| Date post: | 17-Jun-2015 |
| Category: |
Documents |
| Upload: | cardiacinfo |
| View: | 326 times |
| Download: | 0 times |
Andrew Chukwuemeka MD FRCSAndrew Chukwuemeka MD FRCSDepartment of Cardiothoracic SurgeryDepartment of Cardiothoracic SurgeryImperial College Healthcare NHS Trust Imperial College Healthcare NHS Trust St. Mary’s HospitalSt. Mary’s Hospital
CERTIFICATE IN CARDIOVASCULAR CERTIFICATE IN CARDIOVASCULAR MEDICINEMEDICINE
DAY 2 – CHEST PAINDAY 2 – CHEST PAIN 10th June 200910th June 2009
Andrew Chukwuemeka MD FRCSAndrew Chukwuemeka MD FRCSDepartment of Cardiothoracic SurgeryDepartment of Cardiothoracic SurgeryImperial College Healthcare NHS Trust Imperial College Healthcare NHS Trust St. Mary’s HospitalSt. Mary’s Hospital
CERTIFICATE IN CARDIOVASCULAR CERTIFICATE IN CARDIOVASCULAR MEDICINEMEDICINE
DAY 2 – CHEST PAINDAY 2 – CHEST PAIN 10th June 200910th June 2009
Conflict of interestConflict of interest::I AM A CARDIAC SURGEONI AM A CARDIAC SURGEON
Cardiac surgeon
Interventional Interventional CardiologistCardiologist
0
10
20
30
40
77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 9920
0020
0120
02
Pro
ce
du
res
(th
ou
sa
nd
s)
CABG PCI
Annual incidence of Percutaneous Annual incidence of Percutaneous Coronary Intervention and Coronary Artery Coronary Intervention and Coronary Artery
Bypass Grafting in the UKBypass Grafting in the UK
THE ROLE OF THE SURGEONTHE ROLE OF THE SURGEON
• Chest pain doctors• UK 25 - 30 000 CABG operations per
annum• 70% of the cardiac surgical workload
• Angina • Complications of myocardial ischaemia
• Mitral regurgitation• VSD• Heart failure• Ventricular aneurysm
• Prognostic surgery in asymptomatic patients
INDICATIONS FOR SURGERYINDICATIONS FOR SURGERY
• Still evolving: - conflict between trial data, registry data and
real world experience
• General agreement:- LMCA- Proximal LAD- 3 vessel disease- Poor left ventricular function
Yusuf S, Zucker D, Peduzzi P, et al: Effect of coronary artery bypass graft surgery on survival: Overview of 10-year results from randomized trials by the Coronary Artery Bypass Graft Surgery Trialist Collaboration. Lancet 1994; 344:563.
DIAGNOSISDIAGNOSIS
• HISTORY
• ECG• Stress ECG• Echo (stress)• Nuclear
• Angiogram
• CT• MRI
COMORBIDITYCOMORBIDITY
• FBC, U+E, Clotting• Chest X-ray
• Carotid U/S• Spirometry / Lung function tests
• Creatinine clearance• LFTs
• +++
SURGERYSURGERY• Median sternotomy
• Harvest of conduits• Internal mammary artery• Long saphenous vein
SURGERYSURGERY• Cardiopulmonary bypass
• Cardioplegic arrest in diastole
SURGERYSURGERY
Choice of conduits• Long saphenous vein• Short saphenous vein• Upper limb veins
• LITA• RITA• Radial artery• Gastroepiploic artery• Inferior epigastric artery
• Cryopreserved allografts
SURGERY – venous conduitsSURGERY – venous conduits
Problems with saphenous vein• Thrombosis:
– Early; denuded endothelium– Late; plaque related
• Intimal hyperplasia:– Universal after 1/12– Not progressive– Inversely related to flow
• Atherosclerotic plaques:– Rare before 3 years– Universal after 10 years
Patency• 90% at 1 year
• 50-60% at 10 years
• 20% at 20 years
• 80% at 10 years with SV to LAD
SURGERY – arterial conduitsSURGERY – arterial conduitsInternal mammary artery patency• > 95% at 1 year• > 90% at 10 years
Bourassa et al. Circulation 1982
Lytle et al. JTCVS 1985
Zeff et al. Ann Thorac Surg 1988
• 90% at 20 years
SURGERY – arterial conduitsSURGERY – arterial conduits
IF ONE IS GOOD, TWO MUST BE BETTER!
