ApPropriateness of myocaRdial RevascularizatiOn assessed by the SYNTAX score II in a coUntry without cardiac Surgery faciliTies; PROUST study

Quantitative flow ratio versus fractional flow reserve for Heart Team decision-making in multivessel disease: the randomised, multicentre DECISION QFR trial

BACKGROUND

Vessel-level physiological data derived from pressure wire measurements are one of the important determinant factors in the optimal revascularisation strategy for patients with multivessel disease (MVD). However, these may result in complications and a prolonged procedure time.

AIMS

The feasibility of using the quantitative flow ratio (QFR), an angiography-derived fractional flow reserve (FFR), in Heart Team discussions to determine the optimal revascularisation strategy for patients with MVD was investigated.

METHODS

Two Heart Teams were randomly assigned either QFR- or FFR-based data of the included patients. They then discussed the optimal revascularisation mode (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) for each patient and made treatment recommendations. The primary endpoint of the trial was the level of agreement between the treatment recommendations of both teams as assessed using Cohen's kappa.

RESULTS

The trial included 248 patients with MVD from 10 study sites. Cohen's kappa in the recommended revascularisation modes between the QFR and FFR approaches was 0.73 [95% confidence interval {CI} : 0.62-0.83]. As for the revascularisation planning, agreements in the target vessels for PCI and CABG were substantial for both revascularisation modes (Cohen's kappa=0.72 [95% CI: 0.66-0.78] and 0.72 [95% CI: 0.66-0.78], respectively). The team assigned to the QFR approach provided consistent recommended revascularisation modes even after being made aware of the FFR data (Cohen's kappa=0.95 [95% CI:0.90-1.00]).

CONCLUSIONS

QFR provided feasible physiological data in Heart Team discussions to determine the optimal revascularisation strategy for MVD. The QFR and FFR approaches agreed substantially in terms of treatment recommendations.

Appropriateness of the modality of revascularization according to the SYNTAX Score II 2020 in the FASTTRACK CABG study: An interim report on patient selection

BACKGROUND

Personalized long term vital prognosis plays a key role in deciding between percutaneous coronary intervention (PCI) and CABG in patients with complex coronary artery disease. The FASTTRACK CABG trial enrolls patients with the sole guidance of coronary computed tomographic angiography (CCTA) and fractional flow reserve CCTA (FFR_CT). The feasibility/non-feasibility of this approach is determined by the surgeon request to have access to the invasive coronary angiography.

METHODS

This interim analysis, which was requested by the Data and Safety Monitoring Board (DSMB), compared the treatment decision of the "on site" Heart team to the recommended treatment as per the SYNTAX Score II 2020 (SS-2020), which was prospectively assessed by the central core laboratory in the first 57 consecutive patients (half of the planned population) enrolled in this First in Man study.

RESULTS

The average anatomical SYTAX Score is 35.6 ± 11.5. The SS-2020 predicted 5-year MACE and 10-year all-cause mortality are 14.7 % and 21.6 % following CABG, and 23.0 % and 30.4 % following PCI. Among the enrolled patients the SS-2020 predicts long-term PCI outcomes similar to CABG (absolute risk difference ≤0 % in favor of PCI) in only two patients whilst the remaining 55 patients had a predicted survival benefit with CABG.

CONCLUSIONS

According to the SS-2020, the first 57 patients recruited into the FASTTRACK CABG trial received the appropriate modality of revascularization and the DSMB allowed the investigators to complete the study.

ApPropRiateness of myOcardial revascUlarization assessed by SYNTAX Scores in patients with type 2 diabetes melliTus: the PROUST study

INTRODUCTION

Results of currently available trials have shown divergent outcomes in diabetic patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Current guidelines do not recommend PCI in patients with diabetes and a SYNTAX score ≥ 23.

AIM

To compare all-cause 4-year mortality after revascularization for complex coronary artery disease (CAD) in diabetics.

MATERIAL AND METHODS

The study group comprised consecutive patients with three-vessel CAD and/or unprotected left main CAD (≥ 50% diameter stenosis) without major hemodynamic instability, who were treated in two institutions with PCI or referred for CABG.

