0000007871 00000 n Sotomi Y, Cavalcante R, van Klaveren D, Ahn JM, Lee CW, de Winter RJ, Wykrzykowska JJ, Onuma Y, Steyerberg EW, Park SJ, Serruys PW. 0000011895 00000 n Background. PDF | On Dec 20, 2017, Ragab Hani Donkol and others published Evaluation of Coronary Artery Bypass by CT Coronary Angiography | Find, read and cite all … 0000010674 00000 n This article is a companion article to the 2018 ESC/EACTS guidelines on myocardial revascularization expanding on details that are introduced in the chapter revascularization in stable CAD.14. No. Park SJ, Kim YH, Park DW, Lee SW, Kim WJ, Suh J, Yun SC, Lee CW, Hong MK, Lee JH, Park SW; Escaned J, Collet C, Ryan N, De Maria GL, Walsh S, Sabate M, Davies J, Lesiak M, Moreno R, Cruz-Gonzalez I, Hoole SP, Ej West N, Piek JJ, Zaman A, Fath-Ordoubadi F, Stables RH, Appleby C, van Mieghem N, van Geuns RJ, Uren N, Zueco J, Buszman P, Iniguez A, Goicolea J, Hildick-Smith D, Ochala A, Dudek D, Hanratty C, Cavalcante R, Kappetein AP, Taggart DP, van Es GA, Morel MA, de Vries T, Onuma Y, Farooq V, Serruys PW, Banning AP. It's used for people who have severe coronary heart disease (CHD), also called coronary artery disease. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. 0000002358 00000 n Wijns W, Kolh P, Danchin N, Di Mario C, Falk V, Folliguet T, Garg S, Huber K, James S, Knuuti J, Lopez-Sendon J, Marco J, Menicanti L, Ostojic M, Piepoli MF, Pirlet C, Pomar JL, Reifart N, Ribichini FL, Schalij MJ, Sergeant P, Serruys PW, Silber S, Sousa Uva M, Taggart D, Vahanian A, Auricchio A, Bax J, Ceconi C, Dean V, Filippatos G, Funck-Brentano C, Hobbs R, Kearney P, McDonagh T, Popescu BA, Reiner Z, Sechtem U, Sirnes PA, Tendera M, Vardas PE, Widimsky P, Kolh P, Alfieri O, Dunning J, Elia S, Kappetein P, Lockowandt U, Sarris G, Vouhe P, Kearney P, von Segesser L, Agewall S, Aladashvili A, Alexopoulos D, Antunes MJ, Atalar E, Brutel de la Riviere A, Doganov A, Eha J, Fajadet J, Ferreira R, Garot J, Halcox J, Hasin Y, Janssens S, Kervinen K, Laufer G, Legrand V, Nashef SAM, Neumann F-J, Niemela K, Nihoyannopoulos P, Noc M, Piek JJ, Pirk J, Rozenman Y, Sabate M, Starc R, Thielmann M, Wheatley DJ, Windecker S, Zembala M. Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Juni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A. Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH; Patel MR, Calhoon JH, Dehmer GJ, Grantham JA, Maddox TM, Maron DJ, Smith PK. Joseph KS, Hoey J. Osnabrugge RL, Speir AM, Head SJ, Fonner CE, Fonner E, Kappetein AP, Rich JB. 0000008024 00000 n Since then, it has been generally accepted that patients with left main disease should undergo expeditious revascularization by CABG, a recommendation that was sustained in guidelines over years as untreated left main disease is associated with poor prognosis.26,38,39. This surgery uses a. graft (blood . Malenka DJ, Leavitt BJ, Hearne MJ, Robb JF, Baribeau YR, Ryan TJ, Helm RE, Kellett MA, Dauerman HL, Dacey LJ, Silver MT, VerLee PN, Weldner PW, Hettleman BD, Olmstead EM, Piper WD, O'Connor GT; Hannan EL, Racz MJ, Walford G, Jones RH, Ryan TJ, Bennett E, Culliford AT, Isom OW, Gold JP, Rose EA. This new blood vessel is known as a graft. However, the investigators tested for subgroup by treatment interactions across unordered subgroups defined by SYNTAX tertiles, even though the clinically most plausible hypothesis is that HRs comparing CABG with PCI will increase with increasing SYNTAX tertiles. Coronary Artery Bypass Grafting Caron G. Martin, MSN, RN; Sandra L. Turkelson, MSN, RN The role of the professional nurse in the perioperative care of the patient undergoing open heart surgery is beneficial for obtaining a positive outcome for the patient. Maehara A, Ben-Yehuda O, Ali Z, Wijns W, Bezerra HG, Shite J, Genereux P, Nichols M, Jenkins P, Witzenbichler B, Mintz GS, Stone GW. Resident Physician in Cardio-Thoracic and Vascular Surgery, Copyright © 2020 European Society of Cardiology. Operative procedures are