New Developments in the Surgical Treatment of Coronary Artery Disease. Harold A. Fernandez, MD

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1 New Developments in the Surgical Treatment of Coronary Artery Disease Harold A. Fernandez, MD

2

3 Have there been any new developments in surgical treatment of coronary disease?

4 Surgeon: He d had way too many stenting procedures, and his arteries were scarred and blocked, says the surgeon. I m concerned about his long term prospects because his arteries were so badly damaged. Cardiologist: For every one of those patients, I could cite you ten who ve been messed up through bypass surgery, says Jeffrey Moses, chief of interventional cardiology at Lenox Hill Hospital. I could give surgeons tit for tat. Data, he asserts, speaks louder than anecdotes.

5 And according to Moses, there are certain medical centers around the city that push surgeries because the economics are more favorable and they want to get their numbers up. I d like to put up a sign in Times Square: IF YOU VE BEEN RECOMMENDED FOR BYPASS SURGERY, LET US LOOK AT YOUR FILMS.

6 Substantial growth in PCI 5% national sample of Medicare beneficiaries Adapted from Lucas FL et al. Circulation. 2006;113: *Adjusted for age, gender, race

7 Will surgical revascularization continue to play a role in the treatment of ischemic heart disease?

8 History New Developments Less Invasive More Gentle Better surgery Future Hybrid procedures Molecular surgery Summary Outline

9 Our History

10 First Surgery on the Heart Ludwig Rehn: 1896 Repair of Injury to the Right Ventricle Birth of Cardiac Surgery Sutures can be placed on the heart

11 An Idea Langer 1880: Described communications between the coronary circulation of the heart and other surrounding structures, e.g the diaphgram, the bronchi, and the pericardium Described collateral circulation Hope that coronary circulation could be enhanced

12 First anastomosis to the Heart Alexis Carrel, 1910: used arterial and venous grafts to augment the circulation of coronary vessels OP CABG 1912 Novel Prize for transplantation and vascular grafting 1902 Marie Bailly miracle

13 First SVG used for CAD David Sabiston, 1962 First SVG to RCA Patient died 3 days later

14 Who Really did the first CABG? Robert Goetz: (In Bronx) May 2, 1960 RIMA to RCA using a tantalum ring in a 38 year old man David Sabiston: unsuccesful CABG on April 4, 1962 Vasilii Kolesov: February 25, 1964, first CABG using suture technique between the LIMA and the Circumflex Rene Favolaro (Argentinian): May 9, 1967 performed first successful CABG in America at the Cleveland Clinic (in 1968 they performed 171 operations)

15 First Bypas Machine Gibbon: 1953 First effective Heart lung Machine Not used widely for CABG until Late 1960s

16 New Developments Less Invasive Port Access MIDCABG More Gentle Off pump CABG Better Surgery LIMA BIMA

17 Less Invasive Early and mid 1990s Prevention Competing Modalities PCI Statins Laparoscopic Surgery cholecystectomy Robotic Technology

18 Minimally invasive cardiac surgery Port Access Cardiac Surgery Stevens-Stanford (1996) Schwartz/Ribavoke-NYU (1996)

19 What is minimally invasive? No specific definition Components Non-sternotomy No cardio-pulmonary bypass Less trauma to the patient Better results

20 CARDIOPULMONARY BYPASS

21 Endo Balloon

22

23

24 Minimally Invasive CABG Port-Access CABG Multiple vessels LIMA RIMA Gastroeplipoic

25 Port Acess CABG

26 Minimally Invasive CABG MIDCABG Off-Pump CABG

27 More Gentle Cardiopulmonary Bypass is inherently a pathologic condition Kirklin, JK, et al. in Cardiopulmonary Bypass: Principles and Practice Williams & Wilkins, 1993

28

29 CPB Problems Inflammatory response Immune suppression Strokes Cognitive deficits Bleeding Organ failure Aortic dissection

30 CARDIOPULMONARY BYPASS

31 Off Pump Bypass Allows bypass grafting to be performed on the beating heart Eliminates the need for the Heart Lung machine

32 Potential Advantages Minimally Invasive No inflammatory response No hemodilution.less anemia Minimizes the risk of technical misadventures Cheaper

33

34

35 Concerns Technically challenging Hemodynamic instability Graft patency Inadequate revascularization

36 ON-Pump vs. Off-PUMP CABG Khan NE, et al: Randomized Comparison of Off-pump and On-pump multivessel CABG Surgery, NEJM, 350(1): 21-8, patients On-pump vs. 54 patients Of-pump 3.4 grafts/patient On-pump vs. 3.1 grafts/patient Off-pump 98% graft patency On-pump 88% graft patency Of-pump, (p=0.02)

37 ON-Pump vs. Off-PUMP CABG Puskas, JD, et al: Off-pump vs. Conventional CABG; Early and 1-year Graft Patency, Cost, and Quality of Life Outcomes: A Randomized Trial. JAMA 291 (15): , patients randomized No difference in graft patency

38 Experienced OPCAB surgeon with committed surgical team Excellent Results

39 Inexperienced OPCAB surgeons, or many surgeons involved in study Equivocal Results

40 Summary NO literature shows morbidity or mortality with OPCAB to be inferior to CABG Patency data is controversial Benefits of OPCAB are most pronounced in the high risk patient

41 Future directions Better immobilization devices Anastomotic devices Robotic technology Percutaneous devices Commitment/Flexibility

42 Michael Debakey Comment on Off pump CABG Yes it can be done, but it is like making love to your wife on a hammock, and WHY WOULD YOU?

