Coronary heart disease surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2]

Surgery

  • Procedures and surgeries used to treat CHD include:

Angina that changes in intensity, character or frequency is termed unstable. Unstable angina may precede myocardial infarction, and requires urgent medical attention. It is treated with morphine, oxygen, intravenous nitroglycerin, and aspirin. Interventional procedures such as angioplasty may be done.

Indications for Revascularization in Chronic Coronary Artery Disease

  • Improve symptoms
  • Improve long term survival.

Revascularization has not been shown to decrease incidence of myocardial infarction, congestive heart failure and arrhythmias.

Revascularization in Patients with Diabetes

Patients with diabetes and advanced three-vessel coronary artery disease have shown lower mortality and myocardial infarction rates and higher risk of strokes when undergoing CABG compared to PCI with drug eluting stents.[1]

ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/ STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease

Revascularization to Improve Survival Compared With Medical Therapy (DO NOT EDIT)

Anatomic Setting COR LOE
UPLM or complex CAD
CABG and PCI I—Heart Team approach recommended C
CABG and PCI IIa—Calculation of STS and SYNTAX scores B
UPLM
CABG I B
PCI IIa - For SIHD when both of the following are present:

1) Anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (e.g., a low SYNTAX score of ≤ 22, ostial or trunk left main CAD) 2) Clinical characteristics that predict a significantly increased risk of adverse surgical outcomes (e.g., STS-predicted risk of operative mortality ≥ 5%)

B
PCI IIa—For UA/NSTEMI if not a CABG candidate B
PCI IIa—For STEMI when distal coronary flow is TIMI flow grade <3 and PCI can be performed more rapidly and safely than CABG C
PCI IIb—For SIHD when both of the following are present:1) Anatomic conditions associated with a low to intermediate risk of PCI procedural complications and an intermediate to high likelihood of good long-term outcome (e.g., low-intermediate SYNTAX score of <33, bifurcation left main CAD) 2) Clinical characteristics that predict an increased risk of adverse surgical outcomes (e.g., moderate—severe COPD, disability from prior stroke, or prior cardiac surgery; STS-predicted operative mortality >2%) B
PCI III: Harm—For SIHD in patients (versus performing CABG) with unfavorable anatomy for PCI and who are good candidates for CABG B
3-vessel disease with or without proximal LAD artery disease
CABG I B
IIa—It is reasonable to choose CABG over PCI in patients with complex 3-vessel CAD (e.g., SYNTAX score >22) who are good candidates for CABG. B
PCI IIb—Of uncertain benefit B
2-vessel disease with proximal LAD artery disease
CABG I B
PCI IIb—Of uncertain benefit B
2-vessel disease without proximal LAD artery disease
CABG IIa—With extensive ischemia B
CABG IIb—Of uncertain benefit without extensive ischemia C
CABG IIb—Of uncertain benefit B
1-vessel proximal LAD artery disease
CABG IIa—With LIMA for long-term benefit B
PCI IIb—With LIMA for long-term benefit B
1-vessel proximal LAD artery disease
CABG III: Harm B
PCI III: Harm B
LV dysfunction
CABG IIa—EF 35% to 50% B
CABG IIb—EF <35% without significant left main CAD B
PCI Insufficient data
Survivors of sudden cardiac death with presumed ischemia-mediated VT
CABG I B
PCI I C
No anatomic or physiological criteria for revascularization
CABG III: Harm B
PCI III: Harm B
CABG indicates coronary artery bypass graft; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; COR, class of recommendation; EF, ejection fraction; LAD, left anterior descending; LIMA, left internal mammary artery; LOE, level of evidence; LV, left ventricular; N/A, not available; PCI, percutaneous coronary intervention; SIHD, stable ischemic heart disease; STEMI, ST-elevation myocardial infarction; STS, Society of Thoracic Surgeons; SYNTAX, Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery; TIMI, Thrombolysis In Myocardial Infarction; UA/NSTEMI, unstable angina/non–ST-elevation myocardial infarction; UPLM, unprotected left main disease; and VT, ventricular tachycardia.
Noninvasive Risk Stratification
High risk (>3% annual death or MI)

