TY - JOUR
T1 - Revascularization strategies for stable multivessel and unprotected left main coronary artery disease
T2 - From BARI to SYNTAX
AU - Hahalis, George
AU - Dangas, George
AU - Davlouros, Periklis
AU - Alexopoulos, Dimitrios
N1 - Funding Information:
For unprotected LM disease, the best case for PCI should be in ostial and mid-body lesions without additional MVD [16,27] . The currently almost exclusive use of DES seems to be associated with lower mortality, MI and TLR rates in comparison with the older BMS series [48] . Because of the narrow margin for error, the importance of both operator experience and their back-up by highly competent support staff and surgeons should be strengthened [40] . We would additionally emphasize the involvement of the Heart Team [20] for a joint assessment and consensus regarding revascularization therapy on a routine basis for all LM disease patients and in “gray zone” MVD patients. This approach indicates the need to avoid ad-hoc PCI in patients with complex CAD and further enables first, a clear decision for a one-way revascularization treatment option in a substantial proportion of them (and this was mainly surgery among the screened SYNTAX patients) and second, the discussion with the rest, probably the majority of the patients about their alternative choice for either PCI or CABG. Finally, in view of the huge fiscal impact of coronary revascularization, health-care systems should be provided prospectively derived information on cost-effectiveness of the 2 revascularization methods in the context of equally intense secondary prevention and lifestyle modification measures. Ongoing and planned [40,49–52] trials will further facilitate evidence-based clinical decisions both for multivessel disease (FREEDOM trial [40] and Bypass Surgery Versus Everolimus-Eluting Stent Implantation for Multivessel Coronary Artery Disease trial [BEST] [49] ) and for left main stem disease (PREmier of Randomized COMparison of Bypass Surgery Versus AngioplasTy Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease [PRECOMBAT [50] ]; Evaluation of Xience Prime versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization [EXCEL]; [51] ). A novel revascularization approach, hybrid treatment vs. CABG alone, is also being investigated (POL-MIDES trial) [52] . Furthermore, the ISCHEMIA trial is under consideration for funding by the NHLBI, NIH. This large, prospective randomized study will compare PCI to medical therapy in patients with stable ischemic heart disease and documented significant ischemia on noninvasive functional testing. At present there is potential for further outcome improvement in both PCI, by refining adjunctive pharmacology, post-procedural surveillance, patient selection and hemodynamic lesion severity whether assessed non-invasively [3,4] or in the catheterization laboratory as demonstrated by the FAME study [53] ; and in CABG, by using more arterial grafts, post-surgical OMT (possibly including dual antiplatelet therary [54] ) and carefully selecting surgical options [55] .
PY - 2011/12/1
Y1 - 2011/12/1
N2 - Percutaneous coronary interventions are increasingly applied in patients with complex coronary anatomy, including those with stem disease. Coronary artery bypass surgery confers a mortality reduction over optimal medical therapy in high-risk patients with both left main or multivessel coronary artery disease and left ventricular systolic dysfunction. Whether PCI might be preferred as an initial strategy in stable patients with multivessel disease and/or LM disease remains debatable. Emerging evidence suggests that patients with higher atheroma burden, as indicated by older age, presence of diabetes mellitus and extensive MVD in combination with LV dysfunction may derive the greatest benefit from CABG. PCI for unprotected LM with limited additional disease has been revised to a class II recommendation in the recent U.S. and European guidelines. An interdisciplinary team of both cardiac surgeons and cardiologists may optimize treatment in patients with intermediate-to-high disease severity characteristics. Ongoing trials will further strengthen evidence-base clinical decision making.
AB - Percutaneous coronary interventions are increasingly applied in patients with complex coronary anatomy, including those with stem disease. Coronary artery bypass surgery confers a mortality reduction over optimal medical therapy in high-risk patients with both left main or multivessel coronary artery disease and left ventricular systolic dysfunction. Whether PCI might be preferred as an initial strategy in stable patients with multivessel disease and/or LM disease remains debatable. Emerging evidence suggests that patients with higher atheroma burden, as indicated by older age, presence of diabetes mellitus and extensive MVD in combination with LV dysfunction may derive the greatest benefit from CABG. PCI for unprotected LM with limited additional disease has been revised to a class II recommendation in the recent U.S. and European guidelines. An interdisciplinary team of both cardiac surgeons and cardiologists may optimize treatment in patients with intermediate-to-high disease severity characteristics. Ongoing trials will further strengthen evidence-base clinical decision making.
KW - Coronary artery bypass grafting
KW - Coronary artery disease
KW - Percutaneous coronary interventions
KW - Revascularisation
UR - http://www.scopus.com/inward/record.url?scp=81755172053&partnerID=8YFLogxK
U2 - 10.1016/j.ijcard.2011.03.014
DO - 10.1016/j.ijcard.2011.03.014
M3 - Review article
C2 - 21474193
AN - SCOPUS:81755172053
SN - 0167-5273
VL - 153
SP - 126
EP - 134
JO - International Journal of Cardiology
JF - International Journal of Cardiology
IS - 2
ER -