**1. Multivessel disease**

### **1.1 Introduction**

The revascularization of multivessel disease (MVD) has advanced considerably and has gone through periods where angioplasty with the advent of conventional stents (BMS) was competitive with surgery [1]. After the incorporation of drugeluting stents (DES) with the significant reduction of the revascularization of the treated vessel, it was thought that the percutaneous coronary intervention (PCI) would be superior to coronary artery bypass graph (CABG), with the advent of the SYNTAX trial [2], which also incorporated an anatomical score that revolutionized the way of stratifying the patients. Although this trial used stents that are not

currently marketed, called first-generation DES, later came trials with secondgeneration stents that also failed to achieve the desired results [3]. An important element was the incorporation of the in vivo functional study of the lesion and its relation with the prognosis, which is the fractional flow of reserve (FFR) [4] and their instantaneous wave-free ratio (iwFR) [5], which gave a physiological view of the coronary disease and its treatment, although its use in stable patients such as the ORBITA trial [6] failed both by design and by results, since 85% of patients are finally revascularized, and the first randomized trial to assess functional lesion testing before CABG found patients who underwent FFR before CABG experienced similar rates of graft failure at 6 months as those who received angiography-guided by surgery [7]. We re-evaluated the SYNTAX score [8] first, and thus we generated an ERACI score [9] more in line with the modern treatment of severe and rational injuries at the time of complete revascularization, targeting medium-to-large caliber vessels, since only 70% lesions were included and vessel lesions larger than 2 mm were included.

#### **1.2 Main trails of PCI vs. CABG and meta-analysis in MVD**

In our Argentine Randomized Trial of Coronary Angioplasty With Stenting vs. Coronary Bypass Surgery in Patients With Multivessel Disease (ERACI II) 1, where patients were randomized to PCI with BMS vs. CABG after 5 years of follow-up, there were no significant differences in the mortality of all causes, PCI 7.1% vs. CABG 11.5%, p = 0.182. In terms of nonfatal MI, the incidence was 6.2% in the CABG group and 2.8% in the PCI group (p = 0.128), where a significant difference was observed in the need for new revascularization, 7.2% in the CABG group and 28.4% in the PCI group (p = 0.0002). MACCE was also larger in the PCI group than in the CABG, 24.5% vs. 34.7% (p = 0.019). A high rate of patients was asymptomatic without significant differences in both groups. The first randomized trial of patients with first-generation DES vs. CABG and with the creation of an anatomical score to assess severity divided the patients into three groups. This score was based on obstructions of at least 50% in vessels greater than 1.5 mm. Although this very basic score served to stratify patients, the SYNTAX study [2] compared CABG and PCI, followed by placement of paclitaxel-eluting stent in patients with MVD or left main disease (LMCA) or both. At 5 years of follow-up, it was observed that the MACCE between the two groups was significantly higher for the PCI group 37.3% than with the 26.9% CABG (p < 0.0001). The MI and the TVR was significantly higher in the PCI group than with surgery, but the mortality of all causes as well as the stroke was not significantly different between the two groups. When analyzed by groups, in the SYNTAX of low score ≤ 22, the MACCE was similar between both groups, but when analyzing intermediate scores 23–32 and high ≥33, it was significantly higher with PCI commensurate with CABG. The randomized trial was subsequently carried out with the so-called second-generation DES. In the Randomized CABG and Everolimus-Eluting Stent EES Implantation in the Treatment of Patients with MVD, the BEST trial [3] was performed in 27 sites in East Asia and showed PCI with placement of EES. This study had as its primary end point the composite events of death, MI, and TVR. At 2 years of follow-up, it was observed that there were no significant differences with 11% events in the PCI group compared with 7.9% in the CABG group (p = 0.32 for non-inferiority). In the long-term follow-up (4.6 years on average), the events of the primary end point occurred in 15.3% of patients in the PCI group and in 10.6% of those in the CABG group (p = 0.04). This is due to an excess of new interventions in the PCI group, since the TVR was significantly higher in the PCI group (11.0% vs. 5.4%, p = 0.003). There were no significant differences in mortality between the two groups, 6.6% in the PCI group and

