cabg for ischemic cardiomyopathy, post …...cardiogenic shock cardiovascular disease (cvd) accounts...

Yoshiya Toyoda, MD, PhD

William Maul Measey Professor of Surgery

Chief, Cardiovascular Surgery

Surgical Director, Mechanical Circulatory Support

Surgical Director, Thoracic Transplantation

Temple University School of Medicine

Philadelphia, PA

CABG for ischemic cardiomyopathy,

post myocardial infarction and

cardiogenic shock

Cardiovascular disease (CVD) accounts for 34 % of all U.S. deaths each year, countless resources, and healthcare expenditures that approach $300 billion annually.

Coronary artery disease (CAD) is the most common type of heart disease. It is the leading cause of death in the United States in both men and women. CAD resulting in myocardial infarction (MI) claims over one million lives each year in the U.S. and leads to countless more permanent disabilities including heart failure. Approximately five million Americans currently live with heart failure, and an additional 400,000 patients are newly diagnosed each year. CHF is the most common admitting diagnosis for patients over the age of 65 years, and is associated not only with a decreased quality of life, but also significant mortality. CHF carries a mortality rate of at least 40 % within 2 years of diagnosis. For those patients with the most advanced stages of CHF (New York Heart Association class IV), the 1-year mortality rate exceeds 50 %. In addition, the treatment of CHF is associated with very high and continuingly escalating costs. Not only is CHF the most expensive DRG covered by Medicare and Medicaid, remarkably it is estimated that total medical costs (inpatient and outpatient) associated with the treatment of CHF exceed $29 billion per year.

Coronary Artery Disease (CAD)

Syntax (The SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery study) 1-year Data. NEJM 2009;360:961-72.

Randomly assigned 1800 patients with three-vessel or left main coronary artery disease to undergo CABG or PCI (in a 1:1 ratio). A noninferiority comparison of the two groups was performed for the primary end point — a major adverse cardiac or cerebrovascular event (i.e., death from any cause, stroke, myocardial infarction, or repeat revascularization) during the 12-month period after randomization. Results Most of the preoperative characteristics were similar in the two groups. Rates of major adverse cardiac or cerebrovascular events at 12 months were significantly higher in the PCI group (17.8%, vs. 12.4% for CABG; P=0.002), in large part because of an increased rate of repeat revascularization (13.5% vs. 5.9%, PP<0.001) as a result, the criterion for noninferiority was not met. At 12 months, the rates of death and myocardial infarction were similar between the two groups; stroke was significantly more likely to occur with CABG (2.2%, vs. 0.6% with PCI; P=0.003). Conclusions CABG remains the standard of care for patients with three-vessel or left main coronary artery disease, since the use of CABG, as compared with PCI, resulted in lower rates of the combined end point of major adverse cardiac or cerebrovascular events at 1 year.

Coronary Artery Disease (CAD)

CABG vs. PCI for Left Main or Three Vessel Disease

Syntax 1-year Data. NEJM 2009;360:961-72.

1800 patients were randomly assigned to CABG (n=897) or PCI (n=903). After 5 years’ follow-up, Kaplan-Meier estimates of MACCE were 26·9% in the CABG group and 37·3% in the PCI group (p<0·0001). Estimates of myocardial infarction (3·8% in the CABG group vs 9·7% in the PCI group; p<0·0001) and repeat revascularisation (13·7% vs 25·9%; p<0·0001) were significantly increased with PCI versus CABG. All-cause death (11·4% in the CABG group vs 13·9% in the PCI group; p=0·10) and stroke (3·7% vs 2·4%; p=0·09) were not significantly different between groups. 28·6% of patients in the CABG group with low SYNTAX scores had MACCE versus 32·1% of patients in the PCI group (p=0·43) and 31·0% in the CABG group with left main coronary disease had MACCE versus 36·9% in the PCI group (p=0·12); however, in patients with intermediate or high SYNTAX scores, MACCE was significantly increased with PCI (intermediate score, 25·8% of the CABG group vs 36·0% of the PCI group; p=0·008; high score, 26·8% vs 44·0%; p<0·0001).

3-year/5-year SYNTAX trial data in 2012 comparing PCI and CABG provides compelling insights into the statistically significant and overwhelming survival and event-free survival benefit conferred on patients who receive CABG surgery.

At 5-year follow-up, clinical results from SYNTAX showed that CABG was superior to DES-PCI with respect to the composite endpoint of death, myocardial infarction, stroke, or repeat revascularization, with the benefit driven predominantly by decreased rates of repeat revascularization and myocardial infarction with no significant differences in rates of death or stroke.

