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Surgical%20Coronary%20Revascularization%20Who,%20What,%20When

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Title: Surgical%20Coronary%20Revascularization%20Who,%20What,%20When


1
Surgical Coronary Revascularization Who, What,
When
Speaker - Jonathan G. Howlett, MD
FRCPC Chairperson Gordon W. Moe, MD, MSc, FRCPC

2
WELCOME!

3
Accreditation
  • 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.


4
Learning Objectives
  • At 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

5
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


6
Disclosures- Dr. Moe
  • No disclosures


7
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

8
Case 1
  • Echocardiogram performed
  • LVEF 25, global hypokinesis
  • LVIDd 5.8cm LVIDs 5.1cm, EF 29
  • 2MR
  • 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??

9
Questions
  • prepare to provide your answers!

10
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

11
Case 1 - What would you like to do next?
  • Coronary angiogram
  • Myocardial perfusion imaging (persantine
    sestamibi)
  • Cardiac MRI
  • Referral to EP for ICD and or CRT

12
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

13
Questions
  • prepare to provide your answers!

14
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

15
Case 1 - Your recommended course of action ?
  • Discharge w/ a plan for titrated medical tx until
    angina occurs
  • Present the patient to CV surgical colleagues to
    consider for CABG
  • Refer to interventional colleague for multivessel
    PCI
  • Referral for ICD/CRT

16
Ischemic Cardiomyopathy
  • Distinct condition in which cardiac dysfunction
    is felt to be caused by coronary artery disease
    and ischemic injury
  • Usually implies LV systolic dysfunction
  • May or may not be a prior history of MI
  • Usually due to multivessel disease or signficant
    ischemic damage to large territory of myocardium
  • Most common cause of systolic HF (50-65 of all
    cases)
  • Associated with worse prognosis than other forms
    of LV systolic dysfunction

17
Progression of Symptomatic HF Worsening Prognosis
Ischemic heart disease
Ischemic heart disease heart failure
  • Progression to overt HF associated with gt 5-fold
    mortality risk

Wang et al, Circulation 2003 Ammar et al,
Circulation 2007
18
Prognostic significance of ischemic cardiomyopathy
gt1200 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)
Levy et al, Circulation 2006 Aaronson et al,
Circulation 1997
Felker et al, N Engl J Med 2000
19
Cardiac Death in Heart Failure
Ischemia may contribute to any mechanism of
cardiovascular death
Cardiovascular death
Lee et al Circ Heart Failure 2011
20
Surgical Treatment for Ischemic Heart Failure
wheres the evidence?
  • 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

Yusuf et al, Lancet 2004
21
Surgical Treatment for Ischemic Heart Failure
wheres the evidence?
  • In these early studies
  • 90 had angina
  • 80 had normal LVEF
  • 10 had arterial conduits
  • Medical therapy digoxin and diuretics

Need to assess the benefits of revascularization
in contemporary patients with ischemic
cardiomypathy
Yusuf et al, Lancet 2004
22
Current Era Surgical Treatment for Ischemic
Heart failure (STICH)
Randomized non-blinded study of surgical
revascularization Included patients with LVEF
lt35 and CAD suitable for revascularization Hypot
hesis 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 Surg
23
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
mortality seen at median 56 months
follow-up 17 of patients in medical therapy
arm crossed over to surgical arm
24
STICH Hypothesis 1 secondary outcomes
CABG associated with reduction in cardiovascular
death and combined outcome of death or
cardiovascular hospitalization CABG also
associated with 30 relative reduction in
mortality in on-treatment analysis (accounting
for patients crossing over within 1st year of
study)
25
Recommendations - Revascularization Procedures
Assessment for Coronary Disease
We recommend that coronary angiography be Performed in patients with heart failure with ischemic symptoms, who are likely to be good candidates for revascularization. Considered in patients with systolic heart failure (LVEF lt 35) at risk of coronary artery disease, irrespective of angina, who may be good candidates for revascularization. Strong Recommendation Moderate Quality Evidence Strong Recommendation Low Quality Evidence
26
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. Strong Recommendation Moderate Quality Evidence
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.
27
Recommendations - Revascularization Procedures
Assessment for Coronary Disease
We recommend that non-invasive imaging for patients with heart failure be considered in order to determine the presence or absence of coronary artery disease. Strong Recommendation Moderate Quality Evidence
Values and Preferences This recommendation
places value upon identification of coronary
artery disease, which may identify the cause of
heart failure, will have prognostic implications
and will require treatments aimed toward
secondary vascular prevention.
28
Recommendations - Revascularization Procedures
Surgical Revascularization for Patients with IHD
and HF
We recommend consideration of coronary artery bypass surgery for patients with chronic ischemic cardiomyopathy, LVEF lt 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. Strong Recommendation Moderate Quality Evidence
29
Recommendations - Revascularization Procedures
Disease Management, Referral and Peri-operative
Care
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. Strong Recommendation Low Quality Evidence
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
30
Time-varying hazard ratios for all-cause
mortality in patients randomized to CABG or MED.
31
However, there is interaction with risk factors
  • LVEF lt median value (28)
  • LV end systolic index gt 60 ml/M2
  • 3 vessel disease

32
Kaplan-Meier rate estimates of all-cause
mortality among patients with 2-3 (top panel) and
0-1 (bottom panel) prognostic factors.
33
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 lt 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

34
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

35
Case 2
  • Patient wishes to live as long as possible but
    most fearful becoming dialysis dependent

http//riskcalc.sts.org www.euroscore.org
36
Questions
  • prepare to provide your answers!

