Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3614_Библиотеки_им_академика_М_И_Перельмана
.pdf
https://t.me/medicina_free
https://t.me/medicina_free
69
Coronary artery bypass graing with
concurrent transmyocardial laser
revascularization
Joshua L. Chan and Keith A. Horvath
Introduction
Chronic angina pectoris represents a signicant challenge for a
growing population of patients with advanced coronary artery
disease. Of the estimated 7million North Americans aected by
chronic angina, over 2million patients continue to be symptomatic
even with maximal medical therapy. Despite the demonstrated success of conventional interventions, this subpopulation is frequently
not amenable to complete revascularization with percutaneous
transluminal coronary angioplasty or coronary artery bypass gra
(CABG) surgery due to anatomical constraints or diuse disease.
Transmyocardial laser revascularization (TMR) has been established as a feasible surgical modality and shown to relieve angina in
this patient population. Based on the success of sole therapy, TMR
has been incorporated as an adjunctive modality with CABG in
cases where CABG alone would not be expected to provide complete revascularization. is hybrid application now represents over
90% of all TMR procedures performed in the United States and has
become a valuable tool in the treatment of advanced coronary artery
disease.
is chapter will discuss the technological aspects of TMR and review the clinical evidence assessing the use of TMR in combination
with CABG to treat patients with severe angina pectoris refractory
to conventional treatment options.
Historical perspective andmechanism
Early pioneers attempted to treat angina pectoris with direct myocardial revascularization. However, initial eorts with cardiomyopexy
(Beck), cardio-omentopexy (O’Shaughnessy), and direct implantation of the internal thoracic (mammary) artery (Vineberg) were
generally ineective. Later, Sen and associates proposed a model of
creating direct vascular channels, mirroring observations in reptilian
hearts of a transmural sinusoidal perfusion network. Experimental
attempts involved a number of static mechanical methods, but were
hampered by limited success. It was not until the emergence of laser
technologies that TMR was able to achieve signicant symptomatic
relief and technical replicability.
Although the creation of vascular channels was initially assumed
to provide direct myocardial perfusion, clinical work has since demonstrated that it is unlikely to be the principal mode of action for
TMR in providing angina relief. In an autopsy series by Sigel, it was
observed that the carbon dioxide (CO) laser channels were quickly
occluded with granulation tissue in the early postoperative period,
placing signicant doubt on the assertion that these channels provided substantial and continued perfusion.
Instead, it appears that post-treatment angiogenesis is the primary driving force following TMR, as it parallels clinical improvement over time and corresponds to changes in myocardial perfusion
proles. Multiple studies have demonstrated histological evidence
of neovascularization following TMR therapy, and have been substantiated with evidence of upregulation of multiple growth factors
within treated myocardium. While degrees of neovascularization
can occur from other forms of mechanical energy, as previously
shown with acupuncture needles directed into the myocardium,
such methods can result in substantial scar formation, thereby limiting ultimate functional improvement. erefore, the key benet
of TMR laser energy is its ability to limited collateral damage and
scar formation, allowing for maximum angiogenesis to achieve
functional recovery and cardioprotection.
Choice oflasermedium
Several types of solid-state lasers consisting of either a single
laser-active dopant or in combination with an yttrium aluminium
garnet (YAG) gain medium have been assessed for TMR use.
However, only CO (Novadaq Technologies Inc., Mississauga,
ON, Canada) and holmium (Ho):YAG (CryoLife, Inc., Kennesaw,
SECTION 9 Coronary artery bypass grafting and other surgery470
CO2 laser Ho:YAG laser
https://t.me/medicina_free
0.5 ms 1 ms 2 ms 4 ms
11 ms10 ms8 ms
Fig.69.1 Time-stop imaging capturing pulse emittance, operating characteristics, and mechanical effects of CO
systems in water.
GA, USA) mediums have been clinically approved by the Food
and Drug Administration (FDA) in the United States. The resultant tissue interaction differs based on the chosen technology,
as each particular laser type is unique in its operating characteristics and mechanical effects (Fig. 69.1).
can be created with a single emitted pulse, which is synchronized
with the r wave. ese properties are believed to be advantageous as
the characteristics of this single, short laser pulse does not cause explosive tissue ablation, thereby minimizing the extent of myocardial
trauma, and diminishes the risk of arrhythmias.