**5**

**1.4 ERACI risk score**

*Current Status, Perspectives, and Future Directions of Multivessel Disease and Left Main…*

5% in the CABG group (p = 0.30), as well as with the stroke (2.5 and 2.9%, respectively; p = 0.72). The MI was higher in the PCI group than the CABG 4.3% vs. 1.6%, respectively p = 0.02. A recent meta-analysis of Brazilian origin [10] that includes randomized clinical trials (RCT) of multivessel disease performed a group analysis. They identified a total of 15 RCT that satisfied the requirements. The following results were obtained in the pooled data (n = 12,781). Thirty-day mortality and stroke were lower with PCI (1% vs. 1.7%, p = 0.01; and 0.6% vs. 1.7%, p < 0.0001). There was no difference in 1- and 2-year mortality (3.3% vs. 3.7%, p = 0.25; 6.3% vs. 6.0%, p = 0.5). Long-term mortality favored CABG (10.6% vs. 9.4%, p = 0.04), particularly in trials of DES era (10.1% vs. 8.5%, p = 0.01). In diabetics (DM) (n = 3274) long-term mortality favored CABG (13.7% vs. 10.3%, p < 0.0001). In six trials of LMCA (n = 4700), there was no difference in 30-day mortality (0.6% vs. 1.1%, p = 0.15), 1-year mortality (3% vs. 3.7%, p = 0.18), and long-term mortality (8.1% vs. 8.1%) between PCI and CABG. The incidence of stroke was lower with PCI (0.3% vs. 1.5%, p < 0.001). DM and a high SYNTAX score were the subgroups

*DOI: http://dx.doi.org/10.5772/intechopen.89419*

that influenced more adversely the results of PCI (**Table 1**).

**1.3 "Functional" complete or anatomic complete revascularization**

The fractional flow reserve allows to measure the functional capacity of a stenosis, and if it establishes a threshold of 0.80 (which is equivalent to a maximum intracoronary pressure drop of 20%), it determines a degree of ischemia. In fact, the use of this guide in patients with MVD showed that residual angiographic lesions that were functionally nonsignificant did not cause worse evolution [11] and thus indicated that they do not need treatment, giving a complete revascularization (CR) functional rather than anatomical, since the degree of injury is less important than its functional impact, as well as the magnitude of the territory that irrigates. However, the concept of "functional" CR with PCI was introduced many years ago even when FFR was not available. The ERACI I one of the first randomized clinical trials between PCI and CABG in MVD [12] showed similar outcomes in patients with complete "functional" revascularization achieved with PCI and guided by noninvasive tests and in those with complete "anatomic" revascularization achieved with CABG.

The ERACI IV study [13] was a multicenter, observational, and prospective registry with a second-generation DES in patients with MVD and LMCA. We built a score based on our experience in the treatment of patients with more realistic MVD; since our group led by Dr Rodriguez et al. aimed to treat more critical vessel lesions that irrigate a significant territory, based on this concept we created the ERACI score (ES) by modifying the SYNTAX score (SS), as well as the difference between the treated and residual lesions, their corresponding residual ES or residual SS. This reformulated score included lesions greater than or equal to 70% in vessels larger than 2 mm. The analysis of the bifurcations and CTO was preserved as in the previous score. We included in a novel way the restenosis of the treated vessel that was cataloged as a severely calcified lesion. The rest of the variables were preserved as in the previous score [9] (**Figure 1**). The rationality of this revised score was previously published in our *Journal of Interventional Cardiology* of Argentina (RACI) 3 years ago [9]. With this new modality of scoring with the ES in the ERACI IV study, more than half of the patients had a low ES, and only 17% of the patients had a high score, in contrast to the SS that 34% of the patients were with a high score. The first analysis of this data is that with this score patients are re-categorized into a lower-risk group so they could be treated with either PCI or CABG. When we analyzed the residual untreated

*Current Status, Perspectives, and Future Directions of Multivessel Disease and Left Main… DOI: http://dx.doi.org/10.5772/intechopen.89419*

