Paul Sergeant

2014 ESC/EACTS Guidelines on myocardial revascularization The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

Authors/Task Force members: Stephan Windecker* (ESC Chairperson) (Switzerland), Philippe Kolh* (EACTS Chairperson) (Belgium), Fernando Alfonso (Spain), Jean-Philippe Collet (France), Jochen Cremer (Germany), Volkmar Falk (Switzerland), Gerasimos Filippatos (Greece), Christian Hamm (Germany), Stuart J. Head (The Netherlands), Peter Jüni (Switzerland), A. Pieter Kappetein (The Netherlands), Adnan Kastrati (Germany), Juhani Knuuti (Finland), Ulf Landmesser (Switzerland), Günther Laufer (Austria), Franz-Josef Neumann (Germany), Dimitrios J. Richter (Greece), Patrick Schauerte (Germany), Miguel Sousa Uva (Portugal), Giulio G. Stefanini (Switzerland), David Paul Taggart (UK), Lucia Torracca (Italy), Marco Valgimigli (Italy), William Wijns (Belgium), and Adam Witkowski (Poland).

Guidelines on myocardial revascularization.

Guidelines and Expert Consensus Documents summarize and evaluate all available evidence with the aim of assisting physicians in selecting the best management strategy for an individual patient suffering from a given condition, taking into account the impact on outcome and the risk benefit ratio of diagnostic or therapeutic means. Guidelines are no substitutes for textbooks and their legal implications have been discussed previously. Guidelines and recommendations should help physicians to make decisions in their daily practice. However, the ultimate judgement regarding the care of an individual patient must be made by his/her responsible physician(s). The recommendations for formulating and issuing ESC Guidelines and Expert Consensus Documents can be found on the ESC website (http://www.escardio.org/knowledge/ guidelines/rules). Members of this Task Force were selected by the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) to represent all physicians involved with the medical and surgical care of patients with coronary artery disease (CAD). A critical evaluation of diagnostic and therapeutic procedures is performed including assessment of the risk benefit ratio. Estimates of expected health outcomes for society are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to predefined scales, as outlined in Tables 1 and 2. The members of the Task Force have provided disclosure statements of all relationships that might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at European Heart House, headquarters of the ESC. Any changes in conflict of interest that arose during the writing period were notified to the ESC. The Task Force report received its entire financial support from the ESC and EACTS, without any involvement of the pharmaceutical, device, or surgical industry. ESC and EACTS Committees for Practice Guidelines are responsible for the endorsement process of these joint Guidelines. The finalized document has been approved by all the experts involved in the Task Force, and was submitted to outside specialists selected by both societies for review. The document is revised, and finally approved by ESC and EACTS and subsequently published simultaneously in the European Heart Journal and the European Journal of Cardio-Thoracic Surgery. After publication, dissemination of the Guidelines is of paramount importance. Pocket-sized versions and personal digital assistant-downloadable versions are useful at the point of care. Some surveys have shown that the intended users are sometimes unaware of the existence of guidelines, or simply do not translate them into practice. Thus, implementation programmes are needed because it has been shown that the outcome of disease may be favourably influenced by the thorough application of clinical recommendations.

Endovascular Aortic Repair Versus Open Surgical Repair for Descending Thoracic Aortic Disease A Systematic Review and Meta-Analysis of Comparative Studies

