The article by Awad et al in the Journal (1) poses a challenge, since it
is known that LIMA-to-LAD is the major determinant of the patient’s
prognosis and long term survival for a large percentage of the
population with coronary artery disease Despite this, over 20% of
several million patients worldwide have had stents placed into the left
anterior descending coronary artery. Off pump, minimally invasive
LIMA-to-LAD provides excellent long-term results (2- 3). There are
reports of this operation performed on an outpatient basis and with
minimal hospitalization (4). As Awad et al state, this pandemic has
disrupted and challenged delivery of health care services worldwide,
with government-imposed blockade measures, compounded by need for ICU
beds to provide respiratory assistance and mechanical ventilation. This
has necessitated redistribution and reorganization of resources within
hospitals (1). LIMA-to-LAD can be performed with minimal resources in an
isolated area from COVID-19 facilities within the hospital. As Awad et
al pointed out (1), immune compromised patients can have SARSCoV-2 virus
for long periods of time and, since cardiac surgery with cardiopulmonary
bypass induces post-operative immunosuppression and impaired lung
function, there is an argument for PCI. Alternatively, if possible,
surgery may be delayed for at least six weeks.
There are growing concerns about possible increase in platelet
aggregation associated with COVID-19, which can lead to stent
thrombosis. Therefore, patients undergoing coronary artery stenting may
be at increased risk since the ideal antiplatelet therapy for these
patients remains to be determined. Therefore, in these circumstances, it
is important to identify patients who can readily benefit from
LIMA-to-LAD procedure.
Hybrid treatment of coronary heart disease is another option for
patients under these circumstances (5). Surgeons must take the lead and
play an active role in the decision process. It is clear that, with this
option, hospitalization can be greatly reduced, as all procedures are
performed in one location, with little hospitalization. The
circumstances of the pandemic will undoubtedly force us to accelerate
this treatment, and surgeons will have to learn how to perform both the
surgical and the interventional procedures. This will require a paradigm
change, and physicians will have to be retrained to perform both
interventions, with technology that already exists. As the authors
conclude, given fluidity of the current situation, there is need for new
processes and clinical decision – making that will allow patients to
receive appropriate treatment, i.e., CABG or PCI revascularization
strategy amid the COVID-19 pandemic.
References
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Coronary Artery Bypass Grafting Surgery versus Percutaneous Coronary
Intervention: What is the Clinical Decision Framework Amid COVID 19
Era. Journal of Cardiac Surgery (IN PRESS 2020)
2. Benetti FJ., (2010). MINI-off-pump coronary artery bypass graft:
long-term results. Future Cardiol. 6(6):791-5. doi: 10.2217/fca.10.96.
PMID: 21142636, PubMed
3 Repossini A, Di Bacco L, Nicoli F, Passaretti B, Stara A, Jonida B,
Muneretto C
Minimally
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10.1016/j.jtcvs.2018.11.149. Epub 2018 Dec 29.PMID: 307397742.
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left small thoracotomy and angioplasty for multivessel coronary artery
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https://goo.gl/2a1Rn8