Surgical Coronary Revascularization Who, What, When Speaker - Jonathan G. Howlett, MD FRCPC...

Surgical Coronary RevascularizationWho, What, When

Speaker - Jonathan G. Howlett, MD FRCPCChairperson – Gordon W. Moe, MD, MSc, FRCPC

WELCOME!

Heart Failure Guidelines

This event is an Accredited Group Learning Activity (Section 1) as defined by the Maintenance of Certification program of The Royal College of Physicians and Surgeons of Canada, and approved by the Canadian Cardiovascular Society for 1 Royal Credit MOC Section 1 Credit.

Accreditation


Learning ObjectivesAt the conclusion of this webinar, participants will be able to:

•Review the potential role of surgical intervention as a heart failure management and treatment option

•Discuss opportunities and challenges of surgery for heart failure patients – where to begin, where to end

•Develop patient specific treatment plans that take into account the benefits, risks and limitations of surgery as a treatment option

•Integrate CCS guidelines into best clinical practices


Disclosures- J. Howlett

• Speaker and/or Consultant Fees:– AstraZeneca, Bayer, CVRx, Medtronic, Novartis,

Servier, Pfizer, Otsuka, Merck

• Research and/or Funding for Research:– AstraZeneca, Bayer, CVRx, Medtronic, Novartis,

Servier– NGOs: AIHS, NIH, Canada Health Infoway


Disclosures- Dr. Moe

• No disclosures


Case 1 • 75 year old female presenting with a diagnosis of HF

• Progressive SOBOE and orthopnea– Atypical chest discomfort with variable exertion, emotional stress

• Past history– HTN – Former smoker– Negative workup for atypical chest pain 10 years ago

• Initial assessment: – BP 130/82, HR 84 bpm (regular), obvious volume overload– NT-BNP 3800 pg/mL, troponin I negative– ECG: sinus rhythm, Q waves leads II,III, AVF, QRS duration 110 msec


Case 1

• Echocardiogram performed:– LVEF ~25%, global hypokinesis– LVIDd 5.8cm; LVIDs 5.1cm, EF 29%– 2+MR– RVSP ~ 45 mmHg

• Course in hospital over 7 days– Diuresed 4 kg with IV furosemide, at “dry weight”– Started on ramipril 5mg/d, and carvedilol 6.25 mg bid and MRA

Ambulatory, wondering what we are going to do??


……prepare to provide your answers!prepare to provide your answers!


Case 1 - What would you like to do next?

1. Coronary angiogram

2. Myocardial perfusion imaging (persantine sestamibi)

3. Cardiac MRI

4. Referral to EP for ICD and or CRT


Case 1 - What would you like to do next?

1. Coronary angiogram

2. Myocardial perfusion imaging (persantine sestamibi)

3. Cardiac MRI

4. Referral to EP for ICD and or CRT


Back to Case 1

• Angiogram reveals multivessel coronary disease– Occluded RCA– 80% mid LAD lesion– 90% mid LAD lesion– 70% OM1 and 90% OM2 lesions (medium size)

• Surgical colleague reviews the films:– Technically graftable with good distal target vessels

– Serum creatinine stable at 120 mmol/L, GFR 51 ml/min




Case 1- Your recommended course of action ?

1. Discharge w/a plan for titrated medical tx until angina occurs

2. Present the patient to CV surgical colleagues to consider CABG

3. Refer to interventional colleague for multivessel PCI

4. Referral for ICD/CRT


Case 1 - Your recommended course of action ?

1. Discharge w/ a plan for titrated medical tx until angina occurs

2. Present the patient to CV surgical colleagues to consider for CABG

3. Refer to interventional colleague for multivessel PCI



Prognostic significance of ischemic cardiomyopathy

Felker et al, N Engl J Med 2000

>1200 patients with invasive evaluation for cardiomyopathy over 15 years

Ischemic etiology is also an independent predictor of mortality in risk models: Seattle Heart Failure Model (SHFM) Heart Failure Survival Score (HFSS)

Ischemic etiology is also an independent predictor of mortality in risk models: Seattle Heart Failure Model (SHFM) Heart Failure Survival Score (HFSS)

Levy et al, Circulation 2006Aaronson et al, Circulation 1997Levy et al, Circulation 2006Aaronson et al, Circulation 1997


Yusuf et al, Lancet 2004Yusuf et al, Lancet 2004

Individual patient level meta-analysis of 7 trials•2600 patients enrolled 1972-84

•CABG associated with mortality reduction

•39% at 5 years, 17% at 10 years

•No interaction with LV dysfunction and mortality reduction but higher absolute benefits seen in high risk subgroups

Individual patient level meta-analysis of 7 trials•2600 patients enrolled 1972-84

•CABG associated with mortality reduction

•39% at 5 years, 17% at 10 years

•No interaction with LV dysfunction and mortality reduction but higher absolute benefits seen in high risk subgroups

Surgical Treatment for Ischemic Heart Failure – where’s the evidence?