OBJECTIVES The purpose of this study was to determine whether thoracic endovascular aortic repair (TEVAR) reduces death and morbidity compared with open surgical repair for descending thoracic aortic disease. BACKGROUND The role of TEVAR versus open surgery remains unclear. Metaregression can be used to maximally inform adoption of new technologies by utilizing evidence from existing trials. METHODS Data from comparative studies of TEVAR versus open repair of the descending aorta were combined through meta-analysis. Metaregression was performed to account for baseline risk factor imbalances, study design, and thoracic pathology. Due to significant heterogeneity, registry data were analyzed separately from comparative studies. RESULTS Forty-two nonrandomized studies involving 5,888 patients were included (38 comparative studies, 4 registries). Patient characteristics were balanced except for age, as TEVAR patients were usually older than open surgery patients (p = 0.001). Registry data suggested overall perioperative complications were reduced. In comparative studies, all-cause mortality at 30 days (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.33 to 0.59) and paraplegia (OR: 0.42, 95% CI: 0.28 to 0.63) were reduced for TEVAR versus open surgery. In addition, cardiac complications, transfusions, reoperation for bleeding, renal dysfunction, pneumonia, and length of stay were reduced. There was no significant difference in stroke, myocardial infarction, aortic reintervention, and mortality beyond 1 year. Metaregression to adjust for age imbalance, study design, and pathology did not materially change the results. CONCLUSIONS Current data from nonrandomized studies suggest that TEVAR may reduce early death, paraplegia, renal insufficiency, transfusions, reoperation for bleeding, cardiac complications, pneumonia, and length of stay compared with open surgery. Sustained benefits on survival have not been proven.

Assessment of Myocardial Viability in Chronic Coronary Artery Disease Using Technetium-99m Sestamibi SPECT:: Correlation With Histologic and Positron Emission Tomographic Studies and Functional Follow-Up

OBJECTIVES The value of 99mTc-sestamibi (2-methoxy-isobutyl isonitrile [MIBI]) as a viability tracer was investigated in patients undergoing coronary artery bypass graft surgery. BACKGROUND Initial studies claim that rest MIBI single-photon emission computed tomographic (SPECT) studies can be used to assess myocardial viability. METHODS Thirty patients with a severely stenosed left anterior descending coronary artery and wall motion abnormalities were prospectively included. The patients underwent a MIBI rest study, a positron emission tomographic (PET) flow (13NH3) and metabolism (18F-deoxyglucose) study and nuclear angiography before undergoing bypass surgery. A preoperative transmural biopsy specimen was taken from the left ventricular anterior wall. Morphometry was performed to assess percent fibrosis. After 3 months, radionuclide angiography was repeated. RESULTS Statistically significant higher MIBI values were found in the group with myocardial viability as assessed by PET than in the group with PET-assessed nonviability (p < 0.01). Significantly higher MIBI values were found in the group with enhanced contractility at 3 months (76 +/- 13% vs. 53 +/- 22%, p < 0.01). A linear relation was found between MIBI uptake and percent fibrosis in the biopsy specimen (r = 0.78, p < 0.00001). When maximizing the threshold for assessment of viability with MIBI by using functional improvement as the reference standard, a cutoff value of 50% was found, with positive and negative predictive values of 82% and 78%, respectively. CONCLUSIONS 99mTc MIBI uptake was significantly higher in PET-assessed viable areas and in regions with enhanced contractility at 3 months. A linear relation was found between percent fibrosis and MIBI uptake. An optimal threshold of 50% was found for prediction of functional recovery.

Validation and interdependence with patient-variables of the influence of procedural variables on early and late survival after CABG

OBJECTIVE First to identify the patient-, procedural- and surgical experience variables influencing the early and late survival after CABG. Second to identify patients likely to benefit, and those unlikely to benefit, from technical details aimed at improving the results of coronary artery bypass grafting (CABG). METHODS A consecutive series of 9600 patients who underwent CABG using a variety of revascularization methods between 1971 and 1992 were followed with 99.9% success. A multivariable time-related analysis was performed. Patient-specific predictions and nomograms were constructed from it to explore and validate the influences and interdependences of patient-variables with variations in details of the procedure. RESULTS The 1-, 10- and 20-year risk-unadjusted survival was 97, 81 and 50% respectively. Patient-variables influencing early survival included severity of symptoms, patient presentation and extent of coronary disease, while late survival was influenced importantly by left ventricular function and cardiac and non-cardiac comorbidity. Technical details of the operation influencing early survival included use of endarterectomy, while details such as use of arterial grafting, extensiveness of sequential grafting, completeness of revascularization and extent of grafting to small coronaries influenced late survival to a highly variable degree. CONCLUSION The early survival is neither improved nor worsened by single, multiple, sequential or complete arterial coronary reconstruction. The late survival is modestly improved with the use of an arterial graft to a major vessel, preferably but not exclusively to the anterior descendens, except for patients with limited life-expectancy. Differences in time-related survival with and without an arterial graft are nearly the same across all levels of ejection fraction. No late beneficial or detrimental effect was identified with more extensive use of arterial reconstructive surgery in multisystem disease.

