Surgical Coronary Revascularization Who, What, When

1. Surgical Coronary RevascularizationWho, What, When Speaker - Jonathan G. Howlett, MD FRCPC Chairperson – Gordon W. Moe, MD, MSc, FRCPC

2. WELCOME!

3. Accreditation This event is an Accredited Group Learning Activity (Section 1) as defined by the Maintenance of Certification program of The Royal College of Physicians and Surgeons of Canada, and approved by the Canadian Cardiovascular Society for 1 Royal Credit MOC Section 1 Credit.

4. Learning Objectives At the conclusion of this webinar, participants will be able to: • Review the potential role of surgical intervention as a heart failure management and treatment option • Discuss opportunities and challenges of surgery for heart failure patients – where to begin, where to end • Develop patient specific treatment plans that take into account the benefits, risks and limitations of surgery as a treatment option • Integrate CCS guidelines into best clinical practices

5. Disclosures- J. Howlett • Speaker and/or Consultant Fees: • AstraZeneca, Bayer, CVRx, Medtronic, Novartis, Servier, Pfizer, Otsuka, Merck • Research and/or Funding for Research: • AstraZeneca, Bayer, CVRx, Medtronic, Novartis, Servier • NGOs: AIHS, NIH, Canada Health Infoway

6. Disclosures- Dr. Moe • No disclosures

7. Case 1 • 75 year old female presenting with a diagnosis of HF • Progressive SOBOE and orthopnea • Atypical chest discomfort with variable exertion, emotional stress • Past history • HTN • Former smoker • Negative workup for atypical chest pain 10 years ago • Initial assessment: • BP 130/82, HR 84 bpm (regular), obvious volume overload • NT-BNP 3800 pg/mL, troponin I negative • ECG: sinus rhythm, Q waves leads II,III, AVF, QRS duration 110 msec

8. Case 1 • Echocardiogram performed: • LVEF ~25%, global hypokinesis • LVIDd 5.8cm; LVIDs 5.1cm, EF 29% • 2+MR • RVSP ~ 45 mmHg • Course in hospital over 7 days • Diuresed 4 kg with IV furosemide, at “dry weight” • Started on ramipril 5mg/d, and carvedilol 6.25 mg bid and MRA Ambulatory, wondering what we are going to do??

9. Questions …prepare to provide your answers!

10. Case 1 - What would you like to do next? • Coronary angiogram • Myocardial perfusion imaging (persantine sestamibi) • Cardiac MRI • Referral to EP for ICD and or CRT

11. Case 1 - What would you like to do next? • Coronary angiogram • Myocardial perfusion imaging (persantine sestamibi) • Cardiac MRI • Referral to EP for ICD and or CRT

12. Back to Case 1 • Angiogram reveals multivessel coronary disease • Occluded RCA • 80% mid LAD lesion • 90% mid LAD lesion • 70% OM1 and 90% OM2 lesions (medium size) • Surgical colleague reviews the films: • Technically graftable with good distal target vessels • Serum creatinine stable at 120 mmol/L, GFR 51 ml/min

13. Questions …prepare to provide your answers!

14. Case 1- Your recommended course of action ? • Discharge w/a plan for titrated medical tx until angina occurs • Present the patient to CV surgical colleagues to consider CABG • Refer to interventional colleague for multivessel PCI • Referral for ICD/CRT

15. Case 1 - Your recommended course of action ? • Discharge w/ a plan for titrated medical tx until angina occurs • Present the patient to CV surgical colleagues to consider for CABG • Refer to interventional colleague for multivessel PCI • Referral for ICD/CRT

16. Prognostic significance of ischemic cardiomyopathy >1200 patients with invasive evaluation for cardiomyopathy over 15 years Ischemic etiology is also an independent predictor of mortality in risk models: Seattle Heart Failure Model (SHFM) Heart Failure Survival Score (HFSS) Levy et al, Circulation 2006 Aaronson et al, Circulation 1997 Felker et al, N Engl J Med 2000

17. Surgical Treatment for Ischemic Heart Failure – where’s the evidence? • Individual patient level meta-analysis of 7 trials • 2600 patients enrolled 1972-84 • CABG associated with mortality reduction • 39% at 5 years, 17% at 10 years • No interaction with LV dysfunction and mortality reduction but higher absolute benefits seen in high risk subgroups Yusuf et al, Lancet 2004

18. Surgical Treatment for Ischemic Heart Failure – where’s the evidence? • In these early studies: • 90% had angina • 80% had normal LVEF • 10% had arterial conduits • Medical therapy = digoxin and diuretics Need to assess the benefits of revascularization in contemporary patients with ischemic cardiomypathy Yusuf et al, Lancet 2004