1. Severe resting LV dysfunction (LVEF <35%) not readily explained by noncoronary causes

2. Resting perfusion abnormalities ≥10% of the myocardium in patients without prior history or evidence of MI

3. Stress ECG findings including ≥2 mm of ST-segment depression at low workload or persisting into recovery, exercise-induced ST-segment elevation, or exercise-induced VT/VF

4. Severe stress-induced LV dysfunction (peak exercise LVEF <45% or drop in LVEF with stress ≥10%)

5. Stress-induced perfusion abnormalities encumbering ≥10% myocardium or stress segmental scores indicating multiple vascular territories with abnormalities

6. Stress-induced LV dilation

7. Inducible wall motion abnormality (involving >2 segments or 2 coronary beds)

8. Wall motion abnormality developing at low dose of dobutamine (≤ 10 mg/kg/min) or at a low heart rate (<120 beats/min)

9. CAC score >400 Agatston units

10. Multivessel obstructive CAD (≥70% stenosis) or left main stenosis (≥50% stenosis) on CCTA

Intermediate risk (1% to 3% annual death or MI)

1. Mild/moderate resting LV dysfunction (LVEF 35% to 49%) not readily explained by noncoronary causes

2. Resting perfusion abnormalities in 5% to 9.9% of the myocardium in patients without a history or prior evidence of MI

3. ≥1 mm of ST-segment depression occurring with exertional symptoms

4. Stress-induced perfusion abnormalities encumbering 5% to 9.9% of the myocardium or stress segmental scores (in multiple segments) indicating 1 vascular territory with abnormalities but without LV dilation

5. Small wall motion abnormality involving 1 to 2 segments and only 1 coronary bed

6. CAC score 100 to 399 Agatston units

7. One vessel CAD with ≥70% stenosis or moderate CAD stenosis (50% to 69% stenosis) in ≥2 arteries on CCTA

Low risk (<1% annual death or MI)

1. Low-risk treadmill score (score ≥5) or no new ST segment changes or exercise-induced chest pain symptoms; when achieving maximal levels of exercise

2. Normal or small myocardial perfusion defect at rest or with stress encumbering <5% of the myocardium*

3. Normal stress or no change of limited resting wall motion abnormalities during stress

4. CAC score <100 Agaston units 5. No coronary stenosis >50% on CCTA

CAC indicates coronary artery calcium; CAD, coronary artery disease; CCTA, coronary computed tomography angiography; LV, left ventricular; LVEF, left ventricular ejection fraction; and MI, myocardial infarction.

One Vessel Disease

Appropriate Use Score (1-9)
One-Vessel Disease Asymptomatic Ischemic Symptoms
One-Vessel Disease Not on AA Therapy or With AA Therapy Not on AA Therapy On 1 AA Drug (BB Preferred) On ≥2 AA Drugs
Indication PCI CABG PCI CABG PCI CABG PCI CABG
No Proximal LAD or Proximal Left Dominant LCX Involvement
Low-risk findings on noninvasive testing R (2) R (1) R (3) R (2) M (4) R (3) A (7) M (5)
Intermediate- or high-risk findings on noninvasive testing M (4) R (3) M (5) M (4) M (6) M (4) A (8) M (6)
No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 M (4) R (2) M (5) R (3) M (6) M (4) A (8) M (6)
Proximal LAD or Proximal Left Dominant LCX Involvement Present
Low-risk findings on noninvasive testing M (4) R (3) M (4) M (4) M (5) M (5) A (7) A (7)
Intermediate- or high-risk findings on noninvasive testing M (5) M (5) M (6) M (6) A (7) A (7) A (8) A (8)
No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 M (5) M (5) M (6) M (6) M (6) M (6) A (8) A (7)
A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional flow reserve; iFR, instant wave-free ratio; LAD, left anterior descending coronary artery; LCX, left circumflex artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.

