Abstract
Optimal revascularization in severe ischemic heart disease (SIHD) is addressed in
all clinical guidelines. With an aging patient population, a growing challenge remains
the management of patients with SIHD deemed ineligible for surgical revascularization,
the so-called surgical turndown patient. The status of surgical ineligibility remains
associated with worse clinical outcomes. As the general population grows older and
comorbidities increase, this subset of SIHD will likely increase. Ascribing the label
of surgical turndown has significant adverse prognostic implications, and thus, careful
assessment is required as key issues related to frailty and completeness of revascularization
need to be taken into consideration in the decision-making process. Clearly defining
criteria for surgical turndowns are paramount, as well as a comprehensive assessment
of revascularization suitability. As such, an integrated Heart Team represents the
favoured path forward to ensure patient-centred cardiovascular care. The Heart Team
approach can appropriately manage issues related to revascularization in patients
with SIHD with multiple comorbidities. Therefore, the focus of this review will be
on the importance of the diagnosis of surgical turndown, its impact on clinical outcomes,
and factors to bear in mind when considering revascularization in this challenging
patient subgroup.
Résumé
Toutes les lignes directrices cliniques décrivent la technique de revascularisation
optimale en cas de cardiopathie ischémique sévère. La prise en charge des patients
atteints d’une cardiopathie ischémique sévère jugés inadmissibles à la revascularisation
chirurgicale, les patients dits inopérables, continue de représenter un défi, un défi
d’autant plus grand que cette population de patients vieillit. L’inopérabilité demeure
associée à l’issue clinique la plus sombre. Il est fort probable que ce sous-ensemble
de patients atteints d’une cardiopathie ischémique sévère continue de s'accroître
à mesure que la population générale vieillit et que le nombre de comorbidités augmente.
Assigner l’étiquette d’inopérabilité à un patient n’est pas sans conséquences pronostiques
indésirables importantes, si bien qu’une évaluation approfondie s’impose. Les facteurs
clés que sont la fragilité du patient et le caractère complet de la revascularisation
doivent en effet entrer en ligne de compte dans le processus décisionnel. Il est impératif
d’établir clairement les critères qui définissent l’inopérabilité et d’évaluer pleinement
l’adéquation de la revascularisation. Une équipe de soins cardiaques intégrée représente
donc l’approche privilégiée pour faire en sorte que les soins cardiovasculaires soient
centrés sur le patient. Elle permet de gérer correctement les problèmes de revascularisation
chez les patients atteints d’une cardiopathie ischémique sévère présentant plusieurs
comorbidités. Le présent article portera donc sur l’importance du diagnostic d’inopérabilité,
ses répercussions sur les résultats cliniques et les facteurs à prendre en considération
lorsque la revascularisation est envisagée dans ce sous-groupe de patients difficiles
à traiter.
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Article info
Publication history
Published online: May 20, 2019
Accepted:
May 5,
2019
Received:
March 28,
2019
Footnotes
See page 964 for disclosure information.
Identification
Copyright
© 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
