Commentary: Developing accurate tools for predicting outcomes following coronary artery bypass graft surgery: More data are needed
2021; Elsevier BV; Volume: 166; Issue: 3 Linguagem: Inglês
10.1016/j.jtcvs.2021.12.022
ISSN1097-685X
Autores Tópico(s)Coronary Interventions and Diagnostics
ResumoCentral MessageThe SYNTAX score II is more accurate in predicting short- and long-term mortality for patients undergoing coronary revascularization; more data are needed to determine whether PCI or CABG is best.See Article page 793. The SYNTAX score II is more accurate in predicting short- and long-term mortality for patients undergoing coronary revascularization; more data are needed to determine whether PCI or CABG is best. See Article page 793. The emergence of percutaneous coronary interventions (PCI) as an alternative treatment to coronary artery bypass graft (CABG) surgery for 3-vessel disease (3VD) and left main coronary artery disease (LMCAD) has led to the creation of various tools to assess mortality following coronary revascularization. The SYNTAX score was developed to provide an accurate measurement of the anatomic complexity of CAD.1Serruys P.W. Morice M.C. Kappetein A.P. Colombo A. Holmes D.R. Mack M.J. et al.Percutaneous coronary intervention versus coronary artery bypass grafting for severe coronary artery disease.N Engl J Med. 2009; 360: 961-972Crossref PubMed Scopus (3435) Google Scholar It has subsequently been used to help decide the optimal intervention (PCI vs CABG) for patients with 3VD and has been incorporated into the 2014 American and 2018 European guidelines.2Amsterdam E.A. Wenger N.K. Brindis R.G. Casey Jr., D.E. Ganiats T.G. Holmes Jr., D.R. et al.2014 AHA/ACC guidelines for the management of patients with non-ST elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association task force on practice guidelines.J Am Coll Cardiol. 2014; 64: 139-228Crossref PubMed Scopus (2239) Google Scholar,3Neumann F.J. Sousa-Uva M. Ahlsson A. Alfonso F. Banning A.P. Benedetto U. et al.2018 ESC/EACTS guidelines in myocardial revascularization.Eur Heart J. 2018; 40: 87-165Crossref Scopus (4193) Google Scholar However, the original SYNTAX score was based only on the anatomic complexity of CAD and lacked the prognostic effects of concomitant comorbidities known to effect short- and long-term mortality following coronary revascularization. Therefore, the SYNTAX score II was developed to more accurately predict outcomes following coronary revascularization by incorporating 7 clinical variables (ie, age, creatinine clearance, left ventricular ejection fraction, LMCAD, peripheral vascular disease, sex, and chronic obstructive pulmonary disease) in addition to the anatomic complexity of the original SYNTAX score.4Farooq V. van Klaveren D. Steyerberg E.W. Meliga E. Vergouwe Y. Chieffo A. et al.Anatomical and clinical characteristics to guide decision making between coronary artery bypass surgery and percutaneous coronary intervention for individual patients: development and validation of SYNTAX score II.Lancet. 2013; 381: 639-650Abstract Full Text Full Text PDF PubMed Scopus (651) Google Scholar SYNTAX score II has been shown to be a better predictor of long-term mortality following either PCI or CABG in patients with 3VD and LMCAD.5Sotomi Y. Cavalcante R. van Klaveren D. Ahn J.-M. Lee C.W. de Winter R.J. et al.Individual long-term mortality prediction following either coronary stenting or bypass surgery in patients with multivessel and/or unprotected left main disease: an external validation of the SYNTAX Score II model in the 1480 patients of the BEST and PRECOMBAT randomized controlled trials.J Am Coll Cardiol Interv. 2016; 9: 1564-1572Crossref PubMed Scopus (46) Google Scholar Recently, the SYNTAX score II 2020 was developed in which patient sex was removed and diabetes and current smoking history were added as predicted variables.6Takahashi K. Serruys P.W. Fuster V. Farkouh M.E. Spertus J.A. Cohen D.J. et al.Redevelopment and validation of the SYNTAX Score II to individualize decision making between percutaneous and surgical revascularization in patients with complex coronary artery disease: secondary analysis of the multicenter randomized controlled SYNTAXES trial with external cohort validation.Lancet. 2020; 396: 1399-1412Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar The SYNTAX score II 2020 has been externally validated for 5-year outcomes using patient-level data from the Furture Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM), Bypass Surgery versus Everolimus-Eluting Stent Implantation for Multivessel Coronary Artery Disease (BEST), Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease (PRECOMBAT), and Evaluation of the Xience Everolimus Eluting Stent vs Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trials.6Takahashi K. Serruys P.W. Fuster V. Farkouh M.E. Spertus J.A. Cohen D.J. et al.Redevelopment and validation of the SYNTAX Score II to individualize decision making between percutaneous and surgical revascularization in patients with complex coronary artery disease: secondary analysis of the multicenter randomized controlled SYNTAXES trial with external cohort validation.Lancet. 