• In these early studies:– 90% had angina– 80% had normal LVEF– 10% had arterial conduits– Medical therapy = digoxin and

diuretics

• In these early studies:– 90% had angina– 80% had normal LVEF– 10% had arterial conduits– Medical therapy = digoxin and

diuretics

Yusuf et al, Lancet 2004Yusuf et al, Lancet 2004

Surgical Treatment for Ischemic Heart Failure – where’s the evidence?

Need to assess the benefits of revascularization in contemporary patients with ischemic cardiomypathyNeed to assess the benefits of revascularization in

contemporary patients with ischemic cardiomypathy


Current Era: Surgical Treatment for Ischemic Heart failure (STICH)

Randomized non-blinded study of surgical revascularization:

Included patients with LVEF <35% and CAD suitable for revascularization

Hypothesis 1:CABG + medical rx superior to medical rx alone

Hypothesis 2: CABG + SVR superior to CABG alone in patients undergoing revascularization with anterior wall akinesis/dyskinesis

Randomized non-blinded study of surgical revascularization:

Included patients with LVEF <35% and CAD suitable for revascularization

Hypothesis 1:CABG + medical rx superior to medical rx alone

Hypothesis 2: CABG + SVR superior to CABG alone in patients undergoing revascularization with anterior wall akinesis/dyskinesis

Velazquez et al, J Thorac and Cardiovasc SurgVelazquez et al, J Thorac and Cardiovasc Surg


STICH Hypothesis 1: Primary outcome

1212 patients randomized to CABG vs medical therapy

Patients with recent MI, major illness, significant L Main disease and severe angina excluded

No difference in all cause mortalityseen at median 56 months follow-up

17% of patients in medical therapy arm crossed over to surgical arm

1212 patients randomized to CABG vs medical therapy

Patients with recent MI, major illness, significant L Main disease and severe angina excluded

No difference in all cause mortalityseen at median 56 months follow-up

17% of patients in medical therapy arm crossed over to surgical arm


STICH Hypothesis 1: secondary outcomes

CABG associated with reduction in cardiovascular death and combined outcome of death or cardiovascular hospitalizationCABG also associated with 30% relative reduction in mortality in “on-treatment”analysis (accounting for patients crossing over within 1st year of study)

CABG associated with reduction in cardiovascular death and combined outcome of death or cardiovascular hospitalizationCABG also associated with 30% relative reduction in mortality in “on-treatment”analysis (accounting for patients crossing over within 1st year of study)


We recommend that coronary angiography be:

a)Performed in patients with heart failure with ischemic symptoms, who are likely to be good candidates for revascularization.

b)Considered in patients with systolic heart failure (LVEF < 35%) at risk of coronary artery disease, irrespective of angina, who may be good candidates for revascularization.

Strong RecommendationModerate Quality Evidence

Strong RecommendationLow Quality Evidence

Recommendations - Revascularization Procedures

Assessment for Coronary Disease


We recommend that coronary angiography be:

c) Considered in patients with systolic heart failure and in whom non-invasive coronary perfusion testing yields features consistent with high risk.



Assessment for Coronary Disease

Values and Preferences: These recommendations place value on the need of coronary angiography to identify coronary artery disease amenable to revascularization. Patients with systolic heart failure due to ischemic heart disease may derive clinical benefit from coronary revascularization even in the absence of angina or reversible ischemia.


We recommend consideration of coronary artery bypass surgery for patients with chronic ischemic cardiomyopathy, LVEF < 35%, graftable coronary arteries and who are otherwise suitable candidates for surgery, irrespective of the presence of angina in order to improve quality of life, cardiovascular death and hospitalization.



Surgical Revascularization for Patients with IHD and HF


We recommend that performance of coronary revascularization procedures in patients with chronic heart failure and reduced LV ejection fraction should be undertaken with a medical-surgical team approach with experience and expertise in high risk interventions.



Disease Management, Referral and Peri-operative Care

Values and Preferences: This recommendation reflects the panel preferences that high risk revascularization is likely to

best occur in higher volume centres with significant experience, known outcomes, and similar to participating in clinical trials involving high-risk coronary revascularization.

