Complex Multivessel Coronary Artery Disease Research Articles

Mercaptoalbumin Is Associated with Graft Patency in Patients Undergoing Coronary Artery Bypass Grafting.

Coronary artery bypass graft (CABG) surgery still represents the gold standard for patients with complex multivessel coronary artery disease. However, graft occlusion still occurs in a significant proportion of CABG conduits, and oxidative stress is currently considered to be a potential contributor. Human serum albumin (HSA) represents the main antioxidant in plasma through its reduced amino acid Cys34, which can efficiently scavenge several oxidants. In a nested case–control study including 36 patients with occluded grafts and 38 age- and sex-matched patients without occlusion, we assessed the levels of the native mercaptoalbumin (HSA-SH) and oxidized thiolated form of albumin (Thio-HSA) in relation with graft occlusion within 5 years after CABG. We found that the plasma level of preoperative HSA-SH was significantly lower in patients with occluded graft at 5 years follow-up than in patients with graft patency. Furthermore, low HSA-SH remained independently associated with graft occlusion even after adjusting for preoperative D-dimer, a well-known marker of activated coagulation recently found to be associated with graft occlusion. In conclusion, the preoperative level of HSA-SH is independently associated with graft occlusion in CABG and represents a measurable and potentially druggable predictor.

Myocardial perfusion quantification by CMR for detection of obstructive coronary artery disease in patients with previous coronary artery bypass surgery

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): British Heart Foundation Background Coronary artery bypass grafting (CABG) is an established treatment for patients with advanced coronary artery disease (CAD). A subsequent recurrence of symptoms can cause the need for re-assessment of the coronary circulation. The accuracy of visually assessed stress perfusion cardiovascular magnetic resonance (CMR) for the detection of obstructive CAD is reduced in patients with prior CABG. In patients with complex multi-vessel CAD, myocardial perfusion quantification by CMR is superior to visual assessment (VA) for detection of obstructive disease however patients with CABG have been absent from previous studies. Purpose This study sought to assess the performance of myocardial perfusion quantification by CMR against invasive coronary angiography (ICA) for detecting obstructive CAD in patients with previous CABG. Methods Twenty-nine patients with a history of previous CABG and subsequent clinically indicated perfusion CMR study and invasive coronary angiography were recruited. Patients underwent a dual bolus stress perfusion CMR with late gadolinium enhancement (LGE) imaging at 3 Tesla. Stress myocardial blood flow (MBF) was estimated at the coronary territory level according to the AHA 16 segment model using Fermi function-constrained deconvolution. Segments with transmural LGE were excluded from MBF analysis. Stress perfusion images were analysed visually alongside LGE images and matched perfusion-LGE defects were considered negative. On ICA, coronary territories with lumen stenosis >70% without an unobstructed bypass graft (<70% stenosis) were considered positive. Results 86/87 coronary territories were suitable for analysis. Sixty-five territories had at least one bypass graft including 32 territories with arterial grafts. 28/86 territories (33%) had obstructive disease on angiography. Territories with obstructive CAD had significantly lower stress MBF than unobstructed territories (1.21 [IQR: 0.96–1.45] vs 1.58 [1.40–1.84] ml/g/min, p < 0.001, Figure 1). Stress MBF had good accuracy to detect coronary territories with obstructive CAD (sensitivity 71%, specificity 84%, area under the curve (AUC) 0.83, p < 0.001, Figure 2A). For visual assessment, sensitivity was 79%, specificity 78% and diagnostic accuracy 78%. When analysis was confined to only territories with bypass grafts, stress MBF had 78% sensitivity, 81% specificity and AUC of 0.85, p < 0.001 (Figure 2B).. In this subgroup, VA had a sensitivity of 78%, specificity of 76% and a 77% diagnostic accuracy. Conclusions In patients with previous surgical revascularisation, quantification of stress myocardial blood flow by CMR offers good diagnostic accuracy for the detection and localisation of anatomically significant stenoses. Accuracy is reduced compared with published data in patients without coronary grafts but remains comparable to expert visual assessment.

Acute Coronary Syndromes and Nonalcoholic Fatty Liver Disease: "Un Affaire de Coeur".

