Tag Archives: coronary artery bypass surgery

Coronary Artery Bypass Surgery Gets Better

When it comes to treating blocked coronary arteries, the two major options–coronary artery bypass surgery and coronary artery stenting–have traditionally been in competition. And conventional wisdom held that endovascular coronary artery interventions keeps getting better, with improved stents, while surgical bypass remains fairly stable. After all, surgery is surgery, right?

Well, the simple answer is: Wrong! Surgery has gotten better, too, even over the past decade.

Earlier this month, at the annual meeting of the American Association for Thoracic Surgery,

coronary artery bypass; courtesy Wikimedia Commons

I heard some startling statistics on how much cardiac bypass surgery progressed during the 2000s, numbers that bear repeating and even celebrating.

A report by Andrew W. ElBardissi, a cardiac surgeon at Brigham and Women’s Hospital in Boston, used data collected by the Society of  Thoracic Surgeons on U.S. coronary bypass surgeries done in 2000 and in 2009.

In 2000, more than 136,000 U.S. patients underwent bypass surgery. During the 30 days following surgery, their mortality rate was 2.4%, and 1.6% had a stroke. In 2009, more than 160,000 U.S. patients underwent bypass surgery, with a 30-day mortality of 1.9% and a 1.2% stroke rate.

These changes may sound small, a 0.5% drop in mortality and a 0.4% fall in stroke rate, but in addition to being statistically significant these decreases meant better outcomes for hundreds of patients each year.

With more than 160,000 patients having coronary bypass surgery in 2009, the improvement over the course of 10 years meant that in 2009, 800 fewer patients died following surgery and 640 fewer patients had a stroke compared with the rate 10 years earlier. Well over a thousand patients had a substantially better outcome from their surgery a decade later because of improvements in surgical technique and patient management.  Presumably the numbers were at least as good last year, too, as well as today, next year, and beyond.

These improved outcomes are actually even better because other parts of Dr. ElBardissi’s analysis showed that 2009 patients were sicker than coronary bypass patients treated a decade before. Elective cases fell from 58% of all surgeries in 2000 to 41% in 2009. Balancing this shift was a sharp rise in urgent surgical cases, which jumped from 38% of all bypass cases in 2000 to 54% in 2009. Another measure of how the cases grew more complex was the percent of patients who underwent bypass of their left main coronary artery, the coronary procedure that is riskiest because the left main artery is so critical for supplying blood to heart muscle. Left main bypasses jumped from 23% of the coronary surgery cases in 2000 to 32% in 2009. The 2009 patients also had substantial rises in the prevalence of hypertension, hypercholesterolemia, and chronic obstructive pulmonary disease.

Why did bypass surgery do so much better in 2009, even as patients got sicker? Dr. ElBardissi’s data provide a few likely explanations: In 2009, use of internal mammary artery grafts–the optimal graft vessel–rose from 84% of cases in 2000 to 95% of cases in 2009. And use of helpful medications, including beta blockers, aspirin, and statins, all rose from 2000 to 2009.

—Mitchel Zoler (on Twitter @mitchelzoler)

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Let’s Hear It for the Heart Team

A relatively new, somewhat revolutionary concept appears to be quickly crystallizing for cardiac disease management: the Heart Team. Simply put, the heart team is a collaboration of interventionalist cardiologists and cardiac surgeons (and maybe non-interventionalist cardiologists too) at a single center who work together to combine their endovascular and open-surgical skills in a collaborative and complementary way to give patients optimized treatment that thoughtfully combines the best of both approaches.

The heart team concept has even given birth to a related, new phrase: the hybrid cardiac suite, which is the ultimate collaborative site, a room that accommodates both endovascular and open-surgical procedures under one roof.

Peaceable Kingdom By Edward Hicks/courtesy Wikimedia Commons

It sounds great and makes a lot of sense, but until very recently seemed to be the stuff of dreams, as endovascularists and surgeons traditionally acted as worst enemies, jealously guarding their turf and touting their approach as best.

Those days now may be coming to an end. Get ready to root on the heart team.

When I covered the annual meeting of the American Association for Thoracic Surgery in Philadelphia earlier this month, it seemed like I kept bumping into the heart team idea. There was a report from the PARTNER study, which compared endovascular aortic valve repair to open-surgical repair, and relied on heart teams to run the show. PARTNER, a U.S.study, is also credited with providing fertile ground for the heart team idea to take root in America.

In Europe, the heart team concept got jump-started by the European-based SYNTAX trial, which compared coronary stenting and coronary bypass and relied on a heart team at each participating European center to run the trial. The SYNTAX spirit of cooperation led the major European cardiology and thoracic surgery societies, the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery to last year co-write a new set of guidelines for managing coronary revascularization, and endorsement of heart teams is a key feature of those guidelines. These days, in routine practice at the Thoraxcenter inRotterdam for example, a heart team meets every morning to discuss the pending coronary cases and how they’ll be managed, said heart surgeon A. Pieter Kappetein at the meeting.

Heart teams also got mentioned at the meeting as the new way that patients with ruptured aortic aneurysms are getting managed at selected U.S. sites, as endovascularists and surgeons quickly decide on the best way to treat an emergency aneurysm rupture.

Will U.S.guidelines soon appear that follow the European lead and give a formal nod to heart teams? Yes, said John D. Puskas, chief of cardiac surgery at Emory in Atlanta and a member of the joint American College of Cardiology and Society for Thoracic Surgeons guidelines-writing group that will soon issue their recommendations. “The new guidelines are embargoed, but all of the cardiologists and surgeons who wrote the U.S. guidelines read the European guidelines with interest with respect to the heart team,” he told me.

Will the concept catch on for U.S.practice, after so many years of catheterist-surgeon animosity? Dr. Puskas said yes to that too, citing the changing character of U.S.medical practice as a major factor easing the transition.

“Cardiologists and surgeons are being bought by networks and are becoming salaried. That will lower the barriers that have led to competition. I think we’ll see better collaboration in our specialties than ever before. It gets down to patient-centered decision making.”

—Mitchel Zoler (on Twitter @mitchelzoler)

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