• Alternatives to Open-Heart Surgery Pushing Surgeons to Do Better

    Old techniques get a makeover

    Cardiac surgeons are adopting techniques to make surgery more appealing and provide better outcomes for patients -- some of whom would otherwise have the option to go a transcatheter route.

    Surgeons are stepping up their game in surgical aortic valve replacement (SAVR) in part due to lessons learned in the catheterization lab, Michael Reardon, MD, of Houston Methodist DeBakey Heart and Vascular Center, had noted at a session at the TVT meeting last month on PARTNER 3 and Evolut Low Risk trial analyses.

    Those game-changing trials of transcatheter aortic valve replacement (TAVR) in low-risk patients with aortic stenosis showed the surgical group getting bigger valves than in prior trials.

    "Mismatch has a negative effect on survival, exercise tolerance, rehospitalization, and structural valve deterioration. Avoiding it is important and larger valves help do this. This is one of the ways TAVR has made surgeons strive to be better," Reardon told MedPage Today.

    Moreover, younger patients may also benefit from larger surgical bioprosthetic valves given the possibility of a subsequent need for valve-in-valve, said Michael Mack, MD, of Baylor Scott & White The Heart Hospital in Plano, Texas, and a past president of the Society for Thoracic Surgeons.

    "TAVR has refocused surgeons on a number of areas including improving surgical outcomes for atrial fibrillation, transfusion, and renal injury. TAVR has also convinced many aortic surgeons that all SAVR should get a TAVR-level CT angiography first to allow planning for a better procedure," Reardon added in an interview.

    Another technique gaining traction is closed-chest coronary bypass -- known as totally endoscopic coronary arterial bypass surgery (TECAB) -- performed endoscopically via a robot.

    Grafting the left internal mammary artery (LIMA) to left anterior descending artery (LAD) has been the "biggest benefit" of coronary artery bypass grafting (CABG) and is what makes it better than percutaneous coronary intervention (PCI) for that vessel, according to Mack, who is also a past president of the International Society for Minimally Invasive Cardiothoracic Surgery.

    "The problem is it still requires surgery," he said. The less-invasive TECAB approach, requiring no rib spreading or any major chest incisions, may therefore make CABG more appealing to patients.

    "Minimally-invasive LIMA to LAD with stenting of other vessels as a hybrid makes some sense for proximal LAD disease. Outside of the LAD, stenting seems to be about as good," Reardon commented.

    TECAB has been around for 2 decades, but only recently reached New York State, for example. Two heart surgeons performed it for the first time there in late May at Mount Sinai St. Luke's in New York City.

    "All other things being equal, patients and referring physicians will always prefer the less invasive approach as long as the outcomes are roughly the same," Mack said. "And those outcomes are mainly short-term outcomes."

    "The LIMA to the LAD example illustrates this well [in CABG]. Even though their survival is better with a LIMA to the LAD 10 and 20 years down the line, the short-term results are the same and therefore patients prefer PCI," he told MedPage Today.

    Source:

    Read the original article on Medpage Today: Alternatives to Open-Heart Surgery Pushing Surgeons to Do Better

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