Background and Aims Both nonalcoholic fatty liver disease (NAFLD) and ischemic heart disease have common pathogenic links. Evidence for the association of NAFLD with acute coronary syndromes (ACS), complex multivessel coronary artery disease (CAD), and increased mortality risk in ACS patients is still under investigation. Therefore, we conducted a systematic review aiming to clarify these gaps in evidence. Methods We conducted a systematic search on PubMed and EMBASE with predefined keywords searching for observational studies published till August 2020. NAFLD diagnosis was accepted if confirmed through biopsy, imaging techniques, surrogate markers, or codes. Full articles that satisfied our inclusion and exclusion criteria were included in the systematic review. We used the NHLBI quality assessment tool to evaluate included studies. Results Seventeen observational studies with a total study population of approximately 21 million subjects were included. Eleven studies evaluated whether NAFLD is an independent risk factor for developing ACS with conflicting results, of which eight studies demonstrated a significant association between NAFLD and ACS, mainly in Asian populations, while three reported a lack of an independent association. Conflicting results were reported in studies conducted in Europe and North America. Moreover, a total of five studies evaluated whether NAFLD and fatty liver severity in ACS patients are associated with a complex multivessel CAD disease, where all studies confirmed a significant association. Furthermore, seven out of eight studies evaluating NAFLD and hepatic steatosis severity as a predictor of all-cause and cardiovascular mortality and in-hospital major adverse cardiovascular events (MACE) in ACS patients demonstrated a significant independent association. Conclusions NAFLD patients are associated with an independently increased risk of developing ACS, mainly in Asian populations, with inconsistent results in North American and European individuals. Moreover, NAFLD and hepatic steatosis severity were both independently correlated with complex multivessel CAD, mortality, and in-hospital MACE in ACS patients.

Platelet reactivity among patients with acute coronary syndromes and multivessel coronary artery disease

Abstract Background Patients with multivessel or complex coronary artery disease (CAD) are at increased risk of atherothrombotic events. It has been suggested that these patients may derive an incremental benefit with more intense antiplatelet strategies, according to prior subgroup analyses from randomized clinical trials. However, whether there is any association between the presence and extension of multivessel CAD and platelet aggregability (PA) in patients with acute coronary syndromes (ACS) is unknown. Purpose To analyze the independent association between PA and presence of multivessel CAD in patients with ACS. Methods Patients with ACS on dual antiplatelet therapy (aspirin plus clopidogrel) were included in this study. Multivessel CAD was defined as the presence of significant ≥50% stenosis at two or more major epicardic vessels. Platelet aggregability was assessed by VerifyNow P2Y12 assay expressed in P2Y12 Reactivity Units (PRU) on the day of discharge from the coronary care unit. High On-treatment platelet reactivity (HPR) was defined as PRU ≥208. Stepwise linear and logistic regression models were applied to adjust for confounders. Models were adjusted for: age, sex, race, diabetes, hypertension, smoking, dyslipidemia, prior MI, prior PCI, prior CABG, prior HF, prior stroke and ACS phenotype (STEMI vs. Non-ST-segment elevation ACS). Results A total of 237 patients were included, among whom 143 (60.3%) had multivessel CAD at the coronary angiogram and 175 (73.8%) were submitted to PCI during index hospitalization. Patients with multivessel disease were older (mean age 64.8±12.1 vs. 58.9±11.2 years; p<0.001) and more likely to have a history of diabetes (47.6% vs. 29.8%; p=0.006) and non-ST-segment elevation ACS as the index event (55.2% vs. 28.7%; p<0.001), compared to patients without multivessel CAD. After adjustments, presence of multivessel CAD was associated with higher PA (mean 161.4±74 PRU in patients with versus 140.3±70.9 PRU in patients without multivessel CAD; adjusted mean difference 23.7 PRU; 95% CI 4.8 to 42.5; p=0.014). Additionally, there was an incremental of 12.5 PRU (95% CI 2.8 to 22.3; adj p=0.012) for each diseased vessel and of 4.67 PRU (95% CI 0.11 to 9.22; adj p=0.045) for each diseased coronary segment. Compared to patients with single-vessel disease, patients with three-vessel disease had higher rates of HPR. (Figure). Conclusion In patients with ACS, the presence and extension of multivessel CAD were associated with higher levels of platelet aggregability and higher rates of high on-treatment platelet reactivity with clopidogrel. This finding may explain the incremental benefit with more intense antiplatelet therapies seen in this particular subgroup in prior clinical trials. Prevalence of HPR and extension of CAD Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Sao Paulo Research Foundation (FAPESP)

Revascularização híbrida na doença coronária multiarterial: qual é o verdadeiro papel da técnica?