19. Randomized non-blinded study of surgical revascularization: Included patients with LVEF <35% and CAD suitable for revascularization Hypothesis 1: CABG + medical rx superior to medical rx alone Hypothesis 2: CABG + SVR superior to CABG alone in patients undergoing revascularization with anterior wall akinesis/dyskinesis Current Era: Surgical Treatment for Ischemic Heart failure (STICH) Velazquez et al, J Thorac and Cardiovasc Surg

20. 1212 patients randomized to CABG vs medical therapy Patients with recent MI, major illness, significant L Main disease and severe angina excluded No difference in all cause mortality seen at median 56 months follow-up 17% of patients in medical therapy arm crossed over to surgical arm STICH Hypothesis 1: Primary outcome

21. STICH Hypothesis 1: secondary outcomes CABG associated with reduction in cardiovascular death and combined outcome of death or cardiovascular hospitalization CABG also associated with 30% relative reduction in mortality in “on-treatment” analysis (accounting for patients crossing over within 1st year of study)

22. Recommendations - Revascularization Procedures Assessment for Coronary Disease

23. Recommendations - Revascularization Procedures Assessment for Coronary Disease Values and Preferences: These recommendations place value on the need of coronary angiography to identify coronary artery disease amenable to revascularization. Patients with systolic heart failure due to ischemic heart disease may derive clinical benefit from coronary revascularization even in the absence of angina or reversible ischemia.

24. Recommendations - Revascularization Procedures Surgical Revascularization for Patients with IHD and HF

25. Recommendations - Revascularization Procedures Disease Management, Referral and Peri-operative Care Values and Preferences: This recommendation reflects the panel preferences that high risk revascularization is likely to best occur in higher volume centres with significant experience, known outcomes, and similar to participating in clinical trials involving high-risk coronary revascularization. Practical Tip: Assessment for advanced heart failure therapies by an appropriate team should be performed prior to revascularization in any patient with advanced heart failure

26. Time-varying hazard ratios for all-cause mortality in patients randomized to CABG or MED.

27. However, there is interaction with risk factors: • LVEF < median value (28%) • LV end systolic index > 60 ml/M2 • 3 vessel disease

28. Kaplan-Meier rate estimates of all-cause mortality among patients with 2-3 (top panel) and 0-1 (bottom panel) prognostic factors.

29. Case 2 • 65 year old male patient assessed in your office • Multiple admissions for heart failure, difficulty with self management • Past history • Prior lateral wall MI, 2001 (not revascularized) • Hypertension • Significant COPD with FEV1 < 750 ml • Type 2 DM. Right AKA due to severe PVD and ABI 0.22 • CKD Atrial fibrillation, previous right sided CVA • Poor mobility, refuses walking aids, but able to perform basic ADLs slowly

30. Case 2 • Currently NYHA class III, no angina • Medications • Carvedilol 25 mg bid, amlodipine 10mg/d, furosemide 120mg bid, Nitro patch 1.2 mg/h, hydralazine 50mg tid, insulin, warfarin 4 mg OD, rosuvastatin 40mg/d, Slow K 2400 mg/day, several alternative agents and periodic metolazone • Examination: BP 90/70, HR 80 bpm, AF, enlarged heart with normal JVP, 3+ edema and clear chest with poor pulses. • ECG: Atrial fibrillation, Heart rate 76, Q waves lateral and QRS Duration 130 msec. • Hemoglobin 95, Creat 250, GFR 19, K 5.0 and INR 2.8

31. Case 2 • Patient wishes to live as long as possible but most fearful becoming dialysis dependent http://riskcalc.sts.org www.euroscore.org

32. Questions …prepare to provide your answers!

33. Case 2 - Your recommended course of action ? • Angiogram and possible CABG • Angiogram and possible ad hoc PCI of flow-limiting lesions • Non-invasive perfusion/viability test • Referral for ICD/CRT • Ongoing medical optimization only

34. Case 2 - Your recommended course of action ? • Angiogram and possible CABG • Angiogram and possible ad hoc PCI of flow-limiting lesions • Non-invasive perfusion/viability test • Referral for ICD/CRT • Ongoing medical optimization only