2020; 396: 1399-1412Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar,7Takahashi K. van Klaveren D. Steyerberg E.W. Onuma Y. Serruys P.W. Concerns with the new SYNTAX Score—authors' reply.Lancet. 2021; 397: 795-796Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar A unique feature of the SYNTAX score II 2020 is that it can predict not only mortality, but also major adverse cardiovascular events (MACEs) for PCI and CABG in patients with 3VD and LMCAD. Therefore, it was believed that the SYNTAX score II 2020 could provide additional objective data for heart teams to help determine the best approach for coronary revascularization in an individual patient. Hara and colleagues8Hara H. Shiomi H. van Klaveren D. Kent D.M. Steyerberg E.W. Garg S. et al.External validation of the SYNTAX score II 2020.J Am Coll Cardiol. 2021; 78: 1227-1238Crossref PubMed Scopus (24) Google Scholar sought to investigate whether the SYNTAX score II 2020 could be used to identify the benefits of PCI versus CABG in more than 7000 patients with 3VD or LMCAD enrolled in the Japanese Coronary Revascularization Demonstrating Outcome Study in Kyoto (CREDO-KYOTO) Registry.8Hara H. Shiomi H. van Klaveren D. Kent D.M. Steyerberg E.W. Garg S. et al.External validation of the SYNTAX score II 2020.J Am Coll Cardiol. 2021; 78: 1227-1238Crossref PubMed Scopus (24) Google Scholar In this study, an absolute risk difference (ARD)—representing the difference between observed and predicted event rates for mortality and MACE following PCI and CABG—was calculated for each patient. In patients with an ARD 4.5%. Five-year MACE could not be predicted for either PCI or CABG. The authors concluded that the SYNTAX score II 2020 could be used to help decide the best revascularization strategy for patients with 3VD and LMCAD. In this edition of the Journal, Ram and colleagues9Ram E. Kassif T. Peled Y. Kassif Y. Koren R.P. Sternik L. Raanani E. Anatomical and clinical risk stratification tool for mortality risk assessment following revascularization for multivessel coronary artery disease.J Thorac Cardiovasc Surg. 2023; 166: 793-800.e5Abstract Full Text Full Text PDF Scopus (1) Google Scholar sought to determine the ability of the SYNTAX score II to predict short- and long-term mortality in patients undergoing either PCI or CABG for 3VD or LMCAD using a multicenter national registry derived from 22 hospitals in Israel. The 1112 patients were divided into low ( 35) SYNTAX score II groups. The revascularization strategy, PCI versus CABG, was left to the discretion of the treating team. A net reclassification improvement was used to predict the benefit of adding a SYNTAX score II to predict short- and long-term mortality. Patients with a high SYNTAX score II (>35) had significantly higher 30-day mortality (2.8% high vs 0.6% intermediate vs 0% low; P = .001) and 6-year mortality (34.9% high vs 11% intermediate vs 3.8% low; P < .001) compared with the low and intermediate groups. The addition of the SYNTAX score II, compared with the original SYNTAX score, showed a significant net reclassification improvement of 24.2% (P = .003) for predicting 6-year mortality. The authors concluded that in a cohort of real-world patients undergoing coronary revascularization for 3VD or LMCAD, the SYNTAX score II is a better risk-stratification tool for predicting short- and long-term mortality compared with the original SYNTAX score. Although the authors have demonstrated that the SYNTAX score II may better predict mortality for coronary revascularization, they have not shown how these data can be used by heart teams to determine which revascularization strategy, PCI or CABG, should be used in an individual patient. The authors listed the incidence of postprocedural complications following PCI and CABG, but no direct statistical comparisons were made between the 2 techniques. In addition, no statistical analyses were performed to determine the difference in short- and long-term mortality between PCI and CABG in relation to the severity of their SYNTAX score II, and whether the cause of death—cardiac versus noncardiac—could also be predicted for PCI versus CABG patients. Important data in CABG patients predictive of short- and long-term outcomes were not reported. This included the number of grafts per patient, the use of multiple arterial grafts (MAGs), and whether or not complete revascularization was achieved. Although the authors reported data on the use of guideline-directed medical therapy (GDMT) on admission, no data was provided on GDMT on either discharge or long-term. Finally, no mention is made regarding the long-term MACE for PCI versus CABG; especially, the incidence of myocardial infarctions (MIs) and the need for repeat revascularization procedures. Thus the value of the SYNTAX score II to determine coronary revascularization by either PCI or CABG by heart teams remains uncertain. What can be done to improve the prognostic accuracy for determining short- and long-term mortality and MACE following PCI or CABG for patients with 3VD and LMCAD? To develop more accurate tools to predict outcomes following PCI and CABG, more data are needed. Both CABG and PCI outcomes are determined by preprocedure comorbidities and coronary anatomy, procedure-related techniques, and postrevascularization complications. Although preprocedural comorbidities and coronary anatomy are well documented by SYNTAX score II, they fail to take into account the techniques used during the procedure and the immediate postrevascularization complications following PCI and CABG that have a significant effect on mortality and MACE. This explains why both SYNTAX score I and II failed to predict long-term MACE.8Hara H. Shiomi H. van Klaveren D. Kent D.M. Steyerberg E.W. Garg S. et al.External validation of the SYNTAX score II 2020.J Am Coll Cardiol. 2021; 78: 1227-1238Crossref PubMed Scopus (24) Google Scholar A new scoring system needs to be developed to include data during the revascularization procedure and the immediate postrevascularization period for both PCI and CABG to more accurately reflect the benefits of both techniques in patients with 3VD and LMCAD. The new scoring system should include the following: Incomplete revascularization has been associated with decreased late survival following both PCI and CABG.10Schwann T.A. Yammine M.B. El-Hage-Sleiman Engoren M.C. Bonnell M.R. Habib R.H. The effect of completeness of revascularization during coronary artery bypass grafting with single versus multiple arterial grafts.J Card Surg. 2018; 33: 620-628Crossref PubMed Scopus (14) Google Scholar,11Farooq V. Serruys P.W. Bourantas C.V. Zhang Y. Muramatsu T. Feldman T. et al.Quantification of incomplete revascularization and its association with five year mortality in the Synergy between percutaneous coronary intervention with Taxus and Cardiac Surgery (SYNTAX) trial validation of the residual SYNTAX score.Circulation. 2013; 128: 141-151Crossref PubMed Scopus (309) Google Scholar Farooq and colleagues11Farooq V. Serruys P.W. Bourantas C.V. Zhang Y. Muramatsu T. Feldman T. et al.Quantification of incomplete revascularization and its association with five year mortality in the Synergy between percutaneous coronary intervention with Taxus and Cardiac Surgery (SYNTAX) trial validation of the residual SYNTAX score.Circulation. 2013; 128: 141-151Crossref PubMed Scopus (309) Google Scholar reported that following PCI, a residual SYNTAX score I >8 was associated with a 35% all-cause mortality at 5 years (P < .001). Therefore, if a complete revascularization could not be achieved with PCI, CABG would be a more appropriate revascularization procedure in patients with 3VD in whom a residual SYNTAX score >8 after PCI is expected regardless of the baseline SYNTAX score II. MAG has been associated with improved long-term survival, but in the New York State database, the survival curves began to diverge only after 7 years.12Samadashvilli Z. Sundt T.M. Wechsler A. Chickwe J. Adams D.H. Smith C.R. et al.Multiple versus single arterial coronary bypass graft surgery for multi-vessel disease.J Am Coll Cardiol. 2019; 74: 1275-1285Crossref PubMed Scopus (52) Google Scholar Therefore, new scoring systems need to take into account that survival and MACE should be based on both 5- and 10-year follow-up. In the current SYNTAX score II, low-risk, younger patients would have lower scores suggesting no difference in 30-day mortality between PCI and CABG. These patients would more likely be referred for PCI, despite the fact that CABG with MAG would have the potential for better long-term survival and a decreased incidence of re-revascularization, recurrent MI, and recurrent angina. Significant but asymptomatic valve disease and preprocedure atrial fibrillation can increase both short- and long-term mortality and MACE if they are not addressed at the time of the coronary revascularization procedure. A concomitant ablation procedure and left atrial appendage closure at the time of CABG in patients with preoperative atrial fibrillation has been associated with a decreased incidence of strokes, systemic embolization, and improved long-term survival.13Malaisrie S.C. McCarthy P.M. Kruse J. Matsouaka R.A. Churyla A. Grau-Sepulveda et al.Ablation of atrial fibrillation during coronary artery bypass grafting: late outcomes in a Medicare population.J Thorac Cardiovasc Surg. 2021; 161: 1251-1261Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar The ability to treat coexisting comorbidities at the time of coronary revascularization should be reflected in future scoring models. Noncompliance with GDMT following both PCI and CABG has been shown to decrease long-term survival, freedom from MI, and the need for repeat coronary revascularization procedures.14Lazar H.L. The surgeon's role in optimizing medical therapy and maintaining compliance with secondary prevention guidelines in the CABG patient.J Thorac Cardiovasc Surg. 2020; 160: 691-698Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,15Pinho-Gomes A.C. Azevedo L. Aha J.-M. Park S.