50 μs 200 μs 400 μs
800 μs700 μs600 μs500 μs
(left) and Ho:YAG (right) laser
2
Ho:YAG lasers employ a wavelength of 2120mm, delivering sequential pulses at 5 Hz utilizing 1–2 J and 6–8 W/pulse (Fig. 69.2a).
e laser itself is housed within a exible 1mm bre bundle, which
Surgicaltechnique
is advanced manually through the myocardium over multiple cardiac cycles. Pulse activation is unsynchronized to the cardiac cycle.
However, separating successive pulses by time is essential in the
Ho:YAG system to ensure adequate thermal dissipation; if this is
not allowed to occur, accumulated heat may cause excessive tissue
trauma and thermocoagulation.
In contrast, the CO laser wavelength is 10,600mm (Fig. 69.2b).
is system utilizes a single 15–20 J pulse for 25–40 ms. e channel
Patients undergoing TMR are frequently candidates for combination
therapy with CABG and commonly undergo a standard incision with
a median sternotomy. e use of TMR itself does not mandate concurrent use of cardiopulmonary bypass or anticoagulation. When
implemented as adjunctive therapy, the time point at which TMR is
performed in relation to CABG may be based on the surgeon’s preference, such as prior to CABG, following distal coronary anastomosis
Fig.69.2 Two FDA-approved TMR systems commercially available, based on the specific solid-state laser medium:(a) Ho:YAG (CardioGenesis
SolarGen 2100s; CryoLife, Inc., Kennesaw, GA, USA) or (b)CO2 (Heart Laser System™; Novadaq Technologies Inc., Mississauga, ON, Canada).
®
69 Coronary artery bypass grafting with concurrent transmyocardial laser revascularization 471
https://t.me/medicina_free
(a) (b)
Fig.69.3 Creation of transventricular channels shown here following (a)application of TMR hand piece at an angle perpendicular to the epicardium.
(b)Placement of channels are typically in 1cm2 increments.
on cardiopulmonary bypass circuit support, or aer cross-clamp removal. Typically, however, adjunct TMR therapy is performed following cardiac arrest while on cardiopulmonary bypass support, as
it facilitates manipulation of the heart, enables easier access to treatment regions, and eliminates immediate post-treatment arrhythmia
concerns.
A transoesophageal echocardiographic probe can be useful in
conrming adequate channel creation, which can be visualized with
the characteristic liquid vaporization. However, transmurality can
also be determined by additional cues, including auditory pitch
change, pulsatile bleeding from the channel, or tactile feedback with
substantial reduction in resistance upon entry into the ventricular
cavity.
e TMR hand piece is applied at an angle perpendicular to
the epicardium for channel creation, with the location of subsequent channels typically at a distance of every squared centimetre
(Fig. 69.3). Caution is noted against placing TMR channels in excessively close proximity to one another, referred to ‘over-channelling’,
as it may lead to excessive myocardial trauma and increase the risk of
postoperative arrhythmia. Although mild intraoperative bleeding
may occur at the focal ring channel locations, these are not typically substantial in nature and frequently become haemostatic spontaneously without the need for secondary temporizing measures.
If persistent bleeding is observed, manual pressure can be applied
intermittently over tracts; placement of temporizing epicardial sutures is rarely necessary.
Association (ACC/AHA) and Society of oracic Surgeons (STS)
have additionally reinforced the use of adjunctive TMR for these specic indications.
Mortality
In the largest prospective, multicentre, randomized trial, Allen
and associates observed a signicant decrease in inotropic support required for patients treated with TMR plus CABG compared
to CABG-only treatment (30% vs 55%; P= 0.001). e rate of
major adverse cardiac events within the 30-day postoperative period was also reduced in the TMR plus CABG treatment arm (3%
vs 9%; P=0.04). Survival was noted to be superior in the hybrid
revascularization cohort with decreased mortality rates in both
the immediate perioperative period (1.5% vs 7.6%; P=0.02) and
at 1year (5% vs 11%; P= 0.05). In this series, multivariable predictors of operative mortality were CABG-only (odds ratio (OR)
5.3; P=0.04) and advanced age (OR 1.1; P=0.03). Alongitudinal
follow-up of this same study noted comparable survival between
groups at 6years (76% vs 80%; P=0.90).