Does arterial revascularization decrease the risk of infarction after coronary artery bypass grafting

BACKGROUND This study sought to determine whether extensive arterial grafting reduces the prevalence and consequences of infarct after coronary artery bypass grafting. METHODS Post-primary coronary artery bypass grafting infarcts and time-related events thereafter were identified by 99.9% complete follow-up of 9,600 patients (1971 to 1992). The contribution of arterial grafting to freedom from infarct was assessed by multivariable hazard function analysis to adjust for other risk factors. RESULTS Unadjusted 1-month and 10-year freedom from infarction was 97% and 86%. By multivariable analysis, arterial grafting lowered the prevalence of periprocedural (p = 0.005), intermediate term (p = 0.007 and 0.006), and late infarction (arterial grafting to the left anterior descending coronary artery, p = 0.0006). Unadjusted survival after first infarct after coronary artery bypass grafting was 74% and 52% at 1 and 10 years; arterial grafting improved 10-year survival from 48% to 59% (p = 0.002). An additional benefit or cost of extending arterial grafting (n = 1,727) beyond a single one could not be identified (p > 0.1). CONCLUSIONS Arterial conduits, particularly to the left anterior descending coronary artery, should be used for coronary artery bypass grafting to reduce early and late myocardial infarction and its consequences. However, use of more than a single arterial graft appears to confer no additional benefit.

Determinants of early and late results of combined valve operations and coronary artery bypass grafting.

BACKGROUND Factors determining the outcome of operative correction of valvular abnormalities combined with coronary artery bypass grafting are still incompletely defined. METHODS Determinants of early and late (more than 90 days) deaths and event-free survival were studied for combined valve operations and coronary artery bypass grafting in 741 patients using multivariate analysis. RESULTS Ninety-day survival probability was 89% (95% confidence interval, 87% to 92%). Preoperative risk factors for early death were age, female sex, renal failure, New York Heart Association class IV or V, and mitral insufficiency. The operative risk factor was the duration of aortic cross-clamping. Five- and 10-year survival probabilities were 74% (95% confidence interval, 71% to 78%) and 43% (95% confidence interval, 36% to 50%), respectively. Preoperative risk factors for late death were age, preoperative renal failure, New York Heart Association class IV or V, vessel disease, and nonsinus rhythm. Five- and 10-year event-free survival probabilities were 57% (95% confidence interval, 53% to 61%) and 23% (95% confidence interval, 17% to 28%), respectively. Preoperative risk factors for non-event-free survival were age, female sex, reduced left ventricular function, mitral regurgitation, and pacemaker rhythm. CONCLUSION The demographic factors of age and female sex; the comorbid condition of renal failure; the cardiac conditions of advanced New York Heart Association class, left ventricular function, mitral regurgitation, vessel disease, and cardiac rhythm; and the operative condition of ischemia time are the most important predictors of clinical outcome after combined valve operations and coronary artery bypass grafting.