more complicated, reentry of the sternum is sometimes problematic, and dissection of the heart is needed. Stratified analyses according to diabetes mellitus revealed improved survival among patients allocated to CABG compared with those allocated to PCI at 5 years and 10 years of follow-up. It may be needed when the arteries supplying blood to heart tissue, called coronary arteries, are narrowed or blocked. The surgery can be done under direct vision, with a mini-sternotomy or a mini-thoracotomy approach. Patients who undergo redo CABG are older, more comorbid, and with more sclerotic coronary and noncardiac arteries than seen in primary CABG. Garg S, Serruys PW, Silber S, Wykrzykowska J, van Geuns RJ, Richardt G, Buszman PE, Kelbæk H, van Boven AJ, Hofma SH, Linke A, Klauss V, Wijns W, Macaya C, Garot P, DiMario C, Manoharan G, Kornowski R, Ischinger T, Bartorelli A, Van Remortel E, Ronden J, Windecker S. Zhao M, Stampf S, Valina C, Kienzle RP, Ferenc M, Gick M, Essang E, Nuhrenberg T, Buttner HJ, Schumacher M, Neumann FJ. 1993 Feb 15; 148 (4):569–575. 0000002504 00000 n 0000005414 00000 n Peri-procedural MI was recorded in 3.6% of patients undergoing PCI and 5.9% of patients undergoing CABG (HR 0.61, 95% CI 0.40–0.93; P = 0.02) and ST-segment-elevation MI was noted in 0.7% of patients undergoing PCI and 2.3% of patients undergoing CABG within 30 days of the procedure (HR 0.32, 95% CI 0.14–0.74, P = 0.005). Angina is a sign that you are at risk . Based on the review above, the SYNTAX score currently remains the best tool to gauge the anatomical complexity of advanced CAD and is helpful to appraise the relative benefit of choosing between revascularization strategies among patients with multivessel disease. Reprints; Request; Top; Long-term Follow-up After Coronary Artery Bypass Grafting Reoperation. Angiographic–histologic correlative analysis in 28 patients, Comparison of surgical and medical group survival in patients with left main coronary artery disease. During 5-year follow-up, CABG significantly reduced the risk of the primary endpoint death, MI, or stroke compared with PCI. The trial failed to demonstrate non-inferiority of PCI for the primary endpoint and CABG was found superior to PCI (P = 0.0066). The 2018 ESC/EACTS guidelines on myocardial revascularization reflect the joint effort of the European Society of Cardiology (ESC) and the European Association of Cardiothoracic Surgery (EACTS) to provide up-to-date recommendations that are both evidence-based and clinically meaningful. would have to be adjusted for multiple testing, resulting in an adjusted P-value for significance of 0.005 based on the 10 comparisons reported in the original publication. Studies were scored according to degree of adjustment for case mix. 0000002481 00000 n Campos CM, Garcia-Garcia HM, van Klaveren D, Ishibashi Y, Cho YK, Valgimigli M, Raber L, Jonker H, Onuma Y, Farooq V, Garg S, Windecker S, Morel MA, Steyerberg EW, Serruys PW. Coronary-Artery Bypass Grafting stenosis, and the bypass graft is hand-sewn (anastomosed) end-to-side to the incision. Although the proportion of patients with high SYNTAX score was limited in view of the inclusion criteria of the respective studies, there was a trend towards better survival with CABG in this subset (P for trend 0.064). All rights reserved. 0000013202 00000 n The EXCEL trial compared CABG with PCI using new generation DES [Everolimus-Eluting Stent (EES)] among 1905 patients with left main CAD with evidence of invasive or non-invasive ischaemia.42 Although complex left main CAD defined as SYNTAX score of >32 constituted a formal exclusion criterion, the distribution of SYNTAX score tertiles according to the Core laboratory evaluation were 36%, 40%, and 24% for low (<22), intermediate (23–32), and high (>32) SYNTAX score, respectively. 