Additional observational data with the STS National Adult
Cardiac Database assessing nearly 940,000 patients over a 4-year period observed an overall mortality rate of 3.8% in TMR plus CABG
patients compared to 2.7% in those treated with CABG alone (P
<0.001). However, TMR plus CABG patients in this series were
identied to have signicant baseline dierences, reecting a predilection for diuse arterial disease based on their preoperative
demographics (Table 69.1). When patients with unstable angina
were removed, risk-adjustment analysis revealed an observed-to-
Clinical results oftransmyocardial laser
revascularization plus CABG combination
therapy
Indications
Data from multiple retrospective and prospective, randomized trials
have assessed the safety and ecacy of TMR plus CABG. Based on
the cumulative clinical evidence, the use of TMR with CABG has been
recommended for patients with angina pectoris having at least one
myocardial territory not amenable to adequate revascularization with
CABG alone. A consensus statement from the International Society
of Minimally Invasive Cardiac Surgery (ISMICS) as well as practice
guidelines from the American College of Cardiology/American Heart
expected mortality ratio in patients treated with TMR plus CABG
of 0.87. Based on these ndings, the addition of TMR to CABG in
order to achieve a more complete revascularization was not shown
to impact the short-term mortality rate compared to treatment with
CABG alone (5.2% vs 4.3; P=0.13).
Konstanty-Kalandyk recently published actuarial data on 10-year
survival rates in a cohort of patients with severe disseminated coronary atherosclerosis who were treated with CABG and/or TMR.
is retrospective review of 86 patients revealed a cumulative survival of 78.3% at 10years in the CABG plus TMR group compared
to 72.5% in the single-therapy group (P= 0.535). Single therapy
was identied as an independent predictor of late mortality (OR
1.736; P=0.264), potentially further highlighting the importance of
achieving complete revascularization in patients with disseminated
SECTION 9 Coronary artery bypass grafting and other surgery472
https://t.me/medicina_free
Table69.1 Baseline demographics ofTMR plus CABG and CABG-
only patients enrolled inthe STS National Adult Cardiac Database
Characteristics CABG only
Body surface area, m2 (SD) 1.96 (0.24) 1.99 (0.23) <0.001
Diabetes (all types) 34% 50% <0.001
Insulin-dependent diabetes 10% 19% <0.001
Renal failure 5% 7% <0.001
Haemodialysis 1% 2% <0.001
Cerebrovascular accident 7% 9% <0.001
Chronic lung disease 14% 17% <0.001
Peripheral vascular disease 16% 20% <0.001
Cerebral vascular disease 12% 17% <0.001
Myocardial infarction 46% 49% <0.001
Reoperation 9% 26% <0.001
Three-vessel CAD 71% 80% <0.001
Hypercholesterolaemia 62% 73% <0.001
Hypertension 72% 80% <0.001
CABG, coronary artery bypass graft surgery; CAD, coronary artery disease; SD, standard
deviation; TMR, transmyocardial laser revascularization.
n=932,715
TMR + CABG
n=5,618
P-value
angina scores revealed that there was a signicant reduction in the
number of patients with CCS angina scores of III or IV following
hybrid therapy (0% vs 10%; P=0.009) with a notable trend towards
a greater percentage reporting being angina-free (78% vs 63%;
P=0.08). Of interest, a signicantly greater proportion of diabetic
patients, who are more susceptible to diuse microvascular disease,
were angina free following TMR plus CABG (93% vs 63%; P=0.02).
e incidence of additional need for CABG and percutaneous coronary intervention were similar in each group, with statistically
signicant long-term angina improvement (P=0.04) and freedom
from angina (P=0.04) maintained in a multivariate analysis.
Resourceutilization
A retrospective review of 255 patients compared the use of adjunctive
TMR to CABG alone and assessed the potential savings with combination therapy. In this study, patients treated in the adjunctive
treatment arm were observed to have signicantly decreased intensive care unit times (1.6 ± 0.2days vs 2.1 ± 0.2days; P <0.01) and total
hospital lengths of stay (7.1 ± 0.6days vs 8.2 ± 0.4days; P <0.001).
Additionally, 30-day readmission rates were substantially reduced
(2.8% vs 7.8%; P <0.05). Other factors, such as operative times and
ventilator requirement, were similar in both cohorts. Separately,
long-term evaluation of TMR plus CABG in a multicentre trial
involving 44 patients revealed greater event-free survival (dened as
freedom from repeat revascularization, angina, and death) at 4years
coronary atherosclerosis. Of interest, subanalysis based on anatomical location of interventions (anterior vs lateral vs posterior) was
additionally performed. In those with treatment to the anterior wall,
there was a signicant improvement in survival with TMR plus
CABG compared to single therapy (100% vs 72.2%; P=0.027), as
well as in freedom from cardiac death (100% vs 76.4%; P=0.044).
