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CABG in most cases: More durable, better outcomes
Joanna Chikwe MD, FRCS
Professor & Chair Department of Cardiac Surgery Cedars-Sinai Medical Center
Los Angeles, CA
#1 Ranked by U.S. News & World Report for Cardiology and Cardiac Surgery In the West, #3 in the Nation
DISCLOSURES
I have NO disclosures
Cedars-Sinai Medical Center receives fees from Abbott, Edwards Lifesciences and Medtronic among other other commercial entities for
faculty consulting, speaker and device trial activities
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Which survival curve would you want?
Stone et al NEJM 2019
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What else can we learn?
Stone et al NEJM 2019
These were low risk patients, ideal for “gold-standard” CABG
Age (years) 65.9 + 9.5 Male (%) 77.5 Diabetic (%) 28 BMI 28 LVEF (%) 57
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Did they get “gold-standard” CABG?
Stone et al NEJM 2019
Not really…
No CABG (either PCI or nothing) 3.5% No LIMA 1.2% Off-pump 29% Under-revascularized (on-vs. off-pump) 12% (10% vs. 16%) Multi-arterial revascularization: BIMA <30% Intra-operative TEE or US 42% Hospitalization 13+10 days
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Take-homes from EXCEL
• PCI had a third worse mortality at 5 years than CABG
• But the difference could have been even greater – if more CABG patients in the EXCEL trial had received “gold-standard” CABG
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What is the “gold-standard” for CABG?
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What is the “gold-standard” for CABG?
1. Safety (O:E mortality and major complications <<1.0)
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Comparing performance - safety
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Comparing performance - safety
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81% Absence of mortality 10% Absence of morbidity (Stroke, renal failure, respiratory
failure, reoperation, mediastinitis) 7% IMA use 3% Medication: Aspirin, Beta-blocker pre and post, Statin
Comparing safety and quality
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STS Overall Score
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STS Overall Score
Hospital STS Overall Score percentile
Confidence interval
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What is the “gold-standard” for CABG?
1. Safety (O:E mortality and major complications <<1.0)
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What is the “gold-standard” for CABG?
1. Safety (O:E mortality and major complications <<1.0) 2. Long-term efficacy
• Complete revascularization • Effective revascularization • Multi-arterial revascularization (patients <70 years)
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Efficacy: complete revascularization
Stone et al NEJM 2019 Benedetto et al JACC 2019
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Efficacy: complete revascularization
Chikwe et al JACC 2018
• Incomplete revascularization was more common with off vs. on-pump (15.7% vs. 8.8%, P<0.001)
• Incomplete
revascularization was associated with increased long-term mortality (HR 1.15, 95% CI 1.06-1.23)
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Efficacy: multi-arterial revascularization
Chikwe et al JACC 2018
• Multi-arterial revascularization is associated with superior survival, graft patency, and freedom from MI and repeat reintervention
• The benefit is not
significant in patients >70 years
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Results: Wide practice variation
Chikwe et al et al JACC In Press
Overall<15% CABG multiarterial
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Multi-arterial grafting trials
Taggart et al NEJM 2018
Intention-to-treat analysis As-treated analysis
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Multi-arterial grafting trials
Taggart et al NEJM 2018
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Multi-arterial grafting trials
Taggart et al NEJM 2018
• 12 surgeons had 100% conversion to SITA
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Multi-arterial grafting trials
Taggart et al NEJM 2018
• 12 surgeons had 100% conversion to SITA • 19 surgeons converted >50% of the time
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Multi-arterial grafting trials
Taggart et al NEJM 2018
• 1 surgeon randomized 211 patients to BIMA with 1.9% conversion rate.
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Multi-arterial grafting trials
Taggart et al NEJM 2018
• Only 17/ 131 surgeons (13%) randomized more than 10 patients with <10% conversion
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Multi-arterial grafting trials
Benedetto et al JTCVS 2018
Unsuitable 31%
No target 17% Sternal risk
15%
Unstable 8%
Pathology 2%
Time 2%
Unknown 25%
Conversion Compared to 0.6% for LIMA
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Multi-arterial grafting trials
Benedetto et al JTCVS 2018
Unsuitable 31%
No target 17% Sternal risk
15%
Unstable 8%
Pathology 2%
Time 2%
Unknown 25%
Conversion “Damaged” in 44 cases “Poor flow” in 23 cases “Too short” in 13 cases
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Multi-arterial grafting trials
Gaudino et al NEJM 2018
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Better patency with arterial grafts
Chikwe et al et al JACC 2019
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What is the “gold-standard” for CABG?
1. Safety (O:E mortality and major complications <<1.0) 2. Long-term efficacy
• Complete revascularization • Effective revascularization • Multi-arterial revascularization (patients <70 years)
3. Patient centered outcomes (small incision, fast recovery)
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What is the “gold-standard” for CABG?
1. Safety (O:E mortality and major complications <<1.0) 2. Long-term efficacy
• Complete revascularization • Effective revascularization • Multi-arterial revascularization (patients <70 years)
3. Patient centered outcomes (small incision, fast recovery)
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Patient-centered outcomes – after MICS
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Conclusions
• CABG for Most Left Main: PCI had a third worse mortality at 5 years than CABG in the EXCEL trial
• GOLD-STANDARD for every CABG (LMS, diabetic, ↑Syntax) • Safety (O:E mortality and major complications <<1.0) • Long-term efficacy
• Complete revascularization • Effective revascularization • Multi-arterial revascularization (patients <70 years)
• Patient centered outcomes (small incision, fast recovery)
• Target referrals for the most appropriate, effective, and patient centered care
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Thank you
