1. CHANGING WORLDS The Impact of University Research

2. Changing Worlds The Impact of University Research 13 th October 2010, London Safety and advantages of beating heart coronary surgery without cardiopulmonary bypass Professor Raimondo Ascione MD, ChM, FRCS Chair of Cardiac Surgery & Translational Research Bristol Heart Institute, University of Bristol

3. Mortality rates CHD is the most common cause of death 1 in 5 men and 1 in 7 women die from CHD There are 94,000 deaths from CHD each year Morbidity rates 600 heart attacks per 100,000 in men aged 30-69 200 heart attacks per 100,000 in women The incidence of heart attacks increases with age 52,000 new cases of angina per year in men 43,000 new cases in angina in women approx 20.000 bypass operation per year in UK Coronary Heart Disease: incidence and prevalence in UK Isolated CABG in UK Mean agefrom 58 to 66 years Average LV ejection fraction from 65% to 42% Redo operationfrom 2% to 10% Severe LMS diseasefrom 6% to 24% Renal failurefrom 7% to 22% Non-elective surgeryfrom 10% to 42% Diabetes mellitusfrom 10% to 20% Variation in risk profile of CABG patients over time

4. Heart lung machine Myocardial protection Stopping the heart Conventional coronary bypass surgery Beating Heart Coronary Surgery Rationale

5. Validation of OPCAB surgery in Bristol Over 10 trials and over 10 large cohort analyses from BHI data registry 1996-97: Development of a reproducible technique 1997-98: A series of small trials assessing the impact on sub-system organ function: heart, kidney, lungs, brain, inflammation 1999-01: Large trials (BHACAS 1&2) to assess in-hospital clinical impact and hospital resources/costs 2003-08: Impact on late follow-up and graft patency rate 2004-07: Assessment of effects of training

6. Sub-clinical impact: myocardial injury Presented at the 12 th Annual Meeting of the European Association for Cardio-thoracic Surgery Brussels, Belgium, September 20-23, 1998 Ascione et al. Eur J Cardiothorac Surg 1999;15:685-690 Beating versus arrested heart revascularisation: evaluation of myocardial function in a prospective randomised study World first trial on OPCAB surgery

7. Sub-clinical impact: retinal and cerebral injury Retinal fluorescein angiography Ascione et al. Circulation 2005;112:3833-8 Cerebral micro-embolisation was 20.3 less frequent with OPCAB surgery (95% CI 9.1 to 45; p<0.0001 On-pump case 1 Before surgery After surgery Off-pump case After surgery Before surgery Retinal micro-vascular damage: risk difference 55%; 95% CI 23%-88&

8. Clinical impact: in-hospital outcome Direct early patient benefit with reduction of: In-hospital morbidity Blood loss, transfusion requirement Chest infection Inotropic support Arrhythmias Angelini et al. Lancet 2002;359:1194-99 Angelini et al. J Thorac Cardiovasc Surg 2009;137:295-303 PtsNo graftsPatency% On-pump 10125522889.4 Off-pump 9823721189.0 No late safety concerns Early and midterm outcome after off-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 &2): a pooled analysis of two randomised controlled trials

9. Ascione et al. Ann Thorac Surg 2000; 119: 148 – 54. Financial impact Impact on hospital resources: shorter intensive care stay (1 day on average) shorter hospital stay (1 day on average) 25% saving per patient Economic outcome of off-pump coronary artery bypass surgery: a prospective randomised study (BHACAS 1)

10. Impact: training and spreading in UK 7000 off-pump procedures Approx 20-30 Approx 750 22,808 off-pump procedures

11. San Paulo Trinidad & Tobago Kolkata Hong-Kong Tokyo Naples Venice Athens Damascus Amman Riyadh Bristol Impact: training and spreading worldwide Currently it is estimated that 15-20% of CABG operations worldwide are carried out with the OPCAB technique

12. “Surgical Team of Year” by Hospital Doctor in 2005 “Cardiovascular Team of Year-runner up” by Hospital Doctor in 2005 “John Parker Gold Medal” by UK Society of Cardio-thoracic Surgery in 2001 Recognition by independent external sources

13. R.Ascione@bristol.ac.uk Acknowledgments BHI team of Cardiac Anaesthesia BHI team of Clinical and Research Nurse Sir Siegmund Warburg Voluntary Settlement

14. CHANGING WORLDS The Impact of University Research