43 SVG LIMA BIMA Other Better Surgery Is there a better conduit?

44 Fifteen-year freedom from death of any cause between patients who received left internal mammary artery (blue line) or saphenous vein graft (red line). Calafiore A M et al. MMCTS 2005;2005:mmcts by Oxford University Press

45 Fifteen-year freedom from cardiac death between patients who received left internal mammary artery (blue line) or saphenous vein graft (red line). Calafiore A M et al. MMCTS 2005;2005:mmcts by Oxford University Press

46 Is two Better than one?

47 Ten-year freedom from death of any cause between patients who received BIMA±SVG (red line) or LIMA+SVG (blue line). Calafiore A M et al. MMCTS 2005;2005:mmcts by Oxford University Press

48 Ten-year freedom from cardiac death between patients who received BIMA±SVG (red line) or LIMA+SVG (blue line). Calafiore A M et al. MMCTS 2005;2005:mmcts by Oxford University Press

49 Why Not BIMA on everyone? Longer OR Time Increase deep sternal Infections in Diabetics Surgeons are stubborn? Out of comfort zone?

50 Other conduits? Radial artery Inferior Epigastric Cadaveric Vein Genetic vein?

51 Hybrid Procedures Molecular Surgery The Future?

52 Hybrid Procedures Best of both worlds Minimally Invasive LIMA to LAD Thoracoscopic/robotic LIMA harvest Off Pump Mini left lateral thoracotomy PCI to other non LAD vessels

53 MOLECULAR SURGERY

54 VASCULAR INJURY/ INTIMAL HYPERPLASIA SVG failure Restenosis PCI Graft failure/restenosis Pathogenesis Molecular mechanisms

55 INTIMAL HYPERPLASIA Endothelial cell dysfunction Inflammatory cell migration PDGF, EGF, FGF-2, Thrombin (c-fos, c-jun, c-myc, ras, Cdc2-K, PCNA) SMC proliferation SMC migration Increased extracellular matrix (ECM) Neointima formation

56 Adenoviral mediated Gene transfer

57 Cystic Fibrosis

58 Study Overview Mortality due to coronary heart disease has declined substantially in the United States in recent decades A previously validated model was used to estimate the roles of specific cardiac treatments and changes in risk factors in this decline Approximately 47% of the decrease in mortality was attributed to therapeutic interventions and 44% to changes in risk factors

59 Why has mortality from Coronary Estimated and Observed Reductions in Deaths from Coronary Heart Disease in the United States between 1980 and 2000, Stratified According to Age and Sex artery disease decreased? Ford ES et al. N Engl J Med 2007;356:

60 Percentage of the Decrease in Deaths from Coronary Heart Disease Attributed to Treatments and Risk-Factor Changes in Our Study Population and in Other Populations Ford ES et al. N Engl J Med 2007;356:

61 Conclusion Approximately half the decline in U.S. deaths from coronary heart disease from 1980 through 2000 may be attributable to reductions in major risk factors and approximately half to evidence based medical therapies

62 Will surgical revascularization continue to play a role in the treatment of ischemic heart disease?

63 Results consistent with other major studies BARI ARTS CARDia SYNTAX

64 FREEDOM Study Overview TRIAL In this trial, patients with diabetes and multivessel coronary disease had a lower risk of MI and death if they were treated with CABG, as compared with coronary stenting with drug-eluting stents. However, the CABG group had an increased risk of stroke.

65 Farkouh ME et al. N Engl J Med 2012;367:

66 Farkouh ME et al. N Engl J Med 2012;367:

67 Farkouh ME et al. N Engl J Med 2012;367:

68 Farkouh ME et al. N Engl J Med 2012;367:

69 FREEDOM Future Revascularization Evaluation in Patients with Diabetes Mellitus 1900 pts with diabetes randomized to PCI with drug eluting stent or CABG Composite endpoint at 5 years ( 26.6 % in PCI vs in CABG Deaths (16.3% vs. 10.9) MI (13.9 vs. 6%) Stroke (2.4% vs. 5.2%) Strong Support to CABG

70 Conclusions For patients with diabetes and advanced coronary artery disease, CABG was superior to PCI in that it significantly reduced rates of death and myocardial infarction, with a higher rate of stroke.

71 Will surgical revascularization continue to play a role in the treatment of ischemic heart disease? YES

72 UEFA Champions League The results of the FREEDOM trial suggest that patients with diabetes ought to be informed about the potential survival benefit from CABG for the treatment of multivessel disease. These discussions should begin before coronary angiography in order to provide enough time for the patient to digest the information, discuss it with family members and members of the heart team, and come to an informed decision.

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