Efficacy and symptomaticrelief
A retrospective study consisting of 169 high-risk patients identied a sustained improvement in Canadian Cardiovascular Society
(CCS) angina class following TMR plus CABG. At 12months post
treatment, the study cohort was found to have signicant improvement in severe angina (CCS classIII/IV) compared to baseline (4%
vs 90%; P <0.001). Symptomatic relief appears to correlate with independent ndings by Trehan and colleagues, who observed an increase in average exercise tolerance at 12months postoperatively
when this technique was applied to 77 patients (5.2 minutes to 9.7
minutes). Myocardial segments treated with TMR were additionally analysed with thallium perfusion scanning, which revealed a
linear trend of improvement by 25% during the same time period.
Long-term symptomatic relief was conrmed by Allen in a 5-year
follow-up of their prospective, multicentre study of 263 cases. In
the initial study, patients scheduled to undergo CABG who also
compared to isolated CABG (39% vs 14%; P <0.064). During this
time period, the rate of repeat revascularization interventions was
0% with TMR plus CABG and 24% with CABG alone (P <0.05).
Emerging applications withstem cell-basedtherapies
Research has been carried out evaluating the use of stem cellbased therapies combined with the traditional modalities highlighted in this chapter. In a study of six patients undergoing CABG,
co-treatment with mesenchymal stem cells in non-revascularized
segments at time of surgery was found to produce signicant improvements in regional tissue perfusion (from 12.29% ± 0.44% to
15.86% ± 0.77%; P=0.02), and contractility (from −17.26 ± 1.97
to −22.01 ± 2.42; P=0.04). An FDA phase Itrial has also been
conducted investigating direct intramyocardial injection of bone
marrow stromal stem cells in conjunction with TMR. Regional
contractility in the cell-treated areas improved at 12 months
postoperatively (from −0.4% ± 1.4% to −5.1% ± 1.6%; P= 0.02).
Patients additionally reported signicant symptomatic improvement with a reduction of CCS angina scores (3.3 ± 0.5 vs 1.3 ± 1.2;
P <0.01). ese preliminary studies highlight recent innovations to
address ischaemic myocardial regions not amenable to conventional
techniques alone to achieve a more complete revascularization
through a multifaceted, synergistic approach.
had additional areas of ungraable disease were enrolled. Patients
were randomized and blinded to receive CABG alone or CABG with
TMR. While not all centres participated in the subsequent follow-up
Conclusion
study, 83% (218/263) of the original cohort was evaluable and the
baseline demographics were similar between groups. CCS angina
class at baseline was comparable between treatment arms (2.9 ± 1.3
vs 2.8 ± 1.3; P=0.50). Patients in the TMR plus CABG treatment
arm reported a signicantly greater improvement in overall CCS angina severity from baseline compared to CABG alone (0.4 ± 0.7 vs
0.7 ± 1.1; P=0.05). Further characterization of the distribution of
Chronic refractory angina pectoris remains a complex challenge, es-
pecially in those patients with anatomical constraints limiting trad-
itional revascularization. is scenario is becoming more common
as extensive repeated percutaneous coronary intervention has led to
‘full metal jackets’ in the coronary arteries of an increasing number
of patients referred for CABG. Its management is of particular
69 Coronary artery bypass grafting with concurrent transmyocardial laser revascularization 473
https://t.me/medicina_free
relevance as incomplete revascularization is a predictor for poor clinical outcomes and the number of patients with advanced coronary
artery disease is only anticipated to increase. e hybrid application
of TMR and CABG represents one of the few modalities available for
cases not completely amenable to coronary revascularization techniques alone. Overall, the clinical evidence demonstrates that the
adjunctive utilization of TMR with CABG has multiple advantages
in this specic population, including angina relief, increased exercise performance, decreased morbidity, and improved survival. As
reected by multiple recommendations from the STS, ISMICS, and
ACC/AHA, consideration for TMR plus CABG is warranted for select patients with chronic refractory angina pectoris secondary to
diuse disease despite optimal pharmacological and interventional
therapies.
REFERENCES
1. Tavris DR, Brennan JM, Sedrakyan A, Zhao Y, O’Brien SM,
Peterson ED, etal. Long-term outcomes aer transmyocardial
revascularization. Ann orac Surg. 2012;94(5):1500–8.
2. Mirhoseini M, Muckerheide M, Cayton MM. Transventricular
revascularization by laser. Lasers Surg Med. 1982;2(2):187–98.
