Heart Team approach Is Valuable When Making Complex Cardiac Treatment Decisions

10 Jul Heart Team approach Is Valuable When Making Complex Cardiac Treatment Decisions

Researchers at University of Pittsburgh Medical Center in Pennsylvania say that coronary artery bypass grafting (CABG) surgery may be the best treatment option for patients with more than one blocked artery, according to an article published in the Annals of Thoracic Surgery, published in Elsevier. The study reinforces the value of the heart team approach when making treatment decisions, the say.

Cardiac Surgery Photo Credit: Washington.VA.gov

“Our data demonstrate a significant mortality benefit with CABG over percutaneous coronary intervention (PCI), and this benefit is consistent across virtually all major patient groups, suggesting that CABG should be considered in broader patient populations, not just in cases of patients with diabetes and left ventricular dysfunction, which is, what is commonly practiced,” said Suresh R. Mulukutla, M.D., from the University of Pittsburgh Medical Center (UPMC) in Pennsylvania, in a May 2 statement announcing the study’s findings.

Comparing CABG and PCI Procedures

The UPMC researchers examined data from two major clinical outcomes registries for heart patients–The Society of Thoracic Surgeons (STS) National Database, and the American College of Cardiology Foundation National Cardiovascular Data Registry (NCDR). They identified patients with multivessel coronary artery disease who underwent CABG or PCI between 2010 and 2018 at UPMC. Those who met the eligibility criteria were separated into two groups–CABG and PCI–each including 844 patients. The analyses focused on outcomes for mortality, readmission and revascularization, they say.

The researchers found that the estimated one-year mortality for patients in the CABG group was 7.2 percent, as compared to 11.5 percent the PCI group. The CABG group also experienced lower risk of hospital readmission (28.1 percent versus 38.4 percent) and revascularization (1.0 percent versus 6.7 percent) than the PCI group.

“A major point in the study is the focus on the current era of revascularization with the most currently available stents,” noted Dr. Mulukutla. “This research is really a modern, ‘real-world’ experience. While randomized clinical trials are clearly important, real-world analyses also can be very instructive because they provide insights on how we are making clinical decisions. For instance, the last several years have seen a shift toward more PCI over CABG. While there may be valid reasons for this, our data–which show CABG outperforming PCI in almost every patient group–should push us to further discuss all of the options,” he said.

PCI, called angioplasty, is a nonsurgical procedure that uses a thin, flexible catheter placed into an artery in the groin or arm. A balloon on the end of the catheter is positioned in the narrowed coronary artery and inflated to open-up the blockage. On the other hand, a stent is a metal mesh tube that is left behind to help keep the artery from collapsing. Drugs attached to the stent help prevent the body from reacting to the stent and shutting down the artery again.

CABG, the most commonly performed heart operation in the United States, is designed to bypass the blockages in the coronary arteries to create a new pathway for blood flow to the heart.

During this medical procedure, the surgeon removes a healthy blood vessel, usually from the leg, arm, chest or abdomen, and connects it to the other arteries (usually the aorta) in the heart. This allows blood flow to “bypass” or go around the diseased or blocked portion of the coronary artery.

Making the Right Decision Not Always Straightforward

According to Dr. Mulukutla, the decision between open heart surgery and PCI for treatment of patients with multiple narrowed arteries is not always straightforward. He calls for these more complex medical treatment d decisions to be made with the guidance of a heart care team.

“Both cardiac surgery and stenting have roles among patients with coronary artery disease,” said.

Dr. Mulukutla. “Because of this, it is important to deliberate carefully with the help of a heart team. The team can ensure that a multidisciplinary approach is used when offering recommendations to patients and assisting them in making informed decisions,” he says.

A heart care team generally includes cardiothoracic surgeons and cardiologists and other health care providers such as primary care physicians, physician assistants, nurse practitioners, imaging specialists and anesthesiologists. This approach leverages the expertise of these advanced practice providers in an effort to improve the efficiency and advance the quality of care for patients.

Dr. Mulukutla says that with revascularization, heart team input is often limited because PCI can be completed at the time of a patient’s diagnostic procedure. When this happens, the physicians do not have the opportunity to discuss the spectrum of possible treatment options. As a result, the practical and consistent use of the heart team for decision-making in the treatment of patients with complex coronary artery diseases is lacking.

“We are working to better facilitate a heart team approach and overcome some of the limitations given the current infrastructure of how these decisions are made,” says Dr. Mulukutla.