Is CABG getting safer?

Stroke is one of the most devastating complications after coronary artery bypass graft (CABG) surgery, entailing permanent disability, a 3–6 fold increased risk of mortality, an incremental hospital resource consumption and a longer length of hospital stay. Notwithstanding advances in surgical, anaesthetic and medical management across the last 10 years, the risk of stroke after coronary artery bypass graft (CABG) has not significantly declined, likely because an older and sicker population is now deemed suitable to undergo CABG. 

Advances in endovascular surgery have meant that whilst traditional "open heart" procedure is still performed and often preferred in many situations, newer, less invasive techniques have been developed to bypass blocked coronary arteries. "Off-pump" procedures, in which the heart does not have to be stopped, were developed in the 1990's. Other endovascular surgery procedures, such as key-hole surgery (performed through very small incisions) and robotic procedures (performed with the aid of a moving mechanical device), increasingly are being used. 

Risk stratification is of the utmost importance for identifying vulnerable patients. Specifically, pre-existing cerebrovascular disease and atherosclerosis of the ascending aorta are major determinants of the risk of peri-operative stroke, and should be always carefully scrutinised. RCTs and meta-analysis do not clearly support routine implementation of offpump CABG as a strategy to minimise the risk of stroke. Observational studies have suggested that anaortic approaches might reduce the risk of stroke compared with conventional CABG in patients with severe atherosclerosis of the ascending aorta. Further randomised controlled trials are warranted to confirm this hypothesis. Heart stenting is another option for treating patients with CABG. The clinical application of drug-eluting stents (DES) or coronary artery bypass grafting (CABG) for unprotected left main coronary artery disease (ULMCAD) is still controversial. The need for repeat revascularization is significantly lower with CABG, but the risk of stroke is significantly higher, a trade-off that must be taken into account when considering heart stenting for patients with advanced coronary disease.

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FFR-Guided PCI Using Contemporary Drug-Eluting

Fractional flow reserve (FFR)-guided drug-eluting stenting reduces death, myocardial infarction or urgent revascularisation, as compared to medical therapy in patients with stable coronary artery disease (CAD), according to the results of the FAME 2 trial presented at the European Society of Cardiology’s (ESC) Congress. Whilst percutaneous coronary intervention (PCI) has been performed for more than 30 years, its benefits in terms of 'hard endpoints' as compared to medical therapy (MT) have never been demonstrated in patients with stable CAD.  In patients with stable CAD the rate of death, MI, or urgent revascularisation at two years in those treated with FFR-guided PCI using contemporary drug-eluting stenting was less than half of what it was in patients treated with MT alone, in this study.

In another recent study, these stents were compared to the more traditional bare metal stents. Presented at the American College of Cardiology's 63rd Annual Scientific Session, the study showed Medtronic's Endeavor zotarolimus-eluting stent is associated with a lower risk of major cardiovascular events at one year compared to bare metal stents among a patient population normally excluded from treatment with drug-eluting stents.

Advances in the design and technology of medical devices and delivery systems, coupled with demand for alternative non-surgical therapies for common medical problems, including heart failure, have led to an increase in the volume, variety and complexity of non-coronary cardiac interventional procedures performed. The greater complexity of these newer procedures, particularly those involving heart valve intervention, necessitates more sophisticated and exacting imaging techniques, both to facilitate appropriate case selection and to provide procedural guidance, thus increasing the likelihood of successful outcome. Contemporary advances in echocardiography imaging techniques ensure these modalities are well suited to the imaging requirements of this exciting and expanding field of interventional cardiology. Realtime 3D imaging, made possible by the development of a full matrix transducer capable of acquiring pyramidal-shaped ultrasound data sets, has been a major advance in transthoracic echocardiography (TTE) for examining patients with suspected heart failure.

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Cardiology Stem Cell Therapy Offers Cardiac Repair

Cardiology stem cell therapy offers great hope and is the topic of much discussion. Currently, basic research scientists and clinicians worldwide are investigating human embryonic cardiac stem cells, skeletal stem cells (myoblasts), adult bone marrow stem cells, cardiology stem cells and human umbilical cord stem cells for the treatment of patients with MIs and ischaemic cardiomyopathies.ÿWhilst important progress is occurring in the use of stem cells for cardiac repair, the most optimal stem cell(s) for treatment of patients with infarcted myocardium is yet to be determined.

At present, there are no widely used stem cell therapies other than bone marrow transplant. Research is underway to develop various sources for stem cells and to apply them to heart disease and other conditions.

Another exciting area is the field of stenting. The introduction and widespread adoption of drug-eluting stents into routine clinical practice has seen tremendous changes in the practice of interventional cardiology. For a prolonged period, manufacturers have focused research on drugs and polymers that are the key to the prevention of in-stent restenosis. However, stent platform design and its clinical implications have now come back to the fore. Manufacturers and clinicians will have to work closely in partnership to makesure that stenting devices can provide excellent safety and long-term efficacyfor patients.

