Surgical Coronary Revascularization

Who, What, When

Speaker - Jonathan G. Howlett, MD FRCPC
Chairperson – Gordon W. Moe, MD, MSc, FRCPC
WELCOME!
Accreditation

This event is an Accredited Group Learning Activity

(Section 1) as defined by the Maintenance of Certification
program of The Royal College of Physicians and
Surgeons of Canada, and approved by the Canadian
Cardiovascular Society for 1 Royal Credit MOC Section 1
Credit.

Heart Failure Guidelines

Learning Objectives
At the conclusion of this webinar, participants will be
able to:
•Review the potential role of surgical intervention as a heart failure
management and treatment option

•Discuss opportunities and challenges of surgery for heart failure

patients – where to begin, where to end

•Develop patient specific treatment plans that take into account the
benefits, risks and limitations of surgery as a treatment option

•Integrate CCS guidelines into best clinical practices

Heart Failure Guidelines

 Disclosures- J. Howlett

• Speaker and/or Consultant Fees:

– AstraZeneca, Bayer, CVRx, Medtronic, Novartis,
Servier, Pfizer, Otsuka, Merck
• Research and/or Funding for Research:
– AstraZeneca, Bayer, CVRx, Medtronic, Novartis,
Servier
– NGOs: AIHS, NIH, Canada Health Infoway

Heart Failure Guidelines

 Disclosures- Dr. Moe

• No disclosures

Heart Failure Guidelines

 Case 1
• 75 year old female presenting with a diagnosis of HF

• Progressive SOBOE and orthopnea

– Atypical chest discomfort with variable exertion, emotional stress

• Past history
– HTN
– Former smoker
– Negative workup for atypical chest pain 10 years ago

• Initial assessment:
– BP 130/82, HR 84 bpm (regular), obvious volume overload
– NT-BNP 3800 pg/mL, troponin I negative
– ECG: sinus rhythm, Q waves leads II,III, AVF, QRS duration 110 msec

Heart Failure Guidelines

Case 1

• Echocardiogram performed:
– LVEF ~25%, global hypokinesis
– LVIDd 5.8cm; LVIDs 5.1cm, EF 29%
– 2+MR
– RVSP ~ 45 mmHg

• Course in hospital over 7 days

– Diuresed 4 kg with IV furosemide, at “dry weight”
– Started on ramipril 5mg/d, and carvedilol 6.25 mg bid and MRA

Ambulatory, wondering what we are going to do??

Heart Failure Guidelines

… prepare to provide your answers!

Heart Failure Guidelines

Case 1 - What would you like to
do next?

1. Coronary angiogram

2. Myocardial perfusion imaging (persantine sestamibi)

3. Cardiac MRI

4. Referral to EP for ICD and or CRT

Heart Failure Guidelines

 Case 1 - What would you like to
do next?

1. Coronary angiogram

2. Myocardial perfusion imaging (persantine sestamibi)

3. Cardiac MRI

4. Referral to EP for ICD and or CRT

Heart Failure Guidelines

 Back to Case 1

• Angiogram reveals multivessel coronary disease

– Occluded RCA
– 80% mid LAD lesion
– 90% mid LAD lesion
– 70% OM1 and 90% OM2 lesions (medium size)

• Surgical colleague reviews the films:

– Technically graftable with good distal target vessels

– Serum creatinine stable at 120 mmol/L, GFR 51 ml/min

Heart Failure Guidelines

… prepare to provide your answers!

Heart Failure Guidelines

Case 1- Your recommended
course of action ?
1. Discharge w/a plan for titrated medical tx until angina occurs

2. Present the patient to CV surgical colleagues to consider CABG

3. Refer to interventional colleague for multivessel PCI

4. Referral for ICD/CRT

Heart Failure Guidelines

 Case 1 - Your recommended
course of action ?

1. Discharge w/ a plan for titrated medical tx until angina

occurs

2. Present the patient to CV surgical colleagues to

consider for CABG

3. Refer to interventional colleague for multivessel PCI

4. Referral for ICD/CRT

Heart Failure Guidelines

Prognostic significance of ischemic cardiomyopathy

>1200 patients with invasive evaluation for

cardiomyopathy over 15 years

Ischemic etiology is also an

independent predictor of
mortality in risk models:

Seattle Heart Failure

Model (SHFM)

Heart Failure Survival

Score (HFSS)
Levy et al, Circulation 2006
Aaronson et al, Circulation 1997

Felker et al, N Engl J Med 2000

Heart Failure Guidelines

 Surgical Treatment for Ischemic Heart
Failure – where’s the evidence?

