Quality Improvement for Cardiac Surgery

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When working in Orthopaedics, it isn’t uncommon to have patients who require cardiac intervention. And while cardiac surgery can be intimidating—and with good reason—science is continually making advances in cardiac surgery so that procedures are minimally invasive, ensure patient safety, and have better outcomes. I’ve asked Professor, Cardiothoracic Surgery Chief, and Director of the Heart and Vascular Center at the University of Toledo Medical Center, Dr. Thomas Schwann to shed light on these new advances. I want to thank him for taking the time to write this article and for his contributions.

By: Thomas A. Schwann, MD, MBA and Alexandra N. Schwann, BS

Dr. Schwann is a Professor, Cardiothoracic Surgery Chief, and Director of the Heart and Vascular Center at the University of Toledo Medical Center. Ms. Schwann is a medical student here at the University of Toledo.

Cardiovascular disease is a devastating clinical problem in the Western world and represents a serious public health challenge. Cardiovascular disease accounts for 1 out of 7 deaths with an annual price tag of $316 billion in the United States. Coronary artery disease alone accounts for 300,000 deaths and 600,000 heart attacks annually. The underlying pathologic process behind these depressing coronary artery statistics is the deposition of atherosclerotic plaque within the coronary arteries interrupting the delivery of oxygen to the heart muscle cells. The current approaches to coronary artery disease are based on pharmacologic therapy aimed at restoring the balance between oxygen supply and demand without appreciably altering the underlying blockages within the coronary vessels. Alternatively, there are two approaches to addressing the underlying blockages and increasing the blood flow through these blockages; thus, improving the delivery of oxygen to the heart muscle. One modality, known as percutaneous coronary intervention, is a catheter based approach that delivers stents which eliminate the blockage producing plaque by compressing the plaque against the walls of the vessel and clear a path for unobstructed blood flow. The other approach is a surgical approach, known as coronary artery bypass grafting, whereby blood vessels from other parts of the body are transposed to the coronary circulation, constructing an additional circulatory system to the heart, functionally bypassing the blocked coronary arteries and increasing the blood flow down stream from the blockage. Both interventional approaches have been shown to have superior outcomes compared to pharmacological treatment. Multiple practice guidelines have been established allowing physicians to choose between the two interventional approaches to optimize patient centered outcomes.

In 2017 in the United States, 90% of coronary artery bypass grafting (CABG) surgery is accomplished by using a single arterial conduit, typically in the form of the internal thoracic artery which courses on the undersurface of the breast bone and supplemental venous conduits from the lower extremities. This form of CABG has been used clinically since the 1980’s. More recently, a consistent and uniform body of data has emerged that suggests that using more than one arterial graft in CABG improves long term patient survival. The additional arterial grafts can come from the forearm in the form of the radial artery or an additional internal thoracic artery. Both iterations of a multi-arterial approach have been reported by institutions such as the Mayo Clinic, the Cleveland Clinic, Cornell-Weil Medical Center and the University of Toledo to significantly improve outcomes compared to the standard single arterial bypass surgical approach. Indeed a number of professional societies including the American College of Cardiology, the American Heart Association, the European Society of Cardiology, the Society of Thoracic Surgeons and the European Association for Cardiothoracic Surgery have incorporated the routine use of multi-arterial grafting into their practice guidelines. It has been estimated that the aggressive utilization of multi-arterial grating would result in 10,000 fewer deaths over a decade and an additional 64,000 patient years of survival. Despite these facts, American cardiac surgeons have not adopted this approach to patients needing CABG. Indeed only 10% of CABG patients in the US are offered this therapeutic modality. Thus our specialty faces a large quality improvement opportunity.

Failure to adopt these newer life extending techniques by contemporary surgeons are complex and reasons include the perception by surgeons that this approach adds complexity to the operation (true), increases risks of peri-operative mortality (false), lacks comfort and familiarity with the operative techniques required to achieve multi-arterial grafting (true) and a dogmatic dedication to traditional time honored techniques (true). Importantly, in a survey of cardiac surgeons, approximately 50% responded that they would elect to have multiple arterial bypasses placed if they themselves required a CABG. Efforts are being expanded with various professional societies to offer surgeons the appropriate additional training and familiarity with these techniques so that they are comfortable with their routine use. To accelerate this transition, patients need to understand the choices available to them and request that their surgeons use optimal 21st century surgical techniques to improve their peri-operative outcomes. In addition, third party payers—whether that be the Center for Medicare and Medicaid Services or commercial insurance companies—must demand that surgeons perform the optimal operation and simultaneously compensate them appropriately for the increased complexity associated with these procedures.

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