5% in the CABG group (p = 0.30), as well as with the stroke (2.5 and 2.9%, respectively; p = 0.72). The MI was higher in the PCI group than the CABG 4.3% vs. 1.6%, respectively p = 0.02. A recent meta-analysis of Brazilian origin [10] that includes randomized clinical trials (RCT) of multivessel disease performed a group analysis. They identified a total of 15 RCT that satisfied the requirements. The following results were obtained in the pooled data (n = 12,781). Thirty-day mortality and stroke were lower with PCI (1% vs. 1.7%, p = 0.01; and 0.6% vs. 1.7%, p < 0.0001). There was no difference in 1- and 2-year mortality (3.3% vs. 3.7%, p = 0.25; 6.3% vs. 6.0%, p = 0.5). Long-term mortality favored CABG (10.6% vs. 9.4%, p = 0.04), particularly in trials of DES era (10.1% vs. 8.5%, p = 0.01). In diabetics (DM) (n = 3274) long-term mortality favored CABG (13.7% vs. 10.3%, p < 0.0001). In six trials of LMCA (n = 4700), there was no difference in 30-day mortality (0.6% vs. 1.1%, p = 0.15), 1-year mortality (3% vs. 3.7%, p = 0.18), and long-term mortality (8.1% vs. 8.1%) between PCI and CABG. The incidence of stroke was lower with PCI (0.3% vs. 1.5%, p < 0.001). DM and a high SYNTAX score were the subgroups that influenced more adversely the results of PCI (**Table 1**).

#### **1.3 "Functional" complete or anatomic complete revascularization**

The fractional flow reserve allows to measure the functional capacity of a stenosis, and if it establishes a threshold of 0.80 (which is equivalent to a maximum intracoronary pressure drop of 20%), it determines a degree of ischemia. In fact, the use of this guide in patients with MVD showed that residual angiographic lesions that were functionally nonsignificant did not cause worse evolution [11] and thus indicated that they do not need treatment, giving a complete revascularization (CR) functional rather than anatomical, since the degree of injury is less important than its functional impact, as well as the magnitude of the territory that irrigates. However, the concept of "functional" CR with PCI was introduced many years ago even when FFR was not available. The ERACI I one of the first randomized clinical trials between PCI and CABG in MVD [12] showed similar outcomes in patients with complete "functional" revascularization achieved with PCI and guided by noninvasive tests and in those with complete "anatomic" revascularization achieved with CABG.

#### **1.4 ERACI risk score**

*The Current Perspectives on Coronary Artery Bypass Grafting*

**1.2 Main trails of PCI vs. CABG and meta-analysis in MVD**

In our Argentine Randomized Trial of Coronary Angioplasty With Stenting vs. Coronary Bypass Surgery in Patients With Multivessel Disease (ERACI II) 1, where patients were randomized to PCI with BMS vs. CABG after 5 years of follow-up, there were no significant differences in the mortality of all causes, PCI 7.1% vs. CABG 11.5%, p = 0.182. In terms of nonfatal MI, the incidence was 6.2% in the CABG group and 2.8% in the PCI group (p = 0.128), where a significant difference was observed in the need for new revascularization, 7.2% in the CABG group and 28.4% in the PCI group (p = 0.0002). MACCE was also larger in the PCI group than in the CABG, 24.5% vs. 34.7% (p = 0.019). A high rate of patients was asymptomatic without significant differences in both groups. The first randomized trial of patients with first-generation DES vs. CABG and with the creation of an anatomical score to assess severity divided the patients into three groups. This score was based on obstructions of at least 50% in vessels greater than 1.5 mm. Although this very basic score served to stratify patients, the SYNTAX study [2] compared CABG and PCI, followed by placement of paclitaxel-eluting stent in patients with MVD or left main disease (LMCA) or both. At 5 years of follow-up, it was observed that the MACCE between the two groups was significantly higher for the PCI group 37.3% than with the 26.9% CABG (p < 0.0001). The MI and the TVR was significantly higher in the PCI group than with surgery, but the mortality of all causes as well as the stroke was not significantly different between the two groups. When analyzed by groups, in the SYNTAX of low score ≤ 22, the MACCE was similar between both groups, but when analyzing intermediate scores 23–32 and high ≥33, it was significantly higher with PCI commensurate with CABG. The randomized trial was subsequently carried out with the so-called second-generation DES. In the Randomized CABG and Everolimus-Eluting Stent EES Implantation in the Treatment of Patients with MVD, the BEST trial [3] was performed in 27 sites in East Asia and showed PCI with placement of EES. This study had as its primary end point the composite events of death, MI, and TVR. At 2 years of follow-up, it was observed that there were no significant differences with 11% events in the PCI group compared with 7.9% in the CABG group (p = 0.32 for non-inferiority). In the long-term follow-up (4.6 years on average), the events of the primary end point occurred in 15.3% of patients in the PCI group and in 10.6% of those in the CABG group (p = 0.04). This is due to an excess of new interventions in the PCI group, since the TVR was significantly higher in the PCI group (11.0% vs. 5.4%, p = 0.003). There were no significant differences in mortality between the two groups, 6.6% in the PCI group and

