Is Coronary Artery Bypass Surgery Really Better than.ppt

Document Sample
Is Coronary Artery Bypass Surgery Really Better than.ppt Powered By Docstoc
					Is Coronary Artery Bypass Surgery
Really Better than Coronary Stents?
  A look at the risks and benefits
           Sarah Smith
        Advisor: Dr. Grimes
        Why is this important?
   The leading cause of death in the United States is
    coronary heart disease
   It accounts for about 1 million deaths per year
   About 43% of heart disease deaths are related to
    coronary artery disease
   Heart disease is the leading cause of death of
    American women, accounting for 32% of all
    deaths per year.
       One in three women will die from heart disease, while
        one in 25 will die from breast cancer
   Trends in the United States suggest that half of
    healthy 40-year-old males will develop CAD in the
    future, and one in three healthy 40-year-old
   CAD is a chronic disease in
    which the coronary arteries
    gradually harden and
   Limitation of blood flow to
    the heart causes ischemia
    of the myocardial cells,
    leading to a myocardial
   This leads to heart muscle
    damage, heart muscle
    death and later scarring
    without heart muscle
         Pathophysiology Cont.
   CAD can be thought of as a wide spectrum of
    disease of the heart
   At one end is the asymptomatic individual with
    fatty streaks within the walls of the coronary
       Over time these streaks will increase in thickness and
        may affect the flow of blood through the arteries
       As the plaque continues to grow and obstruct the vessel
        to more than 70% the patient typically develops
        symptoms of obstructive coronary artery disease
   At this stage the patient is said to have ischemic
    heart disease, meaning the patient’s heart is
    experiencing an increased workload, thus reduced
    blood supply to the heart walls

   As CAD progresses, there may be nearly
    complete obstruction of the lumen of the
    coronary artery
   Patients at this level have typically suffered
    from 1 or more myocardial infarctions, and
    may have angina at rest and pulmonary
   An individual may develop a rupture of a
    plaque at any stage of the spectrum.
       The acute rupture a plaque may lead to an
        acute MI
           Risk Factors

 Family history of premature CAD
 Smoking
 Diabetes mellitus
 Hyperlipidemia
 obesity

   Generally patients present with stable
    angina, unstable angina, or a myocardial
   Coronary angiogram is currently golden
    standard for determining the presence of
    obstructive coronary artery disease
       Yields a 2D picture of coronary arteries
       A catheter is inserted into the coronary arteries
        and injected with dye
       The dye allows the physician to pinpoint the
        number and location of blockages in the
        coronary arteries
          Treatment Options

   There are many different treatment options
   A physician will look into the patients’
    individual risk factors, severity of the
    blocked artery, and analyze the benefits
    and risks for possible procedures
   Two popular procedures are PCTA/stent
    implantation and CABG surgery
   Medical therapy is also available for a more
    conservative treatment
            Overview of Stents
   1/3 of patients with CAD will undergo coronary angioplasty
    with stents or Percutaneous Transluminal Coronary
    Angioplasty (PCTA)
   Angioplasty involves temporarily inserting and expanding a
    tiny balloon at the site of blockage to help widen the
    narrowed artery
   Usually combined with stent implantation in the artery to
    help prop it open and decrease the chance of it narrowing
    again or restenosis
   Performed in cardiac catheterization lab and are non-surgical
   Usually last about 1-2 hours and most patients are usually
    discharged in 1-2 days after a procedure
   Stents are a stainless or nytinol mesh like device
   Angioplasty and Stents
   YouTube Stent
   A stent is a stainless tube with slots. It
    is mounted on a balloon catheter in a
    collapsed state. When the balloon is
    imflated, the stent expands and pushes
    itself against the inner wall of the
    coronary artery.
