kims presentation web edit
TRANSCRIPT
2
Plan
• Who am I?
• Surgical revascularisation in stable ischaemic heart disease
– PCI or CABG
– Special circumstances
– Off-pump or On-pump
• Cardiac surgery at KIMS
– Who, What, When, Where
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Who am I?
• Cardiac Surgeon
– Papworth Hospital and Royal Brompton Hospital
– Consultant since 2003
• Essex Cardiothoracic Centre 2007 (NEW SERVICE)
– Clinical Governance Lead 2007 to 2013
– Surgical Lead 2013 to date
– SCTS Unit Representative
– CQC Specialist Advisor
• Lead Clinician at The Keyhole Heart Clinic
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Death rates with medical therapy
2013 ESC Guidelines
The more severe the coronary disease the less likely medical therapy is effective
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Cardiac mortality and extent of ischaemia
2013 ESC Guidelines
Presence of ischaemia is also important
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PCI versus CABG
• More than 20 trials of PCI versus CABG – No survival benefit
• <10% eligible population
• 0ne-/two- vessel disease
• Normal ventricular function
• Propensity matched Registry data – Consistent survival benefit for surgery
• Registries can be susceptible to confounding
• SYNTAX TRIAL – ‘all comers’ trial
• Benefit of surgery over PCI in certain subgroups
• Higher incidence of repeat procedures in PCI group
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Special Situations
• Diabetes
– Complex lesions often predicate a preference for surgery especially in multi-vessel disease
• Elderly
– Balance of risk benefit ratio and influence of prognosis becomes difficult to establish
• Chronic renal disease
– Higher risk of renal injury associated with surgery
• Hybrid therapies (MIDCAB and PCI)
– Rebalancing between evidence base and patient preference
MIDCAB / MULTI-MIDCAB
• Acc Left Minithoracotomy(No costal cartilage or bone excision)
Lima to LAD
95% 10 year patency
Home 3.3 days versus 8 days for sternotomy
(more than £1000 cost saving per case)
Ideal patients:Single LAD lesion
Some multi-vessel lesions
Hybrid revascularisation
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Off-Pump or On-Pump
• Off-Pump surgery performed in 20% of CABG patients
• Polarised views (Asia – 60-100% performed Off-pump)
• Afilalo et al Eur Heart J 2012
– Metanalysis of 59 trials (9000pts)
• Significant reduction in stroke in Off-Pump group (1.4 v 2.1; rr0.77)
• Lamy et al N Engl J Med 2012
– Randomised trial looked at 30 day outcomes
• Off-Pump group bled less, required reduced transfusions, and suffered reduced respiratory and renal complications
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Off-Pump or On-Pump continued
• Several large patient Registries suggest:
– Reduction in mortality, stroke and major morbidities
– Less complete revascularisation
– increased incidence of repeat procedures reducing the early mortality benefit
• Real reduction in application of Off-pump surgery since Lamy 2012
• MIDCAB remains extremely attractive either as isolated LAD therapy or
as part of a hybrid protocol with PCI.
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Summary
• High ischaemic burden indicates prognostic need for revascularisation over
medical therapy
• PCI and CABG offer a complimentary package of interventional and surgical
therapies for the correction of myocardial ischaemia
• Off-pump vs On-pump debate continues
• Hybrid revascularisation may offer a rebalancing of clinical benefit and
patient preference
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Cardiac Surgery at KIMS
• Superb Infrastructure (award winning building; superb theatre space and
specifications; spacious rooms; infection control built in to the design)
• Diagnostic capabilities (CT and MRI; onsite Cardiology support)
• Proximity of services for patients and families is of immeasurable benefit
• CONSULTANT LED SERVICE
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Surgeons - Deployment
• No existing surgical platform in Kent
– Multi-professional team based care delivery
• Daily Consultant ward rounds
• Daily MDT decision making
• Rapid deployment of clinical care
• Combined experiences from three major centres for Cardiac Surgery covering
the whole of the South of England East to West
• Over 90 combined years of experience in cardiac surgery
• Surgical backup for Percutaneous Intervention ON-SITE
– Unique for any PCI service in Kent and in line with infrastructure design found in most tertiary centres
SCTS outcome data
Data For period April 2010 - March 2013
Risk adjusted In Hospital Mortality Rate
National Average
Ris
k -A
dju
ste
d M
ort
alit
y R
ate
Number of operations
1.63%1.54%
2.79%
2.21%
3.67%
2.83%
2.43%
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
3.50%
4.00%
0 1,000 2,000 3,000 4,000 5,000 6,000
ECTC
Papworth
Royal Brompton
Barts
Harefield
Guys and StThomas
UCLH
Essex Cardiothoracic Centre
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Surgeons - Expertise
• All types of adult cardiac surgery
• Complete arterial grafting (Beating heart and standard CPB)
• Aortic and Mitral valve repair / replacement
• Surgery for Atrial Fibrillation
• Keyhole heart surgery (MIDCAB : Mini AVR : Mini Mitral)
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Standard Approach Ministernotomy Minithoracotomy
BESPOKE THERAPIES IN KEYHOLE SURGERY
CURRENTLY AVAILABLE AT KIMS
The Keyhole Heart ClinicTM
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Minithoracotomy
No broken boneHeals in 10 daysLess painEarly return to activitiesFacilitates later surgeryCosmetically more appealing
Sternotomy
Broken bone12 weeks to heal
AHA/ACC Guidelines
Chronic Severe Mitral Regurgitation
No Symptoms
Class I
LV Dysfunction
Class IIa
New Onset AFPulmonary HT
Class IIaMitral Valve repair may be performed in asymptomaticpatients if performed by an experienced surgical team andThe likelihood of successful MV repair is > 90%
Keyhole approach makes
early surgery more
acceptable to patients
Additional Resources offered by The KHC
www.thekeyholeheartclinic.com
https://m.youtube.com/channel/UC-
WPe3ECVAApb_XiI-s5Avg
Practice based education and training for Primary
care clinicians an their teams
Clinical partnership in the cardiac patient pathways
especially screening