and leave a further challenge for the surgeon in terms of control of antiplatelet medication and whether to perform bypass grafts to a coronary vessel with a DES without critical restenosis in patients who have multivessel disease.
Impact of previous stenting on the outcome of (2)
Impact Of Previous Stenting On The Outcome Of CABG In Multivessel Disease Saeed M. Refaat Elassy, M.D. Associate professor CTS Ain Shams University
BACKGROUND• Interventional cardiologists have a growing role in treatment of coronary artery stenosis due to improvement of technology.• Its “less invasiveness” is more attractive to patients.• Around one-third of patients with multivessel disease treated with bare metal stents will require re-intervention within few years. Hannan N Engl J Med 2005;352:2174–2183
BACKGROUND Mortality & MI Relief of angina Repeat revascularizationGABI PCI PCI CABGEAST No difference CABG CABGRITA No difference CABG CABGERACI No difference CABG CABGCABRI No difference CABG CABGBARI No difference N/A CABGMASS II CABG (MI) N/A CABGAwesome No difference No difference CABGERACI II PCI CABG CABGSOS CABG (mortality) CABG CABGARTS No difference CABG CABG
BACKGROUND• Even after the introduction of DES, repeat revascularization rate is inferior to CABG.• In the SYNTAX randomized patients, 4-year MACCE rates were significantly higher for PCI than CABG, mainly driven by higher repeat revascularization in the PCI arm.• Significant increase of MI compared to CABG at 4 years driven by higher PCI MI rate between years 1 and 2 and years 2 and 3
OBJECTIVEDoes previous successful coronary stenting has animpact on the outcome of subsequent CABG inmultivessel disease ?
PATIENTS AND METHODS• 200 patients referred for CABG.• Between May 2009 and January 2011.• Divided into two groups: Group A: with no previous stent Group B: with previous stent (DES 100, BMS 98)Exclusion criteria • Single vessel disease. • CABG with other procedure except IMR. • Emergency CABG after PCI. • Redo CABG.
PATIENTS AND METHODS ( cont.)Echo examination preoperatively and 3 monthsafter the operation to monitor: • LVEDD • LVESD • EF • SWMA at rest
PATIENTS CHARACTERISTICS Group I Group II P valueRecent MI, % 7 6 0.774Mean NYHA class, mean SD 1.55 ± 0.88 1.86 ± 0.94 0.012Previous cardiac surgery, % 2 2 1.000Active endocarditis, % 2 0 0.155Peripheral vascular disease, % 16 6 0.027Mitral repair+ CABG, % 4 0 0.043Urgent CABG, % 0 8 0.004Previous MI, % 25 69 0.001ESD, mean SD (cm) 3.87±0.95 3.66±0.78 0.092EDD, mean SD (cm) 4.95±0.93 5.21±0.64 0.021EF, mean SD (%) 55.59±9.81 56±10 0.316Euroscore, mean SD 2.8 ± 5.4 2.1 ± 2.2 0.246
PATIENTS CHARACTERISTICS Group I Group II P valueDiseased vessels, mean SD(n) 3.34±0.52 3.28±0.45 NSLeft main, % 10 18 NSThree vessels, % 68 72 NSFour vessels, % 30 28 NSfive vessels, % 2 0 NS
OPERATIVE CHARACTERISTICS Group I Group II P valueOPCAB, (%) 26 35 0.167ACC time, mean SD (min.) 69.49±24.73 61.81±28.40 0.0994Bypass time , mean SD (min.) 102.07±29.79 91.47±41.49 0.0926Total grafts, mean SD (n) 3.12±0.73 2.46±0.85 0.001Arterial grafts, mean SD (n) 1.24±0.54 1.07±0.33 0.001Venous grafts, mean SD (n) 1.89±0.74 1.39±0.90 0.001Total Revascularization(%) 79 50 0.001Total Arterial Revascularization(%) 18 1 0.001
POSTOPERATIVE EVENTS Group I Group II P valueHospital stay, mean SD (d) 9.30±3.80 11.23±3.80 0.001ICU stay, mean SD (d) 3.30±4.51 2.89±1.44 NSM. ventilation, mean SD (hr) 13.2 ± 12.7 10.2 ± 11.9 NSIABP, (%) 11 13 NSInotropes, (%) 40 62 0.001Clinical symptoms of HF, (%) 11 11 NSReopen for bleeding, (%) 9 25 0.002Dehiscent sternum, (%) 9 5 NSSuperficial Wound infection, (%) 18 35 0.004Deep Wound infection, (%) 3 15 0.002
POSTOPERATIVE EVENTS Group I Group II P valueNeurological complications 2 1 NSRenal impairment 7 2 NSEndocarditis 0 2 NSArrhythmias, (%) 10 21 0.026Post operative organ failure, (%) 2 2 NSPerioperative MI, (%) 18 18 NSTotal morbidity, (%) 40 66 0.001Total mortality, (%) 7 6 NS