ABSTRACT The best treatment option for patients with complex multivessel coronary artery disease remains uncertain. In association with optimal medical therapy, coronary artery bypass graft surgery and percutaneous coronary intervention have been compared over the past decades. Hybrid coronary revascularization applies the best of both strategies, aiming at complete revascularization and lower rates of major adverse cardiovascular events. The technique comprises the use of left internal mammary artery connected to the left anterior descending artery, combining off pump and minimally [...]

P4579Prediction of CABG indication in patients admitted for NSTEMI with the new CABG DAPE2S score

Abstract Introduction A significant number of patients admitted for Non-ST Elevation Myocardial Infarction (NSTEMI) have multivessel complex coronary artery disease (CAD) and benefit from Coronary Artery Bypass Graft surgery (CABG). These patients frequently present high-risk surgical profiles, constituting a challenging group when it comes to balancing ischemic and haemorrhagic risk. Objective To develop a simple predictive risk model of referral to CABG in patients admitted for NSTEMI. Methods The authors present a retrospective, descriptive and correlational study including all patients admitted for NSTEMI in a Cardiology department between the 1st of October 2010 and the 1st of October 2018. Demographic profile, clinical characteristics, risk factors and hospitalization data of NSTEMI patients referred to CABG were studied, and a correlational analysis was performed with Chi-square test for categorical variables and t-Student test for continuous variables (confidence level of 95%). Independent predictors of CABG in patients with NSTEMI were identified through Binary logistic regression analysis, using a significance level of 0,05. A discriminatory function was subsequently applied, and the Wilks lambda test was used to determine the discriminant score for the studied groups. The authors used SPSS 24,0 for statistical analysis. Results A total of 2476 patients were included, 668 (27%) of which were female, with a mean age of 68,5±13,4 years. In the studied sample, 273 patients (11%) were proposed to CABG. The authors found a significant association between CABG and multiple clinical, laboratorial and therapeutical variables, but after multivariate analysis only male sex, previous Diabetes Mellitus, previous angina, previous Percutaneous coronary intervention, absence of a normal EKG, ST segment depression at admission, sinus rythm and brain natriuretic peptide (BNP) >100pg/mL proved to be independent predictors of referral. Using these variables, the authors developed a risk model to predict CABG referral in NSTEMI patients: −0,614 − (0,756 x female sex) + (0,305 x diabetes) + (0,631 x angina) − (1,513 x previous PCI) + (1,216 x sinus rythm) + (0,672 x ST depression) − (0,806 x normal EKG) + (0,562 x BNP>100). In this function, variables should be substituted by 1 or 0, depending on wheter the condition they specify is present or absent. The optimal discrimination cutoff was 0,23, with a 64% sensibility and 59% specificity, and a discriminant power of 60%. Conclusion Being able to predict referral to surgical revascularization in NSTEMI may help physicians to optimize a specific approach in each patient, in particular with regard to anti-thrombotic strategies. The authors developed a risk predicting model for CABG in NSTEMI patients based on simple clinical and laboratory variables, which will require validation in a larger cohort, before it can be applied in a clinical context.

Total arterial off-pump coronary revascularization: The Holy Grail?

Coronary artery bypass grafting (CABG) remains the standard of care for patients with complex multivessel coronary artery disease. However, conventional CABG utilizing left internal mammary artery and supplemental vein grafts performed on cardiopulmonary bypass is marred by questionable long-term patency of vein grafts and risk of neurological injury. Total arterial off-pump CABG is a strategy associated with avoidance of neurological injury and vein graft failure. The aim of this review is to summarize recent evidence on safety and effectiveness of total arterial off-pump CABG. Two key studies have been published recently. One describes a dual inflow technique that achieves anaortic, off-pump complete revascularization using arterial grafts only. The other is single centre study that reports 10-year survival of 89.33%, rate of freedom from repeat revascularization of 91.33% and early stroke rate of 0.9% after total arterial off-pump CABG. Total arterial off-pump CABG with its advantages of improved survival, enhanced freedom from repeat revascularization and low stroke rate can be regarded as the Holy Grail of myocardial revascularization. However, the results of a large, multicenter, prospective trial are required to substantiate this status.

Saphenous vein grafts in contemporary coronary artery bypass graft surgery.