   The risk of emergency referral for
    CABG and need for subsequent
    revascularization procedures has
    reduced by more than 50% because of
    coronary stents
   Stent implantation has shown to
    reduce restenosis in vessels with
    reference diameter >3mm, however
    in-stent restenosis still occurs in about
    10-40% of patients
   According to the American Heart
    Association stents can be considered
    for use in patients who have significant
    disease of left main and left anterior
    descending coronary artery. Also
    patients with 2 or 3-vessel disease
    should be considered
       In previous years these patients
           were only candidates for bypass
        Risks/Benefits of Stents
   Benefits:                        Risks and Limitations:
       Shorter procedural and           Risk of death <1%
        recovery time than               Risk of heart attack,
        CABG                              thrombosis and
       Angina relief about               bleeding <4%
        75% of the time                  Major limitation of
       Decreases the risk for            procedure is a high rate
        heart attack                      of restenosis and need
       Increases blood flow to           for revascularization
        the heart                        Scar tissue formation
                                         Not a cure to the
                                          disease, still need to
                                          reduce risk factors and
                                          make lifestyle changes
                                          to prevent future
                                          disease progression
   Patients receiving stents had lower incidence of
    death, MI, and stroke at 30-day follow-up
    compared to CABG.
   However, patients receiving stents had a higher
    incidence of repeat revascularization procedures
       25% of patients at 1 year and 47% at 5 years
   This high risk of restenosis is one of the major
    reasons for patients refusing angioplasty and
    opting for other treatment modalities like surgery
   The introduction of drug-eluting stents may shift
    patients from surgical procedures back to
    angioplasty and stent use.
         Drug-eluting Stents
   These are stents that are coated with a
    drug that is known to interfere with the
    process of restenosis
   As of December 2007, the FDA has
    approved of 2 DES: sirolimus-eluting stents
    and paclitaxel-eluting stents
   Studies show that there is a 70-90%
    reduced rate of restenosis when compared
    with bare-metal stents
   DES were first introduced in April 2003,
    and just 9 months later made up 35% of
    all stent implantations in the United States
              Problem with DES?
   1. They are expensive
        It costs about $2200 for a DES, when compared to bare-metal
         stents which costs about $600.
        In one study they looked at the cost-effectiveness of DES.
         They took into account the fact that there will be reduced
         repeat revascularization procedures, and discovered that there
         was still an increase in $600 per patient, and with an estimated
         1 million procedures done a year, about $600 million increased
         in annual healthcare spending
   2. The drug agents can interfere with the healing process
    and found to hamper natural vascular healing process
        In 2007, the FDA has cautioned the use of DES, because they
         are associated with increased risks of both early and late stent
         thrombosis, as well as death, and myocardial infarction
   DES are still a novel idea; it will be interesting to see the
    research that comes out in the next couple years looking at
    their effectiveness and future indications
                  Overview of CABG
   CABG is still the best therapy for
    reintervation for most patients with
    proximal left anterior descending,
    multivessel, and left main-stem
    coronary artery disease
   Of the patients with CAD, about 10%
    will undergo CABG surgery
   CABG is a surgery that increases blood
    flow to the heart by creating a detour
    and re-routing the blood flow around
    the blocked portion of the artery.
   A section of a blood vessel from
    another part of the body is removed
    and grafted above and below the
    damaged portion of the coronary
    artery to form an un-blocked artery
        Most commonly used are the
         saphenous vein and internal thoracic
   This procedure is performed with
    assistance of a heart-lung machine,
    which supports the patient’s blood
    during surgery
   CABG Surgery
Risks/Benefits CABG surgery
   CABG was introduced about 50 years ago and is
    now performed in 1 million patients at a cost
    exceeding $20 billion annually
   Many benefits such as decrease in angina,
    improved life-span, and providing an effective
    route for blood with prevention of new plaques to
   Surgery is however a much more serious operation
    that lasts a long time, with a long recovery time
   Some complications seen after surgery are atrial
    fibrillation, increased risk of stroke, and cognitive
   Less than 5% chance of heart damage and less than 2%
    chance of death
   Stroke or other neurological injury occurs in 5% patients
   Atrial fibrillation occurs in 20-40% of patients after CABG
   2 reasons as to why CABG offers survival advantages for
    multivessel and left main-stem coronary artery disease
        1. Bypass grafts are placed on the midcoronary vessel, CABG
         not only protects the culprit lesion, but also offers prophylaxis
         against new lesions in diseased endothelium
             Where stents only treat immediate culprit lesion, with no protective
              effect against the development of new disease
        2. failure of stents to achieve complete revascularization in
         most patients with multivessel disease reduces survival
         proportional to the degree of incomplete revascularization
     Isolated LAD and Left-main
              stem CAD
   CAD in LAD has been reported as high as 50%
    among patients who undergo CABG
   CABG is regarded as an accepted golden standard
    for left main coronary artery disease
   CABG has generally been considered the golden
    standard of therapy for left-main stem stenosis for
    the last decade.
