Reply: Not all incomplete revascularizations are created equal

Abstract

The authors reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. Complete revascularization is achieved more commonly with coronary artery bypass grafting than with percutaneous coronary intervention1Garcia S. Sandoval Y. Roukoz H. Adabag S. Canoniero M. Yannopoulos D. et al.Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 589,883 patients enrolled in randomized clinical trials and observational studies.J Am Coll Cardiol. 2013; 62: 1421-1431Crossref PubMed Scopus (271) Google Scholar and should be the default revascularization strategy. The reason for much of the debate about completeness of revascularization is that there is no magic formula to define it or quantify its impact on patient outcomes.2Weiss A.J. Insler J.E. Bakaeen F.G. Commentary: when possible, revascularize all the important coronary vessels at a minimum.J Thorac Cardiovasc Surg. July 6, 2021; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (1) Google Scholar,3Bianco V. Kilic A. Aranda-Michel E. Serna-Gallegos D. Ferdinand F. Dunn-Lewis C. et al.Complete revascularization during coronary artery bypass grafting is associated with reduced major adverse events.J Thorac Cardiovasc Surg. June 9, 2021; ([Epub ahead of print])Abstract Full Text Full Text PDF Google Scholar Not every diseased vessel should or can be bypassed, but experience over the years has taught us that bypassing important coronary vessels with durable arterial grafts achieves the best possible long-term outcomes.4Bakaeen F.G. Ravichandren K. Blackstone E.H. Houghtaling P.L. Soltesz E.G. Johnston D.R. et al.Coronary artery target selection and survival after bilateral internal thoracic artery grafting.J Am Coll Cardiol. 2020; 75: 258-268Crossref PubMed Scopus (33) Google Scholar Our definition of an important target vessel is that which reaches more than 75% from the base toward the apex of the ventricle or a shorter vessel with branches supplying a substantial myocardial territory.4Bakaeen F.G. Ravichandren K. Blackstone E.H. Houghtaling P.L. Soltesz E.G. Johnston D.R. et al.Coronary artery target selection and survival after bilateral internal thoracic artery grafting.J Am Coll Cardiol. 2020; 75: 258-268Crossref PubMed Scopus (33) Google Scholar The negative effects of forgoing the bypass of less-important vessels on nonmajor adverse clinical outcomes such as angina and quality of life are opaque. We agree with Zhou and colleagues5Zhou Z. Liang M. Wu Z. Complete revascularization in coronary artery bypass grafting: how sure are we?.J Thorac Cardiovasc Surg Open. 2022; 9: 116-117Google Scholar that there are physiologic and anatomic scenarios that may preclude achieving complete revascularization, but left ventricular dysfunction is not one of them. We believe that every effort should be made to achieve complete revascularization of all important coronary targets in patients with left ventricular dysfunction because they have little or no myocardial reserve when it comes to safe recovery from the stress of surgery, and any residual myocardial ischemia may be poorly tolerated.6Bakaeen F.G. Gaudino M. Whitman G. Doenst T. Ruel M. Taggart D.P. et al.American Association for Thoracic Surgery Cardiac Clinical Practice Standards Committee; invited experts. 2021: the American Association for Thoracic Surgery expert consensus document: coronary artery bypass grafting in patients with ischemic cardiomyopathy and heart failure.J Thorac Cardiovasc Surg. 2021; 162: 829-850.e1Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Another important issue raised by Zhou and colleagues is the impact of multiarterial grafting and whether it can blunt or neutralize the adverse outcomes associated with incomplete revascularization. The likely answer is that multiarterial grafting has an additive benefit when all important vessels are completely revascularized.4Bakaeen F.G. Ravichandren K. Blackstone E.H. Houghtaling P.L. Soltesz E.G. Johnston D.R. et al.Coronary artery target selection and survival after bilateral internal thoracic artery grafting.J Am Coll Cardiol. 2020; 75: 258-268Crossref PubMed Scopus (33) Google Scholar In conclusion, the totality of evidence suggests that complete revascularization and multiarterial grafting should, when possible, go hand-in-hand. In addition, some coronary targets are more critical than others and should be reliably and durably bypassed to maximize the benefits of coronary artery bypass grafting. Complete revascularization in coronary artery bypass grafting: How sure are we?JTCVS OpenVol. 9PreviewThe current European guidelines recommend that the completeness of revascularization should be taken into account when determining the most appropriate strategy in treating ischemic heart diseases.1 In patients who undergo coronary artery bypass grafting (CABG), the benefits of complete revascularization appeared to be shown in previous studies.2 Full-Text PDF Open Access