RESULTS

Out of 342 diabetics, 177 patients underwent PCI and 165 patients were referred for CABG. The incidence of all-cause death was different between diabetics treated with PCI or CABG at 4 years (16/177, 9.0% vs. 26/165, 15.8%, respectively, p = 0.03). The difference was not evident in non-diabetics (PCI: 41/450, 9.1% vs. CABG: 19/249, 7.6%, p = 0.173). In diabetics, there was a higher incidence of all-cause mortality in PCI patients with intermediate-high (≥ 23) SYNTAX scores compared with those with low (0-22) SYNTAX scores (10/56, 17.9% vs. 6/121, 5.0%, respectively, p < 0.01). On the other hand, diabetics who underwent CABG showed similar mortality rates irrespective of the SYNTAX scores (SYNTAX 0-22: 3/29, 10.3%; SYNTAX ≥ 23: 23/136, 11.9%, p = 0.46). In the subgroup analysis, there was no interaction according to presence or absence of left main CAD (p for interaction = 0.12) as well as according to diabetes status (p for interaction = 0.38), whereas gender and SYNTAX scores were differentiators between PCI and CABG with a p for interaction < 0.1.

CONCLUSIONS

Our analysis supports recent evidence that diabetes is not a differentiator between PCI and CABG.

Impact of non-respect of SYNTAX score II recommendation for surgery in patients with left main coronary artery disease treated by percutaneous coronary intervention: an EXCEL substudy

OBJECTIVES

The SYNTAX score II (SSII) was developed from the SYNTAX trial to predict the 4-year all-cause mortality after left main or multivessel disease revascularization and to facilitate the decision-making process. The SSII provides the following treatment recommendations: (i) coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) (equipoise risk), (ii) CABG preferred (excessive risk for PCI) or (iii) PCI preferred (excessive risk for CABG). We sought to externally validate SSII and to investigate the impact of not abiding by the SSII recommendations in the randomized EXCEL trial of PCI versus CABG for left main disease.

METHODS

The calibration plot of predicted versus observed 4-year mortality was constructed from individual values of SSII in EXCEL. To assess overestimation versus underestimation of predicted mortality risk, an optimal fit regression line with slope and intercept was determined. Prospective treatment recommendations based on SSII were compared with actual treatments and all-cause mortality at 4 years.

RESULTS

SSII variables were available from EXCEL trial in 1807/1905 (95%) patients. For the entire cohort, discrimination was possibly helpful (C statistic = 0.670). SSII-predicted all-cause mortality at 4 years overestimated the observed mortality, particularly in the highest-risk percentiles, as confirmed by the fit regression line [intercept 2.37 (1.51-3.24), P = 0.003; slope 0.67 (0.61-0.74), P < 0.001]. When the SSII-recommended treatment was CABG, randomized EXCEL patients treated with PCI had a trend towards higher mortality compared with those treated with CABG (14.1% vs 5.3%, P = 0.07) in the as-treat population. In the intention-to-treat population, patients randomized to PCI had higher mortality compared with those randomized to CABG (15.1% vs 4.1%, P = 0.02), when SSII recommended CABG.

CONCLUSIONS

In the EXCEL trial of patients with left main disease, the SSII-predicted 4-year mortality overestimated the 4-year observed mortality with a possibly helpful discrimination. Non-compliance with SSII CABG treatment recommendations (i.e. randomized to PCI) was associated with higher 4-year all-cause mortality.

Relevance of SYNTAX score for assessment of saphenous vein graft failure after coronary artery bypass grafting

Objective

To identify risk factors of saphenous vein graft (SVG) failure and to investigate the utility of anatomical SYNTAX score (SS) and SYNTAX score II (SS-II) in predicting SVG failure.

Methods

A total of 598 patients who underwent angiography for clinical reasons after coronary artery bypass grafting (CABG) were included. Baseline data and factors related to SVG failure were analyzed at the patient and graft levels. Patients were divided in tertiles by anatomical SS and in three groups by SS-II revascularization recommendation, and SVG patency was analyzed across these groups.

Results

Patency rates were similar in all SS-stratified and SS-II recommendation groups within 1, 5, and 10 years after CABG. At the patient level, fasting blood glucose (FBG) level <7.0 mmol/L was less common in SVG failure (68.0% vs. 76.2%). At the graft level, patients with SVG failure tended to have angiography later (4.0 years vs. 3.0 years), poorer FBG control (FBG <7.0 mmol/L: 68.2% vs. 74.7%), and more grafts anastomosed to the right coronary system (59.2% vs. 47.4%). Longer time interval after CABG was related to SVG failure both at the patient and graft levels, and odds ratio (OR)/P values (OR/P) were 1.282/0.029 and 1.384/0.016, respectively. Using independent graft and grafting to the right artery system as risk factors at the graft level, OR/Ps were 3.094/0.000 and 2.524/0.000, respectively.