37
Case 2 - Your recommended course of action ?
  1. Angiogram and possible CABG
  2. Angiogram and possible ad hoc PCI of
    flow-limiting lesions
  3. Non-invasive perfusion/viability test
  4. Referral for ICD/CRT
  5. Ongoing medical optimization only

38
Case 2 - Your recommended course of action ?
  • Angiogram and possible CABG
  • Angiogram and possible ad hoc PCI of
    flow-limiting lesions
  • Non-invasive perfusion/viability test
  • Referral for ICD/CRT
  • Ongoing medical optimization only

39
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, 2005
40
Frailty and cardiac surgery
  • 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, 75.84.4 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 2010
41
Frailty and cardiac surgery
Gait speed predicts mortality/major morbidity (OR
3.05, 95CI 1.237.54)
Afilalo et al J Am Coll Cardiol 2010
42
Viability and LV functional recovery after
revascularization
Systematic review of non-invasive Imaging
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
Bax et al J Am Coll Cardiol 1997
43
Viability and survival after revascularization
Systematic review of 24 observational
studies Evaluating relationship between
death, viability and revascularization
Allman et al, J Am Coll Cardiol 2002
44
STICH Analysis Improved 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
Bonow et al, N Engl J Med 2011
45
STICH Analysis Viability doesnt necessarily
predict improved outcomes with surgery vs medical
therapy
Bonow et al, N Engl J Med 2011
46
Recommendations - Revascularization Procedures
Disease Management, Referral and Peri-operative
Care
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. Strong Recommendation Low Quality Evidence
47
Practical Tips Revascularization
Procedures Imaging
  • 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.
  • 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.

48
Practical Tips (contd) 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 (gt 30 of LV)
by nuclear stress testing/ viability study b)
Reversible ischemia or gt7 hibernating myocardium
on PET scanning c) Reversible ischemia or gt
20 of LV shown as viable by DSE d) Less than
50 wall thickness scarring as shown by late
gadolinium enhancement by cardiac CMR.
49
PCI or CABG for ischemic symptoms and heart
failure? (Angina included!!)
4200 patients with HF referred 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
syndromes Medical management was
suboptimal Revascularization with CABG or PCI
associated with improved survival Signal for
differential outcome, favoring CABG
Revasc.
HR 0.50
Med Rx
Tsuyuki et al, CMAJ 2006
50
Recommendations - Revascularization Procedures
Surgical Revascularization for Patients with IHD
and HF
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 Recommendation Low Quality Evidence
51
Practical Tips Revascularization
Procedures Surgical Revascularization for
Patients with IHD and HF
  • 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.
  • Urgent directed culprit vessel angioplasty
    continues to be the revascularization modality of
    choice for patients with heart failure and acute
    coronary syndrome.

52
Figure 1. Approach to Assessment for Coronary
Artery Disease in Patients with Heart Failure
53
Figure 2. Decision Regarding Coronary
Revascularization in Heart Failure
54
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

55
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

56
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.

57
Questions
  • prepare to provide your answers!

58
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

59
Case 3 - You recommend surgical revascularization
with concomitant
  • Medical therapy
  • Medical therapy CABG
  • Medical therapy CABG SVR
  • Medical therapy SVR CRT/ICD

60
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
Jones et al, N Engl J Med 2009
61
STICH Hypothesis 2 No difference in primary or
secondary outcomes between CABG vs CABG SVR
All cause death or cardiovascular hospitalization
All cause death
Jones et al, N Engl J Med 2009
62
Recommendations - Revascularization Procedures
Surgical Revascularization for Patients with IHD
and HF
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. Strong Recommendation Moderate Quality Evidence
63
Practical Tips Revascularization
Procedures Surgical Revascularization for
Patients with IHD and HF
  • 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.
  • Mitral valve repair may, when used concomitantly
    during CABG, may, in selected cases, lead to
    clinical improvement in symptoms of heart failure.

64
Questions
  • prepare to provide your answers!

65
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

66
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

67
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 gt 1month Revasc gt 3months
DINAMITE (2004) ICD vs no ICD MI lt 40 days -
COMPANION (2004) ICD vs CRT-ICD vs medical rx MI gt 2months Revasc gt2 months
SCD HeFT (2005) ICD vs amio vs placebo MI gt 1month Revasc gt1 month
CARE (2005) CRT vs medical rx MI gt 6 weeks
IRIS (2009) ICD vs no ICD MI lt 1 month -
RAFT (2010) CRT-ICD vs ICD Revasc gt1 month
68
Recommendations - Revascularization Procedures
Device Considerations in HF Patients Following
Cardiac Surgery
We recommend that following successful cardiac surgery, patients with HF undergo assessment for implantable cardiac devices within 3-6 months of optimal treatment. Strong Recommendation High Quality Evidence
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. Strong Recommendation Low Quality Evidence
69
Practical Tip Revascularization
Procedures Device Considerations in HF Patients
Following Cardiac Surgery
  • 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.

70
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71
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