2 mm were included.

currently marketed, called first-generation DES, later came trials with secondgeneration stents that also failed to achieve the desired results [3]. An important element was the incorporation of the in vivo functional study of the lesion and its relation with the prognosis, which is the fractional flow of reserve (FFR) [4] and their instantaneous wave-free ratio (iwFR) [5], which gave a physiological view of the coronary disease and its treatment, although its use in stable patients such as the ORBITA trial [6] failed both by design and by results, since 85% of patients are finally revascularized, and the first randomized trial to assess functional lesion testing before CABG found patients who underwent FFR before CABG experienced similar rates of graft failure at 6 months as those who received angiography-guided by surgery [7]. We re-evaluated the SYNTAX score [8] first, and thus we generated an ERACI score [9] more in line with the modern treatment of severe and rational injuries at the time of complete revascularization, targeting medium-to-large caliber vessels, since only 70% lesions were included and vessel lesions larger than

**4**

The ERACI IV study [13] was a multicenter, observational, and prospective registry with a second-generation DES in patients with MVD and LMCA. We built a score based on our experience in the treatment of patients with more realistic MVD; since our group led by Dr Rodriguez et al. aimed to treat more critical vessel lesions that irrigate a significant territory, based on this concept we created the ERACI score (ES) by modifying the SYNTAX score (SS), as well as the difference between the treated and residual lesions, their corresponding residual ES or residual SS. This reformulated score included lesions greater than or equal to 70% in vessels larger than 2 mm. The analysis of the bifurcations and CTO was preserved as in the previous score. We included in a novel way the restenosis of the treated vessel that was cataloged as a severely calcified lesion. The rest of the variables were preserved as in the previous score [9] (**Figure 1**). The rationality of this revised score was previously published in our *Journal of Interventional Cardiology* of Argentina (RACI) 3 years ago [9]. With this new modality of scoring with the ES in the ERACI IV study, more than half of the patients had a low ES, and only 17% of the patients had a high score, in contrast to the SS that 34% of the patients were with a high score. The first analysis of this data is that with this score patients are re-categorized into a lower-risk group so they could be treated with either PCI or CABG. When we analyzed the residual untreated


**7**

**Study** FREEDOM [67]

Va-Cards [73]

BEST [3] EXCEL [31] NOBLE [30]

Europe

2008–2015

982

LMCAD

DES (Biolimus)

*AWESOME, Angina With Extremely Severe Outcomes; ERACI II, Argentine Randomized Study: Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multivessel Disease;* 

*MASS II, Medicine, Angioplasty, or Surgery Study; ARTS, Arterial Revascularization Therapies Study; SOS, Stent or Surgery trial. SYNTAX, Synergy between PCI with Taxus and Cardiac Surgery;* 

*CARDia: Coronary Artery Revascularization in Diabetes; Le Mans, Left Main Coronary Artery Stenting; FREEDOM, Future Revascularization Evaluation in Patients with Diabetes Mellitus; Va-Cards,* 