Practical Tip:Assessment for advanced heart failure therapies by an appropriate team should be performed

prior to revascularization in any patient with advanced heart failure


Time-varying hazard ratios for all-cause mortality in patients

randomized to CABG or MED.


However, there is interaction with risk factors:

• LVEF < median value (28%)• LV end systolic index > 60 ml/M2• 3 vessel disease


Kaplan-Meier rate estimates of all-cause mortality among patients with 2-3 (top panel) and 0-1 (bottom panel) prognostic factors.


Case 2

• 65 year old male patient assessed in your office• Multiple admissions for heart failure, difficulty with

self management• Past history

– Prior lateral wall MI, 2001 (not revascularized)– Hypertension– Significant COPD with FEV1 < 750 ml– Type 2 DM. Right AKA due to severe PVD and ABI 0.22– CKD Atrial fibrillation, previous right sided CVA– Poor mobility, refuses walking aids, but able to perform

basic ADLs slowly


Case 2

• Currently NYHA class III, no angina• Medications

– Carvedilol 25 mg bid, amlodipine 10mg/d, furosemide 120mg bid, Nitro patch 1.2 mg/h, hydralazine 50mg tid, insulin, warfarin 4 mg OD, rosuvastatin 40mg/d, Slow K 2400 mg/day, several alternative agents and periodic metolazone

• Examination: BP 90/70, HR 80 bpm, AF, enlarged heart with normal JVP, 3+ edema and clear chest with poor pulses.

• ECG: Atrial fibrillation, Heart rate 76, Q waves lateral and QRS Duration 130 msec.

• Hemoglobin 95, Creat 250, GFR 19, K 5.0 and INR 2.8


Case 2

• Patient wishes to live as long as possible but most fearful becoming dialysis dependent

http://riskcalc.sts.orgwww.euroscore.orghttp://riskcalc.sts.orgwww.euroscore.org





1. Angiogram and possible CABG

2. Angiogram and possible ad hoc PCI of flow-limiting lesions

3. Non-invasive perfusion/viability test


5. Ongoing medical optimization only



1. Angiogram and possible CABG

2. Angiogram and possible ad hoc PCI of flow-limiting lesions

3. Non-invasive perfusion/viability test


5. Ongoing medical optimization only


The average heart failure patient

Age 75 years

Hypertension 72%

Diabetes 44%

Atrial fibrillation 31%

COPD 31%

Chronic kidney disease

30%

Gheorghiade, Eur Heart J, 2005Gheorghiade, Eur Heart J, 2005


• Prospective cohort, 4 sites, ≥ 70 yrs, for CABG ± valve– Non-emergent / urgent; no major psychiatric Dx

• 5 meter walk: if ≥6 seconds, classified as frail

• 131 pts, 75.8±4.4 yrs old– 46% frail (usually diabetic, IADL problems)– No correlation with STS risk score (i.e. different domains)

• Outcome: mortality, renal failure, stroke, reoperation, prolonged ventilation, deep sternal infection

Afilalo et al J Am Coll Cardiol 2010Afilalo et al J Am Coll Cardiol 2010

Frailty and cardiac surgery


Gait speed predicts mortality/major morbidity (OR 3.05, 95%CI 1.23–7.54)

Frailty and cardiac surgery

Afilalo et al J Am Coll Cardiol 2010Afilalo et al J Am Coll Cardiol 2010


Viability and LV functional recovery after revascularization

Bax et al J Am Coll Cardiol 1997Bax et al J Am Coll Cardiol 1997

Systematic review of non-invasiveImaging techniques in predicting Regional myocardial recovery

37 observational studies

Thallium, FDG PET and DSE show high degree of sensitivity

DSE and FDG PET show greatest specificity

Systematic review of non-invasiveImaging techniques in predicting Regional myocardial recovery

37 observational studies

Thallium, FDG PET and DSE show high degree of sensitivity

DSE and FDG PET show greatest specificity


Viability and survival after revascularization

Allman et al, J Am Coll Cardiol 2002Allman et al, J Am Coll Cardiol 2002

Systematic review of 24 observational studiesEvaluating relationship between death,

viability and revascularization

Systematic review of 24 observational studiesEvaluating relationship between death,

viability and revascularization


STICH AnalysisImproved prognosis with viability

Analysis of 601 patients with viability testing data available

Viability defined as ≥ 11 segments on SPECT or ≥ 5 segments on DSE imaging

Analysis of 601 patients with viability testing data available

Viability defined as ≥ 11 segments on SPECT or ≥ 5 segments on DSE imaging

Bonow et al, N Engl J Med 2011Bonow et al, N Engl J Med 2011


STICH AnalysisViability doesn’t necessarily predict improved outcomes with surgery vs medical therapy

Bonow et al, N Engl J Med 2011Bonow et al, N Engl J Med 2011


We recommend that the decision to refer patients with heart failure and ischemic heart disease for coronary revascularization should be made on a individual basis and in consideration of all cardiac and non- cardiac factors which affect procedural candidacy.