       However, there are recent studies out that show patients
        underwent PCI more than CABG for this type of disease.
        This artery has a relatively large diameter, making it an
        attractive site for PCI
       Restenosis rates in a study were 30.3% in bare-metal
        stents, 7.4% in DES group, and 3.7% in CABG group
               Multivessel CAD
   MVD accounts for approximately 60% of the CAD
   The use of stents in these patients has resulted in
    higher restenosis and repeat vascularization rates
    than in patients treated with surgery
       Stents group had 16.8% restenosis rate as compared
        with 3.5% who underwent surgery
   CABG patients also experience fewer MI and major
    adverse cardiovascular events
   DES have decreased the difference between CABG
    and bare-metal stents
   In order for PCI to replace CABG as the preferred
    therapy in MVD, clinical trials must demonstrate
    long-term outcomes that are equivalent
          What about the Diabetic
   The diabetic patient is a high risk for coronary artery
    disease, the incidence and severity of the disease are higher
    as compared to nondiabetic patient
   Revascularization of diabetic patients has been a huge
    dilemma and a great challenge
   A study confirmed that even a low-risk diabetic patient there
    is a survival advantage at 10 years for CABG in comparision
    with PCI of 58% vs. 46%
        Also found that there is a huge difference in the need for
         revascularization in both; 18% of CABG patients and 80% of
   Studies state that the preferred revascularization strategy in
    the diabetic patient with MVD is CABG surgery
        Lower mortality in CABG patients vs. PCI patients (1.4% vs.
        Lower major adverse cardiovascular events (8.6% vs. 26.6%)
                       The Future
   Minimally invasive direct coronary artery bypass (MIDCAB) is
    on the rise
   It is performed on a beating heart with use of stabilizing
    devices or using minimal access bypass system with endo-
    aortic clamping and cardioplegic arrest
   Yields shorter hospital stay with lower postoperative
    complications and better quality of life with similar safety
    and long-term efficacy as conventional CABG
   Robotic instrumentation is also developing
        Surgery does not have a single chest incision of any kind, this
         surgery requires 3 pencil-sizes holes made between the ribs
        2 robotic arms and an endoscope gain access to the heart,
         making surgery possible without opening the chest
        Has been proven that these patients get out of the hospital 1-2
         days earlier
        This technique may develop into new technology that might be
         used more often in the future and may replace open heart
   CABG still remains that best therapy in terms of
    superior survival and decreased need for
    reintervention for most patients with proximal
    LAD, multivessel, and left main-stem CAD.
   These affects are magnified in the diabetic patient
   PCI with stent is still chosen as treatment option
    for single-vessel disease, and now considered for
    2 or 3-vessel disease
   Each patient is evaluated for the best treatment
    option based on their own risk factors and
    progression of disease
   Anderson, H. Vernon, Richard E. Shaw, Ralph G Brindis, Kathleen Hewitt, Ronald Krone, Peter C. Block, Charles R. McKay, Williams S.
    Weintraub. “A contemporary overview of percutaneous coronary interventions: The American College of Cardiology-National
    Cardiovascular Registry.” Journal of the American College of Cardiology. 39 (2002): 1096-1103.
   Aziz, Omer, Christopher Rao, Sukhmeet Singh Panesar, Catherine Jones, Stephen Morris, Ara Darzi, Thanos Athanasiou. “Meta-analysis
    of minimally invasive internal thoracic artery bypass versus percutaneous revascularization for isolated lesions of the left anterior
    descending artery.”
   Bair, Tami L., Joseph B. Muhlestein, Heidi T. May, Kent G. Meredith, Benjamin D. Horne, Robert R. Pearson, Qunyu Li, Kurt R. Jensen,
    Jeffrey L. Anderson, and Donald L. Lappe. “ Surgical Revascularization is associated with improved long-term outcomes compared with
    percutaneous stenting in most subgroups of patients with multivessel coronary artery disease: results from the intermountain heart
    registry.” Journal of the American Heart Association. 116 (2007): 226-231.