*Coronary Artery Revascularization in Diabetes in VA Hospitals; BEST, Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease;* 

*PRECOMBAT, Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease; EXCEL, Coronary Artery* 

*Bypass Surgery for Effectiveness of Left Main Revascularization; NOBLE, Nordic-Baltic-British Left Main Revascularization Study [81]. DES, drug-eluting stents; BMS, bare-metal stent.*

*Modified from "Stent versus Coronary Artery Bypass Surgery in Multi-Vessel and Left Main Coronary Artery Disease: A Meta-Analysis of Randomized Trials with Subgroups Evaluation" (Pedro José Negreiros* 

*de Andrade, João Luiz de Alencar Araripe Falcão, Breno de Alencar Araripe Falcão, Hermano Alexandre Lima Rocha)*

**Table 1.**

*Overview of the main trials of MVCAD and LMCAD.*

18

60

16

18

International

2010–2014

1905

LMCAD

DES (Everolimus)

37

57

29

25

Korea

2008–2013

880

2v and 3v

DES (Everolimus)

42

59

64

45

USA

2006–2010

198

2v and 3v

DES, only DBT

Nd

Nd

Nd

100

International

2005–2010

1900

2v and 3v

DES, only DBT

30

65

19

100

The primary outcome occurred more frequently in the PCI

group (p = 0.005), with 5-year rates of 26.6% in the PCI

group and 18.7% in the CABG group

At 2 years, all-cause mortality was 5.0% for CABG and

21% for PCI (HR, 0.30; 95% CI, 0.11–0.80); nonfatal

myocardial infarction was 15% for CABG and 6.2% for

PCI (HR, 3.32; 95% CI, 1.07–10.30)

MACE at 4.6 years: 15.3% for PCI vs. 10.6% for CABG

(p = 0.04)

At 3 years, a primary end-point event had occurred in

15.4% in the PCI group and in 14.7% in the CABG group

(p = 0.02 for non-inferiority; HR, 1.00; 95% CI, 0.79–1.26;

p = 0.98 for superiority)

Kaplan-Meier 5-year MACCE was 28% for PCI and 18%

for CABG (HR, 1·51; 95% CI, 1·13–2·00; p = 0·0044)

**Origin**

**Date**

**N**

**MVD**

**Characteristics**

**UA**

**EF**

**Offpump**

**DM**

**Outcome**

*Current Status, Perspectives, and Future Directions of Multivessel Disease and Left Main…*

*DOI: http://dx.doi.org/10.5772/intechopen.89419*


**Table 1.** *Overview of the main trials of MVCAD and LMCAD.*

*Current Status, Perspectives, and Future Directions of Multivessel Disease and Left Main… DOI: http://dx.doi.org/10.5772/intechopen.89419*

*The Current Perspectives on Coronary Artery Bypass Grafting*

**6**

**Study** AWESOME [76]

ARTS [77, 78]

ERACI II [1]

SOS [79] MASS II [80] LEMANS [29]

SYNTAX [2] CARDia [74] Boudriot et al.

Germany

2003–2009

201

LMCAD

DES (Sirolimus)

ND

ND

46

30

[81]

PRECOMBAT

Korea

2003–2009

600

LMCAD

DES (Everolimus)

45

60

64

42

[28]

UK

2002–2007

510

2v and 3v

BMS and DES, only

22

59

31

100

DBT

Europe and

2005–2007

1800

LM and 3v

DES Taxus

28

Nd

15

35

USA

Poland

2001–2004

105

LMCAD

BMS and DES, DES

32

53

0

25

if LM < 3.8

Brazil

1995–2000

408

2v and 3v

BMS, clinical arm

36

65

0

30

Europe and

1995–1999

988

2v and 3v

BMS, majority 2v

33

Nd

3

15

Canada

Argentina

1196–1998

450

2v and 3v

BMS, majority UA

92

ND

0

17

International

1997–2000

1205

2v and 3v

BMS, majority 2v

30

61

0

21

USA

1995–2000

454

2v and 3v

BMS, CABG

36

45

0

32

Survival rates for CABG and PCI were 79% versus 80% at

36 months (log-rank test, p = 0.46)

