Remote Surgical Discussion of Multivessel Coronary Artery Disease Patients Without Surgery on Site-Retrospective Insights

Overview

Journal J Clin Med

Specialty General Medicine

Date 2024 Jan 11

PMID 38202110

Authors

Ariel Roguin

Simha-Ron Meisel

Yaniv Levi

Ofer Kobo

Majd Yehia

Naama Amsalem

Rami Abu Fanne

Affiliations

Soon will be listed here.

Abstract

Objective: The heart team approach is highly advocated for in treatment decision making in patients with multivessel disease (MVD). Nevertheless, many centers lack on-site cardiac surgical services (CSS)/formal heart team. Our local alternative is of remote surgical consultation without a structured image sharing platform. In our understanding, the incidence of anatomical complete revascularization (ACR) under this daily practice, and its clinical impact, has not been discussed before.

Methods: We analyzed 477 consecutive patients who were surgically revascularized between January 2009 and March 2018 for MVD, after remote surgical consultation. Unstable, late arrival, and ST elevation patients were excluded ( = 163). ACR was considered grafting all anatomic lesions > 50%. Syntax score (SS) calculation and ACR categorization were determined by an independent interventionalist using diagnostic angiograms and available operative reports ( = 267). Patients' outcomes were assessed in relation to multiple clinical variables including troponin result and the revascularization status.

Results: Three hundred and fourteen patients were included. Mean age was 64 years, and mean SS-II was 27.3 ± 11. At the 4-year follow-up, the observed mortality (11.8% and 12.9%, with troponin-positive and -negative groups, respectively), myocardial infarction (11.8%), and repeat revascularization (9.8%) were higher than those predicted using a nomogram depicting the predicted 4-year mortality as a function of the SYNTAX II Score (5.3%, 8.8%, and 3.5%, respectively, = 0.02). ACR was reported in 33% of 267 available patients' reports. After multivariate adjustment ACR was the only variable associated with a significant increase in 4-year mortality (12.3% vs. 6.7%, < 0.05).

Conclusions: Partial revascularization in the absence of on-site CSS and a structured heart team platform is a frequent occurrence. Not surprisingly, this occurrence was associated with a higher risk for mid-term mortality. An upfront, structured, virtual, heart team interface is mandatory to particularly prioritize the completeness of revascularization when considering the optimal revascularization mode.

References

Teo K, Cohen E, Buller C, Hassan A, Carere R, Cox J . Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology/Canadian Society of Cardiac Surgery position statement on revascularization--multivessel coronary artery disease. Can J Cardiol. 2014; 30(12):1482-91. DOI: 10.1016/j.cjca.2014.09.034. View

Bansilal S, Farkouh M, Hueb W, Ogdie M, Dangas G, Lansky A . The Future REvascularization Evaluation in patients with Diabetes mellitus: optimal management of Multivessel disease (FREEDOM) trial: clinical and angiographic profile at study entry. Am Heart J. 2012; 164(4):591-9. PMC: 4536808. DOI: 10.1016/j.ahj.2012.06.012. View

Koriat A . When are two heads better than one and why?. Science. 2012; 336(6079):360-2. DOI: 10.1126/science.1216549. View

Neumann F, Sousa-Uva M, Ahlsson A, Alfonso F, Banning A, Benedetto U . 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2018; 40(2):87-165. DOI: 10.1093/eurheartj/ehy394. View

Farooq V, Serruys P, Garcia-Garcia H, Zhang Y, Bourantas C, Holmes D . The negative impact of incomplete angiographic revascularization on clinical outcomes and its association with total occlusions: the SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) trial. J Am Coll Cardiol. 2012; 61(3):282-94. DOI: 10.1016/j.jacc.2012.10.017. View

Campos C, van Klaveren D, Iqbal J, Onuma Y, Zhang Y, Garcia-Garcia H . Predictive Performance of SYNTAX Score II in Patients With Left Main and Multivessel Coronary Artery Disease-analysis of CREDO-Kyoto registry. Circ J. 2014; 78(8):1942-9. DOI: 10.1253/circj.cj-14-0204. View