Individual patient level meta-analysis of 7 trials

•2600 patients enrolled 1972-84

•CABG associated with mortality reduction

•39% at 5 years, 17% at 10 years

•No interaction with LV dysfunction and mortality

reduction but higher absolute benefits seen in
high risk subgroups

Yusuf et al, Lancet 2004

Heart Failure Guidelines

 Surgical Treatment for Ischemic Heart
Failure – where’s the evidence?

• In these early studies:

– 90% had angina
– 80% had normal LVEF
– 10% had arterial conduits
– Medical therapy = digoxin and
diuretics

Need to assess the benefits of revascularization in

contemporary patients with ischemic cardiomypathy
Yusuf et al, Lancet 2004

Heart Failure Guidelines

 Current Era: Surgical Treatment for
Ischemic Heart failure (STICH)

Randomized non-blinded study of surgical

revascularization:

Included patients with LVEF <35% and

CAD suitable for revascularization

Hypothesis 1:
CABG + medical rx superior to medical rx
alone

Hypothesis 2:
CABG + SVR superior to CABG alone in
patients undergoing revascularization with
anterior wall akinesis/dyskinesis

Velazquez et al, J Thorac and Cardiovasc Surg

Heart Failure Guidelines

STICH Hypothesis 1: Primary outcome

1212 patients randomized to

CABG vs medical therapy

Patients with recent MI, major illness,

significant L Main disease and
severe angina excluded

No difference in all cause mortality

seen at median 56 months follow-up

17% of patients in medical therapy

arm crossed over to surgical arm

Heart Failure Guidelines

STICH Hypothesis 1: secondary outcomes

CABG associated with reduction in cardiovascular death and combined outcome of

death or cardiovascular hospitalization
CABG also associated with 30% relative reduction in mortality in “on-treatment”
analysis (accounting for patients crossing over within 1st year of study)

Heart Failure Guidelines

 Recommendations - Revascularization
Procedures
Assessment for Coronary Disease
We recommend that coronary angiography be:

a)Performed in patients with heart failure with Strong Recommendation

ischemic symptoms, who are likely to be good Moderate Quality
candidates for revascularization. Evidence

b)Considered in patients with systolic heart Strong Recommendation

failure (LVEF < 35%) at risk of coronary artery Low Quality Evidence
disease, irrespective of angina, who may be
good candidates for revascularization.

Heart Failure Guidelines

 Recommendations - Revascularization
Procedures
Assessment for Coronary Disease
We recommend that coronary angiography be:

c) Considered in patients with systolic heart Strong Recommendation

failure and in whom non-invasive coronary Moderate Quality
perfusion testing yields features consistent with Evidence
high risk.

Values and Preferences:

These recommendations place value on the need of coronary angiography to identify coronary
artery disease amenable to revascularization. Patients with systolic heart failure due to ischemic
heart disease may derive clinical benefit from coronary revascularization even in the absence of
angina or reversible ischemia.

Heart Failure Guidelines

 Recommendations - Revascularization
Procedures
Surgical Revascularization for Patients with IHD and HF

We recommend consideration of coronary Strong Recommendation

artery bypass surgery for patients with chronic Moderate Quality
ischemic cardiomyopathy, LVEF < 35%, Evidence
graftable coronary arteries and who are
otherwise suitable candidates for surgery,
irrespective of the presence of angina in order
to improve quality of life, cardiovascular death
and hospitalization.

Heart Failure Guidelines

 Recommendations - Revascularization
Procedures
Disease Management, Referral and Peri-operative Care

We recommend that performance of coronary Strong Recommendation

revascularization procedures in patients with Low Quality Evidence
chronic heart failure and reduced LV ejection
fraction should be undertaken with a medical-
surgical team approach with experience and
expertise in high risk interventions.

Values and Preferences:

This recommendation reflects the panel preferences that high risk revascularization is likely to
best occur in higher volume centres with significant experience, known outcomes, and
similar to participating in clinical trials involving high-risk coronary revascularization.

Practical Tip:
Assessment for advanced heart failure therapies by an appropriate team should be performed
prior to revascularization in any patient with advanced heart failure

Heart Failure Guidelines

Time-varying hazard ratios for all-cause
mortality in patients randomized to
CABG or MED.

Heart Failure Guidelines

However, there is interaction
with risk factors:
• LVEF < median value (28%)
• LV end systolic index > 60 ml/M2
• 3 vessel disease

Heart Failure Guidelines

Kaplan-Meier rate estimates of all-cause mortality among
patients with 2-3 (top panel) and 0-1 (bottom panel) prognostic
factors.

