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Dr. Lucia Torracca
In this interesting session the role of surgical revascularisation was discussed. The number of CABG procedures has considerably decreased in the last ten years, with a concomitant increase in PCI procedures.
Despite this trend, surgical revascularisation still plays an important role. Looking accurately in the results reported by the randomised trials comparing CABG versus PCI in multivessel disease, most of the enrolled patients have two vessel disease and normal ejection fraction. This selection bias eliminates or reduces the group of patients with triple vessel disease, left main stenosis or low ejection fraction, who benefit most from CABG. On the basis of the data from the literature, surgical revascularisation still remains the treatment of choice for patients with triple vessel disease, left main stenosis and low ejection fraction. The advantage of surgical revascularisation is more pronounced in patients treated by complete arterial revascularisation. The results reported in the literature for different type of grafts show that the use of bilateral internal mammary artery have an important impact on long term survival and freedom from reoperation. The use of technical solutions like the Y graft offer the possibility to revascularise all the coronaries with the use of two mammary grafts, giving patients the best option for a durable operation. The role of complete versus incomplete myocardial revascularisation has been analysed, and data currently available are inconclusive on this topic. New data are necessary to answer to this question. Finally an accurate analysis was done about the role of previous PCI on the results of patients treated by CABG. This revision of the literature clearly shows that patients previously treated by PCI have higher mortality and worse long term results after CABG. The reason of this finding is not clear but is probably related to the activation of an inflammatory process by the PCI procedure.
In conclusion, surgical revascularisation, possibly performed by the use of bilateral mammary artery, still remains the treatment of choice in patients with triple vessel disease, left main stenosis and low ejection fraction. The awareness that previous PCI represents a risk factor for patients treated with CABG might be a stimulus for a more accurate selection of patients at their first treatment of coronary artery disease.
Burning questions in coronary revascularisation Symposium