Surgical Myocardial Surgical Myocardial RevascularisationRevascularisation

Alex Cale.BSc(Med Sci), MB ChB, FRCS(Ed), FRCS(CTh), MD.

Consultant Cardiothoracic Surgeon.

The North & East Yorkshire Heart Centre.

Castle Hill Hospital.

Coronary Artery Bypass GraftingCoronary Artery Bypass Grafting

Indications. Techniques. Results. Complications. Angioplasty & Stents. Training.

Management of IHD has a Management of IHD has a long way to go in this country.long way to go in this country.

MINAP data shows that 35,000 patients p.a. with MI do not see a cardiologist.

Mortality rate is 10%.(36,000 deaths pa from lung cancer.)The aim should be to diagnose and

revascularise some/most of these patients before they infarct.

Indications for CABG in Chronic Indications for CABG in Chronic Stable Angina.Stable Angina.

Significant (>50%) left main stem stenosis. Disabling angina despite maximal medical

therapy, when surgery can be performed with acceptable risk.

Three vessel disease (survival benefit greater when LVEF < 50%).

Two vessel disease with significant proximal LAD stenosis and either EF < 50% or demonstrable ischaemia on non-invasive testing.

EYHC

Indications for CABG in Chronic Indications for CABG in Chronic Stable Angina (2).Stable Angina (2).

Left main equivalent; i.e. > 70% stenosis of proximal LAD and circumflex arteries.

One or two vessel disease without significant proximal LAD stenosis, but with a large area of viable myocardium and high risk on non-invasive testing.

Isolated proximal LAD stenosis, especially if EF < 50%.

Indications for CABG in Unstable Indications for CABG in Unstable Angina / Non-Q Wave MI.Angina / Non-Q Wave MI.

Significant LMS stenosis.Left main equivalent.Ongoing ischaemia despite maximal

medical therapy.Proximal LAD stenosis with 1 or 2 vessel

disease.

EYHC

Indications for CABG in S-T Segment Indications for CABG in S-T Segment Elevation (Q-wave) MI.Elevation (Q-wave) MI.

No overall strongly supporting evidence.Angioplasty in first instance.Relative Indications for CABG:

– Ongoing ischaemia/infarction not responsive to maximal non-surgical therapy.

– Progressive pump failure with coronary stenoses compromising viable myocardium outside the infarct area.

Contraindications for CABG.Contraindications for CABG.

One or two vessel disease not involving significant proximal LAD stenosis, in patients (1) who have mild symptoms that are unlikely to be due to myocardial ischaemia or have not received an adequate trial of medical therapy and (A) have only a small area of viable myocardium or (B) have no demonstrable ischaemia on non-invasive testing.

EYHC

Contraindications for CABG.Contraindications for CABG.

Borderline coronary stenoses (50% to 60% of diameter in locations other than LMS), and no demonstrable ischaemia.

Insignificant (< 50%) stenosis.More than 12 hours following MI without

ongoing ischaemia.

Guideline compliance.Guideline compliance.

So, we have guidelines, who follows them?98% compliance 2001-2003

Myths.Myths.

Mortality following CABG higher than PTCA.

CPB causes brain damage.Significant proportion of grafts occlude

early.CABG expensive.

Audit.Audit.National Adult Cardiac Surgical Database.National Adult Cardiac Surgical Database.

Mortality falling despite worstening casemix.– Over 75yrs up 4.5x over last decade (mortality down by

35% over last 5 yrs).– Diabetics up to 22%, 50% reduction in mortality.– Mortality for women fallen by over 30%.– HT up to 65%, 25% reduction in mortality.– Mortality for poor LV down by 30%.

CABG activity stable, combined cases increasing.

Audit.Audit.National Adult Cardiac Surgical Database.National Adult Cardiac Surgical Database.

First-time CABG mortality:

– 2003 1.8% (0.8-3.8%) Hull 1.3%, Leeds 0.9%

– 2001-2003 2% (1.3-3.0%) Hull 1.9%, Leeds 1.3%

Audit.Audit.National Adult Cardiac Surgical Database.National Adult Cardiac Surgical Database.