Cardiology associates should have a complete understanding of the design features of the devices that they are implanting. It is likely that LMS PCI and the treatment of large vessel bifurcations will become a mainstream application of PCI over the forthcoming years and manufacturers may need to consider producing dedicated platforms for the treatment of these vessels. As more patients with multivessel disease are treated greater attention will also need to be placed on longer-term outcomes in more demanding clinical settings, an area aboutwhich cardiology associates will need to be kept up-to-date.

The risks of latent stent fracture may assume a more prominent role in clinical studies in future. Ultimately, as the clinical practice of PCI continues to evolve, manufacturers and clinicians will have to work closely in partnership to make sure that the stenting devices that are implanted can provide excellent safety and long-term efficacy for patients. The importance of stent design has been re-emphasised and is likely to become increasingly relevant in future, where the patient and lesion being treated are likely to mandate very careful selection of the stents that are deployed in each individual setting. The focus should be shifted away from producing ever more deliverable stent platforms and should be moved back to the fundamental properties of what the device has been built to achieve.

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How heart stents (and their relatives) have gone from strength to strength

Heart stents have come a long way since doctors first started using balloon angioplasty to treat narrowed coronary arteries. During this procedure, a very thin, long, balloon-tipped tube (catheter), is inserted into an artery in either the groin or arm and is moved to the site of the blockage with help from an X-ray. The balloon at the tip of the catheter is then inflated to compress the blockage and restore blood flow, and is then deflated to allow the catheter and balloon to be removed. In some cases, these heart stents aren’t enough to prevent collapse of the coronary arteries after the balloon is deflated and restenosis can also be a side-effect. This led to the development of small stents which could be mounted on the balloon section of the catheter. These stents then expand when the balloon is inflated, lock into place, and form a permanent scaffold to hold the coronary artery open after the balloon is deflated and removed.

Carotid artery stenting (CAS) has increasingly assumed an important role in the management of significant carotid artery stenosis, and recent recommendations (by the UK National Institute for Health and Clinical Excellence (NICE) and the American Heart Association (AHA) suggest that it is a viable alternative to carotid endarterectomy (CEA) for standard-risk populations. There is a consensus among experts suggesting that embolic protection devices (EPDs) can reduce the risk of stroke during CAS. These recommendations are supported by an early meta-analysis. Embolic protectiondevices can be divided into three distinct types based on their mechanism of operation: distal occlusion aspiration devices, distal filters and proximal occlusion aspiration devices.

Devices aside, cardiology training in carotid artery stenting is imperative in terms of technical success rates, as it is in any new or technically challenging procedure. In a report which examined four groups of 50 patients, the authors observed a significant increase in technical success rate after 50 procedures and a concomitant reduction in total procedural time and contrast volume used, demonstrating a clear benefit of cardiology training.

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Is CABG getting safer?

Stroke is one of the most devastating complications after coronary artery bypass graft (CABG) surgery, entailing permanent disability, a 3–6 fold increased risk of mortality, an incremental hospital resource consumption and a longer length of hospital stay. Notwithstanding advances in surgical, anaesthetic and medical management across the last 10 years, the risk of stroke after coronary artery bypass graft(CABG) has not significantly declined, likely because an older and sicker population is now deemed suitable to undergo CABG.

Advances in endovascular surgery have meant that whilst traditional "open heart" procedure is still performed and often preferred in many situations, newer, less invasive techniques have been developed to bypass blocked coronary arteries. "Off-pump" procedures, in which the heart does not have to be stopped, were developed in the 1990's. Other endovascular surgery procedures, such as key-hole surgery (performed through very small incisions) and robotic procedures (performed with the aid of a moving mechanical device), increasingly are being used.

Risk stratification is of the utmost importance for identifying vulnerable patients. Specifically, pre-existing cerebrovascular disease and atherosclerosis of the ascending aorta are major determinants of the risk of peri-operative stroke, and should be always carefully scrutinised. RCTs and meta-analysis do not clearly support routine implementation of offpump CABG as a strategy to minimise the risk of stroke. Observational studies have suggested that anaortic approaches might reduce the risk of stroke compared with conventional CABG in patients with severe atherosclerosis of the ascending aorta. Further randomised controlled trials are warranted to confirm this hypothesis.

Heart stenting is another option for treating patients with CABG. The clinical application of drug-eluting stents (DES) or coronary artery bypass grafting (CABG) for unprotected left main coronary artery disease (ULMCAD) is still controversial. The need for repeat revascularization is significantly lower with CABG, but the risk of stroke is significantly higher, a trade-off that must be taken into account when considering heart stenting for patients with advanced coronary disease.

Read More