Myocardial ischaemia resulting from obstructive coronary artery disease is a major cause of morbidity and mortality in the developed world. Coronary artery bypass graft (CABG) surgery is the gold-standard treatment in many patients with complex multivessel coronary artery disease or left main disease. Despite substantial improvements in the outcome of patients undergoing CABG surgery in the past decade, graft patency remains the 'Achilles' heel' of this procedure. Whereas the use of the left internal mammary artery as a conduit is associated with the highest 10-year patency rate (>90%), saphenous vein grafts - the most commonly used conduit in CABG surgery - fail in 40-50% of treated patients by 10 years after surgery. Vein graft disease (VGD) and failure result from complex pathophysiological processes that can lead to complete occlusion of the graft, affecting long-term clinical outcomes. Optimal harvesting techniques, intraoperative preservation strategies and intraoperative patency control have important roles in the prevention of VGD. In addition, several studies published in the past decade have reported similar mid-term patency rates between vein grafts and arterial grafts when veins are used as a composite graft based on the internal mammary artery. In this Review, we present the latest evidence on the utilization of saphenous vein grafts for CABG surgery and provide an overview of the current practices for the prevention of VGD and vein graft failure.

Long-Term Outcomes Following Heart Team Revascularization Recommendations in Complex Coronary Artery Disease.

BackgroundThe Heart Team (HT) comprises integrated interdisciplinary decision making. Current guidelines assign a Class Ic recommendation for an HT approach to complex coronary artery disease (CAD). However, there remains a paucity of data in regard to hard clinical end points. The aim was to determine characteristics and outcomes in patients with complex CAD following HT discussion.Methods and ResultsThis observational study was conducted at St Thomas’ Hospital (London, UK). Case mixture included unprotected left main, 2‐vessel (including proximal left anterior descending artery) CAD, 3‐vessel CAD, or anatomical and/or clinical equipoise. HT strategy was defined as optimal medical therapy (OMT) alone, OMT+percutaneous coronary intervention (PCI), or OMT+coronary artery bypass grafting. From April 2012 to 2013, 51 HT meetings were held and 398 cases were discussed. Patients tended to have multivessel CAD (74.1%), high SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) scores (median, 30; interquartile range, 23–39), and average age 69±11 years. Multinomial logistic regression analysis performed to determine variables associated with HT strategy demonstrated decreased likelihood of undergoing PCI compared with OMT in older patients with chronic kidney disease and peripheral vascular disease. The odds of undergoing coronary artery bypass grafting compared with OMT decreased in the presence of cardiogenic shock and left ventricular dysfunction and increased in younger patients with 3‐vessel CAD. Three‐year survival was 60.8% (84 of 137) in the OMT cohort, 84.3% (107 of 127) in the OMT+PCI cohort, and 90.2% in the OMT+coronary artery bypass grafting cohort (92 of 102).ConclusionsIn our experience, the HT approach involved a careful selection process resulting in appropriate patient‐specific decision making and good long‐term outcomes in patients with complex CAD.

SYNTAX Score in Patients With Diabetes Undergoing Coronary Revascularization in the FREEDOM Trial

BackgroundDiabetes mellitus (DM) is associated with complex coronary artery disease (CAD), which in turn results in increased morbidity and mortality from cardiovascular disease. ObjectivesThis study sought to evaluate the utility of SYNTAX score (SS) for predicting future cardiovascular events in patients with DM and complex CAD undergoing either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). MethodsThe FREEDOM (Future REvascularization Evaluation in patients with Diabetes mellitus: Optimal management of Multivessel disease) trial randomized patients with DM and multivessel CAD to undergo either PCI with drug-eluting stents or CABG. The SS was calculated retrospectively by a core laboratory. The endpoint of hard cardiovascular events (HCE) was a composite of death from any cause, nonfatal myocardial infarction, and nonfatal stroke, while the endpoint of major adverse cardiac and cerebrovascular events (MACCE) was a composite of HCE and repeat revascularization. ResultsA total of 1,900 patients were randomized to PCI (n = 953) or CABG (n = 947). The SS was considered an independent predictor of 5-year MACCE (hazard ratio per unit of SS: 1.02; 95% confidence interval: 1.00 to 1.03; p = 0.014) and HCE (hazard ratio per unit of SS: 1.03; 95% confidence interval: 1.01 to 1.04; p = 0.002) in the PCI cohort, but not in the CABG group. There was a higher incidence of MACCE in PCI patients with low, intermediate, and high SS compared with those who underwent CABG (36.6% vs. 25.9%, p = 0.02; 43.9% vs. 26.8%, p < 0.001; 48.7% vs. 29.7%, p = 0.003, respectively). ConclusionsIn DM patients with multivessel CAD, the complexity of CAD evaluated by the SS is an independent risk factor for MACCE and HCE only in patients undergoing PCI. The SS should not be utilized to guide the choice of coronary revascularization in patients with DM and multivessel CAD. (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes [FREEDOM]; NCT00086450)

