Kims presentation web edit

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1 Cardiac Surgery at KIMS Mr. Inderpaul Birdi Consultant Cardiac Surgeon

Transcript of Kims presentation web edit

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Cardiac Surgery at KIMS

Mr. Inderpaul BirdiConsultant Cardiac Surgeon

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Plan

• Who am I?

• Surgical revascularisation in stable ischaemic heart disease

– PCI or CABG

– Special circumstances

– Off-pump or On-pump

• Cardiac surgery at KIMS

– Who, What, When, Where

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Who am I?

• Cardiac Surgeon

– Papworth Hospital and Royal Brompton Hospital

– Consultant since 2003

• Essex Cardiothoracic Centre 2007 (NEW SERVICE)

– Clinical Governance Lead 2007 to 2013

– Surgical Lead 2013 to date

– SCTS Unit Representative

– CQC Specialist Advisor

• Lead Clinician at The Keyhole Heart Clinic

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Death rates with medical therapy

2013 ESC Guidelines

The more severe the coronary disease the less likely medical therapy is effective

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Cardiac mortality and extent of ischaemia

2013 ESC Guidelines

Presence of ischaemia is also important

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PCI versus CABG

• More than 20 trials of PCI versus CABG – No survival benefit

• <10% eligible population

• 0ne-/two- vessel disease

• Normal ventricular function

• Propensity matched Registry data – Consistent survival benefit for surgery

• Registries can be susceptible to confounding

• SYNTAX TRIAL – ‘all comers’ trial

• Benefit of surgery over PCI in certain subgroups

• Higher incidence of repeat procedures in PCI group

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Triple vessel coronary disease at 3 years

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Triple vessel coronary disease at 4 years

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Triple vessel coronary disease at 4 years

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Method of revascularisation

2013 ESC Guidelines

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Special Situations

• Diabetes

– Complex lesions often predicate a preference for surgery especially in multi-vessel disease

• Elderly

– Balance of risk benefit ratio and influence of prognosis becomes difficult to establish

• Chronic renal disease

– Higher risk of renal injury associated with surgery

• Hybrid therapies (MIDCAB and PCI)

– Rebalancing between evidence base and patient preference

MIDCAB / MULTI-MIDCAB

• Acc Left Minithoracotomy(No costal cartilage or bone excision)

Lima to LAD

95% 10 year patency

Home 3.3 days versus 8 days for sternotomy

(more than £1000 cost saving per case)

Ideal patients:Single LAD lesion

Some multi-vessel lesions

Hybrid revascularisation

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Off-Pump or On-Pump

• Off-Pump surgery performed in 20% of CABG patients

• Polarised views (Asia – 60-100% performed Off-pump)

• Afilalo et al Eur Heart J 2012

– Metanalysis of 59 trials (9000pts)

• Significant reduction in stroke in Off-Pump group (1.4 v 2.1; rr0.77)

• Lamy et al N Engl J Med 2012

– Randomised trial looked at 30 day outcomes

• Off-Pump group bled less, required reduced transfusions, and suffered reduced respiratory and renal complications

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Off-Pump or On-Pump continued

• Several large patient Registries suggest:

– Reduction in mortality, stroke and major morbidities

– Less complete revascularisation

– increased incidence of repeat procedures reducing the early mortality benefit

• Real reduction in application of Off-pump surgery since Lamy 2012

• MIDCAB remains extremely attractive either as isolated LAD therapy or

as part of a hybrid protocol with PCI.

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Summary

• High ischaemic burden indicates prognostic need for revascularisation over

medical therapy

• PCI and CABG offer a complimentary package of interventional and surgical

therapies for the correction of myocardial ischaemia

• Off-pump vs On-pump debate continues

• Hybrid revascularisation may offer a rebalancing of clinical benefit and

patient preference

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Cardiac Surgery at KIMS

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Cardiac Surgery at KIMS

• Superb Infrastructure (award winning building; superb theatre space and

specifications; spacious rooms; infection control built in to the design)

• Diagnostic capabilities (CT and MRI; onsite Cardiology support)

• Proximity of services for patients and families is of immeasurable benefit

• CONSULTANT LED SERVICE

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Surgeons - Deployment

• No existing surgical platform in Kent

– Multi-professional team based care delivery

• Daily Consultant ward rounds

• Daily MDT decision making

• Rapid deployment of clinical care

• Combined experiences from three major centres for Cardiac Surgery covering

the whole of the South of England East to West

• Over 90 combined years of experience in cardiac surgery

• Surgical backup for Percutaneous Intervention ON-SITE

– Unique for any PCI service in Kent and in line with infrastructure design found in most tertiary centres

SCTS outcome data

Data For period April 2010 - March 2013

Risk adjusted In Hospital Mortality Rate

National Average

Ris

k -A

dju

ste

d M

ort

alit

y R

ate

Number of operations

1.63%1.54%

2.79%

2.21%

3.67%

2.83%

2.43%

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

4.00%

0 1,000 2,000 3,000 4,000 5,000 6,000

ECTC

Papworth

Royal Brompton

Barts

Harefield

Guys and StThomas

UCLH

Essex Cardiothoracic Centre

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Surgeons - Expertise

• All types of adult cardiac surgery

• Complete arterial grafting (Beating heart and standard CPB)

• Aortic and Mitral valve repair / replacement

• Surgery for Atrial Fibrillation

• Keyhole heart surgery (MIDCAB : Mini AVR : Mini Mitral)

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Standard Approach Ministernotomy Minithoracotomy

BESPOKE THERAPIES IN KEYHOLE SURGERY

CURRENTLY AVAILABLE AT KIMS

The Keyhole Heart ClinicTM

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Minithoracotomy

No broken boneHeals in 10 daysLess painEarly return to activitiesFacilitates later surgeryCosmetically more appealing

Sternotomy

Broken bone12 weeks to heal

AHA/ACC Guidelines

Chronic Severe Mitral Regurgitation

No Symptoms

Class I

LV Dysfunction

Class IIa

New Onset AFPulmonary HT

Class IIaMitral Valve repair may be performed in asymptomaticpatients if performed by an experienced surgical team andThe likelihood of successful MV repair is > 90%

Keyhole approach makes

early surgery more

acceptable to patients

Additional Resources offered by The KHC

www.thekeyholeheartclinic.com

https://m.youtube.com/channel/UC-

WPe3ECVAApb_XiI-s5Avg

Practice based education and training for Primary

care clinicians an their teams

Clinical partnership in the cardiac patient pathways

especially screening