   Bravata, Dena M., Allison L. Glenger, Kathryn M. McDonald, Vandana Sundaram, Marco V. Perez, Robin Varghese, John R. Kapoor,
    Reza Ardehall, Douglas Owens, and Mark A. Hlatky. “The Comparative effectiveness of Percutaneous Coronary Interventions and
    Coronary Artery Bypass Graft Surgery.” American College of Physicians. 147 (2007): 1-15.
   Davies, MJ. “Coronary Disease: The Pathophysiology of acute coronary syndromes.” Heart. 83 (2000): 361-3666
   Daemen, Joost, Patrick W. Serruys. “Drug-Eluting stent update 2007: Part I: A survey of current and future generation drug-eluting
    stents: meaningful advances or more of the same?” Circulation. 116 (2007): 316-328.
   Daemen, Joost, Pattrick W. Serruys. “Drug-eluting stent update 2007: Part II Unsettled issues” Circulation. 116 (2007): 961-968.
   Elsasser, A. H. Mollmann, H.M. Nef, C.W. Hamn. “How to revascularize patients with diabetes mellitus- Bypass or stents and drugs?”
    Clinical Research in Cardiology. 95.4 (2006): 193-202.
   Eisenberg, Mark J. “Drug-Eluting Stents, The price is not right.” Circulation. 114 (2006): 1745-1754.
   Farb, A. Boam MS. “Stent Thrombosis Redux- the FDA perspective.” New England Journal of Medicine. 356 (2007): 984-987.
   Gupta, S., and Brig MM Gupta. “Coronary Artery Bypass Surgery or Drug Eluting Stent for Unprotected Left Main Coronary Artery
    Disease. Journal of The Association of Physicians of India. 55 (2007): 287-291.
   Harmon DC, Ghori KG, Eustace NP, O’Callaghan SJF, O’Donnell AP, Shorten GD. “Aprotinin decreases the incidence of cognitive deficit
    following CABG and cardiopulmonary bypass: a pilot randomized controlled study.” Canadian Journal of Anethesia 51 (2004)51:10.
   Jaffery, Zehra, Marcin Kowalski, W. Douglas Weaver, Sanjaya Khanal. “A meta-alysis of randomized control trials comparing minimally
    invasive direct coronary bypass grafting versus percutaneous coronary intervention for stenosis of the proximal left anterior descending
    artery.” European Journal of Cardio thoracic Surgery. 31 (2007): 691-697.
   Javaid, Aamir, Daniel H. Steinberg, Ashlesh N. Buch, Paul J. Corson, Steven W. Boyce, Tina L. Pinto Slottow, Probal K, Peter Hill, Teruo
    Okabe, Rebecca Torguson, and et. “Outcomes of Coronary Artery Bypass Grafting versus Percutaneous Coronary Intervention with
    Drug-Eluting Stents for patients with Mulitivessel Coronary Artery Disease.” Circulation. 116 (2007): I-200-I-206.
   Kaiser, Christopher, Hans Peter Brunner-LaRocca, Peter T Buser, Piero O Bonneti, Stefan Osswald, Andre Linka, Andreas Zutter,
    Michael Zellweger, Leticia Grize, Matthias E Pfisteter. “Incremental cost-effectiveness of drug-eluting stents compared with a third
    generation bare-metal stent in a real world setting: randomized Basel Stent Kosten Effectivitats Trial” Lancet. 366 (2005): 921-929.
   Kappert U, Schneider J, Cichon R, Gulielmos V, Tugtekin SM, Nicolai J, Matschke K, Schueler S. “Development of Robotic
    Enhanced Endoscopic Surgery for the treatment of Coronary Artery Disease.” Circulation. 104 (2001): 102-107.
   Lee MS, Kapoor N, Jamal F, Czer L, Aragon J, Forrester J, Kar S, Donhad S, Kass R, Eigler N, Trento A, Shah PK, Makkar
    RR. “Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug eluting stents for
    unprotected left main coronary artery disease.” Journal of American College of Cardiology. 47 (2006): 864-870.