Disease Management, Referral and Peri-operative Care


Practical Tips Revascularization Procedures

Imaging

1.Several non-invasive methods for detection of coronary artery disease are in widespread use

• Dobutamine stress echocardiography (DSE)• perfusion cardiac magnetic resonance (CMR)• cardiac positron emission testing (PET)• nuclear stress imaging

Local factors (availability, price, expertise, practice patterns) will determine the optimal strategy for imaging.

2.Non- invasive imaging modalities may provide critical information such as the degree of ischemic or hibernating myocardium, and may be used to determine the likelihood of regional and global improvement in left ventricular systolic function.


Practical Tips (cont’d)Revascularization Procedures

Imaging

3. Patients with heart failure, and reduced LV ejection fraction are likely to experience significant improvement in LVEF following successful coronary revascularization if they demonstrate:

a) Reversible ischemia or a large segment of viable myocardium (> 30% of LV) by nuclear stress testing/ viability study;

b) Reversible ischemia or >7% hibernating myocardium on PET scanning;

c) Reversible ischemia or > 20% of LV shown as viable by DSE;

d) Less than 50% wall thickness scarring as shown by late gadolinium enhancement by cardiac CMR.


Tsuyuki et al, CMAJ 2006Tsuyuki et al, CMAJ 2006

4200 patients with HFreferred for angiography in Alberta 1995-2001

Adjusted for baseline risk and propensity for revascularization

2538 underwent revascularization; 1690 managed medically

Majority of patients had ischemic syndromesMedical management was suboptimal

Revascularization with CABG or PCI associated with improved survival

Signal for differential outcome, favoring CABG

4200 patients with HFreferred for angiography in Alberta 1995-2001

Adjusted for baseline risk and propensity for revascularization

2538 underwent revascularization; 1690 managed medically

Majority of patients had ischemic syndromesMedical management was suboptimal

Revascularization with CABG or PCI associated with improved survival

Signal for differential outcome, favoring CABG

PCI or CABG for ischemic symptoms and heart failure? (Angina included!!)

CABGCABG

PCIPCI

Med RxMed Rx

Med RxMed Rx

Revasc.Revasc.

HR 0.50HR 0.50


We suggest consideration of percutaneous coronary angioplasty for patients with heart failure and limiting symptoms of cardiac ischemia, and for whom CABG is not considered appropriate.

Weak RecommendationLow Quality Evidence






1.In the setting of heart failure, angina and single territory coronary artery disease, PCI may be the treatment of first choice. However, PCI has not been shown to improve outcomes for patients with chronic stable heart failure, irrespective of underlying anatomy.

2.Urgent directed culprit vessel angioplasty continues to be the revascularization modality of choice for patients with heart failure and acute coronary syndrome.


Figure 1. Approach to Assessment for Coronary Artery Disease in Patients with Heart Failure


Figure 2. Decision Regarding Coronary Revascularization in Heart Failure


Case 3• 77 year old female, recent admission for worsening HF, now

stable NYHA II symptoms- quite happy with current state– Occasional exertional chest discomfort with more than usual activity

• Past history:– Anterior wall MI, late PCI (2005)- no angina since then– Family history of premature CAD– Mild CRF and COPD with FEV1 of 1.9 L (no admissions)– Dyslipidemia- longstanding– IGT but not DM

• Medications:– Lisinopril 20mg/d, bisoprolol 10mg/d, eplerenone 25mg/d,

ASA 81mg/d, atorvastatin 80mg/d, furosemide 20mg/d, metformin, gliclazide, nitroglycerin patch 0.8

• ECG:– Sinus rhythm, LBBB (QRS 144msec), multifocal PVCs


Case 3

• Cardiac SestaMibi with Exercise- 7 METS on treadmill, limited by SOB but not angina, normal recovery– Large area of moderate ischemia in infero-lateral territory on

persantine MIBI imaging. Large apical scar without viability and mild cardiac dilation during exercise.

• Cardiac MRI demonstrates subendocardial scar in inferior and lateral walls, transmural scar at apex with large region of anterior wall akinesis, LVEF 35%


Case 3

• Coronary angiogram during hospitalization shows progressive disease:– Left main disease– Moderate in stent restenosis with focal 80% lesion (mid LAD)– 70% ostial circumflex lesion– Diffuse flow limiting disease in dominant RCA– All vessels graftable– Large akinetic, apical segment of LV Angiogram- no thrombus.– LVEDP 22 mmHG – No valvular heart disease.




Case 3 - You recommend surgical revascularization with concomitant:

1. Medical therapy

2. Medical therapy + CABG

3. Medical therapy + CABG + SVR

4. Medical therapy + SVR + CRT/ICD


Case 3 - You recommend surgical revascularization with concomitant:

1. Medical therapy

2. Medical therapy + CABG

3. Medical therapy + CABG + SVR

4. Medical therapy + SVR + CRT/ICD


Jones et al, N Engl J Med 2009Jones et al, N Engl J Med 2009

STICH Hypothesis 2: CABG and CABG +SVR improved HF symptoms

1000 patients undergoing CABG in STICH trial further randomized to CABG alone vs CABG + SVR

Dominant anterior wall motion abnormality required for inclusion

Median f/u 48 months

CABG + SVR achieved a reduction in LV end-systolic index by 19% vs 6% for CABG alone

1000 patients undergoing CABG in STICH trial further randomized to CABG alone vs CABG + SVR

Dominant anterior wall motion abnormality required for inclusion

Median f/u 48 months

CABG + SVR achieved a reduction in LV end-systolic index by 19% vs 6% for CABG alone


Jones et al, N Engl J Med 2009Jones et al, N Engl J Med 2009

STICH Hypothesis 2: No difference in primary or secondary outcomes between CABG vs CABG + SVR

All cause deathAll cause deathAll cause death or cardiovascular hospitalizationAll cause death or cardiovascular hospitalization




We recommend against routine performance of the SVR or surgical ventricular restoration for patients with heart failure undergoing CABG who have akinetic or dyskinetic LV segments.





1.In highly selected cases, patients with advanced HF symptoms in association with large areas of dyskinetic and non-viable myocardium may experience significant clinical improvement with SVR or similar type procedures, when performed by experienced surgeons.

2.Mitral valve repair may, when used concomitantly during CABG, may, in selected cases, lead to clinical improvement in symptoms of heart failure.




Case 3: When should you insert the ICD/CRT?

1. At the time of surgery

2. Before Surgery (CRT may obviate need of CABG)

3. After surgery, before discharge

4. After 3-6 months stable following surgery


Case 3: When should you insert the ICD/CRT?

1. At the time of surgery

2. Before Surgery (CRT may obviate need of CABG)

3. After surgery, before discharge

4. After 3-6 months stable following surgery


Timing of implantable device therapy in ischemic cardiomyopathy

Study Comparison Included Survival benefit with

device

CABG patch (1997) ICD vs no ICD Implanted at the time of CABG

-

MADIT II (2002) ICD vs no ICD MI > 1month;

Revasc > 3months

+

DINAMITE (2004) ICD vs no ICD MI < 40 days -

COMPANION (2004) ICD vs CRT-ICD vs medical rx

MI > 2months;

Revasc >2 months

+

+

SCD HeFT (2005) ICD vs amio vs placebo

MI > 1month;

Revasc >1 month

+

CARE (2005) CRT vs medical rx MI > 6 weeks +

IRIS (2009) ICD vs no ICD MI < 1 month -

RAFT (2010) CRT-ICD vs ICD Revasc >1 month +


We recommend that following successful cardiac surgery, patients with HF undergo assessment for implantable cardiac devices within 3-6 months of optimal treatment.

Strong RecommendationHigh Quality Evidence


Device Considerations in HF Patients Following Cardiac Surgery

We recommend that patients with implantable cardiac devices in situ should be evaluated for programming changes prior to surgery and again following surgery, in accordance with existing CCS recommendations.



Practical Tip Revascularization Procedures

Device Considerations in HF Patients Following Cardiac Surgery

1.During surgical revascularization, consideration should be given to implantation of epicardial LV leads to facilitate biventricular pacing in eligible patients who may be candidates for cardiac resynchronization therapy, especially if the coronary sinus anatomy is known to be unfavourable for lead placement.



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Surgical Coronary Revascularization Who, What, When Speaker - Jonathan G. Howlett, MD FRCPC...

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