Bijzondere interventies aan het hart - Gezondheidsraad

Treatment of coronary artery stenoses
Stenoses of the coronary arteries were traditionally treated by means of coronary
surgery. Patients with stenoses of this kind experience severe chest pains (angina
pectoris). They may also suffer an acute infarction. During open-heart surgery,
small arteries taken from the patient’s chest, or from their lower arm or leg, are
used to create a by-pass. By this means, the blood flow is restored (revascularisation).
This classic operation (coronary artery bypass grafting - CABG) produces
excellent results, but it still involves a certain surgical risk. The usual procedure
for all patients for whom an operation of this kind is indicated, is to hold a joint
meeting of the heart team, involving the cardiologist and the surgeon.
Comparative studies of coronary surgery and PCI show that, in patients with
single-vessel and double-vessel stenoses, PCI (involving the use of stents) produces
results that are just as good as those obtained by means of CABG. For this
reason, preference is usually given to a PCI, given the limited risk of mortality
and complications. Nevertheless, CABG has been shown to give better results in
some patients with multivessel stenosis. A recent study, which analysed and
compared the results of CABG and PCI, showed that, in the long-term, even
patients with two-vessel disease and three-vessel disease have longer survival if
they have an initial CABG. This approach enables repeated procedures (in connection
with re-stenosis) to be avoided. This would suggest that, prior to carrying
out a procedure (elective or otherwise), therapists should consult the patient
when determining which procedure is to be preferred in that individual case.
About 16,000 open-heart operations and 32,000 PCI procedures are now carried
out in the Netherlands each year. There has been no further increase in the
number of coronary operations performed in recent years, while there continues
to be a marked growth in the number of PCIs performed. At international level,
the trend shows a decline in the number of CABGs.
One major new development is the combined use of interventional cardiology
and coronary surgery, both being carried out in one treatment procedure
(integrated intervention). This may involve a combination of PCI and coronary
surgery, and/or heart-valve procedures, and/or procedures associated with
arrhythmias. The advantage is a reduced surgical risk to these patients, who usually
have a complex pathology.
For many years there was a lack of capacity in the Netherlands, which led to
long waiting times for CABGs. Now, however, patients have good geographical
accessibility to coronary surgery. Furthermore, virtually all centres now have
waiting times of less than two months.
38 Bijzondere interventies aan het hart