Syntax 5-year Data. Lancet, 381 (2013), pp. 629-638.

The Coronary Artery Surgery Study (CASS) trial in 1985, showed that coronary artery bypass graft (CABG) improved survival in comparing 420 medically treated and 231 CABG patients with left ventricular ejection fraction (LVEF) ≤35% in the nonrandomized Registry cohort. The benefit was most apparent for patients with angina and LVEF ≤25%; medically treated patients in this cohort had a 43 % 5-year survival while CABG recipients benefited from a 63 % 5-year survival. Operative mortality in the CASS series was 6.9 %.

CABG vs. Medical Therapy in Ischemic Cardiomyopathy

From July 2002 to May 2007, a total of 1212 patients with an ejection fraction of 35% or less and coronary artery disease amenable to CABG were randomly assigned to undergo CABG plus medical therapy (CABG group, 610 patients) or medical therapy alone (medical-therapy group, 602 patients). The primary outcome was death from any cause. Major secondary outcomes included death from cardiovascular causes and death from any cause or hospitalization for cardiovascular causes. The median duration of follow-up, including the current extended-follow-up study, was 9.8 years. RESULTS A primary outcome event occurred in 359 patients (58.9%) in the CABG group and in 398 patients (66.1%) in the medical-therapy group (hazard ratio with CABG vs. medical therapy, 0.84; 95% confidence interval [CI], 0.73 to 0.97; P=0.02 by log-rank test). A total of 247 patients (40.5%) in the CABG group and 297 patients (49.3%) in the medical-therapy group died from cardiovascular causes (hazard ratio, 0.79; 95% CI, 0.66 to 0.93; P=0.006 by log-rank test). Death from any cause or hospitalization for cardiovascular causes occurred in 467 patients (76.6%) in the CABG group and in 524 patients (87.0%) in the medical-therapy group (hazard ratio, 0.72; 95% CI, 0.64 to 0.82; P<0.001 by log-rank test). CONCLUSIONS In a cohort of patients with ischemic cardiomyopathy, the rates of death from any cause, death from cardiovascular causes, and death from any cause or hospitalization for cardiovascular causes were significantly lower over 10 years among patients who underwent CABG in addition to receiving medical therapy than among those who received medical therapy alone.

CABG in Ischemic Cardiomyopathy

STITCH trial. NEJM 2016;374:1511-20. CABG in ICMP (LVEF<35%)

CABG in Ischemic Cardiomyopathy

STITCH trial. NEJM 2016;374:1511-20. CABG in ICMP (LVEF<35%)

STITCH trial. NEJM 2016;374:1511-20. CABG in ICMP

Myocardial viability by MRI and survival. JACC 2012;59:825-835.

Many believe that the selection of patients with ischemic cardiomyopathy for CABG should be based on the presence of viable myocardium.

DE-CMR may be useful to predict, not only functional improvement of patients with CAD and LV dysfunction, but also survival. Indeed, the study showed that revascularization of dysfunctional viable myocardium provides a significant improvement in patient outcomes versus medical treatment. It thus suggests that patients with viable myocardium should be revascularized to improve survival.

Patients with viable myocardium and low LVEF (24+/- 7%):

Complete Revascularization is better than incomplete revascularization or medical therapy.

W.S., 55-year-old Male, 69 in, 222 lbs, BMI 32

Active Smoker (43 pack years)

DM, HLD, PVD (SFA stent), COPD, OSA

Shortness of Breath for 2 weeks

NSTEMI (TnI 4.4), NYHA Class IV

WBC 9.1, Hct 45, Plt 285

ABG: 7.46/21/81

BUN: 13, Cr 0.82, T-Bil 1.1, Alb 3.2, INR 1.0

Case. Cardiogenic Shock Complicating MI

W.S., 55M, NSTEMI, Shortness of Breath for 2 weeks

LVEF: 10-15%

LVID ed: 68mm

LVID es: 63mm

MV: mild MR

RV: Dilated

Decreased function

TV: no TR


HR: 114

AoP: 92/75 (83)

LVP: 98/36

RAP: 17/12(14)

RVP: 50/18

PAP: 51/34(41)

PCWP: 39/37(34)

SaO2: 94

SvO2: 57

CO (Fick): 4.05

CI (Fick): 1.85

LVSWI: 10.74

RVSWI: 6.08

PVR: 1.73

W.S., 55M, LM+3VD, NSTEMI, NYHA Class IV


W.S., 55-year-old Male

Ischemic Cardiomyopathy (LVEF 10-15%)

LM+3VD, Non STEMI, NYHA IV

VFib Cardioversion x 2

IABP Insertion

VFib Cardioversion x 8

Intubation, CPR

Next Step ??

