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Canadian Journal of Cardiology

Surgical Turndown: “What’s in a Name?” for Patients Deemed Ineligible for Surgical Revascularization

      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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