key: cord-0009596-2i9ide18
authors: Anselmi, Amedeo; Agnino, Alfonso
title: COMMENTARY: COMPLICATIONS RESCUE AND LONG-TERM SURVIVAL - WHERE DO THE PILLARS OF HERCULES LIE?
date: 2020-04-11
journal: J Thorac Cardiovasc Surg
DOI: 10.1016/j.jtcvs.2020.03.123
sha: 4e03e4ef7ea13481deadedd9d8286147cb108385
doc_id: 9596
cord_uid: 2i9ide18

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The STICH trial and the associated sub-studies have provided a great deal of evidence about the effectiveness of CABG in the treatment of ischemic cardiomyopathy. Nonetheless, they also left several gaps in knowledge: in example, the relationship between complications and survival had been analyzed at the 30 th postoperative day only [1] . While it is ascertained that patients with more depressed LVEF have worse late survival despite optimal surgical/medical management than patients with normal LV function, discussions have risen about reasonable and unreasonable employment of human and social resources for the treatment of the most severe patients. These discussions are both clinical and ethical, and they appear every time the limits of contemporary medical knowledge, convictions, healthcare system capacities are overwhelmed. The ongoing SARS-CoV-2 pandemic is painfully illustrating the reality of such aspects to both the medical community and the public opinion. Similar to the sailors of the ancient world, we face in humility and grief the pillars of Hercules marking the limits of our possibilities, only to ask whether and how we will be capable to push them beyond.

In that sense, one interpretation of this important and commendable work by Omer and associates [2] consist in the idea that CABG recipients with preoperative LVEF ≤35% who survived multiple severe postoperative complications will indeed present worse outcome at follow-up, but such outcome will be more likely due to overall fragility and deconditioning following complications themselves and the prolonged hospital/ICU stay rather than to heart failure (LVEF being no more associated in a dose-dependent manner to the risk of late death). This is disturbing for healthcare providers who devoted major efforts in the rescue of cases with most severe postoperative course, which is intuitively considered as a success [3] .

The Authors appropriately conclude that additional energies need to be consecrated to prevention of severe postoperative complications in this subset of patients; yet, the current data unfortunately provide few clues about how to pursue such target. One must underline the importance of extreme vigilance over these patients in the early postoperative and promptness to escalate the level of care in response to a first major complication, in order to prevent additional complications to occur ('domino' effect). Beyond that, more granular strategies can hardly emerge from herein. In fact, the VASQIP database is a tremendous source of valuable information but the current paper lacks potentially significant data: in example, the surgical technique (beating-heart on-pump CABG has been proposed for very depressed LVEF or active ischemia); the number and outcomes of patients later receiving heart transplant or LVAD implantation (and their interaction with the complications burden); the demonstration and extent of myocardial viability. In this respect, it is surprising that late myocardial recovery has been scarcely investigated in prospective studies [4] , despite it constitutes one theoretical legitimation of the current indications to CABG. Other limitations are of minor impact, such as the 99% prevalence of male patients, one of the STICH sub-studies having demonstrated absence of gender-related differences in late outcome among these patients [5] .

Maybe, the greatest value of the current study does not lie in the questions it answers, but in those it (re)opens, as well as the troubled times we are experiencing.

Influence of Baseline Characteristics, Operative Conduct, and Postoperative Course on 30-Day Outcomes of Coronary Artery Bypass Grafting Among Patients With Left Ventricular Dysfunction: Results From the Surgical Treatment for Ischemic Heart Failure (STICH) Trial

Low Left Ventricular Ejection Fraction, Complication Rescue, and Long-Term Survival After Coronary Artery Bypass Grafting

Long-term survival and quality of life of patients with prolonged postoperative intensive care unit stay: Unmasking an apparent success

Myocardial Viability and Long-Term Outcomes in Ischemic Cardiomyopathy

Sex Difference in Patients With Ischemic Heart Failure Undergoing Surgical Revascularization: Results From the STICH Trial (Surgical Treatment for Ischemic Heart Failure)