**10.2. The decision algorithm**

**10. Angioplasty versus bypass surgery: An evolving complex decision**

Decisions regarding revascularization are complex and have been founded on decades of evidence. This body of evidence has evolved in parallel with advances in treatment but also a patient population with increasing medical complexity. Therefore, a contemporary approach to MVD and revascularization must be founded on an understanding of the wide spectrum of disease severity, advances in medical/surgical therapy, diversity in patient populations, patient preference and social circumstances. Optimal treatment strategies must apply the most current evidence in an appropriate clinical context. Furthermore, guiding principles of management with a multidisciplinary 'Heart Team' approach should be the cornerstone of state of the art treatment of multivessel coronary artery disease as supported by recent revascularization guidelines [14]. The basic approach should address a number of basic clinical questions which address the (1) therapeutic goals of the case, (2) the presence or absence of clinical evidence to support revascularization, (3) the presence/absence of prognostic factors that may make surgical revascularization more favorable, (4) whether the anatomy favor PCI or CABG, (5) is the patient a good surgical candidate should prognostic disease be present, (6) does the patient have any particular preferences and (7) are there ambiguities that would

> ● Can we improve symptoms? ● Can we improve both?

● Degree of Medical Optimization

LM, 3VD, or 2VD with proximal LAD with

● High burden of ischemia ("/≥12.5 percent)

● Severity of Symptoms ● Degree of Ischemia

● DM

● LV dysfunction

● Surgical targets ● Diffuseness of disease

● Co-morbidities ● Anatomy

● Complexity

● Age

Ambiguities in Case? Would this benefit from discussion with the Heart Team?

**Table 4.** Key clinical questions forming the basis of the therapeutic decision for management of multivessel coronary

Patient Preference and Social Factors Discussed off the catheterization table

**analysis**

340 Artery Bypass

**Fundamental Question**

versus the other?

artery disease.

Prognostic Factors that may make surgical revascularization more favorable?

Does anatomy favor one mode of revascularization

Is the patient a good surgical candidate? Consider:

**10.1. Establishing a general approach**

benefit from further discussion by a Heart Team [Table 4].

Therapeutic Goals: ● Can we improve survival?

Clinical Evidence to support revascularization ● Severity of disease

Based on existing evidence and guidelines, we have developed an algorithm that may help guide decision-making in the management of MVD [Figure10]. There are a number of factors that support surgical revascularization in SIHD for improving survival over medical therapy or PCI, namely: 1) LM disease, 3VD and likely some subsets of 2VD with proximal LAD; 2) MVD in the presence of mild to moderate LV dysfunction (35-49%) 3) MVD in the presence of diabetes 4) coronary anatomy of intermediate to high level of complexity (SYNTAX >22) and 5) high burden of ischemia (>12.5%). If these are present, then surgery should be considered first unless patient preference dictates otherwise **(Class I recommendation, Level B Evidence).**

If the patient does have prognostic disease, then considering the overall coronary anatomy, patients clinical profile and co-morbidities must be considered to ultimately guide the appropriate therapeutic decision. These factors may alter the likelihood of benefit from revascularization and also affect the patients' potential eligibility CABG and PCI.

If the patient does not appear to have prognostic disease and is not likely to prognostically benefit from revascularization, then the primary goal of treatment would be symptoms. The first goal of alleviating symptoms is medical optimization. If the patient has unacceptable symptoms despite optimal medical therapy, then revascularization (PCI or CABG) would be indicated **(Class I recommendation, Level A Evidence).**

treatment decision. There is currently limited data on the true impact of the Heart Team and

Multivessel Disease in the Modern Era of Percutaneous Coronary Intervention

http://dx.doi.org/10.5772/55103

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The approach to the management of complex CAD will continue to change with exponential growth of knowledge in this area. The majority of clinical trials involving CABG and PCI were largely based on complete revascularization of lesions greater than 50 percent [45]. Use of FFR has shown that PCI with DES of moderately severe lesions (50-70 percent) guided by angiog‐ raphy alone compared with PCI of lesions guided by both angiography and hemodynamic significance (FFR< 0.80) may actually confer a higher rate of death and MI [73]. Given our knowledge of this finding, the SYNTAX trial (where the threshold for revascularization was also a stenosis of 50 percent or greater) may conceivably have different results if FFR was used to guide therapy. Furthermore, investigations with the new second-generation DES, a now better understanding of how to utilize FFR and definition of the impact of coronary complexity may serve as a guide to better define the populations that may benefit from PCI versus CABG.

The other area requiring more research is in the arena of collaboration for decision-making in multivessel disease. The Heart Team, although a promising concept would benefit from formal validation. We also need to better define what type of institutions and what type of cases would most benefit from formal evaluation with a Heart Team approach. Furthermore as these decisions become more complex, we will also need to find better methods/mechanisms of

Complex CAD remains a challenging area both from the scientific and the clinical point of view. The goal should be to build on the research foundations in the management of MVD CAD thus far and continue to improve our understanding of how to better manage and care

informed balanced patient involvement in the final management decision.

for patients with complex CAD.

ASA Aspirin BB Beta Blocker BMS Bare metal stent

ACC American College of Cardiology

ARB Angiotensin Receptor Blocker AHA American Heart Association ARR Absolute risk reduction

ACEi Angiotensin Converting Enzyme inhibitor

**Abbreviations**

**12. The future of research in complex coronary artery disease**

this is certainly an area of worthy future research.

**Figure 10.** Suggested approach for decision making in multivessel coronary artery disease. CAD= coronary artery dis‐ ease; CABG= coronary artery bypass grafting; LAD= left anterior descending artery; LM = left main disease; LV= Left Ventricular; OMT= optimal medical therapy; PCI= percutaneous coronary intervention; SCD= sudden cardiac death; SYNTAX = The Synergy between PCI with Taxus and Cardiac Surgery; T2DM= Type 2 Diabetes Mellitis; UA/NSTEMi = unstable angina/Non ST elevation myocardial infarction; VT= ventricular tachycardia; 3VD = Three vessel disease; 2VD = two vessel disease.
