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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
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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)
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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
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Syntax 1-year Data. NEJM 2009;360:961-72.
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Syntax 1-year Data. NEJM 2009;360:961-72.
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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.
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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
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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%)
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CABG in Ischemic Cardiomyopathy
STITCH trial. NEJM 2016;374:1511-20. CABG in ICMP (LVEF<35%)
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STITCH trial. NEJM 2016;374:1511-20. CABG in ICMP
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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.
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Patients with viable myocardium and low LVEF (24+/- 7%):
Complete Revascularization is better than incomplete revascularization or medical therapy.
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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
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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
Case. Cardiogenic Shock Complicating MI
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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
Case. Cardiogenic Shock Complicating MI
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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
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LIMA-LAD
SVG-Diag1-Diag2
SVG-RI-OM-PDA
Emergency Off-Pump CABG x 6
W.S., 55-year-old Male
Ischemic Cardiomyopathy (LVEF 10-15%)
LM+3VD, Non STEMI, NYHA IV, Cardiac Arrest
Case. Cardiogenic Shock Complicating MI
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W.S., 55-year-old Male
Ischemic Cardiomyopathy (LVEF 10-15%)
LM+3VD, Non STEMI, NYHA IV, Cardiac Arrest
S/P OPCAB x 6
Case. Cardiac Arrest Complicating MI
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
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Biomedicus
Rotaflow CentriMag
TandemHeart
Impella
Short-Term Mechanical Circulatory Support
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Long-Term Mechanical Circulatory Support
HeartWare HVAD Syncardia TAH HeartMate II HeartMate 3
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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
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W.S., 55-year-old Male
Ischemic Cardiomyopathy (LVEF 10-15%)
LM+3VD, Non STEMI, NYHA IV, Cardiac Arrest
S/P OPCAB x 6
Case. Cardiac Arrest Complicating MI
Centrimag LVAD
POD#1: VFib Cardioversion x 3
POD#2-3: VFib Cardioversion x 28
Centrimag RVAD, Off Pump
40Fr. venous in right atrium
20Fr. arterial in pulmonary artery
All grafts patent
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Bi-Ventricular Assist Device with Central Cannulation
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Securing the cannula
for ambulation
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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
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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
POD#1: VFib Cardioversion x 3
Centrimag RVAD
POD#4-11: VFib Cardioversion x 29
Centrimag LVAD
OPCAB x 6
Preop.: VFib Cardioversion x 10
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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
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CentriMag® BiVAD, Bridge-to-Recovery
for Ischemic Cardiomyopathy, Cardiogenic
Shock/Cardiac Arrest, s/p OPCAB x 6,
Doing well 5 years postop
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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
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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
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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
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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)
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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
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Case. 61F, Cardiogenic shock following STEMI
S/P Emergency CABG x 3 (LIMA-LAD, SVG-RCA-OM)
POD# 6: HeartMate II LVAD Implantation
POD# 43: Discharge home
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Case. 61F, Cardiogenic shock following STEMI
S/P Emergency CABG x 3 (LIMA-LAD, SVG-RCA-OM)
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%
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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.
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Off Pump Double Lung Tx
OPCAB x 1 (LIMA-LAD)
Through Median Sternotomy
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Single Left Lung Tx +
OPCAB x 2 (SVG-Ramus-LAD)
for IPF + CAD + Radiation Chest
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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
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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
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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
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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
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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
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CABG (Off-Pump) (n=180)
CABG (On-Pump) (n=202)
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
Isolated CABG (n=382) at Temple from 11-2011 to 12-2014
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CABG (Off-Pump) (n=180)
CABG (On-Pump) (n=202)
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
Isolated CABG (n=382) at Temple from 11-2011 to 12-2014
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• 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
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• 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
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CABG for ischemic cardiomyopathy,
post myocardial infarction and
cardiogenic shock
• Complete revascularization
• Use of mechanical circulatory
support
• Off Pump vs. On Pump