- Email: [email protected]
Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Severe Left Ventricle Dysfunction
1888
CORRESPONDENCE
2. Siddiqui J, Brizard CP, Galati JC, et al. Surgical valvotomy and repair for neonatal and infant congenital aortic stenosis achieves better results than interventional catheterization. J Am Coll Cardiol 2013;62:2134–40. 3. Agnoletti G, Raisky O, Boudjemline Y, et al. Neonatal surgical aortic commissurotomy: predictors of outcome and long-term results. Ann Thorac Surg 2006;82:1585–92. 4. Pan XB, Zhang H, Hu SS, et al. Efficacy of hybrid balloon valvuloplasty via sternotomy for treating low-body weight infants with severe congenital valvular aortic stenosis. Zhonghua Xin Xue Guan Bing Za Zhi 2012;40:681–3.
Reply To the Editor: We thank Ma and colleagues [1] for their comments on our article [2]. The Fuwai Hospital team is wondering which approach to adopt in neonates with critical aortic valve stenosis presenting with very poor left ventricular function [1]. In Melbourne, we opted for surgery and still believe that surgery is superior to balloon valvuloplasty in these extreme cases because our previously reported mortality of 3% for neonates predominantly undergoing surgery over a period of 30 years seems inferior to published results for balloon valvuloplasty [3, 4]. To further investigate this matter we reviewed our recent experience. From 2009 to today we operated on 24 neonates (<3 months). There were no deaths, and 2 patients required extracorporeal membrane oxygenation urgently on admission. Both were operated on the following day. The chest, which was left open at the time of surgery, was closed on day 1 and day 2 postoperatively. They had an uneventful course thereafter. We believe that contemporary techniques of aortic valve repair are superior to balloon valvuloplasty because the majority of these valves are dysplastic and the bulk of fibrotic tissue is not removed by dilatation. We also believe that these techniques allow us to maintain valvular competence. The excellent outcomes of these results push us to maintain a strategy of surgery for critical aortic stenosis even in patients with poor ventricular function. Finally, we have urged caution against the use of the Ross procedure as a bailout for failed balloon valvuloplasty [5]. The mortality of such a rescue procedure has been evaluated to be higher than 50% [6]. In this perspective, we believe that the approach of the Fuwai hospital may be cautious. Performing the balloon dilatation procedure with an open chest in a surgical environment is adding safety to what remains a dangerous procedure in compromised neonates. Yves d’Udekem, MD, PhD Christian P. Brizard, MD Russell Nunn, MSc, BBSc Igor E. Konstantinov, MD, PhD
MISCELLANEOUS
Department of Cardiac Surgery The Royal Children’s Hospital Melbourne Flemington Rd Parkville, Melbourne, Victoria, Australia 3052 e-mail: [email protected] and Murdoch Childrens Research Institute Melbourne, Australia and Department of Paediatrics Faculty of Medicine The University of Melbourne, Australia
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2014;98:1886–91
References 1. Ma K, Pan X, Li S. The approach to a critical aortic stenosis patient with severely depressed left ventricular function (letter). Ann Thorac Surg 2014;98:1887–8. 2. Siddiqui J, Brizard CP, Konstantinov IE, et al. Outcomes after operations for bicuspid aortic valve disease in the pediatric population. Ann Thorac Surg 2013;96:2175–83. 3. Siddiqui J, Brizard CP, Galati JC, et al. Surgical valvotomy and repair for neonatal and infant congenital aortic stenosis achieves better results than interventional catheterization. J Am Coll Cardiol 2014;62:2134–40. 4. McCrindle BW, Blackstone EH, Williams WG, et al. Are outcomes of surgical versus transcatheter balloon valvotomy equivalent in neonatal critical aortic stenosis? Circulation 2001;104(12 Suppl 1):I152–8. 5. Konstantinov IE, d’Udekem Y, Brizard CP. Ross operation or aortic valve repair in neonates and infants? J Thorac Cardiovasc Surg 2014;148:362–3. 6. Kadner A, Raisky O, Degandt A, et al. The Ross procedure in infants and young children. Ann Thorac Surg 2008;85:803–8.
Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Severe Left Ventricle Dysfunction To the Editor: We read with great interest the article by Nagendran and colleagues [1] in which they compared the outcomes of patients with ischemic heart failure undergoing coronary artery bypass grafting (CABG) operations vs percutaneous coronary intervention (PCI). In the largest study of its kind to date, they showed that there was a long-term survival advantage up to 15 years among patients who underwent CABG compared with patients who underwent PCI. This observational analysis of data from a large Canadian registry solidifies the conclusions of the American College of Cardiology Foundation-The Society of Thoracic Surgeons Collaboration on the Comparative Effectiveness of Revascularization Strategies (ASCERT) study [2]. A survival advantage with CABG was observed at 4 years, and this finding was consistent in several subgroups, including patients with severe left ventricle dysfunction [2]. We have two specific concerns regarding this article. First, the assessment of myocardial viability in this subset of patients using multiple imaging strategies, such as single-photon emission computed tomography or low-dose dobutamine echocardiography, is generally performed to predict enhancement in left ventricular function. It would be interesting to know whether the authors possessed preoperative imaging data regarding myocardial viability. Second, the choice between CABG and PCI is based on a thorough evaluation of coronary lesions, comorbidities, and the presence or absence of significant valvular disease or a large left ventricle aneurysm. In the later situation, the guidelines on myocardial revascularization from the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery [3] recommend a left ventricle aneurysmectomy during CABG in patients presenting predominantly with heart failure symptoms. What was the rate of patients in the present study referred solely with heart failure symptoms? Did they include patients with concurrent surgical ventricle reconstruction? Finally, we would like to point out that there is probably a mistake in Table 1, because the authors stated, “that patients undergoing PCI had a higher prevalence of stable angina,” whereas in Table 1 we can easily recognize that stable angina was more frequent in the CABG group (22.5%) than in the PCI group (12.4%).
0003-4975/$36.00
Ann Thorac Surg 2014;98:1886–91
Department of Cardio-thoracic Surgery University Hospital of Poitiers 2 Rue de la Miletrie 86021 Poitiers Cedex, France e-mail: [email protected]
References 1. Nagendran J, Norris CM, Graham MM, et al. Coronary revascularization for patients with severe left ventricular dysfunction. Ann Thorac Surg 2013;96:2038–44. 2. Weintraub WS, Grau-Sepulveda MV, Weiss JM, et al. Comparative effectiveness of revascularization strategies. N Engl J Med 2012;366:1467–76. 3. Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS); European Association for Percutaneous Cardiovascular Interventions (EAPCI), , Kolh P, Wijns W, Danchin N, et al. Guidelines on myocardial revascularization. Eur J Cardiothorac Surg 2010;38(Suppl):S1–52.
Reply To the Editor: Thank you for the opportunity to reply to the comments of HajjChahine and colleagues [1] regarding our retrospective analysis [2] of patients with reduced ventricular function undergoing revascularization. The assessment of myocardial viability is an important topic that has received much attention in the literature recently. Myocardial viability data were not included in our study because the data were not available in the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease database. An extensive record review would have been the only option to extract these data, but given the time span of the study (1995 to 2008) and the sample size (n ¼ 2,926), this was not considered feasible. Given the recent results of the Surgical Treatment for Ischemic Heart Failure trial [3], which demonstrate that inducible ischemia in patients with coronary artery disease and severe left ventricular dysfunction does not discriminate those who will benefit from coronary artery bypass grafting vs medical therapy, further review of our data would likely make little contribution to the literature. The ongoing debate regarding the role of myocardial viability and selection for coronary artery bypass grafting is reflected by the disparate recommendations of various guidelines, with the 2012 European Society of Cardiology guidelines [4] placing greater importance on the role of myocardial viability vs the 2013 American College of Cardiology Foundation/American Heart Association guidelines [5] placing less role on myocardial viability. With respect to surgical ventricular reconstruction, we do not have data on those patients referred solely with heart failure symptoms and who underwent concurrent surgical ventricle reconstruction. Given the results of the Surgical Treatment for Ischemic Heart Failure trial [6], it is unlikely that we would have seen a significant benefit. These results are reflected in a more conservative approach to surgical ventricular reconstruction in the recent European Society of Cardiology and American College of Cardiology Foundation/American Heart Association guidelines [4, 5]. Regarding Table 1, primary data reanalyzed: Table 1 is correct but the text requires correction. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
1889
We hope the questions raised have been addressed adequately and thank the editor for the opportunity to comment on our work. Steven R. Meyer, MD, PhD Division of Cardiac Surgery Department of Surgery University of Alberta 2D4.37 Walter Mackenzie Health Sciences Centre 8440-112 St Edmonton, AB T6G 2B7, Canada e-mail: [email protected]
References 1. Hajj-Chahine J, Clerin P, Corbi P. Percutaneous coronary intervention versus coronary artery bypass grafting in severe left ventricle dysfunction (letter). Ann Thorac Surg 2014;98:1888–9. 2. Nagendran J, Norris CM, Graham MM, et al. Coronary revascularization for patients with severe left ventricular dysfunction. Ann Thorac Surg 2013;96:2038–44. 3. Panza JA, Holly TA, Asch FM, et al. Inducible myocardial ischemia and outcomes in patients with coronary artery disease and left ventricular dysfunction. J Am Coll Cardiol 2013;61:1860–70. 4. McMurray JJ, Adamopoulos S, Anker SD, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012;33:1787–847. 5. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013;128:1810–52. 6. Jones RH, Velazquez EJ, Michler RE, et al. Coronary bypass surgery with or without surgical ventricular reconstruction. N Engl J Med 2009;360:1705–17.