Two-Vessel Disease

Appropriate Use Score (1-9)
Two-Vessel Disease Asymptomatic Ischemic Symptoms
Two-Vessel Disease Not on AA Therapy or With AA Therapy Not on AA Therapy On 1 AA Drug (BB Preferred) On ≥2 AA Drugs
Indication PCI CABG PCI CABG PCI CABG PCI CABG
No Proximal LAD Involvement
Low-risk findings on noninvasive testing R (3) R (2) M (4) R (3) M (5) M (4) A (7) M (6)
Intermediate- or high-risk findings on noninvasive testing M (5) M (4) M (6) M (5) M (6) M (4) A (7) M (6)
No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 in both vessels M (5) M (4) M (6) M (4) A (7) M (5) A (8) A (8)
Proximal LAD Involvement and No Diabetes Present
Low-risk findings on noninvasive testing M (4) M (4) M (5) M (5) M (6) M (6) A (7) A (7)
Intermediate- or high-risk findings on noninvasive testing M (6) M (6) A (7) A (7) A (7) A (7) A (8) A (8)
No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 in both vessels M (6) M (6) M (6) M (6) A (7) A (7) A (8) A (8)
Proximal LAD Involvement With Diabetes Present
Low-risk findings on noninvasive testing M (4) M (5) M (4) M (6) M (6) A (7) A (7) A (8)
Intermediate- or high-risk findings on noninvasive testing M (5) A (7) M (6) A (7) A (7) A (8) A (8) A (9)
No stress test performed or, if performed, results are indeterminate - FFR ≤0.80 in both vessels M (5) M (6) M (6) A (7) A (7) A (8) A (7) A (8)
A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional flow reserve; iFR, instant wave-free ratio; LAD, left anterior descending coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.

Three-Vessel Disease

Appropriate Use Score (1-9)
Three-Vessel Disease Asymptomatic Ischemic Symptoms
Three-Vessel Disease Not on AA Therapy or With AA Therapy Not on AA Therapy On 1 AA Drug (BB Preferred) On ≥2 AA Drugs
Indication PCI CABG PCI CABG PCI CABG PCI CABG
Low Disease Complexity (e.g., Focal Stenoses, SYNTAX ≤22)
Low-risk findings on noninvasive testing M (4) M (5) M (5) M (6) M (6) M (6) A (7) A (7)
Intermediate- or high-risk findings on noninvasive testing - No diabetes M (6) A (7) A (7) A (7) A (7) A (8) A (8) A (8)
Low-risk findings on non-invasive testing - Diabetes present M (4) M (6) M (5) M (6) A (6) A (7) A (7) A (8)
Intermediate- or high-risk findings on noninvasive testing - Diabetes present M (6) A (7) M (6) A (8) A (7) A (8) A (7) A (9)
Intermediate or High Disease Complexity (e.g. Multiple Features of Complexity as Noted Previously, SYNTAX >22)
Low-risk findings on noninvasive testing - No diabetes M (4) M (6) M (4) A (7) M (5) A (7) M (6) A (8)
Intermediate- or high-risk findings on noninvasive testing - No diabetes M (5) A (7) M (6) A (7) M (6) A (8) M (6) A (9)
Low-risk findings on noninvasive testing - Diabetes present M (4) A (7) M (4) A (7) M (5) A (8) M (6) A (9)
Intermediate- or high-risk findings on noninvasive testing - Diabetes present M (4) A (8) M (5) A (8) M (5) A (8) M (6) A (9)
A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; M, may be appropriate; PCI, percutaneous coronary intervention; and SYNTAX, Synergy between PCI with Taxus and Cardiac Surgery trial. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.

