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Conventional Cardiac Surgery in Patients with End-Stage Coronary Artery Disease: Yesterday and Today

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Conventional Cardiac Surgery in Patients with End-Stage Coronary Artery Disease: Yesterday and Today 212 Review Article on Heart Failure in the Young and Old: Insights into Various Therapies Conventional cardiac surgery in patients with end-stage coronary artery disease: yesterday and today Michal Szlapka1, Roland Hetzer2, Jürgen Ennker3, Harald Hausmann1 1Department of Cardiac and Vascular Surgery, MediClin Heart Center Coswig, Coswig, Germany; 2Department of Cardiothoracic and Vascular Surgery, Immanuel Cardio Centrum Berlin, Berlin, Germany; 3Department of Cardiac and Vascular Surgery, Heart Center Niederrhein, Krefeld, Germany Contributions: (I) Conception and design: R Hetzer, H Hausmann, M Szlapka; (II) Administrative support: J Ennker, H Hausmann; (III) Provision of study materials or patients: R Hetzer, J Ennker, H Hausmann; (IV) Collection and assembly of data: M Szlapka, H Hausmann; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. Correspondence to: Harald Hausmann, MD, PhD. Department of Cardiac and Vascular Surgery, MediClin Heart Center Coswig, Lerchenfeld 1, 06869 Coswig, Anhalt, Germany. Email: [email protected]. Abstract: Surgical therapy of combined coronary artery disease (CAD) and heart failure, also referred to as end-stage CAD, has evolved throughout the years and patients are currently being offered traditional coronary artery bypass grafting (CABG), with or without surgical ventricle restoration (SVR), interventions for ischemic mitral valve regurgitation, heart transplantation or implantation of mechanical cardiovascular support systems. Among surgical methods, operative myocardial revascularization (with or without ventricle restoration) is still playing an important role, aiming at restoration of proper myocardial perfusion, especially if heart muscle viability is present. Facing the donor shortage, CABG may constitute a valuable alternative to transplantation in selected patients. In individuals considered not suitable for surgical revascularization, implantation of mechanical circulatory support (MCS) not only appears as a salvage procedure, but also allows for reevaluation of future therapy directions. This article aims at providing an overview of evolving and current surgical practices in patients with end-stage CAD. Keywords: Coronary artery bypass grafting (CABG); end-stage coronary artery disease (CAD); heart transplantation ischemic cardiomyopathy; myocardial viability; surgical ventricle restoration (SVR) Submitted Feb 15, 2020. Accepted for publication Apr 22, 2020. doi: 10.21037/cdt-20-284 View this article at: http://dx.doi.org/10.21037/cdt-20-284 Introduction volume center the operative mortality in patients with end- stage CAD in the late 1980s was disastrous (ca. 25% in 1986), Patients with coronary artery disease (CAD) undergoing though throughout the years it could be substantially reduced myocardial revascularization, with concomitant heart failure to 3.1% in 2000, reflecting obvious improvements in surgical defined by left ventricular ejection fraction (LVEF) lower technique and postoperative care. Survival at 10 years than 35%, constitute a population at risk of poor long-term (Figure 1) reached 51% (2). prognosis and limited survival (1). According to Topkara et al., According to the landmark Coronary Artery Surgery among CAD patients referred for coronary artery bypass Study (CASS) from the early 1980’s of the 20th century, grafting (CABG) procedure, nearly 35% presented with EF 5-year survival in CAD patients with heart failure was poor of 40% or less. In-hospital mortality in these individuals was (38%), though CABG was shown to be a treatment modality related to the extent of left ventricular (LV) dysfunction, offering promising results with acceptable risk, compared to reaching up to 6.5% in the group with EF between 10% and medical therapy. Among study participants, 5-year survival 20% (1). According to Hausmann et al. (2), even in a high- after CABG reached 63%, but only 43% in patients treated © Cardiovascular Diagnosis and Therapy. All rights reserved. Cardiovasc Diagn Ther 2021;11(1):202-212 | http://dx.doi.org/10.21037/cdt-20-284 Cardiovascular Diagnosis and Therapy, Vol 11, No 1 February 2021 203 100 93 90 88.1 90 84.8 80.7 80 77.5 71.8 68 70 63.5 60 57.4 51 50 Patients (%) 40 30 20 10 0 30 1 2 3 4 5 6 7 8 9 10 Days Years Figure 1 Survival rates after CABG in patients with LVEF <30% in a high-volume European cardiac surgery center (German Heart Center Berlin, observational study on 2,158 patients, operated on between 1986 and 2003). CABG, coronary artery bypass grafting; LVEF, left ventricular ejection fraction. conservatively (3). Two years later, Passamani et al. (4) of CAD