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Debates on myocardial revascularisation

Session presentations
Cardiovascular Surgery

In this interesting session presenters advanced their pro and cons arguments in relation to chronic total occlusion (CTO) and oculo-stenotic reflex (OSR) in the context of coronary artery bypass grafting (CABG).

Chronic total occlusion
Prof R. Haaverstad (Bergen, NO) highlighted the evidence supporting the use of CABG for CTOs in keeping with the ESC/EACTS guidelines, the 4-year outcome of the Sintax trial (22% CTO incidence), and the 98% patency rate of a LIMA to occluded-LAD at 1-year. In addition, he showed evidence reporting CTO-PCI limitations (5-20% incidence of serious procedural complications; low 50-80% success rate (operator dependent), and side effects of contrast medium and prolonged radiation.

Prof AR Galassi (Acicastello, IT) reported a 50% incidence of CTO, high success rate of CTO-PCI by high volume operators (with approx 5% composite of perforation, MI, and death - Euro CTO Registry), and showed few representative angiographic results of his experience including a multivessel disease (MVD) patient and a 28yr female with a long proximal occlusion of the LAD and a large distal target lesion treated with CTO-PCI. One of the conclusions was that MVD patients with CTO should be offered PCI by experienced operators.

Oculo-stenotic reflex
Prof P Nataf (Paris, FR) supported the grafting of targets with intermediate lesions (IL) in the context of MVD as a “real life” approach given the lack of functional data at the cardiology work-up to avoid the recognised detrimental effects of incomplete revascularisation. He stressed that fractional flow reserve (FFR) is rarely performed when CABG is considered, the surgical implications of additional grafting of IL, and the importance of complete revascularisation advocating the use of arterial grafts.

Prof V Falk (Zurich, CH) showed evidence on what impacts graft patency rates, the impact of viability/scarring on revascularisation, complete revascularisation, and on functional assessment to guide revascularisation. This suggested that graft patency is lower if a graft is applied to a <60% stenotic coronary, small size targets, or to a coronary vessel supplying a scarred myocardial territory. Hence, he questioned the value of grafting IL during MVD grafting and suggested the need for systematic preoperative functional imaging of all IL to ascertain the presence of ischemia, and scarring/viability prior CABG.

Concluding remarks by the Chairperson
In keeping with the ECS/EACTS guidelines, based on the rebuttals and the discussions at this session, CABG remains the gold standard for revascularisation of CTO lesions in the context of MVD and long proximal LAD lesions. Despite advances in wiring technology of CTOs (“parallel” and “seesaw”, balloon anchoring, subintimal tracking and re-entry, retrograde approach, etc), a plethora of data from few observational studies, and the “active attitude” of few interventional cardiologists, the available evidence supporting the use of CTO-PCI in MVD and proximal LAD lesions remains anecdotal and patchy, warranting more rigorous trials to clarify the issue and bearing in mind that stand alone single vessel CTO in asymptomatic patients or those with limited angina could be managed medically.

The OSR during MVD coronary surgery is controversial and it is a real issue as convincing evidence suggests that a graft to a coronary vessel with IL has a lower late patency rate due to flow competition. This issue could be easily prevented by systematic preoperative functional assessment of ILs at the cardiology work-up (FFR or myocardial perfusion imaging). This might turn out to be also beneficial to the cardiology team given that the OSR is an issue also in the context of PCI revascularisation; it seems to be at present under scrutiny in the USA as reported by the Washington Post on the 8th of August 2012 describing OSR-PCI as an
“Irresistible temptation to expand narrowed coronary arteries during PCI, despite evidence-based guidelines suggesting it shouldn’t be done”.

Naturally, any decision-making process for the treatment of CTO and for the prevention of ORS during CABG should be made by the Heart Team as a whole, possibly with functional imaging of the myocardial territory served by the occluded or intermediately diseased artery.




Debates on myocardial revascularisation

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.