Hannan EL, Wu C, Walford G, Culliford AT, Gold JP, Smith CR, Higgins RS, Carlson RE, Jones RH. This medical policy documents the coverage determination for minimally invasive coronary artery bypass graft surgery. The off-pump coronary artery bypass graft (OPCAB) procedure avoids the use of cardiopulmonary bypass. 2018 ESC/EACTS Guidelines on myocardial revascularization - Supplementary Data: The Task Force on myocardial revascularization of the European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS) Developed with the special contribution of the European Association for Percutaneous Cardiovascular Interventions (EAPCI). Revascularization aims to improve myocardial blood flow thereby reducing ischaemia.51 An important pre-requisite to achieve this goal is the comprehensive assessment and treatment planning of lesions requiring revascularization including treatment optimization. Conversely, the number of patients with high complexity studied in RCTs is low due to exclusion criteria and the risk estimates and CIs remain imprecise. There are two main approaches. 3. One of the major points of discussion surround the issue of choosing between the revascularization strategies based on clinically relevant subsets. H��VMs�6��L|�؎�f�N&֌� 139 0 obj << /Linearized 1 /O 142 /H [ 1217 360 ] /L 354547 /E 106676 /N 4 /T 351648 >> endobj xref 139 32 0000000016 00000 n 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. �)&�D�BKKX�}Z���еU�V���k}P#et����Eg���M܉QI�U4b�RM��շC���'J�d� U�&�w�z|���Ti��V�$�{. Diabetes mellitus, which is observed in 20–30% of patients requiring revascularization, is associated with systemic endothelial dysfunction, accelerated atherosclerosis and more diffuse pattern of CAD.44,45 These disease properties are associated with a more pronounced progression of CAD after revascularization as well as neointimal hyperplastic response after PCI and may explain at least in part the differences in outcomes between CABG and PCI in patients with diabetes and multivessel CAD as compared to patients without diabetes. 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. 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. 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. 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. 0000004024 00000 n Myocardial revascularization as adjunct to guideline-based medical therapy remains the mainstay in the treatment of patients with symptomatic or ischaemia-producing CAD. Coronary artery bypass grafting is indicated in a STEMI only for patients who have coronary anatomy not amenable to PCI with ongoing ischemia, for patients in whom PCI has failed, or in patients who have mechanical complications (ventricular septal defect, myocardial free-wall rupture, or papillary mus-cle rupture) related to their acute coronary syndrome (ACS). 0000001979 00000 n 0000006670 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. © The Author(s) 2018. Description Total Length 45º Blades 7007-442 Micro Fine Blades 10 mm 6 1/2” (16.5 cm) 90º Blades 7007-446 6 1/4” (16 cm) 125º Blades 7007-449 6 1/4” (16 cm) SCANLAN® Premier 0000011872 00000 n 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). 0000001577 00000 n 0000001153 00000 n [PMC free article] Sergeant P, Lesaffre E, Flameng W, Suy R, Blackstone E. The return of clinically evident ischemia after coronary artery bypass grafting. 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. Clinical features of sudden obstruction of the coronary arteries. J Thorac Cardiovasc Surg 1989;97:826-31. Coronary-Artery Bypass Grafting stenosis, and the bypass graft is hand-sewn (anastomosed) end-to-side to the incision. Repeat revascularization (which unlike in previous trials was not included as an endpoint in the MACE analysis) was less common with CABG than PCI (12.9% vs. 7.6%, P < 0.001). The second edition of this book provides updated knowledge about the biological characteristics and clinical use of arterial grafts for coronary artery bypass surgery. 20) Tanimoto Y, Matsuda Y, Masuda T, et al. In the Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial, the largest randomized study in diabetics, PCI with use of early-generation DES was compared with CABG in diabetic patients undergoing elective revascularization for multivessel CAD.50 Out of a total of 33 966 patients screened, 1900 patients (6%) with a mean SYNTAX score of 26 ± 9 were enrolled. 