   Legrand, Victor M.G., Patrick W. Serruys, Felix Unger, Ben A. van Hout, Mathias C.M. Vrolix, Geert M.P. Fransen, Torsten
    Toftegaard Nielsen, Peter Kildeberg Paulsen, Ricardo Seabra Gomes and et. “Three-year outcomes after coronary
    stenting versus bypass surgery for the treatment of multivessel disease” Circulation. 109 (2004): 1114-1120.
   Lemos, Pedro, Patrick Serruys, Edurdo Sousa. “Drug-Eluting Stents; Cost versus clinical benefit.” Circulation. 107 (2003):
   Libby P, Theroux P. “Pathophysiology of Coronary Artery Disease.” Circulation. 111 (2005): 3481-3488.
   Medline Plus: Heart Bypass Surgery. Retrieved August 16, 2008 from
   Mercado, Nestor, William Wijns, Patrick W. Serruys, Ulrich Sigwart, Marcus D. Flather, Rodney H. Stables, William W.
    O’Neil, Alfredo Rodriguez, Pedro A. Lemos, Whady A. Hueb, Bernard J. Gersh, Jean Booth, and Eric Boersma. “One-year
    outcomes of coronary artery bypass graft surgery versus percutaneous coronary intervention with multiple stenting for
    multisystem disease: A meta-analysis of individual patient data from randomized clinical trials.” The Journal of Thoracic
    and Cardiovascular Surgery. 130.2 (2005): 512-519.
   Michaels AD, Chatterjee K. “Angioplasty versus bypass surgery for Coronary Artery Disease.” Circulation. 106 (2000): 187-
   Morrison DA, Sethi G, Sacks J, et al. “Percutaneous coronary intervention versus coronary artery bypass graft surgery for
    patients with medically refractory myocardial ischemia and risk factors for adverse outcome with bypass: a multicenter,
    randomized trial.” Journal of the American College of Cardiology. 38 (2001): 143-149.
   Morton, A.C., R.D. Walker, and J. Gunn. “Current Challenges in coronary stenting: from bench to bedside.” Biochemical
    society transations. 35.5 (2007): 900-904.
   O’Keefe, James H., Thomas R. Kreamer, Philip G. Jones, James L. Vacek, Michael E. Gorton, Gregory F. Muehlebach, Barry
    D. Rutherford, Ben D. McCallister. “Isolated Left Anterior Descending Artery Disease: Percutaneous Transluminal Coronary
    Angioplasty versus Stenting versus Left Internal Mammary artery bypass Grafting.” Circulation. 100 (1999): II114-II118.
   O’Neil, William W., Martin B. Leon. “Drug-Eluting stents: Cost versus clinical benefit.” Circulation. 107 (2003): 3008-3011.
   Ott, Elizabeth, David Mazer, Iulia Tudor, Linda Shore-Lesserson, Stephanie Snyder-Ramos, Barry Finegan, Patrick Mohnle,
    Charles Hantler, Bernd Bottiger, Ray Latimer, Warren Browner, Jack Levin, Dennis Mangano. “Coronary artery bypass
    graft surgery- care globalization: The impack of national care on fatal and nonfatal outcome.” The Journal of Thoracic and
    Cardiovascular Surgery. 133 (2007): 1242-1251.
   Patil, CV., E. Nikolsky, M. Boulos, E. Grenadier, R. Beyar. “Multivessel coronary artery disease: current revascularization strategies.” European Heart
    Journal. 22 (2001): 1183-1197.
   Rao, Christopher, Omer Aziz, Sukhmeet Singh Panesar, Catherine Jones, Stephen Morris, Ara Darzi, Thanos Athanasiou. “Cost Effectiveness analysis of
    minimally invasive internal thoracic artery bypass versus percutatneous revascularization for isolated lesions of the left anterior descending artery.”
    British Medical Journal. 334 (2007): 621-628.
   Rihal, Charanjit, Dominic L. Raco, Bernard J. Gersh, Salim, Yusuf. “Indications for Coronary Artery Bypass Surgery and Percutaneious Coronary
    Intervention in Chronic Stable Angina: Review of the Evidence and Methodological Considerations.” Circulation. 108 (2003): 2439-2445.
