The Role of the Heart Team in Patients with Diffuse Coronary Artery Disease Undergoing Coronary Artery Bypass Grafting
Background In patients eligible for coronary artery bypass grafting, no data assess the importance of the Heart Team in programming the best surgical strategy for patients with diffuse coronary artery disease (CAD). This study aims to determine the contribution of the Heart Team in predicting the feasibility of coronary artery bypass graft and angiographic surgical success in these patients based on visual angiographic analysis.
Methods Patients with diffuse and severe CAD undergoing incomplete coronary artery bypass graft surgery were prospectively included. One-year postoperative coronary angiograms were obtained to evaluate graft occlusion. Two clinical cardiologists, two cardiovascular surgeons, and one interventional cardiologist retrospectively analyzed preoperative angiograms. A subjective scale was applied at a single moment to quantify the chance of successful coronary artery bypass grafting for each coronary territory with anatomical indication for revascularization. Based on individual scores, the Heart Team's and the specialists' scores were calculated and compared.
Results The examiners evaluated 154 coronary territories, of which 85 (55.2%) were protected. The Heart Team's accuracy for predicting the angiographic success of the surgery was 74.9%, almost equal to that of the surgeons alone (73.2%). Only the interventional cardiologist predicted left anterior descending territory grafting success. The Heart Team had good specificity and reasonable sensitivity, and the surgeons had high sensitivity and low specificity in predicting angiographic success.
Conclusion The multispecialty Heart Team achieved good accuracy in predicting the angiographic coronary artery bypass graft success in patients with diffuse CAD, with a high specificity and reasonable sensitivity.
Substantial contributions to the conception or design of the work (L. O. C. D., A. C. P., L. A. M. C., L. H. W. G.), or the acquisition and analysis (A. C. P., N. T. P., R. C., F. G., L. A. O. D.), or interpretation of data for the work (L. O. C. D., A. C. P., M. S. B., L. H. W. G.).
Drafting the work or revising it critically for important intellectual content (L. O. C. D., A. C. P., N. T. P., M. S. B., R. C., F. G., L. A. O. D., L. A. M. C., L. H. W. G.).
Final approval of the version to be published (L. O. C. D., A. C. P., N. T. P., M. S. B., R. C., F. G., L. A. O. D., L. A. M. C., L. H. W. G.
Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved (L. O. C. D., A. C. P., N. T. P., M. S. B., R. C., F. G., L. A. O. D., L. A. M. C., L. H. W. G.).
Eingereicht: 05. November 2019
Angenommen: 28. August 2020
20. November 2020 (online)
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- 1 Thyregod HG, Holmberg F, Gerds TA. et al. Heart Team therapeutic decision-making and treatment in severe aortic valve stenosis. Scand Cardiovasc J 2016; 50 (03) 146-153
- 2 Heuts S, Olsthoorn JR, Hermans SMM. et al. Multidisciplinary decision-making in mitral valve disease: the mitral valve heart team. Neth Heart J 2019; 27 (04) 176-184
- 3 Rea CW, Wang TKM, Ruygrok PN. et al. Characteristics and outcomes of patients with severe aortic stenosis discussed by the multidisciplinary “Heart Team” according to treatment allocation. Heart Lung Circ 2020; 29 (03) 368-373
- 4 Bakelants E, Belmans A, Verbrugghe P. et al. Clinical outcomes of heart-team-guided treatment decisions in high-risk patients with aortic valve stenosis in a health-economic context with limited resources for transcatheter valve therapies. Acta Cardiol 2019; 74 (06) 489-498
- 5 Amrane H, Porta F, Van Boven AV, Kappetein AP, Head SJ. A meta-analysis on clinical outcomes after transaortic transcatheter aortic valve implantation by the Heart Team. EuroIntervention 2017; 13 (02) e168-e176
- 6 Reichenspurner H. The treatment of heart failure: an ideal challenge for the heart team. Eur J Cardiothorac Surg 2019; 55 (Suppl. 01) i1-i2
- 7 Sinning JM, Welz A, Nickenig G. The heart team in planning and performance of revascularization: ESC guidelines versus clinical routine [in German]. Herz 2016; 41 (07) 562-565
- 8 Patterson T, McConkey HZR, Ahmed-Jushuf F. et al. Long-term outcomes following Heart Team revascularization recommendations in complex coronary artery disease. J Am Heart Assoc 2019; 8 (08) e011279
- 9 Domingues CT, Milojevic M, Thuijs DJFM. et al. Heart Team decision making and long-term outcomes for 1000 consecutive cases of coronary artery disease. Interact Cardiovasc Thorac Surg 2019; 28 (02) 206-213