Left Main Coronary Artery Stenosis

Appropriate Use Score (1-9)
Left Main Disease Asymptomatic Ischemic Symptoms
Left Main Disease Not on AA Therapy or With AA Therapy Not on AA Therapy On 1 AA Drug (BB Preferred) On ≥2 AA Drugs
Indication PCI CABG PCI CABG PCI CABG PCI CABG
Isolated LMCA disease - Ostial or midshaft stenosis M (6) A (8) A (7) A (8) A (7) A (9) A (7) A (9)
Isolated LMCA disease - Bifurcation involvement M (5) A (8) M (5) A (8) M (5) A (9) M (6) A (9)
LMCA disease - Ostial or mid shaft stenosis - Concurrent multi vessel disease - Low disease burden (e.g., 1–2 additional focal stenoses, SYNTAX score ≤22) M (6) A (8) M (6) A (9) A (7) A (9) A (7) A (9)
Ostial or mid shaft stenosis - Concurrent multi vessel disease - Intermediate or high disease burden (e.g., 1–2 additional bifurcation stenosis, long stenoses, SYNTAX score >22) M (4) A (9) M (4) A (9) M (4) A (9) M (4) A (9)
Ostial or mid shaft stenosis - Concurrent multi vessel disease - Intermediate or high disease burden (e.g., 1–2 additional bifurcation stenosis, long stenoses, SYNTAX score >22) M (4) A (9) M (4) A (9) M (4) A (9) M (4) A (9)
LMCA disease - Bifurcation involvement - Low disease burden in other vessels (e.g., 1–2 additional focal stenosis, SYNTAX score ≤22) M (4) A (8) M (5) A (8) M (5) A (9) M (6) A (9)
LMCA disease - Bifurcation involvement - Intermediate or high disease burden in other vessels (e.g., 1–2 additional bifurcation stenosis, long stenoses, SYNTAX score >22) R (3) A (8) R (3) A (9) R (3) A (9) R (3) A (9)
A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; LMCA, left main coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; R, rarely appropriate; and SYNTAX, Synergy between PCI with Taxus and Cardiac Surgery trial. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.

IMA to LAD Patent and Without Significant Stenoses

Appropriate Use Score (1-9)
IMA to LAD Patent and Without Significant Stenoses Asymptomatic Ischemic Symptoms
Not on AA Therapy or With AA Therapy Not on AA Therapy On 1 AA Drug (BB Preferred) On ≥2 AA Drugs
Indication PCI CABG PCI CABG PCI CABG PCI CABG
Stenosis Supplying 1 Territory Disease (Bypass Graft or Native Artery) to Territory Other Than Anterior
Low-risk findings on noninvasive testing R (3) R (1) R (3) R (2) M (6) R (3) A (7) M (4)
Intermediate- or high-risk findings on noninvasive testing M (5) R (3) M (5) R (3) A (7) M (4) A (8) M (5)
No stress test performed or, if performed, the results are indeterminate - FFR of stenosis ≤0.80 M (4) R (3) M (4) R (3) M (6) M (4) A (8) M (5)
Stenoses Supplying 2 Territories (Bypass Graft or Native Artery, Either 2 Separate Vessels or Sequential Graft Supplying 2 Territories) Not Including Anterior Territory
Low-risk findings on noninvasive testing R (3) R (2) M (4) R (3) M (6) R (3) A (7) M (5)
Intermediate- or high-risk findings on noninvasive testing M (5) R (3) M (5) M (4) A (7) M (5) A (8) M (6)
A indicates appropriate; AA, Antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional flow reserve; iFR, instant wave-free ratio; IMA, internal mammary artery; LAD, left anterior descending coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.