Revascularization in complex multivessel coronary artery disease after FREEDOM. Is there an indication for PCI and drug-eluting stents?

Diabetes mellitus is a highly prevalent metabolic disorder frequently associated with the development of coronary atherosclerosis. Myocardial revascularization assumes a central role in the treatment of diabetic patients with coronary artery disease. Although coronary artery bypass grafting (CABG) is in principle the revascularization modality of choice in diabetic patients with complex, multivessel disease, percutaneous coronary interventions (PCI) using new-generation drug-eluting stents (DES) remain a valuable treatment option for properly selected diabetic patients. Defining the appropriate revascularization strategy is often a challenging task that requires tailored approaches, accounting for individual patient surgical risk, anatomical configurations, and the technical feasibility of each procedure in addition to careful judgment of the possible benefits and risks inherent to PCI and CABG. Evidence is building that advances in DES technology may mitigate at least in part some of the adverse vascular effects of diabetes; whether this may translate to PCI outcomes comparable with those achieved by CABG is under investigation in randomized trials currently underway. This review article summarizes the indications for myocardial revascularization across the spectrum of clinical presentations and critically discusses current evidence and future perspectives regarding the value of each revascularization mode (CABG vs. PCI) in patients with diabetes.

Simultaneous subacute coronary artery stent thrombosis in a carrier of two CYP2C19 loss–of function polymorphisms (*2/*3)

Simultaneous subacute coronary artery stent thrombosis in a carrier of two CYP2C19 loss–of function polymorphisms (*2/*3)

Physiology-guided myocardial revascularisation in complex multivessel coronary artery disease: beyond the 2014 ESC/EACTS guidelines on myocardial revascularisation

For patients with multivessel coronary artery disease there are two options for revascularisation: Percutaneous coronary intervention (PCI) or Coronary Artery Bypass Graft Surgery (CABG). In daily clinical practice, a heart...

Optimal treatment of multivessel complex coronary artery disease.

The aim of the present study was to investigate major cardiac events and the similarities and differences of medical costs among patients with multivessel complex coronary artery disease (MCCAD) during the three-year follow-up. The MCCAD patients had undergone single complete revascularization (CR), fractionated revascularization (FR) or partial revascularization (PR) and the present study aimed to screen the optimal treatment program. A total of 2,309 MCCAD patients who had been treated at a single center in the last decade, among which 1,020 cases underwent single CR, 856 cases successively underwent FR and 433 cases only underwent PR, were followed-up for three years. Major cardiac events, including all-cause mortality, myocardial infarction, severe heart failure, rehospitalization and revascularization (coronary artery bypass grafting and coronary stent reimplantation), were set as the end points. In addition, the three-year medical costs associated with heart disease were analyzed. The three-year cardiac event rate in the CR group (17%) was significantly lower compared with the other two groups and the average three-year medical costs in the CR group (62,100 RMB) were significantly lower than those in the other two groups. Therefore, under permissive conditions, single CR is the optimal and most economical treatment strategy for patients with MCCAD.

The SYNTAX score does not predict presence of carotid disease in a multivessel coronary disease population