About the Impact of Extracardiac Vascular Disease on Vein Graft Failure To the Editor: Congratulations to the authors for this valuable study [1]. Using data from the Project of Ex-vivo Vein Graft Engineering via Transfection IV (PREVENTIV) trial, authors investigated the 1-year angiographic follow-up and 5-year clinical outcomes (death, myocardial infarction, and revascularization) in patients with and without extracardiac vascular disease. They assessed the risk of vein graft failure. We have some concerns about the methodology of their report. The term “clinical outcomes” included all-cause death, cerebrovascular accidents/stroke, documented myocardial infarction, and any repeat revascularization. As one can easily see, these included lethal and nonlethal events together. This is a common mistake by many authors that equalizes lethal and nonlethal and biased and unbiased events. Which patients did the investigators include? What was the time zero for data collection? Time zero must be the time of formalized heart team discussion. So, investigators must include both patients undergoing operations or percutaneous coronary interventions in the patient population. 0003-4975/$36.00
MISCELLANEOUS
Jamil Hajj-Chahine, MD Pierre Clerin, MS Pierre Corbi, MD, PhD
CORRESPONDENCE
CORRESPONDENCE
2. Siddiqui J, Brizard CP, Galati JC, et al. Surgical valvotomy and repair for neonatal and infant congenital aortic stenosis achieves better results than interventional catheterization. J Am Coll Cardiol 2013;62:2134–40. 3. Agnoletti G, Raisky O, Boudjemline Y, et al. Neonatal surgical aortic commissurotomy: predictors of outcome and long-term results. Ann Thorac Surg 2006;82:1585–92. 4. Pan XB, Zhang H, Hu SS, et al. Efficacy of hybrid balloon valvuloplasty via sternotomy for treating low-body weight infants with severe congenital valvular aortic stenosis. Zhonghua Xin Xue Guan Bing Za Zhi 2012;40:681–3.
Reply To the Editor: We thank Ma and colleagues [1] for their comments on our article [2]. The Fuwai Hospital team is wondering which approach to adopt in neonates with critical aortic valve stenosis presenting with very poor left ventricular function [1]. In Melbourne, we opted for surgery and still believe that surgery is superior to balloon valvuloplasty in these extreme cases because our previously reported mortality of 3% for neonates predominantly undergoing surgery over a period of 30 years seems inferior to published results for balloon valvuloplasty [3, 4]. To further investigate this matter we reviewed our recent experience. From 2009 to today we operated on 24 neonates (<3 months). There were no deaths, and 2 patients required extracorporeal membrane oxygenation urgently on admission. Both were operated on the following day. The chest, which was left open at the time of surgery, was closed on day 1 and day 2 postoperatively. They had an uneventful course thereafter. We believe that contemporary techniques of aortic valve repair are superior to balloon valvuloplasty because the majority of these valves are dysplastic and the bulk of fibrotic tissue is not removed by dilatation. We also believe that these techniques allow us to maintain valvular competence. The excellent outcomes of these results push us to maintain a strategy of surgery for critical aortic stenosis even in patients with poor ventricular function. Finally, we have urged caution against the use of the Ross procedure as a bailout for failed balloon valvuloplasty [5]. The mortality of such a rescue procedure has been evaluated to be higher than 50% [6]. In this perspective, we believe that the approach of the Fuwai hospital may be cautious. Performing the balloon dilatation procedure with an open chest in a surgical environment is adding safety to what remains a dangerous procedure in compromised neonates. Yves d’Udekem, MD, PhD Christian P. Brizard, MD Russell Nunn, MSc, BBSc Igor E. Konstantinov, MD, PhD
MISCELLANEOUS
Department of Cardiac Surgery The Royal Children’s Hospital Melbourne Flemington Rd Parkville, Melbourne, Victoria, Australia 3052 e-mail: [email protected] and Murdoch Childrens Research Institute Melbourne, Australia and Department of Paediatrics Faculty of Medicine The University of Melbourne, Australia