21) He GW, Taggart DP. CMAJ. This article focuses on the preoperative and postoperative nursing care of patients undergoing coronary artery bypass graft surgery. Coronary artery bypass graft surgery--on-pump procedure. The trial failed to demonstrate non-inferiority of PCI for the primary endpoint and CABG was found superior to PCI (P = 0.0066). Tel: +41 31 632 4497, Fax: +41-31-632 4771, Email: Search for other works by this author on: Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Südring 15, Bad Krozingen, Germany, Department of Medicine and Institute of Health Policy, Management and Evaluation, Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, University of Toronto, 30 Bond St, ON, Toronto, Canada, Department of Cardiac Surgery, Hospital Santa Cruz, Av. Guidelines on myocardial revascularization, 2014 ESC/EACTS Guidelines on myocardial revascularization: the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI), American College of Cardiology Foundation, American Heart Association Task Force on Practice Guidelines, Society for Cardiovascular Angiography and Interventions, 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention. Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M, Yang M, Cohen DJ, Rosenberg Y, Solomon SD, Desai AS, Gersh BJ, Magnuson EA, Lansky A, Boineau R, Weinberger J, Ramanathan K, Sousa JE, Rankin J, Bhargava B, Buse J, Hueb W, Smith CR, Muratov V, Bansilal S, King S3rd, Bertrand M, Fuster V; Piccolo R, Giustino G, Mehran R, Windecker S. Van Belle E, Rioufol G, Pouillot C, Cuisset T, Bougrini K, Teiger E, Champagne S, Belle L, Barreau D, Hanssen M, Besnard C, Dauphin R, Dallongeville J, El Hahi Y, Sideris G, Bretelle C, Lhoest N, Barnay P, Leborgne L, Dupouy P; Curzen N, Rana O, Nicholas Z, Golledge P, Zaman A, Oldroyd K, Hanratty C, Banning A, Wheatcroft S, Hobson A, Chitkara K, Hildick-Smith D, McKenzie D, Calver A, Dimitrov BD, Corbett S. Baptista SB, Raposo L, Santos L, Ramos R, Cale R, Jorge E, Machado C, Costa M, Infante de Oliveira E, Costa J, Pipa J, Fonseca N, Guardado J, Silva B, Sousa MJ, Silva JC, Rodrigues A, Seca L, Fernandes R. Zimarino M, Ricci F, Romanello M, Di Nicola M, Corazzini A, De Caterina R. Echavarria-Pinto M, Collet C, Escaned J, Piek JJ, Serruys PW. Published on behalf of the European Society of Cardiology. 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? In contrast, several non-randomized observational studies comparing CABG and PCI using large health record data sets reported better survival with CABG than PCI in the overall cohort with subgroup analyses suggesting a gradient of benefit particularly among patients with three-vessel disease.21–25. Coronary Artery Bypass Grafting (CABG) began in the late 1960s along two parallel paths that included bypassing coronary artery obstructions using either the Internal Mammary artery (IMA) as the bypass conduit or reversed saphenous vein graft (SVG) from the leg. 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. 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. H�b`````9����(���π �,@Q=6���)~``�u��5��)}�t���YZy��]��b l 0�@���jyHU0�E��6H9�4�M`V``�ZƐ�`���0�Q�``�dc�f``4f� Apart from anatomical complexity a number of clinical characteristics that modify the peri-operative and peri-interventional risk need to be considered. 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. 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. 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. 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). 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. Patients who are not candidates for angioplasty … The trial used as definition of peri-procedural (within 72 h of the procedure) MI an increase in CK-MB >10 upper limit of normal (ULN) or CK-MB >5ULN in the presence of angiographically documented graft/stent occlusion, new pathological Q-waves in 2 contiguous leads or imaging evidence of new loss of viable myocardium. Long-term CASS experience, Percutaneous transcatheter assessment of the left main coronary artery: current status and future directions, Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology, Guidelines for percutaneous coronary interventions. 0000005414 00000 n 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. Each approach had early proponents, but the use of saphenous CABG may also be used in an emergency, … Silber S, Albertsson P, Avilés FF, Camici PG, Colombo A, Hamm C, Jørgensen E, Marco J, Nordrehaug J-E, Ruzyllo W, Urban P, Stone GW, Wijns W. Smith SCJr, Feldman TE, Hirshfeld JWJr, Jacobs AK, Kern MJ, King SB3rd, Morrison DA, O’Neill WW, Schaff HV, Whitlow PL, Williams DO, Antman EM, Smith SCJr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; Morice MC, Serruys PW, Kappetein AP, Feldman TE, Stahle E, Colombo A, Mack MJ, Holmes DR, Torracca L, van Es GA, Leadley K, Dawkins KD, Mohr F. Park SJ, Kim YH, Park DW, Yun SC, Ahn JM, Song HG, Lee JY, Kim WJ, Kang SJ, Lee SW, Lee CW, Park SW, Chung CH, Lee JW, Lim DS, Rha SW, Lee SG, Gwon HC, Kim HS, Chae IH, Jang Y, Jeong MH, Tahk SJ, Seung KB. It has been argued that the P-value for interaction in the work by Head et al. 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. 0000008001 00000 n 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. Surgical coronary artery bypass grafting (CABG) is the standard of care for revascularization of left main or three-vessel coronary artery disease. Patients who undergo redo CABG are older, more comorbid, and with more sclerotic coronary and noncardiac arteries than seen in primary CABG. 0000002107 00000 n Key Words: Coronary artery bypass grafting; Coronary artery disease; Percutaneous coronary intervention ORIGINAL ARTICLE anc ulication. 0000006693 00000 n This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (, Low-density lipoprotein cholesterol reduction and statin intensity in myocardial infarction patients and major adverse outcomes: a Swedish nationwide cohort study, The REDUCE-IT verdict on eicosapentaenoic acid and cardiovascular outcome challenged with STRENGTH, EMPEROR-REDUCED reigns while EMPERIAL whimpers, Management of refractory angina: an update, Anatomical complexity of multivessel coronary artery disease and SYNTAX score, https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model, Receive exclusive offers and updates from Oxford Academic, Comparative efficacy of coronary artery bypass surgery vs. percutaneous coronary intervention in patients with diabetes and multivessel coronary artery disease with or without chronic kidney disease, Coronary angioplasty of the unstable angina related vessel in patients with multivessel disease, Complete myocardial revascularization: between myth and reality, Impact of complete revascularization with percutaneous coronary intervention on survival in patients with at least one chronic total occlusion. 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). Peter Jüni serves as unpaid member of the steering group of trials funded by Astra Zeneca, Biotronik, Biosensors, St. Jude Medical and The Medicines Company. This hypothesis can be examined in a test for linear trend of log HRs across ordered SYNTAX tertiles.30 Head et al. 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 … 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. Authors/Task Force Members: Neumann F-J, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet J-P, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. Of note, the relative benefit of CABG over medical therapy increased according to disease severity being greatest among patients with left main, intermediate among patients with three-vessel and least among patients with one- or two-vessel CAD. Coronary artery disease (CAD) is a major cause of mortality and morbidity in the Western world. Yet, none of these scores have been validated in a prospective study. 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 Department of Cardiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital University of Bern, Freiburgstrasse, Bern, Switzerland. Osnabrugge RL, Speir AM, Head SJ, Fonner CE, Fonner E, Kappetein AP, Rich JB. 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. Joseph KS, Hoey J. �N Of note, the American Food and Drug Administration (FDA) subsequently adopted the SYNTAX score to define inclusion criteria for trials comparing PCI and CABG. 0000009426 00000 n Studies were scored according to degree of adjustment for case mix. 0000008024 00000 n Little data are available to compare coronary artery bypass graft surgery (CABG) vs percutaneous coronary intervention (PCI) with drug‐eluting stents (DES) in older adults. 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