Number 29, 2006
Bypass surgery for coronary artery disease: a vanishing treatment?
Bypass surgery for coronary artery disease: a vanishing treatment?
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Frans C. Visser
Academic Hospital Vrije Universiteit, Amsterdam, The Netherlands
Correspondence: Professor Frans C. Visser, Department of Cardiology, Academic Hospital Vrije Universiteit, De Boelalaan 1117, 1081 HV Amsterdam, The Netherlands.
Tel: +31 20 444 44 44; fax: +31 20 444 24 46; e-mail: fc.visser@azvu.nl
Since the introduction of percutaneous coronary interventions (PCIs) for coronary artery disease, interventional cardiologists have assured me that the time for the surgical approach of the disease is almost over, and they have kept on telling me this through the last 25 years. But if we look at the data of the trends in volumes of PCIs (Figure 1) and cardiac surgery (Figure 2) over the last 25 years in the Netherlands, only a small decrease in surgery volume is shown over the last 10 years, despite a three-fold increase in PCIs.
Figure 1. Trends in volumes of percutaneous coronary interventions over the last 25 years in the Netherlands.
Figure 2. Trends in volumes of cardiac surgery over the last 25 years in the Netherlands.
A similar trend is observed in Canada [1]. Part of the decline in surgery volume is compensated by an increase in valve surgery both in valve replacement and repair. In view of the fact that more and more percutaneous procedures are performed on coronary arteries, and on increasingly complex lesions [2], what are/remain the indications for surgery instead of PCI at this moment?
In the ACC/AHA 2004 guideline update for coronary artery bypass graft surgery [3] an extensive overview is given of the outcomes, patient subsets, management strategies, technology, competence, and economics. Most importantly the indications are discussed. First of all, the most important indication for surgery is the relief of symptoms. The randomized trials of CABG versus PCI have shown that the freedom of symptoms and antianginal medication is superior in the CABG cohorts compared to the PCI cohorts (also in stent trials). Also subsequent procedures are less after surgery than after PCI. On the other hand, hospital stay is longer, and initial costs and complication/mortality rates are higher. Therefore the benefits of CABG have to be balanced against the risks.
The second indication is improvement of survival. In the randomized trials no difference in mortality or (re)infarction was shown between bypass surgery and PCI. On the other hand, in a very large registry [4] in the US it was shown that patients with 3 vessel disease and severe proximal LAD disease had improved survival with surgery compared to PCI. Conversely, single vessel disease patients without proximal LAD involvement were better off with PCI. Another important subset of patients are those with diabetes mellitus and multivessel disease. The majority of trials and registries favor the use of surgery to improve outcome in patients with diabetes, although no large scale randomized trial data are available.
Thus, what are the primary indications at this moment for bypass surgery instead of PCI for patients with coronary artery disease?
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Patients with significant left main stenosis.
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Patients needing concomitant other cardiac surgery (valves etc)
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Unsuitable coronary anatomy for PCI
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Severe complications after PCI
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Patients with diabetes mellitus and multivessel disease
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Severe triple vessel disease.
However, the indications of surgery versus PCI for coronary artery disease will continuously be under debate as newer technologies both in PCI (drug-eluting stents) and in bypass surgery (minimally invasive surgery) will undoubtedly alter complication rates and prognosis. Moreover, the widespread use of statins, angiotensin-converting enzyme (ACE) inhibitors and anti-platelet therapy will also change the course of the atherosclerotic disease. From a patient perspective, it is likely that many patients will undergo both procedures during their lives.
Because of this important form of therapy in patients with cardiac disease, and because it has clear metabolic associations, we have decided to devote an issue of Heart and Metabolism to cardiac surgery. Out of a large number of topics we have focused on the perioperative setting. Enjoy reading.
REFERENCES
1. Northrup WF 3rd, Emery RW, Nicoloff DM, Lillehei T, Holter AR, Blake DP.
Opposite trends in coronary artery and valve surgery in a large multisurgeon practice, 1979–1999.
Ann Thorac Surg. 2004;77(2):488–495.
2. Stertzer SH, Myler RK, Insel H, Wallsh E, Rossi P.
Percutaneous transluminal coronary angioplasty in left main stem coronary stenosis: a five-year appraisal.
Int J Cardiol. 1985;9(2):149–159.
3. Eagle KA, Guyton RA, Davidoff RD, et al.
ACC/AHA 2004 guideline update for coronary artery bypass graft surgery.
Circulation. 2004;110(14):e340–e437.
4. Hannan EL, Racz M, McCallister BD, et al.
A comparison of three-year survival after coronary artery bypass graft surgery and percutaneous transluminal coronary angioplasty.
JACC. 1999;33(1):63–72.
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