Case. Cardiac Arrest Complicating MI

LIMA-LAD

SVG-Diag1-Diag2

SVG-RI-OM-PDA

Emergency Off-Pump CABG x 6



LM+3VD, Non STEMI, NYHA IV, Cardiac Arrest





S/P OPCAB x 6


Centrimag LVAD, Off Pump

31Fr. venous cannula in left atrium

20Fr. arterial cannula in aorta

POD#1: VFib Cardioversion x 3

POD#0: Hemodynamically Stable

Biomedicus

Rotaflow CentriMag

TandemHeart

Impella

Short-Term Mechanical Circulatory Support

Long-Term Mechanical Circulatory Support

HeartWare HVAD Syncardia TAH HeartMate II HeartMate 3

VFib x 2

IABP Insertion

VFib x 8, Intubation, CPR

Emergency CABG with VAD back up

OPCAB x 6

Case. 55 M, acute on chronic heart failure, ischemic cardiomyopathy, NSTEMI

POD#0 Hemodynamically stable

POD#1 Vfib x 3

Centrimag LVAD

POD#2: VFib x 2

POD#3: VFib x 26




S/P OPCAB x 6


Centrimag LVAD


POD#2-3: VFib Cardioversion x 28

Centrimag RVAD, Off Pump

40Fr. venous in right atrium

20Fr. arterial in pulmonary artery

All grafts patent

Bi-Ventricular Assist Device with Central Cannulation

Securing the cannula

for ambulation

Ambulation on CentriMag® BiVAD

POD#1: Centrimag LVAD: 6.5 L/min

POD#3: Centrimag RVAD: 5.5 L/min

POD#4~11: Vfib Cardioversion x 29

W.S., 55M, Ischemic Cardiomyopathy

POD#12 POD#28

Centrimag LVAD: 6.5L/min 2.4L/min

Centrimag RVAD: 5.5L/min 1.5L/min

POD#2-3:VFib Cardioversion x 28


Centrimag RVAD

POD#4-11: VFib Cardioversion x 29

Centrimag LVAD

OPCAB x 6

Preop.: VFib Cardioversion x 10

W.S., 55M, s/p OPCAB x 6, Centrimag BiVAD

POD#38: BiVAD Explantation

HR 93

BP 95/57(71)

RAP 13

PAP 38/21(25)

PCWP 16

CO/CI 9.5/4.3

SvO2 87

POD#58: Discharged Home

CentriMag® BiVAD, Bridge-to-Recovery

for Ischemic Cardiomyopathy, Cardiogenic

Shock/Cardiac Arrest, s/p OPCAB x 6,

Doing well 5 years postop

Cardiogenic Shock, Vfib, IABP

Acute on chronic heart failure, ischemic cardiomyopathy, NSTEMI

Complete Revascularization, OPCAB x 6

VAD as Bridge-to-Recovery

Recovery, Centrimag Explant

Postcardiotomy Vfib

Case. 72 M, acute on chronic heart failure, ischemic cardiomyopathy, NSTEMI

Diffuse CAD (3VD), cardiogenic shock placed on Impella LVAD

LVEF 10-15%, LVDd 66mm LVDs 58mm despite on Impella CP

Case. 72 M, ischemic cardiomyopathy, cardiogenic shock on Impella

s/p Off Pump CABG x 6 (LIMA-Diag-LAD, SVG-RI-OM, SVG-PDA-PLA)

Explant of Impella. Discharged home on POD#16.

All grafts patent

LIMA-Diag-LAD SVG-PDA-PLA

SVG-RI-OM

Case. 61F, Cardiogenic shock following STEMI, Severe PAD, Smoker

Diffuse CAD (Left main + 3VD), STEMI, cardiogenic shock placed on IABP

LVEF 15-20%, Emergency OPCAB x 3 (LIMA-LAD, SVG-RCA-OM)

Case. 61F, Cardiogenic shock following STEMI

S/P Emergency CABG x 3 (LIMA-LAD, SVG-RCA-OM)

