Longer term outcomes for heart surgery significantly better than other procedures, new evidence finds

EACTS facilitates an important debate about the most effective treatment options

Patients with heart disease who have surgery have significantly better longer-term outcomes than patients opting for heart stents or transcatheter aortic valve implantation (TAVI), according to new evidence presented today (Saturday 5th) at the 33rd European Association for Cardio-Thoracic Surgery (EACTS) Annual Meeting in Lisbon.

The new findings from several international studies raise questions about whether the innovations have been adopted too quickly in some instances leading to worse five year survival rates for patients. Leading international experts gathering in Lisbon will facilitate an important debate about the most effective treatment options for heart patients as EACTS highlights the importance of introducing new innovation safely and ensuring patients are able to discuss their individual risks and benefits with a multi-disciplinary heart team before having a procedure.

The findings, to be presented at the EACTS conference, the largest cardiothoracic conference in the world, include:

  • For several decades bypass surgery (CABG) has been known to offer better survival and a much reduced risk of subsequent myocardial infarction (heart attack) and need for further interventions compared to stents. It was also thought that patients with less severe disease could do as well with stents. However, a new study (Excel: Everolimus-Eluting Stent of Bypass Surgery for Left Main Artery Disease) now suggests that even patients with less severe forms of this disease who have bypass surgery have a significantly better chance of surviving for five or more years if they choose surgery. The Excel study not only shows that surgery gives patients around a one-third improved survival rate in comparison to stents but that at 5 years that survival benefit appears to be accelerating.
  • The results of the Partner 2 Trial, to be presented for the first time in Europe, found that the five year outcomes for patients with ‘intermediate’ operative risk having surgical aortic valve replacement (SAVR) were significantly better than for those having the TAVI procedure. This means that for every 100 patients dying within 5 years of having the TAVI procedure, 75 people would have died having had surgery.
  • An analysis in Italy of the long-term outcomes of TAVI vs SAVR led by Dr Barili, Cuneo, Italy, found that while early results are promising for TAVI, from 40 months onwards TAVI has significantly worse outcomes than conventional surgery. TAVI procedures are undertaken by both cardiologists and surgeons.
  • The latest update from the North American TAVI registry reveals that the “real world” outcomes for patients are worse than those of the randomised trials. Data also shows that complication rates are not decreasing with time even though the numbers of TAVI procedures are growing.

 

Discussing the findings of the Excel study, Professor David Taggart, Professor of Cardiovascular Surgery at the University of Oxford, said:

“The EXCEL study looked at the best treatment for a potentially particularly lethal form of coronary artery disease called ‘Left main disease’ as it affects the most important blood vessel supplying blood to the heart muscle. While it is widely accepted that for severe patterns of disease that bypass surgery is best it was also previously thought that for less severe forms of disease the same result could be obtained with stents. However, the EXCEL study, the most definitive study of its kind for this type of disease, now shows that, assuming a patient is relatively fit, their chances of being alive after five years are dramatically better – by almost one-third – if they have heart bypass surgery rather than stent treatment.

“This confirms the importance of doing randomised clinical trials to ensure that potentially innovative techniques are actually as safe as the tried and tested standard techniques and that newer techniques must be implemented with caution. If a patient has blockages in the main heart artery or in more than two arteries and especially if the patient is diabetic, I strongly recommend that they get the opinion of a surgeon. Thankfully, in the UK, we have strong ‘Heart Teams’ consisting of cardiologists, surgeons and other experts who working closely together can recommend the best treatment to the individual patient. However, in most parts of the world the decision to recommend treatment is made by a cardiologist and, regrettably, the patient does not get any opinion from a surgeon.”

 Professor Nick Freemantle, Director Institute Clinical Trials and Methodology, University College London UK, said:

“The Partner 2 findings should be considered very carefully in clinical practice. They serve as a wake up call for the profession. It appears that some people may have adopted TAVI for too broad a range of patients. We know that for patients in need of aortic valve replacement – and who are not well enough for surgery – the TAVI procedure can be a lifeline. But now we have clear evidence – even for those patients with an intermediate level of risk – that the longer-term survival rates for patients who have surgical aortic valve replacement are significantly better than for those who have the TAVI procedure.”

Dr Rita Redberg, Cardiologist at University of California San Francisco, who will co-chair the debate on Saturday 5 October, said:

“These new findings highlight that some patients are living longer if they opt for surgery over some other techniques. This should focus minds: when advising on the right procedure for a patient, we need to know and share the data on risks and benefits. While avoiding surgery seems attractive in the short run, this short term benefit pales if it is at the price of longer survival with surgery. Patients will benefit from having their risks and benefits explained by a multi-disciplinary heart team to ensure they are able to access the best and personalized treatment. Innovation is vital and it’s how practice evolves but we must ensure innovation is introduced safely and is best for patients. We should avoid a race to widely adopt new techniques until such innovations can demonstrate equivalent sustainable results to established surgical techniques.”

