Coronary artery disease
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Heart attack (myocardial infarction) interventions and treatment
- In addition to treatment with medications after a heart attack, as part of your overall treatment, you might also have some procedures done. And these range from smaller interventional procedures to big open heart surgeries. Generally these are reserved for patients with STEMIs, ST-Elevation Myocardial Infarcts The more serious type of Infarct. But they can be done for patients with NSTEMIs, Non ST-Elevation Myocardial Infarcts, as well, if they're not responding to treatment with medication alone, or if they have a lot of risk factors for bad coronary vessel disease. So, once you've been given some medications to deal with your myocardial infarct, the first thing that happens, from a interventional point of view, is you'll get a coronary angiogram done. Which is where an interventional cardiologist, a specialized heart doctor, will take a sort of unique type of x-ray of your heart's blood vessels. And normally on a normal x-ray you can't really see people's blood vessels, so in an angiogram, the cardiologist will inject a special type of dye into the patient's circulation. And that dye will help the cardiologist to really see the blood vessels of the heart really clearly. So, coronary angiograms are to check how badly, and also where your coronary arteries are blocked or narrowed. And depending on how the bad the clogging is inside the coronary arteries, the cardiologists will then make a recommendation for what procedure that you need to go on to next to fix the underlying problem with your heart. So, this is what a coronary angiogram looks like. You can see, it's really a cool, sort of, dynamic picture. You can get a real-time look at how healthy the person's coronary arteries are. So, yes, these are blood vessels and this is actually the outline of the heart here. In this coronary artery here, there's a pretty severe blockage, a pretty severe narrowing of this coronary artery. And over here on the right, it's resolved, it's opened up. And that's after treatment. So depending on how bad the clogging is inside a given person's coronary arteries, the cardiologist will then go on to make a recommendation for what procedure to move on to next to fix the underlying problem with someone's heart. So, let's actually have a look at a few of these procedures. Percutaneous Coronary Intervention, or PCI, is where a doctor will insert a catheter. So, here I'm drawing a catheter now, this purple thing. So this is actually a wire-like tube that a doctor will thread into your femoral artery, or actually sometimes some other arteries, but usually the femoral artery. So, he'll thread it into your artery, sort of put it into your artery, and thread it up to your heart and into your coronary vessels. Which, as it probably sounds like, it takes a lot of skill and knowledge to do this. And depending on what they find in your coronary vessels, depending on how bad the blockage in your vessels is, they'll either just do something called an angioplasty, which is where they blow a balloon up, that's on the end of the catheter. So, there's a balloon on the end of the catheter and when they blow it up, it sort of opens up the blockage, pushes all that atherosclerotic plaque aside, and allows blood through again. Or they'll do an angioplasty, so what we saw here, and insert a stent, which is a tough, mesh-like cylinder made out of metal, that gets left behind in your coronary vessel to prop it open. So that's PCI, that's Percutaneous Coronary Intervention. Either just angioplasty, so opening up a clogged artery with a balloon by using a catheter with a balloon on the end, or by doing angioplasty, so the ballooning technique, plus inserting a stent and leaving it in there long-term. So, i.e., forever, right, indefinitely. So, that's PCI. Now, the next sort of grade up, in terms of interventions, is Coronary Bypass Grafts. So, this one is really a whole different ball game. This is an open heart surgery. So, let me clear off some space here. Let me clear off some room here. Because now this is the big time. So, here I'll draw in some more coronary arteries here. And the reason I'm drawing more on, is because I just want to show you that Coronary Artery Bypass Grafts, or cabbage, as the acronym sort of allows us to pronounce it, cabbage, is really only done in patients who have really severe coronary artery disease. And so by severe coronary artery disease I mean if they have pretty significant plaques built up in at least three of their coronary vessels. And we call this condition triple vessel disease. And so you can just kind of imagine that if somebody has triple vessel disease it's really not going to be easy for them to get oxygen, say, from their coronary artery up here, right, down to this part of the heart down here because there's this huge blockage in the way. And that's the same sort of thing goes for this plaque and this plaque right here. So, in the situation like this, you've got huge areas of heart, so basically all of this area of heart that this vessel supplies, actually it supplies more than that but I won't bother drawing it in, and, you know, all of this area of heart and all of this area of heart, that's essentially being deprived of oxygen. So, we have to do something about that. That's really, really serious. So, what happens? What happens in Coronary Artery Bypass Grafting? Well, just as the name suggests, bypassing, we take blood vessels from elsewhere in the body and use them to bypass the atherosclerotic plaque. So, I'll draw some on here to show you exactly what I mean. And I'll actually use pink to draw on the new blood vessels. So a blood vessel might be sort of attached on here before the plaque, and then sort of used to re-route blood around the plaque, so it'd be obviously attached again on the other side, after the plaque. And by doing this, you can restore blood flow to that affected area that I sort of highlighted before, that wasn't getting much oxygen at all. And so the same sort of procedure will happen with the rest of your blocked vessels. And, let me just say, that I'm not drawing it exactly how it's done in theater, in the operating theater, but this is really the general idea of what happens. So, just for interest's sake, blood vessels are usually taken from three main places. So, on the inside of your rib cage. So, what I'm drawing now is on the inside, not on the outside, on the inside of your rib cage, there's one that's really popular for use in bypass graft. That's called your internal mammary artery and there's one on each side. In the forearm, you've got a good one. So, in the forearm you've got a radial artery. And on your inner leg and thigh, you've got another one, a vein, called the great saphenous vein. And, again, just to reiterate, the purpose of Coronary Artery Bypass Grafting is to re-route blood around plaques. So, the blood can get to the heat muscle where it's needed. So this is a really cool surgery. I mean it sounds super complex and difficult and it really is. But I remember the first time I scrubbed into one of these procedures, and the whole time I was really just amazed at the skill and the composure of the surgeons who were doing it. They're really well trained. So the rate of complications is low.