CHANGING WORLDS
The Impact of University Research
Changing Worlds
The Impact of University Research
13th October 2010, London
Safety and advantages of beating heart coronary
surgery without cardiopulmonary bypass
Professor Raimondo Ascione MD, ChM, FRCS
Chair of Cardiac Surgery & Translational Research
Bristol Heart Institute, University of Bristol
Coronary Heart Disease:
incidence and prevalence in UK
Mortality rates
Isolated CABG in UK
• CHD is the most common cause of death
• 1 in 5 men and 1 in 7 women die from CHD
• There are 94,000 deaths from CHD each year
Morbidity rates
• 600 heart attacks per 100,000 in men aged 30-69
• 200 heart attacks per 100,000 in women
• The incidence of heart attacks increases with age
• 52,000 new cases of angina per year in men
• 43,000 new cases in angina in women
• approx 20.000 bypass operation per year in UK
Variation in risk profile of CABG patients over time
Mean age
Average LV ejection fraction
Redo operation
Severe LMS disease
Renal failure
Non-elective surgery
Diabetes mellitus
from 58 to 66 years
from 65% to 42%
from 2% to 10%
from 6% to 24%
from 7% to 22%
from 10% to 42%
from 10% to 20%
Rationale
Conventional coronary bypass surgery
Heart lung machine
Myocardial protection
Stopping the heart
Beating Heart Coronary Surgery
Validation of OPCAB surgery in Bristol
Over 10 trials and over 10 large cohort analyses from BHI data registry
• 1996-97: Development of a reproducible technique
• 1997-98: A series of small trials assessing the impact on sub-system
organ function: heart, kidney, lungs, brain, inflammation
• 1999-01: Large trials (BHACAS 1&2) to assess in-hospital clinical
impact and hospital resources/costs
• 2003-08: Impact on late follow-up and graft patency rate
• 2004-07: Assessment of effects of training
Sub-clinical impact: myocardial injury
Beating versus arrested heart revascularisation:
evaluation of myocardial function in a prospective randomised study
World first trial
on OPCAB surgery
Presented at the 12th Annual Meeting of the European Association for Cardio-thoracic Surgery
Brussels, Belgium, September 20-23, 1998
Ascione et al. Eur J Cardiothorac Surg 1999;15:685-690
Sub-clinical impact: retinal and cerebral injury
Off-pump case
Retinal fluorescein
angiography
Before surgery
After surgery
On-pump case 1
Before surgery
After surgery
•Retinal micro-vascular damage: risk difference 55%; 95% CI 23%-88&
•Cerebral micro-embolisation was 20.3 less frequent with OPCAB surgery (95% CI 9.1 to 45; p<0.0001
Ascione et al. Circulation 2005;112:3833-8
Clinical impact: in-hospital outcome
Early and midterm outcome after off-pump surgery in Beating Heart Against
Cardioplegic Arrest Studies (BHACAS 1 &2):
a pooled analysis of two randomised controlled trials
Direct early patient benefit with reduction of:
No late safety concerns
•In-hospital morbidity
•Blood loss, transfusion requirement
•Chest infection
•Inotropic support
•Arrhythmias
Angelini et al. Lancet 2002;359:1194-99
On-pump
Off-pump
Pts
No grafts
Patency
%
101
98
255
237
228
211
89.4
89.0
Angelini et al. J Thorac Cardiovasc Surg 2009;137:295-303
Financial impact
Economic outcome of off-pump coronary artery bypass surgery:
a prospective randomised study (BHACAS 1)
25% saving per patient
Impact on hospital resources:
•shorter intensive care stay (1 day on average)
•shorter hospital stay (1 day on average)
Ascione et al. Ann Thorac Surg 2000; 119: 148 – 54.
Impact: training and spreading in UK
100%
On pump
Percentage of operations
Off pump
80%
60%
40%
20%
7000 off-pump procedures
0%
1996
1997
Approx 20-30
1998
1999
2000
2001
2002
Financial year
2003
2004
2005
2006
2007
Approx 750
22,808 off-pump procedures
Impact: training and spreading worldwide
Bristol
Naples
Venice
Athens
Damascus
Tokyo
Amman
Hong-Kong
Riyadh
Kolkata
Trinidad & Tobago
San Paulo
Currently it is estimated that 15-20% of CABG operations worldwide are carried out with the OPCAB technique
Recognition by independent external sources
• “Surgical Team of Year”
by Hospital Doctor in 2005
• “Cardiovascular Team of Year-runner up”
by Hospital Doctor in 2005
• “John Parker Gold Medal”
by UK Society of Cardio-thoracic Surgery in 2001
Acknowledgments
BHI team of
Clinical and Research Nurse
BHI team of
Cardiac Anaesthesia
Sir Siegmund Warburg
Voluntary Settlement
R.Ascione@bristol.ac.uk
CHANGING WORLDS
The Impact of University Research