First-time AVR mortality:

– 2003 3.2% (0.6-12.8%) Hull 1.1%, Leeds 3.7%

– 2001-2003 3.2% (1.2-7.7%) Hull 2.8%, Leeds 4.2%)

Multidisciplinary Team.Multidisciplinary Team.

Cardiology.Cardiac Surgery.Primary Care.Rehabilitation.Radiology.Endocrinology.

NICE Guidance on the use of coronary stents. NICE Guidance on the use of coronary stents. Technology Appraisal. October 2003.Technology Appraisal. October 2003.

50 RCTs of PCI vs BMS analysed. Only 12 scientifically adequate for metaanalysis. MACE rates:

- 23% vs 15.4% at 6 months.- 22% vs 18.9% at 12 months.

NICE Guidance on the use of coronary stents. NICE Guidance on the use of coronary stents. Technology Appraisal. October 2003.Technology Appraisal. October 2003.

6 RCTs of CABG vs BMS.MACE rates:

– 12.6% vs 25.8% at 6 months.– 12.3% vs 24.5% at 12 months.

Trials not powered to detect differences in mortality.

However………...

Stent or Surgery Trial.Stent or Surgery Trial.

RCT 988 patients.Minimum 1 year (median 2 yr) follow up.Repeat revascularisation rates;

– 21% PCI vs 6% CABG (p<0.0001)– MACE rates similar (p= 0.8)– Mortality rates significantly different.

PCI 5% vs CABG 2% (p=0.01)

NICE Guidance on the use of coronary stents. NICE Guidance on the use of coronary stents. Technology Appraisal. October 2003.Technology Appraisal. October 2003.

Paclitaxel DES:– Have not shown any advantage over BMS regarding

mortality or MI rates.

Sirolimus DES:– No reduction in MACE rates at 36 days, though lower

later on.– Have not been shown to have either a mortality or MI

advantage over BMS.

NICE Guidance on the use of coronary stents. NICE Guidance on the use of coronary stents. Technology Appraisal. October 2003.Technology Appraisal. October 2003.

The assessment groups model estimated a survival benefit for CABG over PCI of 0.05 QALYs per patient at 5 years.

This benefit would be enough to make CABG the preferred technology on both clinical and cost effectiveness.

However, the clinician consultees vigorously challenged this (4 cardiologists, 1 surgeon).

They would, wouldn,t they !

Meta-analysis of RCTs of DESMeta-analysis of RCTs of DESBabapulle (Lancet August 2004)Babapulle (Lancet August 2004)

11 trials 6-12 month FU (5103 patients).No evidence that DES effect mortality or

MI rates.Restenosis:

– 8.9% DES vs 29.3% BMS

MACE rates:– 7.8% DES vs 16.4% BMS

Problems with DESProblems with DES

Stent thrombosis.Aneurysm formation.

– Late stent thrombosis found to be associated with evidence of localised chronic inflammation and aneurysm formation.

Systemic hypersensitivity reactions.Sirolimus may trigger carcinogenic genes.

Adverse events with Cypher Adverse events with Cypher Stents.Stents.

FDA warning 2004.360 reports of clotted stents (70 deaths,

remainder required medical or surgical treatment)

70 reports (including deaths) of hypersensitivity reactions.

Techniques.Techniques.On or Off Bypass ?On or Off Bypass ?

Minimally Invasive Minimal access Port Access Robotic

Anastamotic Quality?

EYHC

Techniques.Techniques.Choice of ConduitsChoice of Conduits

Veins IMAs Radial Gastroepiploic Inf. Epigastric. ARTS Study

Bovine Umbilical veinEYHC

Techniques.Techniques.EndarterectomyEndarterectomy

Need not be avoided at all cost.

Good long term patency (70% 5yr)

Need to learn the ‘nack’.

Complete coronary reconstruction.

EYHC

Drug-Eluting Stents.Drug-Eluting Stents.When the drugs run out…….When the drugs run out…….

Primary AngioplastyPrimary Angioplasty

Doctors of the future.Doctors of the future.GMC essay competition asked teenagers GMC essay competition asked teenagers

what Doctors would be doing in 2050.what Doctors would be doing in 2050.

Using roller skates to save time.Using cloned eyeballs to examine patients.Will not have to work long hours unless

they want to.Thought most Doctors would be Politicians

in 2050.