Numerous reports have shown the relationship between carotid artery atherosclerosis and coronary artery disease (CAD). However, the association between complex CAD evaluated by SYNTAX score (SxScore) and prevalence of carotid lesion (CL) has not been fully investigated. We sought to assess the prevalence of carotid atherosclerosis in patients with multivessel CAD assessed by SxScore and the relationship between SxScore severity and features of carotid atherosclerosis. Subjects were 204 consecutive patients with multivessel CAD assessed by coronary angiography and no previous history of carotid atherosclerosis that underwent carotid ultrasound scan from June 2012 to 2013. Presence of CL, significant carotid disease (SCD) and carotid plaque morphology was evaluated. At least one CL was found in 159 patients (77.9%) with no significant difference among SxScore groups (P = 0.20 and P = 0.54, respectively). High prevalence of complex carotid plaque (CCP) was found without significant different distribution in SxScore groups (P = 0.69). Age was independently associated with the presence of CL [odds ratio (OR) 1.055; 95% confidence interval (CI): 1.015-1.097; P = 0.007] and SCD (OR 1.057; 95% CI: 1.008-1.097; P = 0.019). Age and diabetes were independently associated with CCP (OR 1.58; 95% CI: 1.023-1.095; P = 0.001; OR 1.848; 95% CI: 1.026-3.327; P = 0.041). SxScore was not independently associated with CL, SCD and CCP (all P > 0.2). We found high prevalence of CL in patients with multivessel complex CAD. However, SxScore does not seem to correlate with carotid atherosclerosis.

Hybrid coronary revascularization: a mainstream revascularization strategy in the future?

Revascularization by coronary artery bypass grafting is superior to percutaneous coronary intervention in cases of complex multivessel coronary artery disease. The superiority is demonstrated by reduced rates of repeat revascularization, myocardial infarction and all-cause death. By contrast, stroke occurs more frequently after coronary artery bypass grafting. Hybrid coronary revascularization combines the survival benefits of left internal mammary artery-to-left anterior descending coronary artery grafting, fast recovery and minimized surgical trauma, reduced risk of stroke by avoidance of aortic manipulation and the long-term patency of drug-eluting stent treatment of left anterior descending coronary artery lesions. Accordingly, results from registry studies are compatible with the short- and long-term superiority of hybrid coronary revascularization as compared with conventional revascularization using percutaneous coronary intervention or coronary artery bypass grafting.

Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial

We report the 5-year results of the SYNTAX trial, which compared coronary artery bypass graft surgery (CABG) with percutaneous coronary intervention (PCI) for the treatment of patients with left main coronary disease or three-vessel disease, to confirm findings at 1 and 3 years. The randomised, clinical SYNTAX trial with nested registries took place in 85 centres in the USA and Europe. A cardiac surgeon and interventional cardiologist at each centre assessed consecutive patients with de-novo three-vessel disease or left main coronary disease to determine suitability for study treatments. Eligible patients suitable for either treatment were randomly assigned (1:1) by an interactive voice response system to either PCI with a first-generation paclitaxel-eluting stent or to CABG. Patients suitable for only one treatment option were entered into either the PCI-only or CABG-only registries. We analysed a composite rate of major adverse cardiac and cerebrovascular events (MACCE) at 5-year follow-up by Kaplan-Meier analysis on an intention-to-treat basis. This study is registered with ClinicalTrials.gov, number NCT00114972. 1800 patients were randomly assigned to CABG (n=897) or PCI (n=903). More patients who were assigned to CABG withdrew consent than did those assigned to PCI (50 vs 11). After 5 years' follow-up, Kaplan-Meier estimates of MACCE were 26·9% in the CABG group and 37·3% in the PCI group (p<0·0001). Estimates of myocardial infarction (3·8% in the CABG group vs 9·7% in the PCI group; p<0·0001) and repeat revascularisation (13·7%vs 25·9%; p<0·0001) were significantly increased with PCI versus CABG. All-cause death (11·4% in the CABG group vs 13·9% in the PCI group; p=0·10) and stroke (3·7%vs 2·4%; p=0·09) were not significantly different between groups. 28·6% of patients in the CABG group with low SYNTAX scores had MACCE versus 32·1% of patients in the PCI group (p=0·43) and 31·0% in the CABG group with left main coronary disease had MACCE versus 36·9% in the PCI group (p=0·12); however, in patients with intermediate or high SYNTAX scores, MACCE was significantly increased with PCI (intermediate score, 25·8% of the CABG group vs 36·0% of the PCI group; p=0·008; high score, 26·8%vs 44·0%; p<0·0001). CABG should remain the standard of care for patients with complex lesions (high or intermediate SYNTAX scores). For patients with less complex disease (low SYNTAX scores) or left main coronary disease (low or intermediate SYNTAX scores), PCI is an acceptable alternative. All patients with complex multivessel coronary artery disease should be reviewed and discussed by both a cardiac surgeon and interventional cardiologist to reach consensus on optimum treatment. Boston Scientific.