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2014;98:1886–91
References 1. Ma K, Pan X, Li S. The approach to a critical aortic stenosis patient with severely depressed left ventricular function (letter). Ann Thorac Surg 2014;98:1887–8. 2. Siddiqui J, Brizard CP, Konstantinov IE, et al. Outcomes after operations for bicuspid aortic valve disease in the pediatric population. Ann Thorac Surg 2013;96:2175–83. 3. Siddiqui J, Brizard CP, Galati JC, et al. Surgical valvotomy and repair for neonatal and infant congenital aortic stenosis achieves better results than interventional catheterization. J Am Coll Cardiol 2014;62:2134–40. 4. McCrindle BW, Blackstone EH, Williams WG, et al. Are outcomes of surgical versus transcatheter balloon valvotomy equivalent in neonatal critical aortic stenosis? Circulation 2001;104(12 Suppl 1):I152–8. 5. Konstantinov IE, d’Udekem Y, Brizard CP. Ross operation or aortic valve repair in neonates and infants? J Thorac Cardiovasc Surg 2014;148:362–3. 6. Kadner A, Raisky O, Degandt A, et al. The Ross procedure in infants and young children. Ann Thorac Surg 2008;85:803–8.
Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Severe Left Ventricle Dysfunction To the Editor: We read with great interest the article by Nagendran and colleagues [1] in which they compared the outcomes of patients with ischemic heart failure undergoing coronary artery bypass grafting (CABG) operations vs percutaneous coronary intervention (PCI). In the largest study of its kind to date, they showed that there was a long-term survival advantage up to 15 years among patients who underwent CABG compared with patients who underwent PCI. This observational analysis of data from a large Canadian registry solidifies the conclusions of the American College of Cardiology Foundation-The Society of Thoracic Surgeons Collaboration on the Comparative Effectiveness of Revascularization Strategies (ASCERT) study [2]. A survival advantage with CABG was observed at 4 years, and this finding was consistent in several subgroups, including patients with severe left ventricle dysfunction [2]. We have two specific concerns regarding this article. First, the assessment of myocardial viability in this subset of patients using multiple imaging strategies, such as single-photon emission computed tomography or low-dose dobutamine echocardiography, is generally performed to predict enhancement in left ventricular function. It would be interesting to know whether the authors possessed preoperative imaging data regarding myocardial viability. Second, the choice between CABG and PCI is based on a thorough evaluation of coronary lesions, comorbidities, and the presence or absence of significant valvular disease or a large left ventricle aneurysm. In the later situation, the guidelines on myocardial revascularization from the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery [3] recommend a left ventricle aneurysmectomy during CABG in patients presenting predominantly with heart failure symptoms. What was the rate of patients in the present study referred solely with heart failure symptoms? Did they include patients with concurrent surgical ventricle reconstruction? Finally, we would like to point out that there is probably a mistake in Table 1, because the authors stated, “that patients undergoing PCI had a higher prevalence of stable angina,” whereas in Table 1 we can easily recognize that stable angina was more frequent in the CABG group (22.5%) than in the PCI group (12.4%).
0003-4975/$36.00
Ann Thorac Surg 2014;98:1886–91
Department of Cardio-thoracic Surgery University Hospital of Poitiers 2 Rue de la Miletrie 86021 Poitiers Cedex, France e-mail: [email protected]
References 1. Nagendran J, Norris CM, Graham MM, et al. Coronary revascularization for patients with severe left ventricular dysfunction. Ann Thorac Surg 2013;96:2038–44. 2. Weintraub WS, Grau-Sepulveda MV, Weiss JM, et al. Comparative effectiveness of revascularization strategies. N Engl J Med 2012;366:1467–76. 3. Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS); European Association for Percutaneous Cardiovascular Interventions (EAPCI), , Kolh P, Wijns W, Danchin N, et al. Guidelines on myocardial revascularization. Eur J Cardiothorac Surg 2010;38(Suppl):S1–52.