Persistent low cardiac output, Ventricular tachcardia/fibrillation

POD# 6: All grafts patent



POD# 6: HeartMate II LVAD Implantation

POD# 43: Discharge home



POD#6 from OPCAB: s/p HeartMate II LVAD

POD#85 from HeartMate II LVAD: HeartMate II LVAD Explant

5 Years postop. NYHA Class I, LVEF 45%, improved from 15-20%

At least one in three heart surgeons has refused to treat critically ill patients because they are worried it will affect their mortality ratings if things go wrong. 84 percent said they were aware of other surgeons doing the same. Clinical decision-making had been adversely affected by the culture of transparency.

http://www.phc4.org/default.htm

Off Pump Double Lung Tx

OPCAB x 1 (LIMA-LAD)

Through Median Sternotomy

Single Left Lung Tx +

OPCAB x 2 (SVG-Ramus-LAD)

for IPF + CAD + Radiation Chest

Hospital Stay: 11 days

Single Left Lung Tx, Off-Pump OPCAB x 1 (LIMA-LAD) Ischemic Time: 172 minutes

Recipient: 63M, 71in, 207lbs, IPF, CAD Donor: 44M, 71in, 181lbs

Lung Transplantation at Temple N=240, 2012.3 - 2016.8

Concomitant CABG + Lung Transplant (N=17, 7%)

CABG: bypass grafts 1-3 Survival rate: 100% during the first year

Isolated CABG (YT: n=466) at Temple from 11-2011 to 1-2017 Complete Revascularization

CABG x 4 – 8 (n=310, 67%)

6 32

118

182

96

27 3 2 0

20

40

60

80

100

120

140

160

180

200

x 1 x 2 x 3 x 4 x 5 x 6 x 7 x 8

Isolated CABG (YT: n=466) at Temple from 11-2011 to 1-2017 Off Pump vs. On Pump

416, 89%

50, 11%

Off Pump

On Pump

Demographics CABG (Off-Pump) (n=180)

CABG (On-Pump) (n=202)

P-value

Age 63 ± 9

62 ± 10 0.201

Gender (male) 66% 70% 0.652

Height (inches) 66 ± 7 67 ± 4 0.138

Weight (lbs) 192 ± 45 188 ± 44 0.444

BMI (kg/m2) 31 ± 7 30 ± 6 0.145

Smokers 65% 23% 0.0001

Hypertension 80% 86% 0.111

Diabetes 54% 51% 0.331

Isolated CABG (n=382) at Temple from 11-2011 to 12-2014

CABG (Off-Pump) (n=180)


P-value

Race 34%- AA 27%- W 49%- O

24%- AA 27%- W 40%- O

0.110

Previous MI 21% 33% 0.011

Previous CVA 13% 12% 0.720

Pre-EF (%) 44 ± 18 (5-70%)

48 ± 16 (10-70%)

0.982


CABG (Off-Pump) (n=180)


P-value

Emergency/ Urgent

56%

35% 0.001

Grafts (average)

3.3 ± 1.2 2.7 ± 1.0 0.0001

Bypass grafts# (ranges)

1 to 8 1 to 5 0.0000

Observed/Expected Mortality

Index

0.73 1.67 0.05

Cerebrovascular Events

(stroke)

0 10 0.0000


• Off Pump vs. On Pump

– Avoid global ischemia to already damaged

myocardium

– Use shunt to minimize regional ischemia

– On pump, beating heart without global

ischemia: when hemodynamically unstable,

severe cardiomegaly

– Proximal anastomosis first to measure the

exact length of free grafts

– Proximal anastomoses with HeartString to

avoid side biting clamp for hostile aorta

– Sequential anastomoses with respect to the

target anatomy

– More targets possible

CABG for ischemic cardiomyopathy, post

myocardial infarction and cardiogenic shock

• Cardiogenic Shock

– Mechanical circulatory support to achieve

optimum hemodynamics: Bridge-to-Decision

• Peripheral: IABP, Impella (LVAD, RVAD),

TandemHeart (LVAD, RVAD), Veno-

Arterial ECMO

• Central: Veno-Arterial ECMO, LVAD,

RVAD, BiVAD

– Bridge-to-PCI, Support for high risk PCI

– Bridge-to-CABG

– Bridge-to-Long Term VAD: no viability, poor

targets, poor run off, good social support

CABG for ischemic cardiomyopathy, post

myocardial infarction and cardiogenic shock

CABG for ischemic cardiomyopathy,

post myocardial infarction and

cardiogenic shock

• Complete revascularization

• Use of mechanical circulatory

support

• Off Pump vs. On Pump

cabg for ischemic cardiomyopathy, post …...cardiogenic shock cardiovascular disease (cvd) accounts...

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