Heart Failure Guidelines

Case 2
• 65 year old male patient assessed in your office
• Multiple admissions for heart failure, difficulty with
self management
• Past history
– Prior lateral wall MI, 2001 (not revascularized)
– Hypertension
– Significant COPD with FEV1 < 750 ml
– Type 2 DM. Right AKA due to severe PVD and ABI 0.22
– CKD Atrial fibrillation, previous right sided CVA
– Poor mobility, refuses walking aids, but able to perform
basic ADLs slowly

Heart Failure Guidelines

Case 2
• Currently NYHA class III, no angina
• Medications
– Carvedilol 25 mg bid, amlodipine 10mg/d, furosemide 120mg
bid, Nitro patch 1.2 mg/h, hydralazine 50mg tid, insulin,
warfarin 4 mg OD, rosuvastatin 40mg/d, Slow K 2400
mg/day, several alternative agents and periodic metolazone

• Examination: BP 90/70, HR 80 bpm, AF, enlarged

heart with normal JVP, 3+ edema and clear chest
with poor pulses.

• ECG: Atrial fibrillation, Heart rate 76, Q waves lateral

and QRS Duration 130 msec.
• Hemoglobin 95, Creat 250, GFR 19, K 5.0 and INR 2.8

Heart Failure Guidelines

 Case 2

• Patient wishes to live as long as possible but most

fearful becoming dialysis dependent

http://riskcalc.sts.org
www.euroscore.org

Heart Failure Guidelines

… prepare to provide your answers!

Heart Failure Guidelines

Case 2 - Your recommended course of
action ?
1. Angiogram and possible CABG

2. Angiogram and possible ad hoc PCI of flow-limiting lesions

3. Non-invasive perfusion/viability test

4. Referral for ICD/CRT

5. Ongoing medical optimization only

Heart Failure Guidelines

Case 2 - Your recommended course of
action ?
1. Angiogram and possible CABG
2. Angiogram and possible ad hoc PCI of flow-limiting
lesions
3. Non-invasive perfusion/viability test
4. Referral for ICD/CRT
5. Ongoing medical optimization only

Heart Failure Guidelines

The average heart failure patient
Age 75 years

Hypertension 72%

Diabetes 44%

Atrial fibrillation 31%

COPD 31%

Chronic kidney 30%

disease

Gheorghiade, Eur Heart J, 2005

Heart Failure Guidelines

Frailty and cardiac surgery

• Prospective cohort, 4 sites, ≥ 70 yrs, for CABG ± valve

– Non-emergent / urgent; no major psychiatric Dx

• 5 meter walk: if ≥6 seconds, classified as frail

• 131 pts, 75.8±4.4 yrs old

– 46% frail (usually diabetic, IADL problems)
– No correlation with STS risk score (i.e. different domains)

• Outcome: mortality, renal failure, stroke, reoperation,

prolonged ventilation, deep sternal infection
Afilalo et al J Am Coll Cardiol 2010

Heart Failure Guidelines

 Frailty and cardiac surgery

Gait speed predicts mortality/major morbidity (OR 3.05, 95%CI 1.23–7.54)

Afilalo et al J Am Coll Cardiol 2010

Heart Failure Guidelines

 Viability and LV functional recovery
after revascularization

Systematic review of non-invasive

Imaging techniques in predicting
Regional myocardial recovery

37 observational studies

Thallium, FDG PET and DSE show

high degree of sensitivity

DSE and FDG PET show greatest

specificity

Bax et al J Am Coll Cardiol 1997

Heart Failure Guidelines

Viability and survival after
revascularization

Systematic review of 24 observational studies

Evaluating relationship between death,
viability and revascularization

Allman et al, J Am Coll Cardiol 2002

Heart Failure Guidelines

STICH Analysis
Improved prognosis with viability

Analysis of 601 patients with

viability testing data available

Viability defined as ≥ 11
segments on SPECT or ≥ 5
segments on DSE imaging

Bonow et al, N Engl J Med 2011

Heart Failure Guidelines

STICH Analysis
Viability doesn’t necessarily predict improved outcomes
with surgery vs medical therapy

Bonow et al, N Engl J Med 2011

Heart Failure Guidelines

 Recommendations - Revascularization
Procedures
Disease Management, Referral and Peri-operative Care

We recommend that the decision to refer Strong Recommendation

patients with heart failure and ischemic heart Low Quality Evidence
disease for coronary revascularization should
be made on a individual basis and in
consideration of all cardiac and non- cardiac
factors which affect procedural candidacy.