Reply To the Editor: Thank you for the opportunity to reply to the comments of HajjChahine and colleagues [1] regarding our retrospective analysis [2] of patients with reduced ventricular function undergoing revascularization. The assessment of myocardial viability is an important topic that has received much attention in the literature recently. Myocardial viability data were not included in our study because the data were not available in the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease database. An extensive record review would have been the only option to extract these data, but given the time span of the study (1995 to 2008) and the sample size (n ¼ 2,926), this was not considered feasible. Given the recent results of the Surgical Treatment for Ischemic Heart Failure trial [3], which demonstrate that inducible ischemia in patients with coronary artery disease and severe left ventricular dysfunction does not discriminate those who will benefit from coronary artery bypass grafting vs medical therapy, further review of our data would likely make little contribution to the literature. The ongoing debate regarding the role of myocardial viability and selection for coronary artery bypass grafting is reflected by the disparate recommendations of various guidelines, with the 2012 European Society of Cardiology guidelines [4] placing greater importance on the role of myocardial viability vs the 2013 American College of Cardiology Foundation/American Heart Association guidelines [5] placing less role on myocardial viability. With respect to surgical ventricular reconstruction, we do not have data on those patients referred solely with heart failure symptoms and who underwent concurrent surgical ventricle reconstruction. Given the results of the Surgical Treatment for Ischemic Heart Failure trial [6], it is unlikely that we would have seen a significant benefit. These results are reflected in a more conservative approach to surgical ventricular reconstruction in the recent European Society of Cardiology and American College of Cardiology Foundation/American Heart Association guidelines [4, 5]. Regarding Table 1, primary data reanalyzed: Table 1 is correct but the text requires correction. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
1889
We hope the questions raised have been addressed adequately and thank the editor for the opportunity to comment on our work. Steven R. Meyer, MD, PhD Division of Cardiac Surgery Department of Surgery University of Alberta 2D4.37 Walter Mackenzie Health Sciences Centre 8440-112 St Edmonton, AB T6G 2B7, Canada e-mail: [email protected]
References 1. Hajj-Chahine J, Clerin P, Corbi P. Percutaneous coronary intervention versus coronary artery bypass grafting in severe left ventricle dysfunction (letter). Ann Thorac Surg 2014;98:1888–9. 2. Nagendran J, Norris CM, Graham MM, et al. Coronary revascularization for patients with severe left ventricular dysfunction. Ann Thorac Surg 2013;96:2038–44. 3. Panza JA, Holly TA, Asch FM, et al. Inducible myocardial ischemia and outcomes in patients with coronary artery disease and left ventricular dysfunction. J Am Coll Cardiol 2013;61:1860–70. 4. McMurray JJ, Adamopoulos S, Anker SD, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012;33:1787–847. 5. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013;128:1810–52. 6. Jones RH, Velazquez EJ, Michler RE, et al. Coronary bypass surgery with or without surgical ventricular reconstruction. N Engl J Med 2009;360:1705–17.
About the Impact of Extracardiac Vascular Disease on Vein Graft Failure To the Editor: Congratulations to the authors for this valuable study [1]. Using data from the Project of Ex-vivo Vein Graft Engineering via Transfection IV (PREVENTIV) trial, authors investigated the 1-year angiographic follow-up and 5-year clinical outcomes (death, myocardial infarction, and revascularization) in patients with and without extracardiac vascular disease. They assessed the risk of vein graft failure. We have some concerns about the methodology of their report. The term “clinical outcomes” included all-cause death, cerebrovascular accidents/stroke, documented myocardial infarction, and any repeat revascularization. As one can easily see, these included lethal and nonlethal events together. This is a common mistake by many authors that equalizes lethal and nonlethal and biased and unbiased events. Which patients did the investigators include? What was the time zero for data collection? Time zero must be the time of formalized heart team discussion. So, investigators must include both patients undergoing operations or percutaneous coronary interventions in the patient population. 0003-4975/$36.00
MISCELLANEOUS
Jamil Hajj-Chahine, MD Pierre Clerin, MS Pierre Corbi, MD, PhD
CORRESPONDENCE