35. The average heart failure patient Gheorghiade, Eur Heart J, 2005

36. Prospective cohort, 4 sites, ≥ 70 yrs, for CABG ± valve Non-emergent / urgent; no major psychiatric Dx 5 meter walk: if ≥6 seconds, classified as frail 131 pts, 75.8±4.4 yrs old 46% frail (usually diabetic, IADL problems) No correlation with STS risk score (i.e. different domains) Outcome: mortality, renal failure, stroke, reoperation, prolonged ventilation, deep sternal infection Frailty and cardiac surgery Afilalo et al J Am Coll Cardiol 2010

37. Frailty and cardiac surgery Gait speed predicts mortality/major morbidity (OR 3.05, 95%CI 1.23–7.54) Afilalo et al J Am Coll Cardiol 2010

38. Viability and LV functional recovery after revascularization Systematic review of non-invasive Imaging techniques in predicting Regional myocardial recovery 37 observational studies Thallium, FDG PET and DSE show high degree of sensitivity DSE and FDG PET show greatest specificity Bax et al J Am Coll Cardiol 1997

39. Viability and survival after revascularization Systematic review of 24 observational studies Evaluating relationship between death, viability and revascularization Allman et al, J Am Coll Cardiol 2002

40. STICH AnalysisImproved prognosis with viability Analysis of 601 patients with viability testing data available Viability defined as ≥ 11 segments on SPECT or ≥ 5 segments on DSE imaging Bonow et al, N Engl J Med 2011

41. STICH AnalysisViability doesn’t necessarily predict improved outcomes with surgery vs medical therapy Bonow et al, N Engl J Med 2011

42. Recommendations - Revascularization Procedures Disease Management, Referral and Peri-operative Care

43. Practical Tips Revascularization Procedures Imaging • Several non-invasive methods for detection of coronary artery disease are in widespread use • Dobutamine stress echocardiography (DSE) • perfusion cardiac magnetic resonance (CMR) • cardiac positron emission testing (PET) • nuclear stress imaging Local factors (availability, price, expertise, practice patterns) will determine the optimal strategy for imaging. • Non- invasive imaging modalities may provide critical information such as the degree of ischemic or hibernating myocardium, and may be used to determine the likelihood of regional and global improvement in left ventricular systolic function.

44. Practical Tips (cont’d) Revascularization Procedures Imaging 3. Patients with heart failure, and reduced LV ejection fraction are likely to experience significant improvement in LVEF following successful coronary revascularization if they demonstrate: a) Reversible ischemia or a large segment of viable myocardium (> 30% of LV) by nuclear stress testing/ viability study; b) Reversible ischemia or >7% hibernating myocardium on PET scanning; c) Reversible ischemia or > 20% of LV shown as viable by DSE; d) Less than 50% wall thickness scarring as shown by late gadolinium enhancement by cardiac CMR.

45. PCI or CABG for ischemic symptoms and heart failure? (Angina included!!) CABG PCI Med Rx 4200 patients with HF referred for angiography in Alberta 1995-2001 Adjusted for baseline risk and propensity for revascularization 2538 underwent revascularization; 1690 managed medically Majority of patients had ischemic syndromes Medical management was suboptimal Revascularization with CABG or PCI associated with improved survival Signal for differential outcome, favoring CABG Revasc. HR 0.50 Med Rx Tsuyuki et al, CMAJ 2006

46. Recommendations - Revascularization Procedures Surgical Revascularization for Patients with IHD and HF

47. Practical Tips Revascularization Procedures Surgical Revascularization for Patients with IHD and HF In the setting of heart failure, angina and single territory coronary artery disease, PCI may be the treatment of first choice. However, PCI has not been shown to improve outcomes for patients with chronic stable heart failure, irrespective of underlying anatomy. Urgent directed culprit vessel angioplasty continues to be the revascularization modality of choice for patients with heart failure and acute coronary syndrome.

48. Figure 1. Approach to Assessment for Coronary Artery Disease in Patients with Heart Failure

49. Figure 2. Decision Regarding Coronary Revascularization in Heart Failure

50. Case 3 • 77 year old female, recent admission for worsening HF, now stable NYHA II symptoms- quite happy with current state • Occasional exertional chest discomfort with more than usual activity • Past history: • Anterior wall MI, late PCI (2005)- no angina since then • Family history of premature CAD • Mild CRF and COPD with FEV1 of 1.9 L (no admissions) • Dyslipidemia- longstanding • IGT but not DM • Medications: • Lisinopril 20mg/d, bisoprolol 10mg/d, eplerenone 25mg/d, ASA 81mg/d, atorvastatin 80mg/d, furosemide 20mg/d, metformin, gliclazide, nitroglycerin patch 0.8 • ECG: • Sinus rhythm, LBBB (QRS 144msec), multifocal PVCs