De Rosa S.

Indolfi C.

Mongiardo A.

Spaccarotella C.

Torela D.

Yasuda M.

English

Archivio della ricerca - Università degli studi di Napoli Federico II

The everlasting dispute between coronary bypass andangioplasty in patients with multivessels coronaryartery disease: results of the SYNTAX II studyCiro Indolfi, Salvatore De Rosa, Annalisa Mongiardo, Masakazu Yasuda,Daniele Torella, and Carmen SpaccarotellaCardiology Unit, UOC Cardiologia Emodinamica ed UTICRT CNR di IFC Università degli Studi Magna Graecia diCatanzaro, ItalyKEYWORDS: PCI; CABG; IVUS; iFR/FFR; CTOCoronary angioplasty, introduced 40years ago, has seensignificant technologic progress, particularly in the devel-opment of stents,1 in the understanding of coronary physi-ology,2–4 and coronary imaging, becoming the standardcoronary revascularization technique for patients withnon-complicated coronary artery disease. Nonetheless, inpatients with three vessels coronary artery disease (3VD),the choice between percutaneous coronary intervention(PCI), and coronary artery bypass grafting (CABG) stillremains problematic. In the last few years, efforts havebeen made to identify objective parameters able to guidethe therapeutic option in patients with multivessels dis-ease. The SYNTAX I (SYNergy between PCI with TAXUS andCardiac Surgery) study, published in 2013, compared PCI(with first generation stents) with CABG in patients with3VD.5 The 5 years results of the SYNTAX I documentedthat PCI had a higher mortality rate, myocardial infarction,and need for repeated revascularization than CABG.Accordingly, CABG has confirmed the treatment of choicefor patients with complex multivessels disease, whilePCI was recommended as an acceptable alternative treat-ment for patients with uncomplicated disease (SYNTAXscore intermediate or low). The study results regardingcomplex multivessels disease have been challenged byrecent technologic and procedural advancements of PCI.Furthermore, it has become clear that the decision as tothe strategy of revascularization should have not beenbased on coronary anatomy only [SYNTAX SCORE I (SS I) 22], as recommended by the guidelines,6 but needed toconsider the specifics of the patient clinical situation.These considerations gave impetus for the introductionof the SYNTAX II score (SS II) (Figure 1).7SYNTAX II score was developed,7 with the aim of improv-ing clinical risk stratification, and facilitate the decision as- SYNTAX SCORE I - Age - Glomerular filtration rate (CrCl mL/m) - LVEF (%) - Unprotected Left Main - Sex - COPD - PAD Figure 1 SYNTAX II variables. In the SYNTAX II score have been includedeight variables to accurately predict 4 years mortality in the individualpatient. For instance, a man 60 years old, with SYNTAX SCORE I of 30, andunprotected left main disease, creatinine clearance of 60 mL/m, leftventricular ejection fraction of 50%, and chronic obstructive pulmonarydisease, would have a SYNTAX II score of 41 points (predicted 4 years mor-tality ¼ 16.3%) in case of coronary artery bypass grafting, but 33 points(predicted 4 years mortality ¼ 8.7%) in case of percutaneous coronary in-tervention. The same patients, but without chronic obstructive pulmo-nary disease, would have the same predicted mortality after coronaryartery bypass grafting or percutaneous coronary intervention.Published on behalf of the European Society of Cardiology. VC The Author(s) 2019.This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License(http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction inany medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.comEuropean Heart Journal Supplements (2019) 21 (Supplement B), B55–B56The Heart of the Matterdoi:10.1093/eurheartj/suz019to which revascularization technique should be preferred.The SS II besides the anatomical variables, includesalso those clinical factors known to affect prognosis, suchas unprotected left main disease, female gender, chronicobstructive pulmonary disease, left ventricular ejectionfraction, renal function, and peripheral arterial disease(Figure 1).The study demonstrated that clinical outcomes with theSYNTAX II strategy were associated with improved clinicalresults comparedwith the PCI performed in similar patientsfrom the original SYNTAX I trial, with a lower incidenceof Major Adverse Cardiovascular Event (MACCE), as deter-mined by a reduction of the individual endpoints: myo-cardial infarction, need for revascularization, stentthrombosis after 1 year of follow-up.8Themain results of this study can be summarized as:• Clinical outcomes with the SYNTAX II strategy were as-sociated with improved clinical results compared withthe PCI performed in similar patients from the originalSYNTAX I trial with a lower incidence of MACCE, as de-termined by a reduction of the individual endpoints:myocardial infarction, need for revascularization,stent thrombosis after 1 year of follow-up.• Short-term results of patients at intermediate ana-tomical risk (SS I 23-32) treated with PCI according tothe SS II, had similar results than patients at low ana-tomical risk (SS I  22).• A physiologic evaluation was possible in 75% of thelesions, and contributed to delaying the treatment of25% of the lesion studied.