0000006693 00000 n These data therefore also satisfy statistical criteria of significance for the interaction between SYNTAX tertiles and outcomes between PCI and CABG. CABG) is a treatment that can help. Ad N, Holmes SD, Patel J, Pritchard G, Shuman DJ, Halpin L. Wykrzykowska JJ, Garg S, Girasis C, de Vries T, Morel MA, van Es GA, Buszman P, Linke A, Ischinger T, Klauss V, Corti R, Eberli F, Wijns W, Morice MC, di Mario C, van Geuns RJ, Juni P, Windecker S, Serruys PW. 0000001979 00000 n Coronary artery bypass surgery (also called . 20) Tanimoto Y, Matsuda Y, Masuda T, et al. The SYNTAX score remains the best tool to guide decisions on the revascularization strategy among patients with multivessel CAD complemented by considerations in the presence of left main CAD and diabetes. CMAJ. However, only three of the subgroup analyses, namely diabetes status, tertiles of SYNTAX score, and left main disease would be considered key interactions and primary in nature, backed by prior pathophysiological, clinical and/or anatomical concepts, while the other subgroup analyses with interaction tests would be considered hierarchically subordinate and secondary in nature. With low SYNTAX scores PCI and CABG achieve similar long-term outcomes with respect to survival and the composite of death, myocardial infarction (MI), and stroke. In summary, the SYNTAX score remains the best tool to guide evidence-based decisions on the revascularization strategy (Take home figure and Figure 1). Coronary artery bypass grafting (CABG) remains a routine operation despite major advancements in angioplastic procedures. Oxford University Press is a department of the University of Oxford. Mit Flexionstabellen der verschiedenen Fälle und Zeiten Aussprache und relevante Diskussionen Kostenloser Vokabeltrainer Thus, based on current evidence diabetes mellitus is the strongest predictor of a survival benefit of CABG as compared with PCI in patients with multivessel CAD. 0000010651 00000 n Outcome impact of coronary revascularization strategy reclassification with fractional flow reserve at time of diagnostic angiography: insights from a large French multicenter fractional flow reserve registry, Does routine pressure wire assessment influence management strategy at coronary angiography for diagnosis of chest pain? The seminal individual patient data meta-analysis of seven RCTs comparing CABG with medical therapy by Yusuf et al.19 firmly established a survival benefit of surgical revascularization over medical therapy. 0000009275 00000 n Coronary artery bypass grafting (CABG) is the revascularization strategy of choice for patients with multivessel coronary artery disease, particularly those with complex lesions and high SYNTAX scores, those with diabetes mellitus, and those with left ventricular systolic dysfunction. 0000004175 00000 n Data [rates, hazard ratios (HR), 95% confidence intervals (CI) and P-values] are derived from the individual-pata data meta-analysis by Head et al.29. A coronary artery bypass graft involves taking a blood vessel from another part of the body (usually the chest, leg or arm) and attaching it to the coronary artery above and below the narrowed area or blockage. Data [rates, hazard ratios (HR), 95% confidence intervals (CI), and P-values] are derived from the individual-pata data meta-analysis by Head et al.29. The failure to demonstrate significant differences in terms of survival during long-term follow-up was thought to be related to the fact that these trials included highly selected patients (10% of screened patients) and excluded patients with complex and advanced CAD (three-vessel or left main disease). Chronic Metabolic Acidosis in Chronic Kidney Disease. The appropriate treatment allocation among patients with left main and coronary artery disease (CAD) at estimated low surgical risk remains a complex decision process. Farooq V, van Klaveren D, Steyerberg EW, Meliga E, Vergouwe Y, Chieffo A, Kappetein AP, Colombo A, Holmes DRJr, Mack M, Feldman T, Morice MC, Stahle E, Onuma Y, Morel MA, Garcia-Garcia HM, van Es GA, Dawkins KD, Mohr FW, Serruys PW. The SYNTAX