Event-free survival at 5 years: 58.3% for PCI vs. 78.2% for

CABG (p < 0.0001)

Freedom from MACE at 5 years was lower with PCI than

with CABG (65.3% vs. 76.4%; p = 0.013)

At a median follow-up of 6 years, 53 patients (10.9%)

died in the percutaneous coronary intervention group

compared with 34 (6.8%) in the CABG group (HR, 1.66;

95% CI, 1.08–2.55; p = 0.022)

The 10-year survival rates were 74.9% with CABG, 75.1%

with PCI, and 69% with MT (p = 0.089)

At 10 years, the mortality of PCI vs. CABG was (21.6% vs.

30.2%; p = 0.41) and MACCE (51.1% vs. 64.4%; p = 0.28)

5-year MACCE in all: 37.3% for PCI vs. 26.9% for CABG

(p < 0.001)

5-year MACCE in 3 VD: 37.5% for PCI vs. 24.2% for CABG

(p < 0.001)

At 1 year of follow-up, the composite rate of death, MI,

and stroke was 10.5% in the CABG group and 13.0% in the

PCI group (HR, 1.25; 95% CI, 0.75–2.09; p = 0.39)

At 1 year of follow-up, the combined primary end point

was 13.9% of patients after surgery, as opposed to 19.0%

after PCI (p = 0.19 for non-inferiority)

At 5 years, MACCE in PCI group and the CABG group

(cumulative event rates of 17.5% and 14.3%, respectively;

HR, 1.27; 95% CI, 0.84–1.90; p = 0.26)

previous

**Origin**

**Date**

**N**

**MVD**

**Characteristics**

**UA**

**EF**

**Offpump**

**DM**

**Outcome**

#### **Figure 1.**

*Modification of the SYNTAX score by ERACI score, with residual SYNTAX and ERACI scores and its implications. SYNTAX score = 28 points (red and white arrows). Hypothetically the patients need 4 DES. Modified ERACI score, in the ERACI IV, the SYNTAX score (only the red arrows) was 16 points = patient received 2 DES. The residual ERACI score was 3.5. If the patient was scored with the SYNTAX score, he would have had 17 residual SYNTAX score.*

lesions between these two scores, we also found significant differences between these two groups of patients since with RSS it was 8.7 ± 5.9 vs. and with RES it was 3.5 ± 4.6, p = 0.003. In addition, reasonably incomplete revascularization was defined, defined by a residual of ≤5 (**Table 2**). If we take the RSS, only 35% of the patients reached this goal, but if we analyze it with the RES, they reached 80%, which suggests that most patients achieved a functional rather than an anatomical revascularization (**Table 2**). This could be corroborated in the long-term follow-up where these patients had a MACCE less than 10% at 3 years of follow-up. In addition, this score was validated in another trial of our group called the WALTZ registry [14]. A total of 201 real-life patients were included prospectively, in 11 centers in the Argentine Republic using the same criteria of ERACI IV. The study design, as well as the rationale, was previously published [15]. When we performed the analysis regarding the scores, we found a significant difference with respect to the baseline (SS 11.8 + 6.8 vs. ES 7.8 + 5.3, p = 0.0016), and the same happened with the residual (RSS 5.4 + 5.6 vs. RES 1.3 + 2.9, p < 0.001). The analysis that we carry out is that the presence of

**9**

**1.5 Guidelines**

**Table 2.**

**1.6 Ongoing trials**

*Current Status, Perspectives, and Future Directions of Multivessel Disease and Left Main…*

Low group 33.8% 54.8% < 0.001 Intermediate group 32.4% 27.9% = 0.35 High group 33.8% 17.2% <0.001 Baseline mean 27.7 ± 11.3 22 ± 11.02 =0.0004 Residual mean 8.7 ± 5.9 3.5 ± 4.6 =0.003 Residual ≤5 35% 80% <0.001 Residual <8 48% 93.5% =0.002 *From "Lowering Risk Score Profile During PCI in Multiple Disease is Associated with Low Adverse Events: The ERACI Risk Score" (Alfredo E. Rodriguez, Carlos Fernandez-Pereira, Juan Mieres, Hernan Pavlovsky, Juan del Pozo,* 