IMA to LAD Not Patent

Appropriate Use Score (1-9)
IMA to LAD Not Patent Asymptomatic Ischemic Symptoms
Not on AA Therapy or With AA Therapy Not on AA Therapy On 1 AA Drug (BB Preferred) On ≥2 AA Drugs
Indication PCI CABG PCI CABG PCI CABG PCI CABG
Stenosis Supplying 1-Territory Disease (Bypass Graft or Native Artery)–Anterior (LAD) Territory
Low-risk findings on noninvasive testing M (4) R (3) M (5) R (3) M (6) M (4) A (7) M (5)
Intermediate- or high-risk findings on noninvasive testing M (6) M (4) M (6) M (4) A (7) M (5) A (8) M (6)
No stress test performed or, if performed, the results are indeterminate - FFR of stenosis ≤0.80 M (5) M (4) M (6) M (4) A (7) M (5) A (7) M (6)
Stenoses Supplying 2 Territories (Bypass Graft or Native Artery, Either 2 Separate Vessels or Sequential Graft Supplying 2 Territories) LAD Plus Other Territory
Low-risk findings on noninvasive testing M (5) M (4) M (6) M (4) A (7) M (5) A (7) M (6)
Intermediate- or high-risk findings on noninvasive testing M (6) M (5) A (7) M (6) A (7) A (7) A (8) A (8)
Stenoses Supplying 3 Territories (Bypass Graft or Native Arteries, Separate Vessels, Sequential Grafts, or Combination Thereof) LAD Plus 2 Other Territories
Low-risk findings on noninvasive testing M (5) M (5) M (6) M (5) M (6) M (6) A (7) A (7)
Intermediate- or high-risk findings on noninvasive testing A (7) A (7) A (7) A (7) A (7) A (7) A (8) A (8)
A indicates appropriate; AA, Antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional flow reserve; iFR, instant wave-free ratio; IMA, internal mammary artery; LAD, left anterior descending coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate. A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.

2017 ESC/EACTS Guidelines for the management of valvular heart disease [2]

Management of Coronary Artery Disease (CAD) in patients with Valvular Heart Disease (VHD)

Recommendations Class Level
Diagnosis of Coronary Artery Disease
Coronary angiography is recommended before valve surgery in patients with severe VHD and any of the following:

• history of cardiovascular disease

• suspected myocardial ischaemiad

• LV systolic dysfunction • in men >40 years of age and postmenopausal women

• one or more cardiovascular risk factors.

I C
Coronary angiography is recommended in the evaluation of moderate to severe secondary mitral regurgitation. I C
CT angiography should be considered as an alternative to coronary angiography before valve surgery in patients with severe VHD and low probability of CAD or in whom conven- tional coronary angiography is technically not feasible or associated with a high risk. II A
CT angiography should be considered as an alternative to coronary angiography before valve surgery in patients with severe VHD and low probability of CAD or in whom conven- tional coronary angiography is technically not feasible or associated with a high risk. IIa C
Indications for Myocardial Revascularization
CABG is recommended in patients with a primary indication for aortic/mitral valve surgery and coronary artery diameter stenosis ≥70% I C
CABG should be considered in patients with a primary indication for aortic/mitral valve surgery and coronary artery diameter stenosis ≥50–70%. IIa C
PCI should be considered in patients with a primary indication to undergo TAVI and coronary artery diameter stenosis >70% in proximal segments. IIa C
PCI should be considered in patients with a primary indication to undergo transcatheter mitral valve interventions and coronary artery diameter stenosis >70% in proximal segments. IIa C
CABG = coronary artery bypass grafting; CAD = coronary artery disease; CT = computed tomography; LV = left ventricular; MSCT = multislice computed tomography; PCI = percutaneous coronary intervention; TAVI = transcatheter aortic valve implantation; VHD = valvular heart disease.

References

  1. Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M; et al. (2012). "Strategies for Multivessel Revascularization in Patients with Diabetes". N Engl J Med. doi:10.1056/NEJMoa1211585. PMID 23121323.
  2. Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, Iung B, Lancellotti P, Lansac E, Muñoz DR, Rosenhek R, Sjögren J, Tornos Mas P, Vahanian A, Walther T, Wendler O, Windecker S, Zamorano JL (2017). "2017 ESC/EACTS Guidelines for the management of valvular heart disease". Eur. Heart J. 38 (36): 2739–2791. doi:10.1093/eurheartj/ehx391. PMID 28886619.

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