levels are correlated with progression of lesions, and HDL with long-term survival.
 $65
• BMP: Potassium, BUN, creatinine, sodium, glucose, bicarbonate, and chloride.
 $45
• Hemoglobin A1C: The level of hemoglobin A1C is increased in the RBCs of patients with poorly controlled diabetes mellitus. Since the glucose stays attached to hemoglobin for the life of the RBC (normally about 120 days), the level of hemoglobin A1C reflects the average blood glucose level over the past 4 months.
 $43
• Stress test: The patient’s heart is “stressed” by exercise or stressed pharmacologically to illicit EKG, echocardiography, or perfusion images indicative of ischemia.
 $465

IMAGING CONSIDERATIONS

→ Echocardiography: Preoperative ultrasound evaluation of cardiac valves and wall motion is essential for operative planning. Unsuspected aortic stenosis, ventricular aneurysm, or severe aortic atherosclerosis may drastically alter the therapeutic approach.
 $325
→ Cardiac catheterization: Angiography of the coronary arteries to define coronary anatomy, the extent of the lesion(s), and possible percutaneous intervention.

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on Coronary Revascularization (Case 40)

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