Chapters Transcript Video CABG is the More Appropriate Therapy in Most Scenarios Cardiac surgeon Jennifer Lawton discusses circumstances that would warrant coronary artery bypass graft surgery versus alternatives. Share Fast Facts Coronary artery bypass graft surgery may be a better option. Learn more. Click to Tweet So when we talk to patients with coronary artery disease, which is when they have blockages in the arteries that supply the heart with blood. We often recommend therapy that maybe medical therapy per cutaneous intervention, which is involves stents or surgical therapy, which is what I do. I'm a heart surgeon. So I do coronary artery bypass graft surgery, which is where we provide more blood flow to the heart itself by sewing new blood vessels around the blockages. When we discussed the different therapy options with patients, we try to guide the patient into making the most appropriate decision with their involvement in terms of risks and benefits for the procedures, patients who have multi vessel disease, meaning more than two or three blood vessels that are blocked, particularly the blood vessel in the front of the heart, the left anterior descending coronary artery, which is the most important artery on the front of the heart. So a couple blood vessels that are blocked with this most important blood vessel or this most important blood vessel in another blood vessel. Those patients that have multi vessel disease, we know do better in the long run with coronary artery bypass graft surgery in certain situations. So if we took 1000 patients with multi vessel disease and flipped a coin and said you're going to have per cutaneous intervention or multiple stents or you're going to have bypass surgery, how would they do? People who have diabetes, we know from many large trials do better with coronary artery bypass grafting surgery as the choice given that option, it's a little more invasive upfront, it's a big operation and it's a recovery period. Um, but those patients we know over time have prolonged survival, reduce risk of dying of a heart attack and relief of symptoms. In the same situation, if those patients undergo multi vessel per cutaneous intervention or stenting, we know that they will get relief of symptoms, but they're often back again for repeat revascularization procedures or other therapies and they don't get the protection and the prolonged survival, particularly if we use coronary artery bypass surgery with arterial grafts, those blood vessels that are inside the chest wall are in the arm because we know those stay open longer than the vein from the patient's leg. Other situations where coronary artery bypass surgery would be better is in patients that have a reduced left ventricular ejection fraction, or the amount of blood if you if you will, that the heart can pump out with each beat if that has reduced over time due to blockages in the coronary arteries. We know again that those patients do better with coronary artery bypass surgery. Similarly, in patients who are unable to adhere afford or stay on a schedule of anti platelet therapy, which we call dual anti platelet therapy, which includes aspirin and another anti platelet agents for at least three months and sometimes up to a year. We know that stenting in those patients is not the right option. So we do refer those patients to coronary artery bypass surgery, bypass surgery as we know, is a recovery period of about seven days average in the hospital and no lifting or heavy driving for four weeks. Whereas PC tends to be or stenting tends to be a shorter recovery time. There are also patients with abnormalities of the chest wall, radiation to the chest or perhaps a redo operation. In those patients we may discuss in what's called heart team discussion that those patients may be better served with stenting. So what is a hard team discussion? So hard team discussion is recommended by all of our organizations, including the american Heart Association and in the guidelines, it is recommended to have this discussion that involves the patient, the patients, caregivers and family members and also a cardiologist that is an interventional ist, a cardiologist that's not an interventional ist and a cardiac surgeon. And sometimes in that discussion we involve other people um in terms of the patient's medical care if they have significant uncle logic problems, we may involve the oncologist or other people to help us make the right decision to guide the patient to the appropriate therapy. These are the types of decisions that we're making here at johns Hopkins. If we look at complex decisions with the heart team in patients who have coronary artery disease. We may look at some of the more recent studies that have come out in patients comparing the different treatment options. We know that several studies have come out from the since the time of the American Heart Association guidelines in 2011 and the european guidelines on coronary revascularization came out in 2019. And since that time, we've seen studies such as the Ischemia trial or the Excel trial, It's important to delve into the details of these trials to determine what is the best therapy for each individual patient. We often have a hard team discussion regarding, for example, patients that may have been enrolled in the Excel trial which may be left main disease, coronary artery patients who may have complex disease or may have other comorbidities. And in that sense, we would involve a hard team to decide which is the best revascularization option in the ischemia trial. We may also consider medical therapy because that trial randomized patients to guideline directed medical therapy versus an initial invasive approach. Now, whereas the majority of patients in the trial had a revascularization strategy of PC I or stenting. We know that a very small proportion had coronary artery bypass surgery. But as you know, in the results of that trial, there was very little difference over time in mortality. So we have to weigh all the options when we talk to patients about coronary revascularization and we do that here in our heart team approach and are difficult case conference at johNS Hopkins Created by Related Presenters Jennifer Lawton, MD Chief, Division of Cardiac SurgeryProfessor of Surgery Expertise: Aortic Aneurysms, Aortic Dissections, Aortic Surgery, Cardiac Care, Cardiac masses, Cardiac Surgery, Cardiothoracic Surgery, Cardiovascular Diseases, Cardiovascular Surgery, Coronary Artery Bypass Graft Surgery (CABG), Coronary ... View full profile
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