Fractional flow reserve for the assessment of complex multivessel disease in a patient after hybrid coronary revascularization

We present a case of a 43-year-old woman with history of hybrid coronary revascularization [endoscopic atraumatic coronary artery bypass (ACAB)] of left internal mammary artery (LIMA) to the left anterior descending artery (LAD) and stent implantation in right coronary artery (RCA), who presented 6 years later with recurrent atypical angina. Coronary angiography revealed patent LIMA to LAD and RCA stent, with a new lesion in an obtuse marginal artery and significant progression of disease in the proximal/mid LAD proximal to LIMA touchdown. To further evaluate the hemodynamic significance of these new disease segments, the patient underwent fractional flow reserve (FFR) assessment of the left coronary system with subsequent stent implantation in the proximal/mid LAD. This case illustrates (1) the critical value of FFR assessment in determining the ischemia provoking lesions in this post ACAB patient with complex multivessel coronary artery disease; and (2) the accelerated progression of atherosclerosis in bypassed segments as compared to segments proximal to stents.

Current concepts on coronary revascularization in diabetic patients

Diabetic mellitus (DM) patients with coronary artery disease (CAD) are at higher risk of cardiovascular events compared with non-DM individuals. While aggressive cardiovascular prevention and adequate blood glucose control remain cornerstones of therapy, the decision when and how to proceed to coronary revascularization in an individual DM patient should be based on the extent of CAD, ischaemic burden, ventricular function, as well as comorbidities. While in patients with stable symptoms, moderate CAD on coronary angiography and preserved left ventricular function a conservative strategy may be a valuable initial strategy, in patients with acute coronary syndromes (ACS) an early invasive approach should be favoured. The revascularization strategy for DM patients with complex multivessel CAD should be discussed within a heart team consisting of cardiologists, cardiac surgeons, and anaesthesiologists. In general, the threshold for coronary artery bypass surgery (CABG) should be lower for DM than for non-DM individuals. In patients undergoing percutaneous coronary intervention, the use of drug-eluting stents (DES) and--in the setting of ACS--of potent platelet inhibitors, such as prasugrel or ticagrelor, should be favoured. In the near future, multiple strategies may further favourably impact the prognosis of DM patients undergoing coronary revascularization. These include alternative antiplatelet agents such as thromboxane receptor inhibitors, the broad use of second generation DES, and possibly the implantation of bioresorbable stents. Coronary artery bypass surgery outcomes may also further improve by wide implementation of arterial revascularization, reduction in perioperative stroke by avoiding clamping of the aorta, reduction in wound infection by minimally invasive techniques, and optimization of post-operative medical management.

Die Behandlung der koronaren Mehrgefäßerkrankung: Bypassoperation oder perkutane Katheterintervention?

Seit ihrer Einfuhrung im Jahr 1968 ist die aortokoronare Venenbybassoperation und seit Mitte der neunziger Jahre die verbesserte Variante der arteriellen Koronarrevaskularisation unter Verwendung einer oder beider Mammaria-interna-arterien die Standardtherapie der symptomatischen koronaren Herzkrankheit (KHK) mit komplexer Mehrgefasbeteiligung. Dennoch haben die technischen Fortschritte der perkutanen Interventionstechnik mit der Entwicklung von Stents – schlieslich auch Medikamenten-beschichtet – und die Weiterentwicklung der begleitenden medikamentosen Therapien dazu gefuhrt, dass heute auch komplexe Mehrgefaserkrankungen mit und ohne Hauptstammbeteiligung immer haufiger durch interventionelle Techniken behandelt werden. Dem Vorteil der weniger traumatischen Behandlung durch Interventionstechniken steht deren historischer Nachteil entgegen: die durch Restenose verursachte Notwendigkeit zur haufigeren Reintervention im Vergleich zur Bypassoperation. Die technischen Fortschritte in beiden Behandlungsmethoden machen einen wiederholten Vergleich der Behandlungserfolge durch kontrollierte und randomisierte Studien erforderlich, um evidenzbasierte Daten uber die beste Behandlungsstrategie der komplexen Manifestationsformen der KHK zu generieren. Auf diesen Daten beruht die Beratung des Patienten fur die individuell optimierte Behandlung der koronaren Herzkrankheit. Diese Arbeit gibt einen historischen und aktuellen Uberblick uber Studien, die die Weiterentwicklungen der interventionellen Therapiemodalitaten der KHK mit dem historischen Goldstandard der ACB-Operation vergleichen.