Patients with 3-vessel disease should be operated!

Point-Counter point 1

Best way to revascularize patients with main stem and three-vessel lesions. Patients should be operated! [i]

An abundance of clinical trials has proven that coronary artery bypass surgery (CABG) is superior to Stenting (PCI) in almost every type of multivessel or left main Coronary Artery Disease (CAD.These days however, even the most complex coronary lesions are treated with PCI, although current guidelines suggest CABG as the superior treatment for patients with three-vessel or left main coronary disease.

A number of institutions, including the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) once again have recommended CABG in all clinical settings where revascularization is necessary. PCI was rated appropriate in acute myocardial injury and in patients with one- or two-vessel disease with involvement of the proximal LAD, but uncertain or even inappropriate for all patients with three-vessel disease and/or left main stenosis.

The criteria provide optimal treatment strategies in many other clinical circumstances such as diabetes, prior bypass surgery (with or without patent grafts), high surgical risk due to non-cardiac co-morbidities or acute coronary syndromes.

Another important issue in the therapy for multivessel or left main CAD is that of re-intervention due to stent restenosis or graft occlusion. Although failure rates of the initial revascularization procedure were found to be not significantly different for PCI and CABG in the SYNTAX trial, the consequences of the two respective events are known to differ enormously. While stent thrombosis frequently results in myocardial infarction (up to 80% of cases) with reported mortality rates between 30 and 45%, graft occlusion usually becomes apparent with recurring angina, which then leads to repeat revascularization. This effect is well known from the literature and did indeed translate into increased rates of myocardial infarction and cardiac death in the PCI group of the SYNTAX trial:

“CABG remains the standard of care for patients with three-vessel or left main coronary artery disease”[ii]

[ii] “CABG remains the standard of care for patients with three-vessel or left main coronary artery disease” (Serruys et al. in N Engl J Med 360:961-972, 2009).