- 10 Yanagawa B, Puskas JD, Bhatt DL, Verma S. The coronary heart team. Curr Opin Cardiol 2017; 32 (05) 627-632
- 11 McNeil M, Buth K, Brydie A, MacLaren A, Baskett R. The impact of diffuseness of coronary artery disease on the outcomes of patients undergoing primary and reoperative coronary artery bypass grafting. Eur J Cardiothorac Surg 2007; 31 (05) 827-833
- 12 Rocha AS, Dassa NP, Pittella FJ. et al. High mortality associated with precluded coronary artery bypass surgery caused by severe distal coronary artery disease. Circulation 2005; 112 (09) I328-I331
- 13 Goldman S, Zadina K, Moritz T. VA Cooperative Study Group #207/297/364. et al. Long-term patency of saphenous vein and left internal mammary artery grafts after coronary artery bypass surgery: results from a Department of Veterans Affairs Cooperative Study. J Am Coll Cardiol 2004; 44 (11) 2149-2156
- 14 Mohr FW, Rastan AJ, Serruys PW. et al. Complex coronary anatomy in coronary artery bypass graft surgery: impact of complex coronary anatomy in modern bypass surgery? Lessons learned from the SYNTAX trial after two years. J Thorac Cardiovasc Surg 2011; 141 (01) 130-140
- 15 Sianos G, Morel MA, Kappetein AP. et al. The SYNTAX Score: an angiographic tool grading the complexity of coronary artery disease. EuroIntervention 2005; 1 (02) 219-227
- 16 Kinoshita T, Asai T, Suzuki T. Preoperative SYNTAX score and graft patency after off-pump coronary bypass surgery. Eur J Cardiothorac Surg 2013; 44 (01) e25-e31
- 17 Shiono Y, Kubo T, Honda K. et al. Impact of functional focal versus diffuse coronary artery disease on bypass graft patency. Int J Cardiol 2016; 222: 16-21
- 18 Graham MM, Chambers RJ, Davies RF. Angiographic quantification of diffuse coronary artery disease: reliability and prognostic value for bypass operations. J Thorac Cardiovasc Surg 1999; 118 (04) 618-627
- 19 Jalal A. An objective method for grading of distal disease in the grafted coronary arteries. Interact Cardiovasc Thorac Surg 2007; 6 (04) 451-455
- 20 Neumann FJ, Sousa-Uva M, Ahlsson A. ESC Scientific Document Group. et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2019; 40 (02) 87-165
- 21 Tura BR, Martino HF, Gowdak LH. et al. Multicenter randomized trial of cell therapy in cardiopathies - MiHeart Study. Trials 2007; 8: 2
- 22 Jolicoeur EM, Cartier R, Henry TD. et al. Patients with coronary artery disease unsuitable for revascularization: definition, general principles, and a classification. Can J Cardiol 2012; 28 (02) S50-S59
- 23 Kwon O, Park DW, Park SJ. Completeness of revascularization as a determinant of outcome: a contemporary review and clinical perspectives. Can J Cardiol 2019; 35 (08) 948-958
- 24 Head SJ, Kaul S, Mack MJ. et al. The rationale for Heart Team decision-making for patients with stable, complex coronary artery disease. Eur Heart J 2013; 34 (32) 2510-2518
- 25 Holmes Jr DR, Rich JB, Zoghbi WA, Mack MJ. The heart team of cardiovascular care. J Am Coll Cardiol 2013; 61 (09) 903-907
- 26 Chu D, Anastacio MM, Mulukutla SR. et al. Safety and efficacy of implementing a multidisciplinary heart team approach for revascularization in patients with complex coronary artery disease: an observational cohort pilot study. JAMA Surg 2014; 149 (11) 1109-1112
- 27 Sanchez CE, Dota A, Badhwar V. et al. Revascularization heart team recommendations as an adjunct to appropriate use criteria for coronary revascularization in patients with complex coronary artery disease. Catheter Cardiovasc Interv 2016; 88 (04) E103-E112
- 28 Pavlidis AN, Perera D, Karamasis GV. et al. Implementation and consistency of Heart Team decision-making in complex coronary revascularisation. Int J Cardiol 2016; 206: 37-41
- 29 Thourani VH, Edelman JJ, Satler LF, Weintraub WS. Surgical aortic valve replacement in the transcatheter aortic valve replacement era: implications for the heart Team. JACC Cardiovasc Interv 2018; 11 (21) 2157-2159
- 30 Dourado LO, Bittencourt MS, Pereira AC. et al. Coronary artery bypass surgery in diffuse advanced coronary artery disease: 1-year clinical and angiographic results. Thorac Cardiovasc Surg 2018; 66 (06) 477-482
- 31 Pereira AC, Lopes NH, Soares PR. et al. Clinical judgment and treatment options in stable multivessel coronary artery disease: results from the one-year follow-up of the MASS II (Medicine, Angioplasty, or Surgery Study II). J Am Coll Cardiol 2006; 48 (05) 948-953
- 32 Sanchez CE, Badhwar V, Dota A. et al. Practical implementation of the coronary revascularization heart team. Circ Cardiovasc Qual Outcomes 2013; 6 (05) 598-603