David Taggart: I thought that EuroPCR with much greater involvement of surgeons in both the plenary and main sessions was a major step forward. There is recognition both among the cardiology and cardiac surgery community of the need for greater collaboration and a more formalised multi-disciplinary team approach. Both Dr Wijns and Prof Marco also emphasised in ‘Do it for the patient’ the vital importance of a collegiate and collaborative approach between cardiologists and surgeons when recommending the optimal intervention for an individual patient and stressed that because a percutaneous intervention was technically possible did not necessarily mean that it was the best treatment.
A number of circumstances have conspired to advance the cause of the multi-disciplinary team. The cardiology interventional community have recognised through SYNTAX that there are still a significant number of patients for whom surgery is best while the cardiac surgical community have recognised that there are certain types of left main stem (ostial and mid shaft lesions) and multivessel disease (with low SYNTAX scores) that may do well with Percutaneous Coronary Interventions (PCI). Meanwhile the introduction of transcutaneous aortic valve programmes has also increased the collaboration between surgeons and cardiologists. The need for the multi-disciplinary team approach will be more formally recognised in the ESC guidelines for management of stable coronary artery disease which will be published in 2010.
David Taggart: The most important thing to remember when discussing one year outcomes of SYNTAX is that this is an interim analysis of five-year results. This is important because many studies in the literature have shown that the benefits of surgery tend to accrue with time particularly in terms of survival and that this usually becomes obvious at around 2-3 years.
There are two major strengths of SYNTAX.
First, as an ‘all comer’ trial SYNTAX is a major advance over previous trials of PCI and Coronary Artery Bypass Grafts (CABG) which were very highly selective in terms of patient enrolment (only around 5-10% of all eligible patients were recruited, the majority of whom had single or double vessel disease and normal left ventricular function - a population known not to benefit from surgery).
Second, SYNTAX included a simultaneous parallel nested registry of patients deemed ineligible for randomization to either CABG or PCI. The SYNTAX trial showed that around one third of ‘all comer’ patients were only suitable for CABG (1077 patients in the registry) while there were only 198 patients deemed unsuitable for CABG because of other co-morbidity (included in the PCI registry).
A very useful part of the SYNTAX trial was not only reinforcing a multi-disciplinary team approach but the introduction of the SYNTAX score. This will become an invaluable tool in making recommendations for what is the most appropriate intervention in terms of surgery or PCI. Essentially SYNTAX showed that the patients with the highest SYNTAX scores (ie the most severe coronary artery disease) did significantly better with CABG at one year whereas patients with lower SYNTAX scores had no obvious differences in terms of survival at one year but a higher rate of reintervention. As I have already emphasised however these are interim analysis of 5 year results.
One other thing of note was that higher rate of stroke in patients with CABG versus PCI. However, around 0.9% of the strokes in the CABG group were perioperative (including 0.3% which occurred before surgery) but with a higher rate of stroke over the following year with CABG versus PCI. However there was substantially lower use of secondary prevention in the CABG group in terms of dual antiplatelet medication, statins, beta blockers and ACE inhibitors and this is quite unacceptable in current practise.
Finally, we will await with very keen interest the two year outcomes of SYNTAX to be presented at ESC Congress 2009 this year.
David Taggart: The surgical community are very appreciative of the opportunity to formally contribute to the ESC. The current ESC Working Group in Surgery’s chair is Dr Miguel Sousa Uva and I have the privilege of being vice-chair. Dr Uva has proved to be an excellent chair initiating several new projects including active participation in ESC guidelines (myocardial revascularisation in both elective and urgent situations, endocarditis, cardiovascular disease during pregnancy) and recommendations for surgical practice (e.g. use of perioperative antiplatelet medication). Dr Uva has also organised an outstanding joint program with cardiologists at the next ESC Congress.
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