Ram E, Raanani E, Klempfner R, Peled Y, Sternik L, Segev A . Midterm outcomes of patients with multivessel disease treated at centers with and without on-site cardiac surgery services. J Thorac Cardiovasc Surg. 2020; 163(5):1852-1861.e3. DOI: 10.1016/j.jtcvs.2020.04.170. View

Shaw L, Berman D, Maron D, Mancini G, Hayes S, Hartigan P . Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy. Circulation. 2008; 117(10):1283-91. DOI: 10.1161/CIRCULATIONAHA.107.743963. View

Farooq V, van Klaveren D, Steyerberg E, Meliga E, Vergouwe Y, Chieffo A . Anatomical and clinical characteristics to guide decision making between coronary artery bypass surgery and percutaneous coronary intervention for individual patients: development and validation of SYNTAX score II. Lancet. 2013; 381(9867):639-50. DOI: 10.1016/S0140-6736(13)60108-7. View

10.

Wolf M, Krause J, Carney P, Bogart A, Kurvers R . Collective intelligence meets medical decision-making: the collective outperforms the best radiologist. PLoS One. 2015; 10(8):e0134269. PMC: 4534443. DOI: 10.1371/journal.pone.0134269. View

11.

Hillis L, Smith P, Anderson J, Bittl J, Bridges C, Byrne J . 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft 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. DOI: 10.1161/CIR.0b013e31823b5fee. View

12.

Ram E, Goldenberg I, Kassif Y, Segev A, Lavee J, Shlomo N . Comparison of patients with multivessel disease treated at centers with and without on-site cardiac surgery. J Thorac Cardiovasc Surg. 2018; 155(3):865-873.e3. DOI: 10.1016/j.jtcvs.2017.09.144. View

13.

Kurvers R, Herzog S, Hertwig R, Krause J, Carney P, Bogart A . Boosting medical diagnostics by pooling independent judgments. Proc Natl Acad Sci U S A. 2016; 113(31):8777-82. PMC: 4978286. DOI: 10.1073/pnas.1601827113. View

14.

Woolley A, Chabris C, Pentland A, Hashmi N, Malone T . Evidence for a collective intelligence factor in the performance of human groups. Science. 2010; 330(6004):686-8. DOI: 10.1126/science.1193147. View

15.

Patterson T, McConkey H, Ahmed-Jushuf F, Moschonas K, Nguyen H, Karamasis G . Long-Term Outcomes Following Heart Team Revascularization Recommendations in Complex Coronary Artery Disease. J Am Heart Assoc. 2019; 8(8):e011279. PMC: 6507188. DOI: 10.1161/JAHA.118.011279. View

16.

Yamasaki M, Abe K, Horikoshi R, Hoshino E, Yanagisawa H, Yoshino K . Enhanced outcomes for coronary artery disease obtained by a multidisciplinary heart team approach. Gen Thorac Cardiovasc Surg. 2019; 67(10):841-848. DOI: 10.1007/s11748-019-01108-4. View

17.

Fihn S, Blankenship J, Alexander K, Bittl J, Byrne J, Fletcher B . 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice.... J Am Coll Cardiol. 2014; 64(18):1929-49. DOI: 10.1016/j.jacc.2014.07.017. View

18.

Rashid M, Ludman P, Mamas M . British Cardiovascular Intervention Society registry framework: a quality improvement initiative on behalf of the National Institute of Cardiovascular Outcomes Research (NICOR). Eur Heart J Qual Care Clin Outcomes. 2019; 5(4):292-297. DOI: 10.1093/ehjqcco/qcz023. View

19.

Garcia S, Sandoval Y, Roukoz H, Adabag S, Canoniero M, Yannopoulos D . Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies. J Am Coll Cardiol. 2013; 62(16):1421-31. DOI: 10.1016/j.jacc.2013.05.033. View

20.

Tsang M, Schwalm J, Gandhi S, Sibbald M, Gafni A, Mercuri M . Comparison of Heart Team vs Interventional Cardiologist Recommendations for the Treatment of Patients With Multivessel Coronary Artery Disease. JAMA Netw Open. 2020; 3(8):e2012749. PMC: 7417969. DOI: 10.1001/jamanetworkopen.2020.12749. View