Number of patients (n) 225 225

*Alfredo M. Rodriguez-Granillo, David Antoniucci, On behalf of ERACI IV Investigators)*

*Differences in baseline and residual risk scores: ERACI IV registry.*

**SYNTAX score ERACI score P value**

neoatherosclerosis [16] that we believe is also present in the second- and thirdgeneration stents is a growing concern, which is why this more rational strategy of the use of these devices can lead to better results long term. When we look closely at the results of the Syntax II study where iwFR was used, we can verify that the conservative strategy is beneficial [17]. When we compare the PCI group guided by the iwFR with the SYNTAX I in the PCI group, we find a decrease in MI and MACCE, similar to the SYNTAX I CABG group. SYNTAX II treated fewer lesions per patient than SYNTAX I (2.6 vs. 4, p < 0.001) and then implanted fewer stents per patient (3.8% vs. 5.2%, p < 0.001) despite the fact that the two groups of patients were scored similarly, with SS (p = 0.16). These results are consistent with our ERACI IV trial. We also have to recognize that the FFR analysis has numerous limitations, among them it can be technically difficult in segments of diffuse disease, tandem lesions and bifurcation lesions. When performed in patients with severe aortic stenosis, the evaluation is more complex to analyze. Also you have to assume the cost of catheters that cannot be ignored. It is also important to mention that studies of CABG guided by FFR [18] have not achieved the expected results when compared when guided by angiography, and studies such as FAME 2 comparing optimal medical treatment vs. guided PCI

have not observed reduction in MI or long-term mortality [19].

The evidence suggests that in MVD without DM and low anatomical complexity, PCI and CABG achieve similar long-term outcomes with respect to survival and the composite of death, MI, and stroke, justifying a class I recommendation for PCI. Consistent results were also obtained for patients with MVD in the recent individual patient-level meta-analysis. Thus, the previous class III recommendation for PCI in MVD and intermediate-to-high complexity was maintained [20]. The intermediate and high SYNTAX scores are associated with better evolution with the CABG. Although this score is very limited and impractical for its application, its use for making decisions in patients with MVD is reasonable [21]. The ERACI score could be more rational for making decisions due to being more realistic and conservative [9].

The Prospective Multicenter Registry of Hybrid Coronary Artery Revascularization

Combined with Surgical Bypass and Percutaneous Coronary Intervention Using

*DOI: http://dx.doi.org/10.5772/intechopen.89419*

*Current Status, Perspectives, and Future Directions of Multivessel Disease and Left Main… DOI: http://dx.doi.org/10.5772/intechopen.89419*


*From "Lowering Risk Score Profile During PCI in Multiple Disease is Associated with Low Adverse Events: The ERACI Risk Score" (Alfredo E. Rodriguez, Carlos Fernandez-Pereira, Juan Mieres, Hernan Pavlovsky, Juan del Pozo, Alfredo M. Rodriguez-Granillo, David Antoniucci, On behalf of ERACI IV Investigators)*

#### **Table 2.**

*The Current Perspectives on Coronary Artery Bypass Grafting*

lesions between these two scores, we also found significant differences between these two groups of patients since with RSS it was 8.7 ± 5.9 vs. and with RES it was 3.5 ± 4.6, p = 0.003. In addition, reasonably incomplete revascularization was defined, defined by a residual of ≤5 (**Table 2**). If we take the RSS, only 35% of the patients reached this goal, but if we analyze it with the RES, they reached 80%, which suggests that most patients achieved a functional rather than an anatomical revascularization (**Table 2**). This could be corroborated in the long-term follow-up where these patients had a MACCE less than 10% at 3 years of follow-up. In addition, this score was validated in another trial of our group called the WALTZ registry [14]. A total of 201 real-life patients were included prospectively, in 11 centers in the Argentine Republic using the same criteria of ERACI IV. The study design, as well as the rationale, was previously published [15]. When we performed the analysis regarding the scores, we found a significant difference with respect to the baseline (SS 11.8 + 6.8 vs. ES 7.8 + 5.3, p = 0.0016), and the same happened with the residual (RSS 5.4 + 5.6 vs. RES 1.3 + 2.9, p < 0.001). The analysis that we carry out is that the presence of