3. Sen PK, Udwadia TE, Kinare SG, Parulkar GB. Transmyocardial
acupuncture:a new approach to myocardial revascularization. J
orac Cardiovasc Surg. 1965;50:181–9.
4. Sigel JE, Abramovich CM, Lytle BW, Ratli NB. Transmyocardial
laser revascularization:three sequential autopsy cases. J orac
Cardiovasc Surg. 1998;115(6):1381–5.
5. Pelletier MP, Giaid A, Sivaraman S, Dorfman J, Li CM, Philip
A, Chiu RC. Angiogenesis and growth factor expression in a
model of transmyocardial revascularization. Ann orac Surg.
1998;66(1):12–8.
6. Horvath KA. Transmyocardial laser revascularization. J Card Surg.
2008;23(3):266–76.
7. Jones JW, Richman BW, Crigger NA, Baldwin JC. Technique of
transmyocardial revascularization:avoiding complications in
high-risk patients. J Cardiovasc Surg (Torino). 2001;42(3):353–7.
8. Diegeler A, Cheng D, Allen K, Weisel R, Lutter G, Sartori M, etal.
Transmyocardial laser revascularization:a consensus statement
of the International Society of Minimally Invasive Cardiothoracic
Surgery (ISMICS) 2006. Innovations (Phila). 2006;1(6):314–22.
9. Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG,
etal. 2011 ACCF/AHA Guideline for coronary artery bypass gra
surgery:executive summary:a report of the American College of
Cardiology Foundation/American Heart Association Task Force
on Practice Guidelines. Circulation. 2011;124(23):2610–42.
10. Bridges CR, Horvath KA, Nugent WC, Shahian DM, Haan CK,
Shemin RJ, etal. e Society of oracic Surgeons practice
guideline series:transmyocardial laser revascularization. Ann
orac Surg. 2004;77(4):1494–502.
11. Allen KB, Dowling RD, DelRossi AJ, Realyvasques F, Lefrak
EA, Pfeer TA, etal. Transmyocardial laser revascularization
combined with coronary artery bypass graing:a multicenter,
blinded, prospective, randomized, controlled trial. J orac
Cardiovasc Surg. 2000;119(3):540–9.
12. Allen KB, Dowling RD, Schuch DR, Pfeer TA, Marra S, Lefrak
EA, etal. Adjunctive transmyocardial revascularization:ve-year
follow-up of a prospective, randomized trial. Ann orac Surg.
2004;78(2):458–65.
13. Horvath KA, Ferguson TB, Guyton RA, Edwards FH. Impact
of unstable angina on outcomes of transmyocardial laser
revascularization combined with coronary artery bypass graing.
Ann orac Surg. 2005;80(6):2082–5.
14. Konstanty-Kalandyk J, Piątek J, Kędziora A, Bartuś K, Drwila
R, Darocha T, etal. Ten-year follow-up aer combined
coronary artery bypass graing and transmyocardial laser
revascularization in patients with disseminated coronary
atherosclerosis. Lasers Med Sci. 2018;33(7):1527–35.
15. Stamou SC, Boyce SW, Cooke RH, Carlos BD, Sweet LC,
Corso PJ. One-year outcome after combined coronary artery
bypass grafting and transmyocardial laser revascularization
for refractory angina pectoris. Am J Cardiol.
2002;89(12):1365–8.
16. Trehan N, Mishra Y, Mehta Y, Jangid DR. Transmyocardial
laser as an adjunct to minimally invasive CABG for
complete myocardial revascularization. Ann orac Surg.
1998;66(3):1113–8.
17. Wehberg KE, Julian JS, Todd JC, Ogburn N, Klopp E, Buchness
M. Improved patient outcomes when transmyocardial
revascularization is used as adjunctive revascularization. Heart
Surg Forum. 2003;6(5):328–30.
18. Frazier OH, Tuzun E, Eichstadt H, Boyce SW, Lansing AM,
March RJ, etal. Transmyocardial laser revascularization as
an adjunct to coronary artery bypass graing:a randomized,
multicenter study with 4-year follow-up. Tex Heart Inst J.
2004;31(3):231–9.
19. Karantalis V, DiFede DL, Gerstenblith G, Pham S, Symes
J, Zambrano JP, etal. Autologous mesenchymal stem cells
produce concordant improvements in regional function, tissue
perfusion, and brotic burden when administered to patients
undergoing coronary artery bypass graing:the Prospective
Randomized Study of Mesenchymal Stem Cell erapy in
Patients Undergoing Cardiac Surgery (Prometheus) trial. Circ
Res. 2014;114(8):1302–10.