Heart Failure Guidelines

 Practical Tips
Revascularization Procedures
Imaging

1.Several non-invasive methods for detection of coronary artery disease are in

widespread use
• Dobutamine stress echocardiography (DSE)
• perfusion cardiac magnetic resonance (CMR)
• cardiac positron emission testing (PET)
• nuclear stress imaging

Local factors (availability, price, expertise, practice patterns) will determine the
optimal strategy for imaging.

2.Non- invasive imaging modalities may provide critical information such as the
degree of ischemic or hibernating myocardium, and may be used to determine the
likelihood of regional and global improvement in left ventricular systolic function.

Heart Failure Guidelines

 Practical Tips (cont’d)
Revascularization Procedures
Imaging

3. Patients with heart failure, and reduced LV ejection fraction are likely to
experience significant improvement in LVEF following successful coronary
revascularization if they demonstrate:

a) Reversible ischemia or a large segment of viable myocardium (> 30% of

LV) by nuclear stress testing/ viability study;

b) Reversible ischemia or >7% hibernating myocardium on PET scanning;

c) Reversible ischemia or > 20% of LV shown as viable by DSE;

d) Less than 50% wall thickness scarring as shown by late gadolinium

enhancement by cardiac CMR.

Heart Failure Guidelines

PCI or CABG for ischemic symptoms
and heart failure? (Angina included!!)

Revasc. 4200 patients with HF

referred for angiography in Alberta 1995-2001
HR 0.50

Adjusted for baseline risk and propensity for

Med Rx revascularization

2538 underwent revascularization; 1690

managed medically

Majority of patients had ischemic syndromes

Medical management was suboptimal
CABG
Revascularization with CABG or PCI associated
PCI with improved survival

Med Rx Signal for differential outcome, favoring CABG

Tsuyuki et al, CMAJ 2006

Heart Failure Guidelines

 Recommendations - Revascularization
Procedures
Surgical Revascularization for Patients with IHD and HF

We suggest consideration of percutaneous Weak Recommendation

coronary angioplasty for patients with heart Low Quality Evidence
failure and limiting symptoms of cardiac
ischemia, and for whom CABG is not
considered appropriate.

Heart Failure Guidelines

 Practical Tips
Revascularization Procedures
Surgical Revascularization for Patients with IHD and HF

1.In the setting of heart failure, angina and single territory coronary artery disease,
PCI may be the treatment of first choice. However, PCI has not been shown to
improve outcomes for patients with chronic stable heart failure, irrespective of
underlying anatomy.

2.Urgent directed culprit vessel angioplasty continues to be the revascularization

modality of choice for patients with heart failure and acute coronary syndrome.

Heart Failure Guidelines

Figure 1. Approach to Assessment for
Coronary Artery Disease in Patients with
Heart Failure

Heart Failure Guidelines

Figure 2. Decision Regarding Coronary
Revascularization in Heart Failure

Heart Failure Guidelines

Case 3
• 77 year old female, recent admission for worsening HF, now
stable NYHA II symptoms- quite happy with current state
– Occasional exertional chest discomfort with more than usual activity
• Past history:
– Anterior wall MI, late PCI (2005)- no angina since then
– Family history of premature CAD
– Mild CRF and COPD with FEV1 of 1.9 L (no admissions)
– Dyslipidemia- longstanding
– IGT but not DM
• Medications:
– Lisinopril 20mg/d, bisoprolol 10mg/d, eplerenone 25mg/d,
ASA 81mg/d, atorvastatin 80mg/d, furosemide 20mg/d, metformin,
gliclazide, nitroglycerin patch 0.8
• ECG:
– Sinus rhythm, LBBB (QRS 144msec), multifocal PVCs

Heart Failure Guidelines

Case 3

• Cardiac SestaMibi with Exercise- 7 METS on treadmill,

limited by SOB but not angina, normal recovery
– Large area of moderate ischemia in infero-lateral territory on
persantine MIBI imaging. Large apical scar without viability and
mild cardiac dilation during exercise.

• Cardiac MRI demonstrates subendocardial scar in

inferior and lateral walls, transmural scar at apex with
large region of anterior wall akinesis, LVEF 35%

Heart Failure Guidelines

Case 3

• Coronary angiogram during hospitalization shows

progressive disease:
– Left main disease
– Moderate in stent restenosis with focal 80% lesion (mid LAD)
– 70% ostial circumflex lesion
– Diffuse flow limiting disease in dominant RCA
– All vessels graftable
– Large akinetic, apical segment of LV Angiogram- no thrombus.
– LVEDP 22 mmHG
– No valvular heart disease.