BITA(n=2001)
SITA(n=8123)
p
5 years 94 92 < 0.00110 years 84 79 < 0.00115 years 67 64 < 0.001
Lytle BW, Blackstone EH, Loop FD et al. Two internal thoracic artery grafts are better than one. JTCVS 1999;117;855-72.
SURGERY – arterial conduitsSURGERY – arterial conduits
NOT NECESSARILY!• No survival advantage for BITA• No reduction in re-operations
Seargeant P, Blackstone E, Meyns B. Validation and interdependence with patient variables of the influence of
procedural variables on early and late survival after CABG. K. U. Leuven Coronary Surgery Program. Eur J Cardiothorac Surg 1997;12:1-9
Pick AW, Orszulak TA, Anderson BJ, Schaff HV. Single versus bilateral internal mammary artery grafts: 10-year outcome analysis. Ann Thorac Surg 1997;64:599-605
Naunheim KS, Barner HB, Fiore AC. Results of internal thoracic artery grafting over 15 years: single versus double grafts. 1991 update. Ann Thorac Surg 1992;53:716-8
•Short term disadvantages vs. potential, but “unproven” long term benefits
•STS Registry data shows only 3-4% BITA use
SURGERY – arterial conduitsSURGERY – arterial conduits
Radial artery patency:• 98% at 6 months: Parolari et al. Ann Thorac Surg 2001
• 85-90% at 5 years: Acar et al. JTCVS 1998, Possati et al. JTCVS 1998,
Iaco et al. Ann Thorac Surg 2001
• 91% at 10 years: Possati et al. Circulation 2003
SURGERY – arterial conduitsSURGERY – arterial conduits
Radial (n=39) RITA (n=29) p
Gp I (< 70 yr) 95 86 0.4
Radial (n=24) SV (n=22)
Gp II (>70 yr) 86 95 0.5
RAPCO study:Buxton BF, Raman JS, Ruengsakulrach P, et al. Radial artery patency and clinical outcomes: Five-year interim results of a randomised trial. JTCVS 2003;125;1363-71.
5 year patency:
RAPS study:Desai ND, Cohen EA, Naylor CD, Fremes SE. A randomised comparison of radial-artery and saphenous-vein coronary bypass grafts. N Engl J Med 2004;351;2302-9.
Radial
SV
p
TIMI 0 (Occluded)
8.2% 13.6% 0.009
TIMI 0,1,2 12.3% 14.3% 0.37
Angiographic “string sign”
7.0% 0.9% 0.001
11 month patency:
SURGERYSURGERY
• Minimally invasive incisions (MIDCAB)• Robotically-assisted/ endoscopic techniques
• OPCAB
SURGERY - SURGERY - OPCABOPCAB
• “Off-pump coronary artery bypass surgery”
• Counters the deleterious effects of cardiopulmonary bypass
• Popular with the media and therefore with some patients
• Conflicting outcome data
• 20% of CABG in USA, less in UK and Europe
SURGERY - SURGERY - OPCABOPCAB
• 40 randomized clinical trials• Over 50 papers • Over 3000 patients • 3 robust meta-analyses
Failure conclusively to demonstrate:
• graft patency rates that are at least equivalent to conventional techniques
• reduced morbidity and mortality especially in high-risk groups
• a more rapid return to usual functional capacity
• an economic benefit.
SURGERY - SURGERY - OPCABOPCAB
• Surgeon and patient choice for specific indications
• Consistent improvements in some end-points: blood loss transfusion requirement atrial fibrillation chest infection
SURGERY - SURGERY - RISK ASSESSMENTRISK ASSESSMENT
EuroEuropean SSystem for CCardiac OOperative RRisk EEvaluationEur J Cardiothorac Surg 1999;16:9-13
• www.euroscore.org/logisticEuroSCORE.htm
• EuroSCORE (additive and logistic) Patient-related factors Cardiac-related factors Operation-related factors
• Risk-stratified comparisons
• Not predictive for individual patientsNot predictive for individual patients
COURAGECOURAGE
CClinical OOutcomes UUtilising RRevascularization and AAggressive Drug EEvaluation NEJM 2007;356:1503-16
As an initial management strategy in patients with stable coronary artery disease, PCI did not reduce the risk of death, MI or other major cardiovascular events when added to optimal medical therapy.
“Poor old cardiologists, just when they thought they had it all their own way!! Better cancel the order for the Porsche boys and girls!”
John Dixon, London, UK
