Quick Chat About Coronary Artery Disease with Yale Surgeon Fabio Ramponi

Coronary artery disease (CAD) is one of the most common cardiovascular conditions, affecting over 18 million Americans ages 20 and older. The condition, characterized by the narrowing and hardening of the coronary arteries due to plaque buildup, can lead to significant health issues, as it impairs the heart's ability to receive adequate blood supply, potentially causing symptoms such as chest pain, shortness of breath, and, in severe cases, a heart attack.

According to Fabio Ramponi, MD, a Yale Medicine cardiovascular surgeon, CAD is a critical concern that requires accurate diagnosis and effective treatment to prevent serious cardiovascular events.

“Yale offers a comprehensive approach to managing coronary artery disease, leveraging advanced diagnostic and treatment options along with the expertise of skilled cardiologists and surgeons,” he says. “Patients choosing Yale for their CAD treatment benefit from personalized and optimal therapy to ensure the best possible outcomes.”

We caught up with Dr. Ramponi for a brief discussion about coronary artery disease, including treatments and prevention.

The responses below have been edited for space and clarity.

Coronary arteries are small blood vessels that supply blood to the heart. There are two main systems: the left system supplies the front and lateral side of the heart, and the right system supplies the inferior, or lower, part of the heart.

If coronary arteries are blocked or narrowed, the heart can't get enough blood, leading to a mismatch between the heart's demand and the supply. This can cause symptoms like chest pain and shortness of breath and potentially lead to a heart attack.

Coronary artery disease involves the hardening and narrowing of the coronary arteries due to plaque buildup. This plaque consists of fats, lipids, and calcium; some plaques can potentially rupture, leading to acute thrombosis [a blood clot that has been present for less than 14 days], complete blockage, and heart muscle damage—a process known as a heart attack.

The main risk factors include high blood pressure, high cholesterol, diabetes, obesity, family history, and smoking.

Diagnosis often begins with symptoms like chest discomfort or shortness of breath. Tests include lab tests, EKGs, exercise stress tests, nuclear tests, CT scans, and invasive angiograms to visualize the blockages.

The use of sophisticated CT scans, known as CT coronary angiograms, is becoming a more common noninvasive tool to diagnose coronary blockages. This specialized CT shows the presence of blockages and how they impact blood flow to the heart. Recent studies show that in the near future, this CT will become the gold standard for the diagnosis of patients with coronary disease, thus avoiding invasive catheterization.

Treatments include lifestyle changes, medications, stents, and coronary artery bypass surgery (CABG). The choice depends on the severity and location of the blockages, as well as the patient's overall health.

A stent is a small metallic cage inserted into a blocked artery to relieve the blockage and keep it open. It's used when blockages are less extensive and can be managed without major surgery.

CABG involves using blood vessels from other parts of the body to create a bypass around the blocked arteries. This improves blood flow to the heart and is especially beneficial for patients with extensive coronary artery disease. While a stent’s benefit is limited to treating the blockage, the advantage of bypass grafting goes beyond that. In fact, multiple studies have shown a role in the prevention of coronary disease progression in the coronary artery treated with a bypass graft.

Off-pump surgery, or beating heart surgery, avoids the use of the heart-lung machine [a device that temporarily takes over the function of the heart and lungs during surgery, maintaining blood circulation and oxygenation], reducing the risk of inflammatory reactions and complications such as stroke, cognitive decline, and bleeding, as well as kidney and lung injury.

Moreover, completely avoiding handling the aorta when creating composite bypass grafts [called the “anaortic technique”] lowers the risk of stroke even more, making it comparable to that of stents.

When planning a CABG operation, the surgeon can choose between two types of conduits to build the bypass: arteries or veins. Typically, arterial conduits are harvested from within the chest wall or from an arm, while veins are taken from the legs. Multiple studies have shown that using arteries instead of veins leads to better long-term results, especially in younger patients and diabetic patients.

Total arterial revascularization is a surgical technique used in CABG, in which only arterial grafts, as opposed to vein grafts, are used to bypass blocked coronary arteries. It’s not yet common—it’s used in less than 10% of cases in the U.S. However, because it shows significant benefits in long-term outcomes, it might become more standard in the future.

Yale offers a comprehensive heart team approach, advanced diagnostic and treatment options, and the expertise of skilled cardiologists and surgeons. This allows for individualized and optimal therapy for each patient.

At Yale, I focus on advanced coronary surgery techniques, including off-pump coronary bypass surgery and the use of multiple arterial grafts. I tailor the operation to the individual needs of each patient to ensure the best short- and long-term results.