trial was the first multicentre RCT comparing CABG with PCI using drug-eluting stents (DES) that employed a heart-team based, all-comer approach, and succeeded to include 41% of screened patients increasing its external validity.26 All patients were required to have severe CAD by limiting inclusion to patients with three-vessel and left main CAD. There are also important anatomico-pathological considerations owing to the differences between aorto-ostial lesions and the distal left main with involvement of the bifurcation in >60% of cases. Stone GW, Sabik JF, Serruys PW, Simonton CA, Généreux P, Puskas J, Kandzari DE, Morice M-C, Lembo N, Brown WM, Taggart DP, Banning A, Merkely B, Horkay F, Boonstra PW, van Boven AJ, Ungi I, Bogáts G, Mansour S, Noiseux N, Sabaté M, Pomar J, Hickey M, Gershlick A, Buszman P, Bochenek A, Schampaert E, Pagé P, Dressler O, Kosmidou I, Mehran R, Pocock SJ, Kappetein AP; Makikallio T, Holm NR, Lindsay M, Spence MS, Erglis A, Menown IB, Trovik T, Eskola M, Romppanen H, Kellerth T, Ravkilde J, Jensen LO, Kalinauskas G, Linder RB, Pentikainen M, Hervold A, Banning A, Zaman A, Cotton J, Eriksen E, Margus S, Sorensen HT, Nielsen PH, Niemela M, Kervinen K, Lassen JF, Maeng M, Oldroyd K, Berg G, Walsh SJ, Hanratty CG, Kumsars I, Stradins P, Steigen TK, Frobert O, Graham AN, Endresen PC, Corbascio M, Kajander O, Trivedi U, Hartikainen J, Anttila V, Hildick-Smith D, Thuesen L, Christiansen EH; Luscher TF, Creager MA, Beckman JA, Cosentino F. Kappetein AP, Head SJ, Morice MC, Banning AP, Serruys PW, Mohr FW, Dawkins KD, Mack MJ; Hlatky MA, Boothroyd DB, Bravata DM, Boersma E, Booth J, Brooks MM, Carrie D, Clayton TC, Danchin N, Flather M, Hamm CW, Hueb WA, Kahler J, Kelsey SF, King SB, Kosinski AS, Lopes N, McDonald KM, Rodriguez A, Serruys P, Sigwart U, Stables RH, Owens DK, Pocock SJ. J Thorac Cardiovasc Surg 1989;97:826-31. �)&�D�BKKX�}Z���еU�V���k}P#et����Eg���M܉QI�U4b�RM��շC���'J�d� U�&�w�z|���Ti��V�$�{. Based on the available evidence as established in dedicated RCTs and the distinct anatomico-pathophysiological properties of this lesion, left main CAD needs to be considered as a separate clinical and anatomical entity in practice guidelines. trailer << /Size 171 /Info 135 0 R /Root 140 0 R /Prev 351637 /ID[<08201b12ccd8fe822d37fd89e2bbe332><08201b12ccd8fe822d37fd89e2bbe332>] >> startxref 0 %%EOF 140 0 obj << /Pages 136 0 R /Outlines 123 0 R /Type /Catalog /DefaultGray 137 0 R /DefaultRGB 138 0 R /PageMode /UseThumbs /OpenAction 141 0 R >> endobj 141 0 obj << /S /GoTo /D [ 142 0 R /FitH -32768 ] >> endobj 169 0 obj << /S 92 /T 218 /O 265 /Filter /FlateDecode /Length 170 0 R >> stream The randomized BARI trial comparing PCI with use of balloon angioplasty and CABG in selected patients with multivessel CAD reported similar mortality for both revascularization strategies at 5 and 10 years.46,47 In 1992, the Data Safety and Monitoring Board recommended to monitor outcomes among diabetic patients, a subgroup that had not been a priori defined as subgroup in the original protocol. 0000008001 00000 n Coronary artery bypass grafting with the gastroepiploic artery. 0000001555 00000 n including 4478 patients with left main CAD randomly assigned to CABG or PCI with a mean follow-up of 3.4 ± 1.4 years.29 The authors reported similar risks for the primary outcome all-cause mortality (PCI: 10.7% vs. CABG 10.5%, HR 1.07, 95% CI 0.87–1.33; P = 0.52) throughout 5 years.29 There were no significant differences in mortality between PCI and CABG in subgroup analyses according to SYNTAX score (Figure 1). Spasm in Arterial Grafts in Coronary Artery Bypass Grafting Surgery. In 2007, Bravata et al.20 reported the results of a meta-analysis of 23 RCTs comparing CABG and PCI (balloon angioplasty and bare metal stents) among approximately 10 000 patients. While there were no differences in the incidence of all-cause and cardiac death, PCI was associated with a higher incidence of non-procedural MI (7% vs. 2%, P = 0.004) and repeat revascularization (16% vs. 10%, P = 0.03). There were formally negative tests for interaction between subgroups of patients with low, moderate, or high SYNTAX scores and hazard ratios (HRs) of death. Left main CAD has been recognized as specific disease entity since its first description by Herrick and the advent of coronary angiography in the 1960s34–36 and is observed in 4–7% of patients undergoing diagnostic coronary angiography.37 Due to its proximal location in the coronary artery tree, lesions of the left main may jeopardize blood flow subtending up to 60–90% of the myocardium. �N�C~{�M����6��v�۽ڮh�~����k��?���rC�u�����C�)I�/�uQۯ��cD H��VMs�6��L|�؎�f�N&֌� One of the major points of discussion surround the issue of choosing between the revascularization strategies based on clinically relevant subsets. In 2009, Hlatky et al.49 reported the results of an individual patient data meta-analysis of 10 RCTs (6 RCTs with balloon angioplasty, 4 RCTs with bare metal stents) including 7812 patients comparing PCI and CABG among patients with multivessel CAD with a mean follow-up of 5.9 years. Of note, it prospectively validated the SYNTAX score, an angiography based index of anatomical complexity among patients with multivessel and left main disease using evaluation by an independent core laboratory. Of note, considering life expectancy of patients included in the latest trials investigating revascularization in the setting of left main CAD, longer follow-up results of these trials are awaited. The statistical analysis plan of the SYNTAX trial implemented a hierarchical approach whereby subgroup analyses would only be allowed if the primary endpoint would be met. Coronary artery bypass grafting (CABG) is a procedure to improve poor blood flow to the heart. Cavalcante R, Sotomi Y, Mancone M, Whan Lee C, Ahn JM, Onuma Y, Lemos PA, van Geuns RJ, Park SJ, Serruys PW. From a statistical point of view, the stratified outcome analysis of the SYNTAX trial was therefore formally hypothesis generating. 3. This test for trend of HRs of death across ordered SYNTAX tertiles was positive in the overall population at P = 0.00114 and positive for the population with multivessel disease (in the absence of left main disease) at P = 0.00055. Consistent with the reports above, the individual patient data meta-analysis of 11 RCTs by Head et al.29 reported a significant interaction by revascularization allocation in stratified analysis according to diabetes mellitus. The most recent synthesis of available evidence stems from the individual patient pooled analysis by Head et al. 0000001153 00000 n Department of Cardiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital University of Bern, Freiburgstrasse, Bern, Switzerland. �100�10�=`4`V`\�p�!���A� ����KN1�21H�U`s`�������)H��8,^�@� ,��� ����g7g5����-�4#� �.� endstream endobj 170 0 obj 238 endobj 142 0 obj << /Type /Page /MediaBox [ 0 0 612 828 ] /Parent 136 0 R /Resources << /Font << /F4 149 0 R /F7 160 0 R /F6 157 0 R /F0 145 0 R /F1 143 0 R /F2 144 0 R /F5 150 0 R /F3 146 0 R >> /XObject << /Im1 168 0 R >> /ProcSet [ /PDF /Text /ImageB ] >> /Contents [ 148 0 R 152 0 R 154 0 R 156 0 R 159 0 R 162 0 R 164 0 R 166 0 R ] /Thumb 124 0 R /CropBox [ 0 0 612 828 ] /Rotate 0 >> endobj 143 0 obj << /Type /Font /Subtype /TrueType /Name /F1 /BaseFont /TimesNewRoman,Bold /Encoding /WinAnsiEncoding >> endobj 144 0 obj << /Type /Font /Subtype /TrueType /Name /F2 /BaseFont /TimesNewRoman /Encoding /WinAnsiEncoding >> endobj 145 0 obj << /Type /Font /Subtype /TrueType /Name /F0 /BaseFont /TimesNewRoman,Bold /Encoding /WinAnsiEncoding >> endobj 146 0 obj << /Type /Font /Subtype /TrueType /Name /F3 /BaseFont /TimesNewRoman /Encoding /WinAnsiEncoding >> endobj 147 0 obj 1306 endobj 148 0 obj << /Filter /FlateDecode /Length 147 0 R >> stream Superior in terms of long-term outcome … this medical policy documents the coverage for. 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