CABG and PCI—just as we said it!

Abstract

Let me preempt any presumption of the reader of my being a surgical hawk-I am not decrying percutaneous coronary interventions (PCI), but to the very contrary, I acknowledge, loud and clear, that PCI is one of the greatest boons to the society-albeit with a caveat. Just akin to salt in food, in right amounts-an elixir, but a little more or less and it messes up the taste-PCI too has its rightful place in the armamentarium for coronary artery disease (CAD), but only when optimally used. Cardiac surgeons have never challenged PCI, but have been bemoaning the fact that PCI has been overused over the last decade or so. That Bintuitive wisdom^is now being given the wind of Bevidence^as acknowledged by the recent European Society of Cardiology (ESC)/European Association of Cardiothoracic Surgeons (EACTS) guidelines released during the recent meeting in Munich in August 2018 [1]. That clinical profile matters has been acknowledged by the Clinical / Functional SYNergy between PCI with TAXus and Cardiac Surgery (SYNTAX) Score, which was shown to be superior in risk prediction than the anatomical SYNTAX Score. But now, even in anatomical SYNTAX scores less than 23, in patients with diabetes, coronary artery bypass graft (CABG) surgery has been shown to have superior outcomes to PCI. Left ventricular (LV) dysfunction and heart failure are other major clinical phenotypes with surgical superiority [1]. Further recent guidelines prioritize completeness of revascularization as the Braison d'etre^of the decision making process and that surgery provides more complete revascularization than PCI is a Bgiven.^So moving forwards, with better understanding of the indications and outcomes of the two major modalities of treatment of CAD, viz PCI and CABG, without giving a short shrift to the third modality-the medical treatment-which in fact may supersede the other two, especially in stable CAD, CABG is likely to re-discover itself.The recent publication of the SYNTAX II [2] and the SYNTAX III Revolution [3] trials too serves the surgical community well, as the gatekeeper role seems to be slipping out of the cardiologist's domain into the radiologist's. Time is not far, when the latter would sit on jury, as a neutral ombudsman, adjudicating on the optimum mode of treatment in an index case. This chutzpah emanates from the ever refining accuracy of the coronary computed tomography (CT) angiography-bordering, but not yet quite, challenging cine angiography. The evidence generated by the Fractional Flow Reserve Versus Angiography for Multivessel Evaluation (FAME) and the FAME 2 studies on physiological assessment of coronary stenosis has been given further impetus and a thumbs up by the SYNTAX III Trial, which clearly showed that the outcomes were better with Fractional Flow Reserve Computed Tomography (FFR CT)based PCI over classical cine angiography-based myocardial revascularization [3]. SYNTAX 3 Revolution Study thus provides evidence base and a window of opportunity for incorporating the radiologist in the Heart-Team. The surgeon may ...