-J. Hamza T.H. Farkouh M.E. et al.Compliance with guideline directed medical therapy in contemporary coronary revascularization trials.J Am Coll Cardiol. 2018; 71: 591-602Crossref PubMed Scopus (87) Google Scholar The lack of compliance with GDMT is especially detrimental for CABG patients. The beneficial advantages of CABG over PCI with 3VD and LMCAD have been found to be negated in those CABG patients who are noncompliant with GDMT.14Lazar H.L. The surgeon's role in optimizing medical therapy and maintaining compliance with secondary prevention guidelines in the CABG patient.J Thorac Cardiovasc Surg. 2020; 160: 691-698Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,15Pinho-Gomes A.C. Azevedo L. Aha J.-M. Park S.-J. Hamza T.H. Farkouh M.E. et al.Compliance with guideline directed medical therapy in contemporary coronary revascularization trials.J Am Coll Cardiol. 2018; 71: 591-602Crossref PubMed Scopus (87) Google Scholar Therefore, compliance with GDMT should be factored into new scoring systems to more accurately reflect long-term mortality and MACE. Currents scoring systems do not take into account the morbidity and mortality involved when a future revascularization procedure is required. This is especially true for younger patients with low SYNTAX scores who are more likely to receive a multivessel PCI. However, patients with previous multivessel stenting who subsequently undergo CABG have an increased risk for hospital mortality, MACE, and decreased long-term survival compared with patients without a previous PCI, especially in patients with diabetes.16Lazar H.L. Detrimental effects of coronary stenting on subsequent coronary artery bypass surgery: is there another flag on the field?.J Thorac Cardiovasc Surg. 2009; 138: 276-277Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 17Rao C. Stanbridge R.D.L. Chikwe J. Pepper J. Skapinakis P. Aziz O. et al.Does previous percutaneous coronary stenting compromise the long-term efficacy of subsequent coronary artery bypass surgery? A microsimulation study.Ann Thorac Surg. 2008; 85: 501-507Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 18Mannacio V. Tommaso L.D. DeAmicis V. Lucchitti V. Pepino P. Musumeci F. et al.Previous percutaneous coronary interventions increase mortality and morbidity after coronary surgery.Ann Thorac Surg. 2012; 93: 1956-1963Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 19Theilman M. Neuhauser M. Knipp S. Kottenberg-Assenmacher E. Marr A. Pizanis N. et al.Prognostic impact of previous percutaneous coronary intervention in patients with diabetes mellitus and triple vessel disease undergoing coronary artery bypass surgery.J Thorac Cardiovasc Surg. 2007; 134: 470-476Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 20Niclauss L. Colombier S. Petre R. Percutaneous coronary interventions prior to coronary artery bypass surgery.J Card Surg. 2015; 30: 313-318Crossref PubMed Scopus (9) Google Scholar This should be reflected in future scoring systems and be discussed more thoroughly in heart teams; especially in relation to younger patients with lower SYNTAX scores. Because of the shortcomings of the current scoring systems, heart teams must continue to take into account not only preoperative comorbidities and coronary anatomy, but also the ability the achieve a complete revascularization, the durability of the conduits and the stents used, and the ability to treat other comorbidities at the time of revascularization such as atrial fibrillation and valve disease. Furthermore, it is important to note that compared with PCI, although CABG mortality may be slightly higher during the first year following revascularization, CABG results in a significant increase in freedom from recurrent angina and the need for repeat revascularization in the long term. This is similar to the findings from the Placement of Aortic Transcatheter Valves 3 (PARTNER 3) trial comparing surgical aortic valve replacement with transcatheter aortic valve replacement in low-risk patients where the advantages seen in mortality and stroke at 1 year in the transcatheter aortic valve replacement group were no longer seen after 2 years.21Leon M.B. Mack M.J. Hahn R.T. Thourani V.H. Makkar R. Kodali S.K. et al.Outcomes 2 years after transcatheter aortic valve replacement in patients at low surgical risk.J Am Coll Cardiol. 2021; 77: 1149-1161Crossref PubMed Scopus (146) Google Scholar The SYNTAX score II has been shown to be more accurate than its predecessor, but to better predict short- and long-term mortality and MACE in order to better determine the role of PCI versus CABG in individual patients, more data are needed. Anatomical and clinical risk stratification tool for mortality risk assessment following revascularization for multivessel coronary artery diseaseThe Journal of Thoracic and Cardiovascular SurgeryVol. 166Issue 3PreviewThis study aimed to assess the prognostic ability of SYNTAX score II in left main and/or 3-vessel disease patients undergoing revascularization either by coronary artery bypass grafting or percutaneous coronary intervention in a national registry. Full-Text PDF
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