CABG Options and reality in 2009 M. Šetina Dept of Cardiac Surgery University Hospital Motol, Prague

CABG Standardized procedure proven by a long-time One of the best, most effective, best documented methods of treatment Demonstrate improvement – difficult – needs large cohorts Most important factors from long-term perspective mortality (hospital) ~ 2% stroke/TIA ~ 2% 2 most important factors for operative strategy and results ECC Grafts (arterial vs vein)

ECC Advantages quiet, clean operative field routine procedure stable circulation technically less demanding easier for surgeon Disadvantages another device (cost, people, space,..) cannulation - risk of complications ↑ risk of stroke ↑ invasivness of operation contact of blood with non-natural surface mechanical trauma of blood elements inflammatory response

Off-pump Advantages avoiding of ECC ↓ risk of complications ↓ inflammatory response ↓ invasive for patient ↓ risk of stroke ↓ mortality? Disadvantages heart continue beating to maintain circulation less stable haemodynamics? operative field comfort for surgeon? technically more demanding stressful for staff? quaility and number of anastomoses?

Grafts Long-term patency 10 years 20 years IMA 90% 80 – 90% RGEA 80 – 90% ?? 70 - 80% Vein 50 – 60% 30 - 40%

IMA Best long-term patency In situ (nutrition, proximal anastomosis) Elastic artery (the only small artery in the body) Resistant to spasm Resistant to atherosclerosis Relatively easy handling Possibly 2 grafts Optimal graft

RGEA Probably very good long-term patency In situ Muscular More prone to spasm Resistant to atherosclerosis Open peritoneal cavity Sometimes small caliber Does not reach all coronaries More difficult handling Only one graft

AR Long-term patency? No in situ – proximal anastomosis Muscular Prone to spasm Less resistant to atherosclerosis Good caliber Relatively thick wall (2x more then IMA) – nutrition Possibly 2 grafts Easy handling

Comparison vein vs arterial grafts Vein grafts ↓ long-term patency standard procedure technically easier proximal anastomosis to aorta – ↑ risk of stroke Arterial grafts ↑ long-term patency more technically demanding longer procedure

Optimal strategy for revascualrization Based on the knowledge of long-term patency and risk for patient Full arterial revascularization preferable both IMA Off-pump

Reality Sts database Mean age (yrs) 65 Mean EF (%) 50 Operative mortality (%) 2 Stroke/TIA (%) 2 ( permanent 1,2%) Length of stay (days) mean 9,1 median 7,0

Reality On-pump 80% (2004 – 87%) At least one IMA 93% LIMA 88% RIMA 0,5% BIMA 4,6% AR 10% (2004 – 20%)

On-pump (%) Off-pump (%) Results On-pump (%) Off-pump (%) observed predicted observed predicted Mortality 2,0 1,8 1,8 1,9 Stroke 1,3 0,9 0,8 0,9 Renal failure 3,6 2,9 2,8 2,9 MACE 15,0 12,3 11,9 12,6 ICU (hrs) 63,8 54,8 Ventilation (hrs) 22,5 18,9

Results On-pump Off-pump Mean age (yrs) 65 66 Tripple vessel 79,5 62,1 LM 31,3 28,0 EF < 40% 17,2 14,5 LOS (days) mean 9,2 8,5 median 7,0 7,0

Reality Gold?? standard today On – pump 80 – 85% LIMA + vein graft 80 – 90% ACB Full arterial revascularization < 10% BIMA < 5%

Why? Scepticism and conservatism – mainly older surgeons Lack of training and inexperience of younger surgeons (trained by on-pump surgeons) Self-confidence Herd effect Unwilingness of re-training and adoption new operative strategy Violation of rules Team approach fail– need not only surgeons but dedicated anesthesiologists as well If team fail – method is rejected

Method is discredited and rejected OPCAB in ill-trained team, who do not follow all surgical and aneastesiological rules and guidelines do not bring benefit for patient. On the contrary it faces increased morbidity, probably mortality and definitely increases operative stress for the whole team. Thus the only conclusion: Method is discredited and rejected

Conclusion Future? OPCAB based on strict protocol and guidelines Full arterial revascularization Preferably BIMA

Factors Mortality, morbidity Return to normal life activity Long – effect of surgery Prolongation of life Improvement of quality of life

Prodloužení života Souvisí s průchodností štěpů BIMA vs single IMA + vsm desetileté přežití srovnatelné v prvních 10 letech vyšší výskyt reintervencí ve skupině single IMA mezi 10 až 20 lety zlepšené přežití BIMA vs single IMA

Kvalita života Off-pump vs on-pump z dlouhodobého hlediska zásadně neovlivňuje Volba štěpu tepenné štěpy méně reintervencí, hospitalizací ponechána vsm pro další rekonstrukce

Návrat do normálního života Off-pump kognitivní funkce méně ovlivněny menší zánětlivá odpověď organismu Volba štěpu významně neovlivňuje

Srovnání Off-pump menší operační trauma, nižší mortalita, nižší výskyt mozkových příhod, vyšší technická náročnost On-pump standardní postup, klid na práci Tepenné štěpy vyšší dlouhodobá průchodnost, vyšší technická náročnost, delší výkon Žilní štěpy standardní postup, snazší technicky Optimum Plně tepenná revaskularizace (nejlépe BIMA) off-pump Lze rutinně? ANO Předpoklad změna operační strategie tréning chirurg i celý tým striktně dodržovat zásady (protokol)