future of coronary surgery - livemedia.gr · turina m, gruntzig a, krayenbuhl c, senning a, ann...
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Future of coronary surgery
Marko Turina
Zürich
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Rapid growth of cardiac surgery in seventies and
eighties was almost exclusively due to increase of
CABG procedures
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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!
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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
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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
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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: [email protected]
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Percentage of PCIs depends on payment modality
Cardiologists paid for PCICardiologist income
independent of PCI
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In all highly developed countries, number of PCIs is still
increasing and CABGs is going down
New
ESC/EACTS
GUIDELINES
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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
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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.”
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North America interventional cardiology devices
market, 2012 - 2020 (USD Million)
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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
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Bilateral IMA grafting: a “permanent” and
protective solution, with no distal
progression 20 years later
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Benefit of IMA was firmly established in 1986, after this
report from Cleveland Clinic
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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
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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
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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
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There were almost 16 % crossovers in
bilateral IMA group
15 % crossovers
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Business projection of CABG market in
USA: still high use of SVG
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Evidence is emerging that CABG should be
performed by specialized cardiac surgeons
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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
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OPCAB should be reserved for specialized
surgeons working with an expert team, and should
be used only in suitable patients
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Is robotic CABG a possibility?
Worldwide
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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.
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The art of statesmanship is to foresee the inevitable
and to expedite its occurrence.
Charles-Maurice de Talleyrand-Périgord (1774 - 1838),
famous French diplomat
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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