• The systematic use of IVUS (IntraVascularUltraSound)guided stent implantation determined a further stentoptimization (mostly post-dilatation) in 32.2% of thelesion treated.• Contemporary chronic total occlusion revasculariza-tion techniques are associated with significantly im-proved results.The SYNTAX II study is the demonstration that PCI prac-ticed with the improved technologic and pharmacologicstrategies available today provides a better prognosisthan the procedure employed for the patients in theSYNTAX I study. Furthermore, the decision to proceed withCABG should not only be based on the coronary anatomy(SS I 22), but should include the clinical parameters in-cluded in the SYNTAX II score. Second generation stents,IVUS guidance, iFR/FFR, and a careful implantation tech-nique, all contributed to the improvement of the clinicalresults of PCI. The long-term follow-up of the study willprovide information regarding the persistence of the resultsin the long term, and whether it is safe to delay treatmentof coronary lesions based on iFR/FFR assessment.In patients with 3VD, the choice between PCI or CABGshould be made after careful assessment of the risksand benefits according to an overall evaluation whichincludes the anatomical/functional coronary situationand the clinical characteristics of every single patient.The choice, in light of the current data, is becoming morestraightforward.Conflict of interest: none declared.References1. Indolfi C, De Rosa S, Colombo A. Bioresorbable vascular scaffolds—basicconcepts and clinical outcome. Nat Rev Cardiol 2016;13:719–729.2. Indolfi C, Mongiardo A, Spaccarotella C, Torella D, Caiazzo G,Polimeni A, Sorrentino S, Micieli M, Sabatino J, Curcio A, De Rosa S.The instantaneous wave-free ratio (iFR) for evaluation of non-culpritlesions in patients with acute coronary syndrome and multivessel dis-ease. Int J Cardiol 2015;178:46–54.3. Davies JE, Sen S, Dehbi HM, Al-Lamee R, Petraco R, Nijjer SS, BhindiR, Lehman SJ, Walters D, Sapontis J, Janssens L, Vrints CJ, KhashabaA, Laine M, Van Belle E, Krackhardt F, Bojara W, Going O, Härle T,Indolfi C, Niccoli G, Ribichini F, Tanaka N, Yokoi H, Takashima H,Kikuta Y, Erglis A, Vinhas H, Canas Silva P, Baptista SB, Alghamdi A,Hellig F, Koo BK, Nam CW, Shin ES, Doh JH, Brugaletta S, Alegria-Barrero E, Meuwissen M, Piek JJ, van Royen N, Sezer M, Di Mario C,Gerber RT, Malik IS, Sharp ASP, Talwar S, Tang K, Samady H, Altman J,Seto AH, Singh J, Jeremias A, Matsuo H, Kharbanda RK, Patel MR,Serruys P, Escaned J. Use of the instantaneous wave-free ratio or frac-tional flow reserve in PCI. N Engl J Med 2017;376:1824–1834.4. De Rosa S, Polimeni A, Petraco R, Davies JE, Indolfi C. Diagnostic per-formance of the instantaneous wave-free ratio: comparison with frac-tional flow reserve. Circ Cardiovasc Interv 2018;11:e004613.5. Mohr FW, Morice MC, Kappetein AP, Feldman TE, Ståhle E, Colombo A,Mack MJ, Holmes DR, Morel MA, Van Dyck N, Houle VM, Dawkins KD,Serruys PW. Coronary artery bypass graft surgery versus percutaneouscoronary intervention in patients with three-vessel disease and leftmain coronary disease: 5-year follow-up of the randomised, clinicalSYNTAX trial. Lancet 2013;381:629–638.6. Authors/Task Force Members, Windecker S, Kolh P, Alfonso F, ColletJP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P,Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, NeumannFJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP,Torracca L, Valgimigli M, Wijns W, Witkowski A. 2014 ESC/EACTSGuidelines on myocardial revascularization: the task force on myocar-dial revascularization of the European Society of Cardiology (ESC) andthe European Association for Cardio-Thoracic Surgery(EACTS)Developed with the special contribution of the EuropeanAssociation of Percutaneous Cardiovascular Interventions (EAPCI). EurHeart J 2014;35:2541–2619.7. Farooq V, van Klaveren D, Steyerberg EW, Meliga E, Vergouwe Y,Chieffo A, Kappetein AP, Colombo A, Holmes DR, Mack M, Feldman T,Morice M-C, Ståhle E, Onuma Y, Morel M-A, Garcia-Garcia HM, van EsGA, Dawkins KD, Mohr FW, Serruys PW. Anatomical and clinical char-acteristics to guide decision making between coronary artery bypasssurgery and percutaneous coronary intervention for individualpatients: development and validation of SYNTAX score II. Lancet2013;381:639–650.8. Escaned J, Collet C, Ryan N, Luigi De Maria G, Walsh S, Sabate M,Davies J, Lesiak M, Moreno R, Cruz-Gonzalez I, Hoole SP, Ej West N,Piek JJ, Zaman A, Fath-Ordoubadi F, Stables RH, Appleby C, vanMieghem N, van Geuns RJ, Uren N, Zueco J, Buszman P, I~niguez A,Goicolea J, Hildick-Smith D, Ochala A, Dudek D, Hanratty C,Cavalcante R, Kappetein AP, Taggart DP, van Es G-A, Morel M-A, deVries T, Onuma Y, Farooq V, Serruys PW, Banning AP. Clinical outcomesof state-of-the-art percutaneous coronary revascularization inpatients with de novo three vessel disease: 1-year results of theSYNTAX II study. Eur Heart J 2017;38:3124–3134.B56 C. Indolfi et al.

The everlasting dispute between coronary bypass and angioplasty in patients with multivessels coronary artery disease: Results of the SYNTAX II study

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The everlasting dispute between coronary bypass and angioplasty in patients with multivessels coronary artery disease: Results of the SYNTAX II study

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