20. Chan JL, Miller JG, Zhou Y, Robey PG, Stroncek DF, Arai
AE, etal. Intramyocardial bone marrow stem cells in patients
undergoing cardiac surgical revascularization. Ann orac Surg.
2020;109(4):1142–9.
https://t.me/medicina_free
https://t.me/medicina_free
70
Prior percutaneous coronary intervention
and surgicalrevascularization
Suvitesh Luthra, Sunil K. Ohri, and David P. Taggart
Introduction
Surgical revascularization may be needed aer a prior percutaneous
coronary intervention (PCI) due to further progression of de novo
disease or failure of a PCI due to in-stent restenosis (ISR) or stent
thrombosis. e proportion of patients referred for coronary artery
bypass graing (CABG) with prior PCI varies between institutions
from 5% to 30%.
Magnitude and scope oftheproblem
According to the National Cardiovascular Data CathPCI Registry
that was set up in 1998 to provide a mechanism for centres to
identify opportunities for quality improvement on the basis of evidence-based performance feedback, there were 667,424 PCIs performed in 1612 centres in the United States in 2014. Overall, 41.2%
of patients had undergone a prior PCI. Among those presenting
without an acute coronary syndrome, only 53.5% were deemed appropriate according to the appropriate use criteria. Similarly, data
from the Duke Databank for Cardiovascular Disease from July
2009 to March 2015 showed that repeat PCI accounted for 39% of
interventions and in whom PCI was performed for ISR (7.5% of all
PCI procedures). In the Synergy between Percutaneous Coronary
Intervention with Taxus and Cardiac Surgery (SYNTAX) trial
at 5 years, repeat revascularization occurred dramatically more
oen aer initial PCI than aer initial CABG (25.9% vs 13.7%, respectively; P <0.001), and more oen consisted of multiple repeat
revascularizations (9.0% vs 2.8%, respectively; P=0.022). Repeat
PCI procedures were more frequently performed for de novo lesions in the PCI than CABG group (33.3% vs 13.4%, respectively;
P <0.001). ese patients had signicantly higher rates of the composite safety end point of death, stroke, and myocardial infarction
aer initial PCI than aer initial CABG (33.8% vs 16.6%; P <0.001).
Any repeat revascularization was an independent predictor of the
composite safety end point aer both initial PCI (hazard ratio (HR)
2.2, 95% condence interval (CI) 1.6–3.0; P <0.001) and initial
CABG (HR 1.8, 95% CI 1.2–2.9; P=0.011).
Cassese etal., in one of the largest PCI series for de novo lesions,
reported that 26.4% of patients had angiographic restenosis by 6–8
weeks. ey reported ISR rates of 30.1%, 14.6%, and 12.2% in patients treated with bare-metal stents (BMSs), rst-generation drugeluting stents (DESs), and second-generation DESs, respectively.
Large observational studies have been inconsistent in assessing
the impact of prior PCI on outcomes aer CABG (Table 70.1).–
In a retrospective analysis of 12,270 patients over 17years of whom
3% had prior PCI, Barakate etal. found no signicant dierence in
30-day mortality and post-CABG myocardial infarction rates. In
one of the largest studies to date by Sánchez etal. with over 63,000
patients, previous PCI (4.9% of patients) was not an independent
risk factor for in-hospital mortality (odds ratio 0.88, 95% CI 0.72–
1.07; P=0.20) nor aer adjusting for propensity score (odds ratio
0.9, 95% CI 0.75–1.08; P=0.27).
However, at least three previous editorials have armed the adverse eects of prior PCI on CABG outcomes.– Aprevious metaanalysis of 14 studies showed that early mortality rates were higher
with prior PCI (relative risk (RR) 1.54, 95% CI 1.19–2; P=0.007),
while myocardial infarction (RR 1.46, 95% CI 1.04–2.06; P=0.06)
was not signicantly increased and stroke rates were comparable in
both cohorts (P=0.95). e risk of renal failure was lower in the
primary CABG cohort. However, survival at 3years was comparable. Another meta-analysis of nine studies by Biancari etal. concluded that 30-day/in-hospital mortality was signicantly higher in
patients with prior PCI (pooled rate 2.7% vs 2.0%, RR 1.39, 95% CI
1.06–1.84; P=0.02), but prior PCI did not aect late outcome (RR
1.07, 95% CI 0.90–1.28; P=0.43). Ueki etal. in their pooled analysis reported that mortality was adversely aected only in the subgroup of studies with 40% or more multiple prior PCI episodes (OR
1.99, 95% CI 1.56–2.53).