Conclusions

Longer time interval after CABG, independent grafts, and grafting to the right artery system are associated with SVG failure. Anatomical SS or SS-II may not be reasonable tools for predicting SVG failure.

PCI and CABG for Treating Stable Coronary Artery Disease: JACC Review Topic of the Week

Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are considered revascularization procedures, but only CABG can prolong life in stable coronary artery disease. Thus, PCI and CABG mechanisms may differ. Viability and/or ischemia detection to guide revascularization have been unable to accurately predict treatment effects of CABG or PCI, questioning a revascularization mechanism for improving survival. By contrast, preventing myocardial infarction may save lives. However, the majority of infarcts are generated by non-flow-limiting stenoses, but PCI is solely focused on treating flow-limiting lesions. Thus, PCI cannot be expected to significantly limit new infarcts, but CABG may do so through providing flow distal to vessel occlusions. All comparisons of CABG to PCI or medical therapy that demonstrate survival effects with CABG also demonstrate infarct reduction. Thus, CABG may differ from PCI by providing "surgical collateralization," prolonging life by preventing myocardial infarctions. The evidence is reviewed here.

Is the SYNTAX Score II applicable in all percutaneous coronary intervention patients?

OBJECTIVES

This study aimed to assess the risk stratification value of the SYNTAX Score II (SS II) in consecutive PCI patients and to analyze whether the predictive ability of SS II was consistent in patients with complex and non-complex coronary artery disease.

BACKGROUND

SS II was designed for patients with complex coronary artery disease and has been validated by a number of studies in such patients.

METHODS

The SS II for PCI was assessed in 10,072 consecutive patients who underwent PCI in Fuwai Hospital from January to December 2013. The patients were stratified according to SS II tertiles and divided into two subgroups: one-vessel or two-vessel disease (1 or 2VD) group (n = 5,709) and left main (LM) and/or three-vessel disease (3VD) group (n = 4,363). The endpoint was 30-month all-cause death following PCI procedure.

RESULTS

The high SS II group showed significantly higher 30-month mortality. Multivariate analyses showed that in the all-patients cohort and the two subgroups, SS II was an independent predictor of 30-month mortality (P < 0.0001). Based on receiver operating characteristic curves analysis, SS II showed moderate discrimination ability for 30-month mortality (C-statistics = 0.68, Hosmer-Lemeshow test P value >.05) and appeared to have better discrimination ability in the LM and/or 3VD subgroup (C-statistics = 0.631 vs. 0.722 for 1 or 2VD and LM and/or 3VD subgroups).

CONCLUSIONS

SS II was able to risk-stratify patients and predict 30-month mortality in all PCI patients. The discrimination ability of SS II appeared to be better in the LM and/or 3VD subgroup.

Cardiac surgery 2016 reviewed

For the year 2016, more than 20,000 published references can be found in Pubmed when entering the search term "cardiac surgery". Publications last year have helped to more clearly delineate the fields where classic surgery and modern interventional techniques overlap. The field of coronary bypass surgery (partially compared to percutaneous coronary intervention) was enriched by five large prospective randomized trials. The value of CABG for complex coronary disease was reconfirmed and for less complex main stem lesions, PCI was found potentially equal. For aortic valve treatment, more evidence was presented for the superiority of transcatheter aortic valve implantation for patients with intermediate risk. However, the 2016 evidence argued against the liberal expansion to the low-risk field, where conventional aortic valve replacement still appears superior. For the mitral valve, many publications emphasized the significant impact of mitral valve reconstruction on survival in structural mitral regurgitation. In addition, there were many relevant and other interesting contributions from the purely operative arena in the fields of coronary revascularization, surgical treatment of valve disease, terminal heart failure (i.e., transplantation and ventricular assist devices), and aortic surgery. While this article attempts to summarize the most pertinent publications it does not have the expectation of being complete and cannot be free of individual interpretation. As in recent years, it provides a condensed summary that is intended to give the reader "solid ground" for up-to-date decision-making in cardiac surgery.