   Rodriguez, Alfredo E., Andrew O. Maree, Juan Mieres, Daniel Berrocal, Lilliana Grinfeld, Carlos Fernandez-Pereira, Valeria Curotto, Alfredo Rodriguez-
    Granillo, William O’Neill, and Igor F. Palacios. “Late loss of early benefit from drug-eluting stents when compared with bare-metal stents and coronary
    artery bypass surgery: 3 years follow-up of the ERACI III registry.” The European Society of Cardiology. 28 (2007): 2118-2125
   Ryan, Jason, David Cohen. “Will drug-eluting stents bankrupt the healthcare system? Are drug-eluting stents cost-effective? It depends on who you
    ask.” Circulation. 114 (2006): 1736-1744.
   Schaar, Johannes A., James E. Muller, Erling Falk, Renu Virmani, Valentin Fuster, Patrick Serruys, Antonio Colombo, Christodoulos Stefanadis, S. Ward
    Casscells, Pedro R. Moreno, Attilio Maseri, Anton van der Steen. “Terminology for high-risk and vulnerable coronary artery plaques.” European Heart
    Journal. 25 (2004): 1077-1082.
   Serruys, Patrick W., Felix Unger, J. Eduardo Sousa, Adib Jatene, Hans J.R.M. Bonnier, Jacques P.A.M Schonberger, Nigel Buller, Robert Bonser, Marcel
    J.B. VAN DEN Brand, Lex A. VAN Herwerden, Marie-Angele M. Morel, and Ben A. VAN HOUT. “Comparison of Coronary-Artery Bypass Surgery and
    Stenting for the Treatment of Multivessel Disease.” New England Journal of Medicine. 344.15 (2001): 1117-1124.
   Serruys, Patrick W., Andrew T. L. Ong, Lex A. van Herwerden, Eduardo Sousa, Adib Jantene, Johannes Bonnier, Jacque Schoenberger, Nigel Buller,
    Robert Bonser, Clemens Disco, Bianca Backx, Paul Hugenholtz, Brian Firth, Felix Unger. “Five-year outcomes after coronary stenting versus bypass
    surgery for the treatment of mulivessel disease.” Journal of American College of Cardiology. 46 (2005): 575-581.
    Spiess, B, et al. “Platelet transfusions during coronary artery bypass graft surgery are associated with serious adverse outcomes.” Transfusion 44
   Stephenson, Larry W. Mercedes K. C. Dullum. “Coronary Artery Bypass Surgery.” Available at:, December 2004. Retrieved February 7, 2008.
   Sundt, Thoralf M. “Adult Cardiac Surgery: Coronary Artery Bypass Grafting Surgery.” Retrieved February 7, 2008 from
   Taggart, DP. “Coronary artery bypass graft vs. percutaneous coronary angioplasty: CABG on the rebound?” Lippincott Williams and Wilkins, Inc. 22
    (2007): 517-523.
   Villareal, Rollo P., Vei-Vei Lee, MacArthur A. Elayda, and James M. Wilson. "Coronary Artery Bypass Surgery versus Coronary Stenting." Texas Heart
    Institute Journal 29.1 (2002): 3-9.
   Virmani, R, Farb A., “Pathology of in-stent restenosis.” Curropin Lipidol. 10(1999): 499-506.
   Yang, Zhen Kun, Wei Feng Shen, Rui Yan Zhang, Ye Kong, Jian Sheng Zhang, Jian Hu, Qi Zhang, and Feng Hua Ding. "Coronary Artery Bypass Surgery
    Versus Percutaneous Coronary Intervention with Drug-Eluting Stent Implantatio in Patinets with Multivessel Coronary Disease." Journal of Interventional
    Cardiology 20.1 (2007): 10-16.
   Zaman, Azfar G., Andrew Archbold, Gerard Helft, Elizabeth A. Paul, Nicholas P. Curzen, Peter G. Mills. “Atrial fibrillation after coronary artery bypass
    surgery: A model for Preoperative Risk Stratification Circulation. 101 (2000): 1403-1408.

Shared By:
handongqp handongqp