POSTOPERATIVE ECHO3 Months Group I Group II P valueESD, mean SD (cm) 3.46±0.75 3.50±0.76 0.7148EDD, mean SD (cm) 4.45±0.98 5.09±0.66 0.3107EF, mean SD (%) 60.20±6.28 58±8 0.0001RSWMA, (%) 16 43 <0.0001Improvement of dimensions, (%) 87 73 0.048Improvement of EF, (%) 85 70 0.038Improvement of SWMA, (%) 97 78 <0.0001Post op normal EF, (%) 78 57 0.005
POSTOPERATIVE ECHO 3 Months Group I Group II P valueESD, mean of the difference SD (cm) 0.34 ± 0.64 0.12 ± 0.57 0.015EDD, mean of the difference SD (cm) 0.48 ± 0.67 0.11 ± 0.6 0.001EF, mean of the difference SD (%) 4.1 ± 9.1 1.32 ± 6.8 NS
DISCUSSION• Eifert et al has found that patients with prior PCI presented for CABG with more severe CAD.• Morbidity, mortality and reoperation rate during mid term were significantly higher in patients with prior PCI. Eiffert et a l Vascular Health and Risk Management 2010:6 495–501
DISCUSSIONChocron et al reanalyzed the primary end-point of theIMAGINE trial and compared outcome after CABG in455 patients with PCI and 2098 without prior PCI.Patients with a history of PCI prior to surgery had aworse outcome post-CABG than those with no priorPCI as regards unstable angina requiringhospitalization [HR ¼ 2.43 (1.54–3.83), P = 0.0001]and repeat coronary revascularization [HR =1.85(1.17–2.90), P ¼ 0.008]. European Heart Journal (2008) 29, 673–679
DISCUSSIONHassan et al. compared outcome after CABG in 919 patientswith and 5113 without prior PCI. Although the prior PCIgroup had less severe coronary artery disease and less co-morbidity, multivariate analyses identiﬁed prior PCI as anindependent predictor of hospital mortality (HR 1.93; P=0.003). In propensity-matched patients, the in-hospitalmortality was 3.6% in the prior vs. 1.7% in the non-prior PCIgroup (P = 0.01). Hassan et al. Am Heart J 2005;150:1026–1031
DISCUSSIONThielmann and colleagues investigated outcome in 2626consecutive patients undergoing ﬁrst time CABG withoutprior PCI in comparison with 360 after a single and 289patients with multiple prior PCI. Using risk-adjustedmultivariate logistic regression analysis they reported thatmultiple prior PCIs were associated with increased in-hospital mortality [HR=2.24 (95% CI 1.52–3.21); P < 0.001]and the risk of major adverse cardiovascular Thielmann et al. J Thorac Cardiovasc Surg 2007;134:470–76.
DISCUSSION• Kanemitsu et al, found that the clinical introduction of DES was associated with more serious preoperative conditions. Kanemitsu et al interact CardioVasc Thorac Surg 2007;6:632-635• Several meta-analyses have demonstrated that DES have a high repeat revascularization rate.• DES impair endothelialization, leaving a potentially prothrombotic substrate within the vessel.
DISCUSSIONEXPLANATIONS• Worse preoperative condition as age, ventricular function and extent of coronary artery.• Prior PCI patients often present with more unstable symptoms.• Prior stents encourage more distal bypass grafting with less favorable graft run off.• Lack of completeness of appropriate revascularization.• DES cause dysfunction of the endothelium both overlying the stent and further downstream.• BMS may compromise endothelial function overlying the stent which is exaggerated by changes in the inflammatory and coagulation status precipitated by cardiac operations.
CONCLUSION• Prior PCI (BMS & DES) increases the risk of subsequent CABG.• Prior PCI reduces the improvement of cardiac function after subsequent CABG.
MESSAGE• The belief that CABG can always be safely deferred in favor of an initial strategy of PCI in multivessel disease is not correct.• These observations should be carefully considered in patients with multivessel disease who are likely eventually to require CABG.