Improved outcome after off-pump versus on-pump coronary artery

Shared by: malj
Tags
Stats
views:: 7
posted:: 7/26/2012
language:: Latin
pages:: 80
Public Domain
Document Sample
							Heart Surgery – latest
developments
Dr DG Harris

Vergelegen Hospital
In Africa:
   No new developments outside SA
   Africa devoid of cardiac surgical units
   SA, Namibia (new), Kenya, Sudan, Egypt,
    Algeria, Libya, Ivory coast, Ghana,
    Nigeria. (previously in Zimbabwe)
   Expense (disposables, expertly trained
    staff)
Advances in Cardiac surgery
1) Technical advances (new surgical
    techniques, operations) – NO COST

2) Technological advances
                     – very useful
                      - very EXPENSIVE
The Internet!!
   Information about diseases
   Information about treatments
   Information about hospitals
   Information about Doctors


 www.heart-valve-surgery.com
Coronary Surgery – new
developments:

 ‘OffPump’ coronary bypass
 Minithoracotomy coronary bypass

 Total arterial grafting
Traditional CABG
 1 internal mammary artery + veins
 Excellent initial response, later on re-
  intervention is common
 Gold standard, it works well..`if it ain`t broke,
  do`nt fix it``
 BUT: Damaging effects of INVASIVE procedure
               – Wounds / Mediastinitis
               -- Heart lung machine
               -- Incidence is significant
Veins do not last as long as arteries
What`s New in Cardiothoracic
Surgery?
Complications of
Cardiopulmonary bypass
   Neurological problems, varying from stroke to
    cognitive impairment (microemboli)
   Bleeding due to platelet damage
   Whole body inflammatory response – need for
    postop ventilation
   Renal failure
   Cardiogenic shock / failure to wean
   Permanent pacemaker
   Respiratory failure
   Long term: cardiomyopathy
`OFF PUMP CABG` (OPCAB)
   NO HEART LUNG MACHINE , CORONARIES
    INDIVIDUALLY IMMOBILISED WITH
    STABILISER
   SURGERY DONE ON BEATING HEART
   PERSONAL EXPERIENCE SINCE 1999
   WORLDWIDE :VARIABLE FROM SURGEON
    TO SURGEON AND BETWEEN UNITS
   USA: 20%   INDIA, CHINA 80% FRANCE,
    BELGIUM 40-50%
ADVANTAGES OF OPCAB
   LESS BLEEDING - can operate 2 days after plavix
   LOWER MORTALITY
   LESS NEUROLOGICAL SIDE EFFECTS, INCL
    STROKE, CONFUSION, COGNITIVE DECLINE
   LESS STERNAL INFECTIONS
   LESS RENAL FAILURE
   LESS RESPIRATORY COMPLICATIONS, SHORTER
    PERIOD OF VENTILATION AND CAN OFTEN
    EXTUBATE IN THEATRE
   Graft patency equivalent in most studies
   PROCEDURE OF CHOICE IN CERTAIN PATIENTS –
    elderly, renal failure, redo, Caicified aorta
         HOSPITAL MORTALITY
         unrestricted in interval, excluding acute infarcts
         up to 5 % predicted EuroSCORE risk
         45 % relative risk reduction
       0.03




                                                                Pred. risk
       0.02                                                     2.77 (ECC)
                                                                2.88 (OPCAB)
Risk




                                                                Obs. risk
                                                                1.46 %
       0.01
                                                                ECC 955 pts


                                                                Obs. risk
                                                                0.81 %
         0                                                      OPCAB 1722 pts
              0        0-1        0-2           0-3       0-4          0-5

                              Cumulative Euroscore risk
Freedom fromEarly MORTALITY (3-months interval)


