Thorac Cardiovasc Surg 2015; 63(04): 270-276
DOI: 10.1055/s-0034-1395393
Original Cardiovascular
Georg Thieme Verlag KG Stuttgart · New York

The Potential Impact of Functional Imaging on Decision Making and Outcome in Patients Undergoing Surgical Revascularization

Andre Plass
1   Clinic for Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
,
Robert P. Goetti
2   Institute for Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
,
Maximilian Y. Emmert
1   Clinic for Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
,
Etem Caliskan
1   Clinic for Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
,
Paul Stolzmann
2   Institute for Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
,
Monika Wieser
1   Clinic for Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
,
Olivio Donati
2   Institute for Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
,
Hatem Alkadhi
2   Institute for Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
,
Volkmar Falk
1   Clinic for Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
› Author Affiliations
Further Information

Publication History

03 February 2014

04 September 2014

Publication Date:
02 December 2014 (online)

Abstract

Objective Coronary angiography (CA) remains the standard for preoperative planning for surgical revascularization. However, besides anatomical imaging, current guidelines recommend additional functional imaging before a therapy decision is made. We assess the impact of functional imaging on the strategy of coronary artery bypass grafting (CABG) with particular regards on postoperative patency and myocardial perfusion.

Methods After CA, 55 patients (47 males/8 females; age: 65.1 ± 9.5 years) underwent perfusion cardiovascular magnetic resonance (CMR) and dual-source computed tomography (DSCT) before isolated CABG (n = 31), CABG and concomitant valve surgery (valve + CABG; n = 10) and isolated valve surgery (n = 14; control). DSCT was used for analysis of significant stenosis, CMR for myocardial-perfusion to discriminate between: no ischemia (normal), ischemia, or scar. The results, unknown to the surgeons, were compared with CA and related to the location and number of distal anastomoses. Nineteen CABG patients underwent follow-up CMR and DSCT (FU: 13 ± 3 months) to compare the preop findings with the postop outcomes.

Results Thirty-nine patients either received CABG alone (n = 31) or a combined procedure (n = 10) with a total of 116 distal anastomoses. DSCT was compared with CA regarding accuracy of coronary stenosis and showed 91% sensitivity, 88% specificity, and negative/positive predictive values of 89/90%. In total, 880 myocardial segments (n = 55, 16 segments/patient) were assessed by CMR. In 17% (149/880) of segments ischemia and in 8% (74/880) scar tissue was found. Interestingly, 14% (16/116) of bypass-anastomoses were placed on non-ischemic myocardium and 3% (4/116) on scar tissue. In a subgroup of 19 patients 304 segments were evaluated. Thirty-nine percent (88/304) of all segments showed ischemia preoperatively, while 94% (83/88) of these ischemic segments did not show any ischemia postoperatively. In regard to performed anastomoses, 79% of all grafts (49/62) were optimally placed, whereas 21% (13/62) were either placed into non-ischemic myocardium or scar tissue, including 10% occluded grafts (6/62).

Conclusion In the whole cohort analysis, 17% of grafts were placed in regions with either no ischemia or scar tissue. The subgroup analysis revealed that 94% of all ischemic segments were successfully revascularized after CABG. Thus, functional imaging could be a promising tool in preoperative planning of revascularization strategy. Avoidance of extensive and unnecessary grafting could further optimize outcomes after CABG.

Note

Parts of this article were presented at the annual meetings of the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS), 2011 and 2012.


 
  • References

  • 1 Budoff MJ, Dowe D, Jollis JG , et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol 2008; 52 (21) 1724-1732
  • 2 Sicari R, Nihoyannopoulos P, Evangelista A , et al; European Association of Echocardiography. Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC). Eur J Echocardiogr 2008; 9 (4) 415-437
  • 3 Sicari R, Nihoyannopoulos P, Evangelista A , et al; European Association of Echocardiography. Stress echocardiography expert consensus statement–executive summary: European Association of Echocardiography (EAE) (a registered branch of the ESC). Eur Heart J 2009; 30 (3) 278-289
  • 4 Chung SY, Lee KY, Chun EJ , et al. Comparison of stress perfusion MRI and SPECT for detection of myocardial ischemia in patients with angiographically proven three-vessel coronary artery disease. AJR Am J Roentgenol 2010; 195 (2) 356-362
  • 5 Ishida M, Kato S, Sakuma H. Cardiac MRI in ischemic heart disease. Circ J 2009; 73 (9) 1577-1588
  • 6 Kolh P, Wijns W, Danchin N , et al; 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). Guidelines on myocardial revascularization. Eur J Cardiothorac Surg 2010; 38 (Suppl): S1-S52
  • 7 Wijns W, Kolh P, Danchin N , et al; 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). Guidelines on myocardial revascularization. Eur Heart J 2010; 31 (20) 2501-2555
  • 8 Serruys PW, Morice MC, Kappetein AP , et al; SYNTAX Investigators. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009; 360 (10) 961-972
  • 9 Plass A, Emmert MY, Azemaj N , et al. Importance of advanced imaging in coronary bypass surgery. Innovations 2011; ; Annual Meeting, International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS), Conference Abstract: 6
  • 10 Plass A, Emmert MY, Goetti R. Dual-source computed tomography and magnetic resonance perfusion imaging: How good do we revascularize?. Innovations 2012; ; Annual Meeting, International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS), Conference Abstract: 7
  • 11 Dikkers R, Willems TP, Piers LH , et al. Coronary revascularization treatment based on dual-source computed tomography. Eur Radiol 2008; 18 (9) 1800-1808
  • 12 Favaloro RG. Critical analysis of coronary artery bypass graft surgery: a 30-year journey. J Am Coll Cardiol 1998; 31 (4, Suppl B): 1B-63B
  • 13 Hachamovitch R, Berman DS, Shaw LJ , et al. Incremental prognostic value of myocardial perfusion single photon emission computed tomography for the prediction of cardiac death: differential stratification for risk of cardiac death and myocardial infarction. Circulation 1998; 97 (6) 535-543
  • 14 Greenwood JP, Maredia N, Younger JF , et al. Cardiovascular magnetic resonance and single-photon emission computed tomography for diagnosis of coronary heart disease (CE-MARC): a prospective trial. Lancet 2012; 379 (9814) 453-460
  • 15 Schwitter J, Wacker CM, Wilke N , et al; MR-IMPACT investigators. Superior diagnostic performance of perfusion-cardiovascular magnetic resonance versus SPECT to detect coronary artery disease: The secondary endpoints of the multicenter multivendor MR-IMPACT II (Magnetic Resonance Imaging for Myocardial Perfusion Assessment in Coronary Artery Disease Trial). J Cardiovasc Magn Reson 2012; 14: 61
  • 16 Holmes Jr DR, Rich JB, Zoghbi WA, Mack MJ. The heart team of cardiovascular care. J Am Coll Cardiol 2013; 61 (9) 903-907
  • 17 Long J, Luckraz H, Thekkudan J, Maher A, Norell M. Heart team discussion in managing patients with coronary artery disease: outcome and reproducibility. Interact Cardiovasc Thorac Surg 2012; 14 (5) 594-598