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After CABG most patients can have symptom free life for up to 15 years.

Byline: Prof. Arif Ur Rahman

KARACHI -- Coronary Artery Bypass Graft (CABG) surgery offers immediate relief of symptoms in a fatal illness. It is easily reproducible and has acceptable morbidity and mortality. After CABG operation most of the patients can expect up to fifteen years symptom free life. This was stated by Prof.Arif Ur Rahman Prof. of Cardiac Surgery at National Institute of Cardiovascular Diseases. He was speaking at a seminar organized by Dr. Essa Laboratory in is programme of Continuing Medical Education for the healthcare professionals recently.

Peaking about the historical background Prof. Arif Ur Rahman said that the first close heart operation in Pakistan was performed in 1948 while first open heart operation was performed in 1977. Earlier the first heart operation in Pakistan was performed by a visiting team in Lahore in 1964 as well. Talking about the indications for surgery he mentioned chronic angina, unstable angina, acute myocardial infarction, severe coronary artery disease, complications of myocardial infarction, acute failure of percutaneous perfusion, blocked arteries etc. LIMA is the most patent graft while other grafts which are also used include RIMA, BIMA, and SVG, Radial Left Right single or composite, sternal wound problems could be encountered because of obesity or diabetes. In younger age patients BIMA or RIMA grafts are used. After CABG almost 90% of patients get immediate relief and over 80% remain angina free even after five years.

There is low chance of restenosis and according to various studies there is 95% survival after one year.

CABG patients remain in ICU for two to three days and have to remain hospitalized for seven to eight days. Recovery time is about three to six months. As per various studies the complications rate is reported between 5-10%. As regards cost of CABG operation at NICVD in the general ward, patients have to pay up to forty thousand rupees but in private healthcare facilities, the CABG operation costs over two lac rupees, he added. In the minimally invasive direct CABG Cardio Pulmonary Bypass is not used and now in some centers it accounts for almost 90% of procedures performed. MIDCAB, Prof. Arif Ur Rahman said started in 1990 and it has been gaining popularity. However, since now much more complicated procedures are done, MIDCAB is not used much. These procedures are usually done for LIMA to LAD.

MIDCAB, Prof. Arifur Rahman said offers many advantages which included reduced need for blood transfusion and less time under anesthesia, the patient is quickly out of the ICU, has less pain and discomfort and it is also economical as it costs up to 40% less as compared to CABG surgery. He then also referred to AHA/ACA guidelines as to when the patients should be operated in different classes. In patients Class-III, these surgical procedures should not be performed as they are considered harmful. Patients with poor LV function and diabetics are different patients. Major predictors of mortality include clinical heart failure, poor LV function. Diabetic patients are different from non-diabetics. They have more diffuse atherosclerosis pattern and increased response to vascular injury.

Speaking about angioplasty vs. CABG Prof. Arifur Rahman said that CABG is advisable in patients with diffuse disease, multivesel disease, LMS of those with complex lesions. Patients with multivesel disease, complex disease, CTO and single vessel disease are preferred for PCI. It has been observed that PCI fails because of non-compliance to drug therapy. Progression of the disease could be due to size of the coronary arteries, lack of secondary prevention, wrong selection of the cases due to patient refusal for surgery of physician's bias. It is important to select appropriate patients for both the procedures as to who will go for CABG and who should go for angioplasty. BARI trial showed that diabetics have better survival with CABG. Five years survival after CABG after five years was 81% as compared to 80% with PCI which shows there is not much difference in both. However, after three years there were only 5% repeat revascularizations in CABG group as compared to 25% in PCI patients.

He also talked about gene therapy and use of better Statins which are quite helpful. Syntax trial Prof.Arifur Rahman said showed that in patients with multivesel disease, after one year repeat interventions were three times higher in PCI group. He concluded his presentation by stating that indications for PCI and CABG are well delineated and both these procedures are complimentary to each other but CABG gives better results in diabetics.

Later one of the Rotarians gave details about the polio campaign which they have been supporting in the country. Dr. Qadeer Ahmad from Roche highlighted the efficacy of Troponin -T as a cardiac marker. This, he said, is more sensitive and is also approved by FDA for use in patients with kidney disorders. Prof. Arifur Rahman and other guest speakers were also presented mementoes on behalf of Dr. Essa Laboratories.
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Publication:Pulse International
Geographic Code:9PAKI
Date:Aug 14, 2011
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