*points = patient received 2 DES. The residual ERACI score was 3.5. If the patient was scored with the SYNTAX* 

*Modification of the SYNTAX score by ERACI score, with residual SYNTAX and ERACI scores and its implications. SYNTAX score = 28 points (red and white arrows). Hypothetically the patients need 4 DES. Modified ERACI score, in the ERACI IV, the SYNTAX score (only the red arrows) was 16* 

**8**

**Figure 1.**

*score, he would have had 17 residual SYNTAX score.*

*Differences in baseline and residual risk scores: ERACI IV registry.*

neoatherosclerosis [16] that we believe is also present in the second- and thirdgeneration stents is a growing concern, which is why this more rational strategy of the use of these devices can lead to better results long term. When we look closely at the results of the Syntax II study where iwFR was used, we can verify that the conservative strategy is beneficial [17]. When we compare the PCI group guided by the iwFR with the SYNTAX I in the PCI group, we find a decrease in MI and MACCE, similar to the SYNTAX I CABG group. SYNTAX II treated fewer lesions per patient than SYNTAX I (2.6 vs. 4, p < 0.001) and then implanted fewer stents per patient (3.8% vs. 5.2%, p < 0.001) despite the fact that the two groups of patients were scored similarly, with SS (p = 0.16). These results are consistent with our ERACI IV trial. We also have to recognize that the FFR analysis has numerous limitations, among them it can be technically difficult in segments of diffuse disease, tandem lesions and bifurcation lesions. When performed in patients with severe aortic stenosis, the evaluation is more complex to analyze. Also you have to assume the cost of catheters that cannot be ignored. It is also important to mention that studies of CABG guided by FFR [18] have not achieved the expected results when compared when guided by angiography, and studies such as FAME 2 comparing optimal medical treatment vs. guided PCI have not observed reduction in MI or long-term mortality [19].

#### **1.5 Guidelines**

The evidence suggests that in MVD without DM and low anatomical complexity, PCI and CABG achieve similar long-term outcomes with respect to survival and the composite of death, MI, and stroke, justifying a class I recommendation for PCI. Consistent results were also obtained for patients with MVD in the recent individual patient-level meta-analysis. Thus, the previous class III recommendation for PCI in MVD and intermediate-to-high complexity was maintained [20]. The intermediate and high SYNTAX scores are associated with better evolution with the CABG. Although this score is very limited and impractical for its application, its use for making decisions in patients with MVD is reasonable [21]. The ERACI score could be more rational for making decisions due to being more realistic and conservative [9].

#### **1.6 Ongoing trials**

The Prospective Multicenter Registry of Hybrid Coronary Artery Revascularization Combined with Surgical Bypass and Percutaneous Coronary Intervention Using

Everolimus-Eluting Metallic Stents evaluates the efficacy of hybrid coronary revascularization (HCR) combining CABG and PCI in the treatment of MVD. CABG is to be performed in the left anterior descending artery and the left circumflex artery using only arterial grafts, whereas PCI is to be conducted for the treatment of the right coronary artery with everolimus-eluting stents (EESs) [22]. The Comparison of One-stop Hybrid Revascularization vs. Off-pump Coronary Artery Bypass for the Treatment of Multi-vessel Disease combines minimally invasive direct CABG and PCI to be performed in the hybrid operating suite, an enhanced operating room equipped with radiographic capability [23].

### **1.7 Conclusions**

In our long experience in the treatment of MVD for more than two decades and according to our score, we believe that the stratified treatment can be divided into two groups, patients with low and intermediate scores in whom the results of PCI are comparable with surgery. The other group of patients are those with high scores, we think that the current state-of-the-art CABG is the treatment of choice. However, with the increase in stent technology this difference can be reduced.