To follow the session live at the 33rd EACTS Annual Meeting, visit the EACTS live stream here: www.eacts.org/annual-meeting/eactslive/

The session will also be available to watch again at:

ENDS

Further details on the Annual Meeting are available at the EACTS website: www.eacts.org

Notes to Editors

Experts contributing to the EACTS Annual Meeting discussion include:

  • Dr Rita Redberg(Chair of the Trial Update and Evidence Review session)

Cardiologist at University California San Francisco and Editor in Chief of JAMA Internal Medicine

  • Professor David Taggart, University Oxford

Professor of Cardiovascular Surgery at the University of Oxford

  • Professor Friedhelm Beyersdorf

University Heart Center Freiburg and Editor In Chief of EACTS Journals

  • Professor H. Schünemann

Department of Health Research Methods, Evidence & Impact (HEI), Hamilton, Canada and chair of GRADE collaboration

  • Dr S. Fremes, Toronto

Sunnybrook Health Sciences Centre, Toronto

  • Professor Nick Freemantle, Director Institute Clinical Trials and Methodology, University College London UK

The Excel Extended Survival study

September 2019

STATEMENT – UPDATE ON UNACCEPTABLE SPEAKER SLIDES

19 September 2019

From the Secretary General

On behalf of the Association I would like to state that we are deeply sorry for the sexist, unprofessional and unauthorised slide used by an external speaker at an event in Homburg (Saar), Germany yesterday. This is an issue we are taking extremely seriously and this has been discussed with the Officers of the EACTS Council. I would like to thank Rebecca Dobson (on Twitter @theharveys) for bringing this to our attention. I’m also grateful that another speaker on the course subsequently raised the issue in front of the audience and a full apology was made to the audience at the time. There is no place for sexism or other forms of discrimination in our Association.

We understand that the offensive slide was part of a presentation by an external speaker. We have initiated an investigation to understand the full circumstances. Our investigation continues.

We have reviewed and updated our guidance to speakers. It’s disappointing that we need to state explicitly in writing that slides of this nature will not be tolerated, but we have updated our guidance in any case to make it abundantly clear. It’s vital that EACTS speakers and trainers – as well as our members and staff – uphold the highest professional standards at all times.

EACTS has a long history of inclusiveness and this individual’s slide does not reflect the values and standards that our global members represent.  We are committed to accelerating diversity and openness across the organisation – and the cardio-thoracic specialty more broadly. That’s why we have been working over the summer to establish a new Women in Cardio-Thoracic Surgery Committee. We’re in the final stages of recruitment and the Chair will be appointed and announced in the coming weeks.

ACD: Access your bespoke Centre Report

Adult Cardiac Database: Download your Bespoke Centre Report

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Bespoke Centre Reports are now available for participating hospitals using data from the Adult Cardiac Database. This report provides a detailed summary of the hospital’s data in the registry, including statistical charts, comparative data and benchmarking outcomes.

Hospitals can access their bespoke report by clicking on the ‘Centre Report’ button in the ACD tool ‘Downloads’ page. When prompted enter your login details and your report will automatically download.

If you have any questions about the data in your report, please contact EACTSFeedback@uhb.nhs.uk.

To join the EACTS Quality Improvement Programme and access the EACTS Adult Cardiac Database, please contact quip@eacts.co.uk.

The ADULT CARDIAC DATABASE reaches 100,000 procedures

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EACTS is pleased to announce that the Adult Cardiac Database now contains 100,000 cardiac surgical procedures in the benchmarking tool. Participating European hospitals have been submitting cardiac surgical data from 2010 onwards. This tool is accessible for surgeons to recognise the data and outcomes from their hospital, enabling them to draw comparable data analysis with other hospitals anonymously.

New advanced benchmarking features available

The benchmarking outputs team has implemented a number of advanced features and rigorous data validation processes to improve statistical analysis and research. This includes:

• Information on how many records do not meet reasonable validation criteria
• Additional metrics for hospital comparison
• More detailed filters and procedures
• Statistical controls (mean + / – 1SD, 95% CIs and IQRs)
• Survival curves by individual procedures or all-cases
• An updated clinical support tool page
• An interactive updates page for participants

See below some screenshots of the advanced benchmarking features: