Posts Tagged ‘Coronary Artery Bypass Surgery’
Do we have the COURAGE to change?
I have blogged about the COURAGE trial in the past and I frequently refer to many of the common misunderstandings that patients have regarding the various treatments for coronary artery disease. As I have often said, the treatment for coronary artery disease is medical and then when medical treatment fails to treat the symptoms adequately, and that varies from patient to patient, angioplasty and then coronary artery bypass surgery is called for, depending on the angiogram findings.
The COURAGE trial was published in the NEJM in 2007 and became a recent topic in the Wall Street Journal on February 11, 2010. Keith J Winstein writing in the WSJ suggests that cardiologists have not changed their practice to account for the COURAGE results and this has cost 5 billion wasted dollars. The total US healthcare system spends an estimated 15 billion dollars a year on stenting procedures.
Further, the article makes the point that neither Medicare nor private insurance companies have changed their payments in regard to this issue. This may change as time goes on.
One of the integral parts of this controversy is our (speaking as an Interventional cardiologist) inability to always determine that an individual lesion is important. Angiography at a cardiac catheterization is the “gold standard” to determine the extent of coronary artery disease but it does not provide a “functional test”. What is meant by this is, “does the lesion in the coronary artery provide a lack of blood flow to the distal cardiac muscle bed?” We have methods of determining this before the catheterization by nuclear stress testing and at the catheterization by fractional flow reserve which I have blogged about in the past. This component was not part of the COURAGE trial. This test can safely determine which lesions are “safe” to defer angioplasty in.
In my daily practice I am already impacted in my ability to treat people as I wish. I will not “name names” but many insurance companies routinely deny nuclear stress testing regardless of the reason for the test and make you appeal the decision. I often have to get on the phone and explain to someone why I’m ordering a test. Medications are changed for “cheaper “versions in spite of long term success for the individual patient ignoring the successful achievement of “goal” targets.
I have spent my professional life helping to develop guidelines for the treatment of the illnesses with which I deal. Medicine and health care are not linear fields, often its one step forward and two steps back. I firmly believe in the COURAGE trial results but it did not impact my practice because that it how I practiced before the trial. We need to continue to do these studies and then incorporate them into our daily practice. The time will soon be here that patients will be better served by us by adhering to “state of the art guidelines.”
The History of Coronary Artery Bypass Surgery
Coronary artery bypass operations are again in the news. This operation is the most performed operation in the world and dates back to the early 1960’s. We are still trying to improve upon it and enhance the results we can achieve.
Open heart surgery dates back to the early 1950’s when Dr. John Lewis repaired an atrial septal defect (a hole between the top parts of the heart known as the atrium, a birth defect). He did this by cooling the 5 year old girl’s heart. At about the same time, the heart-lung machine was first used by Dr. John Gibbon also to repair an atrial septal defect.
In 1956, Dr. Walton Lillehei corrected a patient with mitral regurgitation under direct vision using the heart lung machine. He went on to develop some of the new artificial heart valves and the pioneering techniques for this type of surgery.
In 1946, Dr Arthur Vineberg developed a technique to implant the mammary artery directly into the myocardium, allowing it to collateralize the vessels to the front of the heart. Roughly 5,000 Vineberg procedures took place between 1950 and 1970.
Dr. Vasilii Kolessov, a Russian cardiac surgeon, performed the first internal mammary to coronary artery anastomosis in 1964. Dr Rene Favaloro, a physician at the Cleveland Clinic, performed the first saphenous vein operation by harvesting a vein from a patients leg and bypassing the right coronary artery in 1967. Soon after Dr. Dudley Johnson in Milwaukee used the vein grafts to bypass the left coronary arteries.
Bypass surgery was out of the gate and to this day has not changed much in technique. It is invasive and the heart lung machine is believed to be detrimental at times to patients. Over the years the ability of surgeons has increased so that they now routinely perform this operation on sicker and older patients and to continue to drive the mortality to the operation to 1.6%.
Can this operation be done in a safer manner? Are the alternatives better?
Next…the alternative.
Look into Stent Options Before undergoing Catheterization
I will like to elaborate on a point I made in my last blog. I want to talk about the issue of patients who are undergoing cardiac catheterization for preoperative evaluation. These patients may or may not have evidence for cardiac disease either by stress testing or symptoms. What is done after the cath is critical and the need for non-cardiac surgery must be thoroughly discussed and analyzed before proceeding with any revascularization by stenting or coronary artery bypass surgery.
A study concerning this issue was just published in the journal Heart 2009; 95:1303-1308. It is titled Non-Cardiac Surgery and Antiplatelet Therapy Following Coronary Artery Stenting. This article reports a Meta analysis of this common clinical scenario. A Meta analysis is not a study. It is a statistical analysis of like studies that are melded together to seek out common similarities and differences in treatments. Although they often don’t fully answer questions, they point us in directions to ask better questions and can lead to meaningful dialogue.
This report covers 50,000 patients and finds that undergoing non-cardiac surgery while on low dose aspirin i.e. 81 mg. increases the risk of minor bleeding by 50%. There is no change in major bleeding except in prostate and neurosurgery procedures.
The use of Plavix during surgery increases the risk of major bleeding.
In previous blogs, I have discussed the use of these agents after stenting. If you have a non-drug stent, the current recommendations are to take aspirin and Plavix for a minimum of a month but if possible for one year. If you have a drug stent, the recommendation is to take aspirin and Plavix for one year. If you were stented for a myocardial infarction or unstable angina then the recommendations are one year regardless of what stent you have implanted.
In my patients depending on what type of surgery is needed, I often do not repair the coronary blockages until after surgery. Many operations can be done safely with aspirin and beta-blocking drugs such as Toprol and atenolol. There are many options but if not discussed this clinical scenario can lead to disaster. It is always necessary to thoroughly discuss all aspects of your medical condition with all your doctors.
Endoscopic vs. Open Vein-Graft Harvesting in Coronary-Artery Bypass Surgery
As discussed last time, an article was published in N. Engl. J. Med. 361 (3): 235-44 titled “Endoscopic versus Open Vein-Graft Harvesting in Coronary-Artery Bypass Surgery.” This article evaluated the data from another study the PREVENT IV. The PREVENT IV study was a randomized trial of 3,014 patients, who underwent surgery and had three-year-follow-event data.
Compared to standard open harvesting, endoscopic harvesting had higher rates of vein graft failure (46.7% vs. 38.0%) when analyzed by patient or by graft (27.2% vs. 22.6%). The primary clinical outcome measure was the composite of death, myocardial infarction and repeat revascularization. This measured 20.0% vs. 17.04%. The study showed that the recognized short term benefits of less pain, less infection and better cosmetic result was offset by higher graft failure leading to a wide array of problems.
If you have had coronary bypass and are wondering which type of harvesting you had, look at your legs. If you had standard harvesting, you will have long incisions. If you have several very short incisions, you had endoscopically harvested veins. Your doctors should be aware of which type of procedures you had. At present, there is no knowledge of how best to proceed. The use of additional antiplatet medications such as Plavix, better control of lipids with higher dose statins and better control of high blood pressure may be helpful. Stress testing may be of value to identify bypass grafts before they close, but this is not proven or recommended.
If you are going to have bypass surgery, you should discuss this issue with your cardiologist and surgeon.
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