                                      K.U.Leuven 1997-2006
                                      Excluding acute infarcts
                                      OPCAB-effect
                                      Non-risk adjusted            P= 0.009
                                      Risk-adjusted                P= 0.05
                            OPCAB N=2864          - Saturated prop. score (AUC 0.83)
                            3 mnths 97.4±0.3      - Age
                                                  - Gender
                                                  - Renal failure (dialysis /creat>2)
                                                  - Any vascular disease
                                                  - Ejection Fraction
                                                  - Unstable ST at surgery



                           ECC N=1583
                           3 mnths 95.9±0.5
Non-risk adjusted        P= 0.05
Risk-adjusted (AUC=0.84) P= 0.23
          - Saturated propensity score (AUC 0.83)
          - Age
          - Creatinine preop
          - Unstable ST at surgery
Freedom from STROKE (8 days interval)
       Severe carotid stenosis ≥ 80 % stenosis


                                     K.U.Leuven 1997-2006
                                     Excluding acute infarcts
                                     Non-risk adjusted          P= 0.10


                   OPCAB N=395
                   8 days 97.7±0.7




                   ECC N=190
                   8 days 95.2±1.5
PERSONAL EXPERIENCE
(SINCE 2004)
   STROKE = 0%
   MORTALITY 0.6%
   TRANSFUSION +/- 20%
   BLEEDING 0.3%
   RENAL FAILURE -> DIALYSIS = 0
   MEDIASTINITIS (sternal bone infection) = 0
   Prolonged ventilation = 0.6%
AIMS OF OPCAB
   AVOID CARDIOPULMONARY BYPASS
   AVOID STOPPING THE HEART
   AVOID TOUCHING AORTA
   MOVE TOWARD SMALLER INCISION
   PATENCY AND NUMBER OF GRAFTS
    MUST BE EQUIVALENT
   MOVE TOWARD HYBRID
    PROCEDURES
OPCAB: Graft patency
   All large, randomised studies show
    equivalent patency with on pump
   One smaller study showed decreased
    patency
   Over 2000 articles published
   Decrease of Major Adverse Cardiac
    Events is proportional to number of arterial
    grafts, as well as completeness of revasc
Mini-thoracotomy CABG
   Next logical step
   Clutter from bypass tubing no longer an
    issue
   Established procedure since 1980`s – the
    origin of OPCAB
   LIMA to LAD – relatively easy, both lie just
    under skin incision
MINITHORACOTOMY OPCAB
CT Scanning of heart
Coronary stents
   Less invasive, faster recovery
   Not always same long term success as
    coronary bypass, ESPECIALLY:
       - Multiple stents
       - Complex, long narrowings
       - Narrowings on branches
Stents vs surgery
Total arterial grafting
Impact of conduits on survival
Patency IMA > Radial > veins

Main impact from previous slide is LIMA – LAD,
 not whether vein grafts or stents used in the
 other vessels.

Patency of stents vs veins is probably similar but
  long term studies need to confirm this
Single versus bilateral internal
mammary grafts: 10 year outcome
analysis. AW Pick et al (Mayo
clinic, USA). Ann Thorac Surg
1997;64:599-605

> 10 yr survival is 76% for those
getting single IMA vs 85% for
those receiving bilateral IMA`s
Valve surgery – new
developments
   Percutaneous valves
   Tissue valves
   Sutureless valves
   Valve repair
   Minimally invasive incisions
Mechanical valve (patients < 65 yrs)
Clotted valve
Tissue valve
Tissue valve - porcine
Percutaneous valves
Percutaneous transcatheter valve
Percutaneous valves
   Price!! R 250 000!!
   Still no long term follow up
   Suitable for patients too high risk for
    surgery
   Higher risk of stroke
   Future:’valve in valve’, implanted into worn
    tissue valve – tissue valves could be placed in
    younger patients
Sutureless valves
   Less operating time, therefore decreases
    risk
   Price!! (R 100 000)
   (standard prosthesis R 25 000)
Smaller incisions
Small thoracotomy (between ribs)
Hemi sternotomy (only bottom or top half of
 breastbone is cut)
Upper sternotomy
Lower hemi sternotomy