Heart Failure Guidelines

… prepare to provide your answers!

Heart Failure Guidelines

Case 3 - You recommend surgical
revascularization with concomitant:

1. Medical therapy

2. Medical therapy + CABG

3. Medical therapy + CABG + SVR

4. Medical therapy + SVR + CRT/ICD

Heart Failure Guidelines

Case 3 - You recommend surgical
revascularization with concomitant:

1. Medical therapy

2. Medical therapy + CABG

3. Medical therapy + CABG + SVR

4. Medical therapy + SVR + CRT/ICD

Heart Failure Guidelines

STICH Hypothesis 2:
CABG and CABG +SVR improved HF symptoms

1000 patients undergoing

CABG in STICH trial further
randomized to CABG alone vs
CABG + SVR

Dominant anterior wall

motion abnormality required
for inclusion

Median f/u 48 months

CABG + SVR achieved a

reduction in LV end-systolic
index by 19% vs 6% for CABG
alone

Jones et al, N Engl J Med 2009

Heart Failure Guidelines

STICH Hypothesis 2:
No difference in primary or secondary outcomes
between CABG vs CABG + SVR

All cause death or cardiovascular hospitalization All cause death

Jones et al, N Engl J Med 2009

Heart Failure Guidelines

 Recommendations - Revascularization
Procedures
Surgical Revascularization for Patients with IHD and HF

We recommend against routine performance of Strong Recommendation

the SVR or surgical ventricular restoration for Moderate Quality
patients with heart failure undergoing CABG Evidence
who have akinetic or dyskinetic LV segments.

Heart Failure Guidelines

 Practical Tips
Revascularization Procedures
Surgical Revascularization for Patients with IHD and HF

1.In highly selected cases, patients with advanced HF symptoms in association

with large areas of dyskinetic and non-viable myocardium may experience
significant clinical improvement with SVR or similar type procedures, when
performed by experienced surgeons.

2.Mitral valve repair may, when used concomitantly during CABG, may, in selected
cases, lead to clinical improvement in symptoms of heart failure.

Heart Failure Guidelines

… prepare to provide your answers!

Heart Failure Guidelines

Case 3: When should you insert
the ICD/CRT?

1. At the time of surgery

2. Before Surgery (CRT may obviate need of CABG)

3. After surgery, before discharge

4. After 3-6 months stable following surgery

Heart Failure Guidelines

Case 3: When should you insert
the ICD/CRT?

1. At the time of surgery

2. Before Surgery (CRT may obviate need of

CABG)

3. After surgery, before discharge

4. After 3-6 months stable following surgery

Heart Failure Guidelines

Timing of implantable device therapy in ischemic
cardiomyopathy
Study Comparison Included Survival
benefit with
device
CABG patch (1997) ICD vs no ICD Implanted at the -
time of CABG
MADIT II (2002) ICD vs no ICD MI > 1month; +
Revasc > 3months
DINAMITE (2004) ICD vs no ICD MI < 40 days -
COMPANION (2004) ICD vs CRT-ICD vs MI > 2months; +
medical rx Revasc >2 months +

SCD HeFT (2005) ICD vs amio vs MI > 1month; +

placebo Revasc >1 month
CARE (2005) CRT vs medical rx MI > 6 weeks +
IRIS (2009) ICD vs no ICD MI < 1 month -
RAFT (2010) CRT-ICD vs ICD Revasc >1 month +

Heart Failure Guidelines

 Recommendations - Revascularization
Procedures
Device Considerations in HF Patients Following Cardiac Surgery

We recommend that following successful Strong Recommendation

cardiac surgery, patients with HF undergo High Quality Evidence
assessment for implantable cardiac devices
within 3-6 months of optimal treatment.

We recommend that patients with implantable Strong Recommendation

cardiac devices in situ should be evaluated for Low Quality Evidence
programming changes prior to surgery and
again following surgery, in accordance with
existing CCS recommendations.

Heart Failure Guidelines

 Practical Tip
Revascularization Procedures
Device Considerations in HF Patients Following Cardiac Surgery

1.During surgical revascularization, consideration should be given to implantation

of epicardial LV leads to facilitate biventricular pacing in eligible patients who may
be candidates for cardiac resynchronization therapy, especially if the coronary
sinus anatomy is known to be unfavourable for lead placement.

Heart Failure Guidelines

Heart Failure Guidelines
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