ISCHEMIA, Surgical Experience Trials Refine Current Practice

Ibrahim Sultan, MD

Ibrahim Sultan, MD

Two hot topics will be discussed and debated at an adult cardiac session on Monday afternoon—the ISCHEMIA trial and the impact of surgical experience on mortality rates following reoperative cardiac surgery. 

“The session puts these trials into perspective, which is critical,” said Ibrahim Sultan, MD, from the University of Pittsburgh Medical Center in Pennsylvania. “We can be overwhelmed by the amount of information coming our way. This session focuses on what is relevant and important to us as surgeons.”

The ISCHEMIA trial compared outcomes for patients with stable ischemic heart disease who received optimal medical therapy and lifestyle interventions versus optimal medical therapy plus angiography and revascularization by percutaneous intervention or coronary artery bypass grafting (CABG) surgery. Nearly 5,200 patients with confirmed stable ischemic heart disease were randomized and followed for 3.3 years. 

Patients who received optimal medical therapy plus lifestyle interventions had more spontaneous myocardial infarctions (MIs), while patients who received percutaneous intervention or CABG had more procedural MIs. The overall composite outcome of cardiovascular death, MI, hospitalization for unstable angina, heart failure, or resuscitation from cardiac arrest were similar between the two groups. 

Adult Cardiac: Ischemic

1:15 p.m. – 3:15 p.m.
Room 211

“ISCHEMIA confirmed what some of the prior work has shown for patients with stable angina—that the noninvasive approach does not increase mortality in the medium term,” said Dr. Sultan, who is a member of the STS Workforce on Annual Meeting Program Task Force and helped plan the Adult Cardiac: Ischemic session.

“These results are not likely to change anything major for surgeons,” Dr. Sultan continued. “What it may change is the number of invasive coronary angiograms that are done for patients with stable disease. If these patients continue to have significant disease and progress, they will continue to be referred for surgery. It is important to realize that CABG is still beneficial for patients who present with acute coronary syndrome such as a non-ST segment elevation myocardial infarction.” 

The session also will feature scientific abstracts on bilateral versus single internal mammary artery grafts for CABG, the optimal configuration for bypass of the left anterior descending artery during bilateral internal thoracic artery grafting, total arterial off-pump multivessel revascularization, and the impact of surgical experience on operative mortality following reoperative cardiac surgery.

Marc R. Moon, MD, from the Washington University School of Medicine in St. Louis, and his colleagues found that standardized mortality ratios are higher early in a surgeon’s career, but also that surgical outcomes decline during the later years of a surgeon’s working life.

“Our data suggest that there is a learning curve during the initial years of practice and a degree of skill attrition with very senior surgeons,” Dr. Moon said. 

To offer additional perspectives on the topic, two surgeons will debate whether age matters when performing cardiac surgery. Audience members also will be encouraged to share their opinions.

“We all should be asking for assistance as needed and making sure that those who are assisting us are at a high level–the senior resident as opposed to a junior intern or even a colleague for selected cases,” Dr. Moon said. “That is true at both ends of our individual career spectrums.”