Future of coronary surgery

Marko Turina

Zürich

Rapid growth of cardiac surgery in seventies and

eighties was almost exclusively due to increase of

CABG procedures

First clinical PCI experience in Zurich, 1977/78

Turina M, Gruntzig A, Krayenbuhl C, Senning A, Ann Thorac Surg 28(2):103-12, 1979

In the first series of 95 patients, there were 9

serious complications (9.5 %) necessitating

emergency CABG, with several patients under

continuous resuscitation. There was no mortality or

myocardial infarction, due to an immediate surgical

revascularization within 2 hours after vessel

closure.

In the beginning, PTCA was a risky procedure!

PCI and ACBP

Switzerland 1992-2012

Prof. Carrell, Bern

In recent years only 25 % of patients with

CAD received CABG; all the rest had PCI

Trends in Coronary Revascularization and Ischemic Heart Disease–Related Mortality in

Israel. Orit Blumenfeld, et al.

Journal of the American Heart Association, DOI:10.1161/JAHA.116.004734

Revascularization procedures performed in countries throughout the Western world.

Head S J et al. Eur Heart J 2013;eurheartj.eht059

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2013. For permissions please email: journals.permissions@oup.com

Percentage of PCIs depends on payment modality

Cardiologists paid for PCICardiologist income

independent of PCI

In all highly developed countries, number of PCIs is still

increasing and CABGs is going down

New

ESC/EACTS

GUIDELINES

Case report of an asymptomatic patient who

received 2 stents, developed stent

thrombosis 2 times, had 3 more PCIs and

ended with CABG 6 months later

Date of download:

3/6/2014

Copyright © The American College of Cardiology.

All rights reserved.

From: A Heart With 67 Stents

J Am Coll Cardiol. 2010;56(19):1605-1605. doi:10.1016/j.jacc.2010.02.077

“Sometimes patients have so many stents that later bypass

surgery becomes impossible. That’s called a full metal

jacket.”

North America interventional cardiology devices

market, 2012 - 2020 (USD Million)

Rates of Survival in the CABG and PCI Populations, Adjusted with the Use of Inverse Probability Weighting.

Weintraub WS et al. N Engl J Med 2012;366:1467-1476.

Analysis of ~

200’00 patients

with CAD

In real-life observations, CABG guarantees better

long-term survival than CI

Bilateral IMA grafting: a “permanent” and

protective solution, with no distal

progression 20 years later

Benefit of IMA was firmly established in 1986, after this

report from Cleveland Clinic

New Concepts About Coronary Bypass Surgery

Alistair Royse, Zulfayandi Pawanis, David Canty, Jared Ou-Young, David Eccleston, Andrew Ajani,

Christopher Reid, Rinaldo Bellomo, Colin Royse.

Australian Registry of 51,113 primary CABG

Radial artery conduits improve long-term survival after coronary artery bypass

grafting.

Robert F. Tranbaugh, Kamellia R. Dimitrova, +5 authors Darryl M. Hoffman

The Annals of thoracic surgery

DOI:10.1016/j.athoracsur.2010.05.038

Copyright ©2012 The Society of Thoracic Surgeons

Dimitrova K. R. et al.; Ann Thorac Surg 2012;94:475-481

Kaplan-Meier-estimated disease progression rates in all territories with patent conduits

IMA implantation seems to exert a protective effect on

coronary vascular bed distal to IMA

There were almost 16 % crossovers in

bilateral IMA group

15 % crossovers

Business projection of CABG market in

USA: still high use of SVG

Evidence is emerging that CABG should be

performed by specialized cardiac surgeons

High-volume centers perform CABG with low mortality

Health Serv Res. 2017 Apr; 52(2): 863–878.

Hospital Surgical Volumes and Mortality after Coronary Artery Bypass Grafting: Using International Comparisons to Determine a Safe Threshold

Nils Gutacker, Ph.D., et al.

The “occasional open heart surgeon” revisited

Joseph S.Carey et al., jtcvs.2007.10.077

OPCAB should be reserved for specialized

surgeons working with an expert team, and should

be used only in suitable patients

Is robotic CABG a possibility?

Worldwide

What is the role of hybrid procedure?

• Several prospective randomized trials are

underway.

• Recently published, albeit smaller studies,

do not indicate an advantage over

conventional CABG.

• Favored technique is LIMA to LAD with a

mini-thoracotomy, followed by PCI to CX

and/or RCA, preferably in a hybrid OR.

The art of statesmanship is to foresee the inevitable

and to expedite its occurrence.

Charles-Maurice de Talleyrand-Périgord (1774 - 1838),

famous French diplomat

What is the future of coronary surgery?

• PCI will become standard treatment in a substantial proportion (~4/5) of CAD patients

• Arterial revascularization and OPCAB will advance, but will be concentrated in specialized centers

• Low-volume CABG centers will disappear

• CABG and combined interventions (valve and CABG) will be performed in hybrid operative rooms, with surgeons and cardiologists working as a team