Nature ofdisease and impact onfutureprognosis
In patients with prior PCI, CABG may be required for either stent
failure (thrombosis or ISR) or progression of de novo disease in
other territories and disease progression by either mechanism
Table70.1 Studies comparing impact ofprior PCI overthe last 20years
https://t.me/medicina_free
First
author,
year (ref)
Kalaycioğlu,
6
1998
Barakate,
7
2003
Hassan,
8
2005
Van den
Brule, 2005
Gürbüz,
10
2006
Thielmann,
11
2006
Pliam,
12
2007
Alcázar,
13
2008
Number of patients FU (years) Stent type Survival MACCE Conclusions
PCI Control % Prior PCI Type PCI No PCI P-value Outcome PCI No PCI P-value
40 40 50 3 PTCA ‘Early’
‘Late’
1 (0.4)
2 (0.8)
1 (0.4)
1 (0.4)
Higher cross-clamp, bypass
times, in-hospital stay, and
angina at 3years with previous
PTCA
361 11,909 2.9 17 PTCA 30-day 6 (2) 195 (2) NS No difference on 30-day
mortality
Higher in-hospital stay (8 vs 9.1)
in no PTCA group
919 5113
(919 PM)
113 1141 9 1 PTCA (most
9
15.2 4 Unknown In-hospital 33 (3.6)
PM 25 (2.7)
not stented)
In-hospital
1-year cardiac
4 (3.5)
0 (0 )
related
87 (1.7)
PM 7 (0.8)
24 (2.1)
13 (1.2)
0.01
0.003
0.32
0.25
Prior PCI is a significant predictor
of in-hospital mortality
No difference in cardiac
mortality at 1year
High OR of hospital
mortality:age, pulmonary
disease, NYHA, LVEF, preop
MI, reintervention, renal
complications, stroke
190 421 31.1 2.45
(median)
Unknown Event-free
survival
19 (10) 15 (3.6) 0.0001 Preop PCI is an independent risk
factor for symptom recurrence,
cardiac events, and increased
overall mortality
Overall worse outcomes in
failed PCI
360 single
289
Multi
2626 19.8 BMS > DES In-hospital 12 (3.3) single
17 (5.9) multi
53 (2) <0.0001 MACE
Stroke
SCD
Cardiac death
LCOS
Periop MI
1:24 (6.6)
≥2:41 (14.1)
1:8 (2.2)
≥2:6 (2.1)
1:4 (1.1)
≥2:5 (1.7)
144 (5.5)
56 (2.1)
11 (0.4)
42 (1.6)
60 (2.3)
126 (4.8)
<0.001
1.00
<0.02
<0.001
<0.04
<0.007
Multiple PCI increase
perioperative risk for in-hospital
mortality and MACE
1:9 (2.5)
≥2:15 (5.1)
1:9 (2.5)
≥2:13 (4.5)
1:18 (5)
≥2:26 (9)
137 (1–3)
17 (>3)
1317 10.5 5 BMS and
DES
In-hospital
5-year
0 (0 )1–3
1 (5.9) >3
21 (15.3) 1–3
5 (27.4) >3
22 (1.7)
236 (17.9)NS>0.05
MACE
Stroke
MI
IABP
5 (3.2)
0 (0 )
0 (0 )
1 (0.6)
68 (5.2)
32 (2.4)
14 (1.1)
3 (0.2)
NS
<0.05
NS
NS
Stented patients had more
complications, longer hospital
stays
No difference in survival
Trend to worse survival if >3
stented vessels
116 680 14.6 3 BMS and
DES
30-day 11 (9.5)
BMS:3 (6.8)
DES:5 (10.4)
29 (4.3) 95%CI
(1.6–8.34)
MACE
Perioperative MI
Cardiac
death
Stroke
32 (21.9)
25 (22.6)
9 (7.8)
0 (0 )
114 (16.8)
67 (9.9)
16 (2.4)
5 (0.7)
RR:1.65
(1.17–2.31)
RR:2.19
(1.44–3.31)
RR:3.3
Patients with PCI have more MI,
cardiac death and all cause death
Type of stent has no significant
difference in survival
(1.49–7.28)
RR:0.16
(0.14–9.86)
Chocron,
https://t.me/medicina_free
14
2008