Multivariate analysis of angiographic, histologic, and electrocardiographic data in patients with coronary heart disease

In 61 consecutive patients undergoing aortocoronary bypass grafting, angiographic and electrocardiographic (ECG) changes were studied. Histologic delineation of myocardium was obtained by analysis of transmural biopsy specimens acquired at the time of surgery. The use of principal-component analysis revealed three definite groups of patients. Group I comprised patients with histologic findings associated with severe left anterior descending coronary artery (LAD) stenosis, without abnormal wall motion or ejection fraction. ECG abnormalities were limited to ST changes. Group II comprised patients with severe myocardial cell degeneration with only modest fibrosis associated with severe LAD stenosis and severely impaired wall motion. The incidence of infarction on the ECG was low. Group III patients had important myocardial cell degeneration with severe fibrosis associated with severe LAD stenosis, severely depressed wall motion, and significantly impaired ejection fraction. In this group there was a high incidence of infarction apparent on the ECG. Postoperative follow-up (24 months) showed a total survival of 94.4% in group I, 92.8% in group II, and only 72.7% in group III. This identification of subtypes of coronary artery disease seems to be helpful in estimating patient prognosis after coronary surgery.

Is return of angina after coronary artery bypass grafting immutable, can it be delayed, and is it important?

BACKGROUND Because survival after either an operation or angioplasty is similar across a wide spectrum of coronary patients, lasting symptom relief assumes high priority. OBJECTIVES The objectives of this observational clinical study were (1) to determine whether the return of angina is immutable; (2) to identify factors that might delay its return, and (3) to evaluate whether its return is predictive of subsequent adverse events. METHODS The return of angina of any degree of severity and morbid events subsequent to its return were studied by multivariable time-related analyses in a consecutive series of 9600 patients who were undergoing primary isolated coronary bypass operations between 1971 and 1992. RESULTS The freedom rate from return of angina was 94%, 82%, 61% and 38% at 1, 5, 10, and 15 years. Increased modest risk of early return of angina was associated with preoperative demographic, symptom, coronary and vascular disease variables but reduced by more extensive arterial grafting. The ever-increasing risk of late return of angina was associated with demographic, symptomatic, left ventricular function, and coronary disease variables and was related strongly to comorbidity but was weakly reduced by controllable surgical variables. After the return of angina, 10-year freedom rate from infarct and survival was 71% and 68% respectively. CONCLUSIONS (1) The risk of angina return increases relentlessly after operation, so it is likely immutable. (2) Delay of late angina return by use of arterial grafting is clinically trivial; control of noncardiac comorbidity may be more effective. (3) Fortunately, the return of angina after coronary artery bypass grafting has minimal impact on survival and is not predictive of imminent infarct.

First cardiological or cardiosurgical reintervention for ischemic heart disease after primary coronary artery bypass grafting

OBJECTIVE To study the first reintervention for ischemic heart disease anytime after coronary artery bypass grafting (CABG) and the variables that drive its need or bias its occurrence. Reintervention is defined as an isolated or combined repeat surgical or cardiological procedure for ischemic heart disease. METHODS A consecutive series of 9600 CABG patients (1971-1992) were followed for up to 20 years (99.9% complete). A multivariable time-related analysis was performed. RESULTS The 1-, 10- and 15-year freedom from reintervention was 99, 89 and 72% respectively. A three-phase hazard function was identified. Patient variables influencing early freedom included anginal instability, completeness of revascularization and institutional variables. Late freedom was influenced importantly by demographic variables, cardiac and non-cardiac comorbidity and extensive arterial grafting. The 1-month and 10-year survival after reintervention was 95 and 73%. The 1- and 10-year freedom from angina after reintervention was 74 and 32%. CONCLUSION Reinterventions for ischemic heart disease by interventional cardiology or surgery are rather infrequent in the first decade after CABG but nearly half the patients surviving their second decade undergo one. The increased reintervention rate, apparent after 1985 did not go parallel with improved late post-CABG survival. Older age and the presence of multiple arterial grafts seem to reduce but also to bias the event. The very good survival, only when return of angina is present, suggests a more restrictive differential therapy approach, certainly in the presence of a well functioning arterial graft to the antero-septal region and where the co-morbidity might induce a high reinterventional survival cost.