complexity and emphasize the role of reported survival at 7 years of 84% after CABG, compared interdisciplinary decision making, which enables choosing to 70% in patients undergoing only medical therapy. It is less invasive interventional solutions in patients with worth mentioning, however, that the number of patients unacceptable high risk, who are not suitable for surgical with EF less than 50%, enrolled in the CASS study, was revascularization. Changing approach to CAD patients relatively low (5). Currently, long-term mortality from has been a consequence of recently published SYNTAX cardiovascular reasons during a mean follow-up of 9.4 years and EXCEL trials (7,8). The main goal of the SYNergy in end-stage CAD patients has been reported to be 40% between percutaneous coronary intervention with TAXus in CABG and 49% in those treated medically, showing and cardiac surgery (SYNTAX) study was to randomly superiority of operative revascularization over conservative compare the efficacy of two therapeutic modalities, i.e., treatment in terms of increased survival (6). CABG vs. percutaneous coronary intervention (PCI), for Nowadays, surgical therapy of end-stage CAD patients treatment of coronary three-vessel disease with or without comprises operative myocardial revascularization (CABG), stenosis of the left main (LM) coronary artery. The with or without surgical ventricle restoration (SVR), Evaluation of XIENCE versus Coronary Artery Bypass surgical intervention for ischemic mitral valve regurgitation, Surgery for Effectiveness of Left Main Revascularization implantation of mechanical circulatory support (MCS) and (EXCEL) trial shared similar investigation principle with heart transplantation. the SYNTAX study but focused specifically on patients with LM coronary disease. To enable evaluation of CAD complexity, the SYNTAX investigators came up with a Surgical approaches in end-stage CAD SYNTAX score, which involved assessment of: (I) Coronary dominance; Myocardial revascularization: changing guidelines (II) Number of lesions; Since the beginning of the 21st century, recommendations (III) Segments involved per lesion, with lesion regarding myocardial revascularization in patients with characteristics; end-stage CAD have evolved substantially. Previously, (IV) Total occlusions with subtotal occlusions; European guidelines on surgical CAD therapy focused (V) Trifurcation, number of segments diseased; predominantly on coronary artery anatomy and disease (VI) Bifurcation type and angulation; distribution. Presently, they reflect a growing understanding (VII) Aorto-ostial lesions; © Cardiovascular Diagnosis and Therapy. All rights reserved. Cardiovasc Diagn Ther 2021;11(1):202-212 | http://dx.doi.org/10.21037/cdt-20-284 204 Szlapka et al. Previous and current surgical treatment for end-stage CAD (VIII) Severe tortuosity; a subject of change within the last decades. European (IX) Lesion length; Guidelines on myocardial revascularization from 2010 (X) Heavy calcification; recommended consideration of concomitant CABG and (XI) Thrombus; SVR, if a substantial dilation of left ventricle [Left Ventricle (XII) Diffuse disease, with number of segments. End-Systolic Volume Index (LVESVI) >60 mL/m2] and The Guidelines of the European Society of Cardiology/ scarred left anterior descending (LAD) territory were European Association of Cardio-Thoracic Surgery from present (9). Subsequent guidelines from 2014 suggested 2010 on therapy of CAD in patients with heart failure performing SVR in patients with ‘large ventricle aneurysm’ recommended surgical revascularization for significant at risk of rupture, thrombus formation and life-threatening LM coronary artery stenosis or its equivalent, as well as for arrhythmias. However, the guidelines did not provide proximal LAD stenosis, accompanied by double or triple precise parameters to define the term ‘large aneurysm’. coronary disease (9). In subsequent guideline version from SVR, combined with CABG was also justified whenever 2014 (10) LM stenosis remained an indication for surgical reduction of LVESVI (values lower than 70 mL/m2) could intervention, but then 4 years later, class I recommendation (11) be achieved (10). relied upon predicted ‘revascularization suitability’ of In 2018, the indication for simultaneous CABG and SVR coronary targets and consideration of acceptable risk, rather remained valid for ‘large aneurysm’ in patients presenting than on stenosis location. In addition, recent guidelines (11) symptoms of advanced heart failure (NYHA III/IV), in considered growing potential of PCI as alternative to presence of intraventricular thrombus and arrhythmias. CABG in end-stage CAD with multivessel disease, According to Guidelines, SVR and CABG should be provided that complete revascularization could be achieved. performed in selected patients in centers of
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