GaszewskaZurek,
15
2009
430 2059 17.3 5 PTCA, BMS,
DES
162
149 52.1 3 BMS In-hospital
(PCI <2years
prior to
5-year cardiac
death
3-year
CABG)
Yap, 2009161457 11,727 11.1 7 Unknown In-hospital
1-year
3-year
5-year
Kinoshita,
17
2009
Massoudy,
18
2009
Bonaros,
19
2009
Tran, 200920221 1537 12.6 5 (3.6
Stevens,
21
2010
79 196 (all
28.7 6 Unknown Surgical mortality 6 (7.6) 2 (1) 0.008 Previous PCI increased surgical
off-pump)
3078 (1)
25,752 14 5 Unknown In-hospital death 80 (2.6)
1098 (≥2)
306 452 40.4 5 BMS and
DES
Unknown Operative
median)
823
809 (PM)
8819
2427 (PM)
8.5 5 Unknown 30-day
Perioperative
30-day
2-year
Remote PCI:
1-year
2-year
3-year
4-year
5-year
Recent PCI:
1-year
2-year
3-year
4-year
5-year
9 (2.1) 23 (1.1) 1.91
(0.86–4.26)
PM:1.72
(0.78–3.77)
1 (0.6)
4 (2.5)
24 (1.65)
39 (2.7)
82 (5.6)
130 (8.9)
1 (0.7)
5 (3.4)
182 (1.55)
410 (3.5)
797 (6.8)
797 (6.8)
NS
NS
0.78
0.013
1159 (4.5) 0.03 MACE Single:265 (8.6)
25 (2.3)
12 (4.4)
10 (3.3)
6 (2.7)
15 (6.6)
11 (2.4)
8 (1.8)
15 (1)
194 (12.6)
<0.001
<0.001
2.65
(1.03–6.85)
0.017
9 (1.1)
32 (3.9)
56 (6.8)
73 (8.9)
91 (11.1)
110 (13.4)
77 (9.5)
96 (11.9)
116 (14.3)
139 (17.2)
160 (19.8)
168 (1.9)
503 (5.7)
723 (8.2)
970 (11)
1217 (13.8)
1508 (17.1)
138 (5.7)
199 (8.2)
267 (11)
335 (13.8)
0.432
0.004
0.555
(PM)
0.073
0.353
(PM)
415 (17.1)
MACE
MI
Cardiac death
Stroke
Angina
UA
Revascularization
Cardiac arrest
CHF
73 (17)
8 (1.9)
9 (2.1)
6 (1.4)
32 (7.4)
26 (6)
24 (5.6)
2 (0.5)
8 (1.9)
240 (11.6)
28 (1.4)
23 (1.1)
23 (1.1)
128 (6.2)
53 (2.6)
66 (3.2)
3 (0.1)
19 (0.9)
0.0016
HR:1.38
(0.63–3.03)
HR:1.91
(0.88–4.13)
HR:1.28
(0.52–3.14)
HR:1.22
(0.83–1.8)
Increase in overall MACE
composite in PCI arm as well as
unstable angina and need for
revascularization
HR:2.43
(1.52–3.89)
HR:1.8
(1.13–2.87)
HR:3.2
(0.53–19.17)
HR:2.01
(0.88–4.60)
No difference in death at 3years
or in-hospital
Higher rate of chest pain with
PCI (P=0.04)
MACE 40 (3) 350 (3) 0.99 Prior PCI was not associated with
higher in-hospital mortality or
MACE rates
mortality after off-pump in
diabetics with multivessel disease
2517 (8.4) 0.0003 Multiple previous PCI (≥2) had
≥2:131 (11.9)
increased in-hospital death and
MACE
MACE
LCOS
IABP
Stroke
MI
24 (7.9)
4 (6.7)
7 (11.7)
6 (1.7)
5 (8.3)
19 (4.3)
4 (3.6)
10 (8.9)
1 (0.9)
2 (1.8)
<0.001
0.031
0.034
0.58
0.002
PCI has increased perioperative
and 30-day death, MACE,
bleeding complications, need for
transfusion, and renal failure
PCI pretreated had an increased risk
of operative death, MACE, and AF
At 2year:increased mortality
with PCI
Low EF increased mortality in
CABG only
MACE
Perioperative MI
334 (41)
21 (2.6)
963 (40)
76 (3.1)
0.385
0.444
Prior PCI did not affect 30-day
mortality and overall mortality in
matched cohorts
Recent (<14days) vs remote
(>14days) PCI did not affect
survival.
(continued)
Соседние файлы в папке Библиотека им академика М.И. Перельмана