1.pathophysiology of Heart Disease A Collaborative Project of Medical Student

2018 ESC/EACTS Guidelines on
myocardial revascularization – part 2
Choice between PCI or CABG for Stable Coronary Artery Disease – cont’d
Decision-Making and Patient Information
Revascularization in Heart Failure
Repeat Revascularization
Technical Aspects of CABG
What’s New in Relation With CABG
1
www.escardio.org/guidelines 2018 ESC/EACTS Guidelines on myocardial revascularisation
European Heart Journal (2018) 00, 1-96 - doi:10.1093/eurheartj/ehy394
2
Type of revascularization in patients with stable coronary
artery disease with suitable coronary anatomy for both
procedures and low predicted surgical mortality (3)
CABG PCI
Recommendations according to extent of CAD
Class Level Class Level
Three-vessel CAD without diabetes mellitus
Three-vessel disease with low SYNTAX score (0-22). I A I A
Three-vessel disease with intermediate or high SYNTAX score I A III A
(>22).a
Three-vessel CAD with diabetes mellitus
Three-vessel disease with low SYNTAX score (0-22). I A IIb A
Three-vessel disease with intermediate or high SYNTAX score I A III A
(>22).a
a PCIshould be considered, if the Heart Team is concerned about the surgical risk or if the patient
refuses CABG after adequate counselling by the Heart Team. http://www.syntaxscore.com
3
Considerations for the choice between
coronary artery bypass grafting and
percutaneous coronary intervention as
revascularization strategies in major
categories of patients with stable
multivessel coronary artery disease: an
accompanying article of the task force of
the 2018 ESC/EACTS guidelines on
myocardial revascularization
Stephan Windecker, Franz-Josef Neumann, Peter Jüni,
Miguel Sousa-Uva, and Volkmar Falk
10.1093/eurheartj/ehy532
This accompanying article is online – free to read

European Heart Journal
Type of revascularization in patients with stable
three-vessel or left main coronary artery disease
Windecker S et al., Eur Heart J 2018, in press

5
Aspects to be considered by the Heart Team for decision
-making between PCI and CABG among patients with
stable multivessel and/or left main coronary artery
disease (1)
PCI FAVOURS PCI
Clinical caracteristics
Presence of severe co-morbidity (not adequately
reflected by scores).
Left coronary
artery Advanced age/frailty/reduced life expectancy.
Restricted mobility and conditions that affect the
Right Circumflex rehabilitation process.
coronary coronary
artery artery Anatomical and technical aspects
MVD with SYNTAX score 0-22.
Left anterior Anatomy likely resulting in incomplete
descending revascularization with CABG due to poor quality or
Distal right coronary missing conduits.
coronary artery Severe chest deformation or scolliosis.
artery
Sequelae of chest radiation.
Porcelain aorta.a
6
Aspects to be considered by the Heart Team for decision
-making between PCI and CABG among patients with
stable multivessel and/or left main coronary artery
disease (2)
CABG FAVOURS CABG
Clinical caracteristics
Left internal thoracic Diabetes.
artery to left anterior Reduced LV function (EF ≤35%).
descending Contraindication to DAPT.
Recurrent diffuse in-stent restenosis.
Right internal thoracic Anatomical and technical aspects
artery or radial artery MVD with SYNTAX score ≥23.
Anatomy likely resulting in incomplete
revascularization with PCI.
Severely calcified coronary artery lesions limiting
Sequential anastomosis lesion expansion.
to obtuse marginal Need for concomitant interventions
1 and 3 Ascending aortic pathology with indication for
surgery.
Concomitant cardiac surgery.
7
8
Decision-making and patient
information in the elective setting
Recommendations Class Level
It is recommended that patients undergoing coronary angiography are
informed about benefits and risks, as well as potential therapeutic I C
consequences, ahead of the procedure.
It is recommended that patients are adequately informed about short- and
long-term benefits and risks of the revascularization procedure with
information about local experience, and allowed enough time for informed I C
decision-making.
It is recommended that institutional protocols are developed by the Heart
Team to implement the appropriate revascularization strategy in I C
accordance with current Guidelines.
In PCI centres without on-site surgery, it is recommended that institutional I
protocols are established with partner institutions providing cardiac surgery. C
9
10
Revascularizations in patients with chronic heart
failure and systolic left ventricular dysfunction
(ejection fraction ≤35%)
In patients with severe LV systolic dysfunction and coronary artery disease
I B
suitable for intervention, myocardial revascularization is recommended.
CABG is recommended as the first revascularization strategy choice in
I B
patients with multivessel disease and acceptable surgical risk.
In patients with one- or two-vessel disease, PCI should be considered as
IIa C
an alternative to CABG when complete revascularization can be achieved.
In patients with three-vessel disease, PCI should be considered based on
the evaluation by the Heart Team of the patient’s coronary anatomy, the
IIa C
expected completeness of revascularization, diabetes status, and
comorbidities.
11
12
Repeat revascularization for late graft failure
Procedural aspects of the revascularization modalities
CABG
IMA is the conduit of choice for redo CABG in patients in whom
the IMA was not used previously. I B
Redo CABG should be considered for patients without a patent
IMA graft to the LAD. IIa B
PCI
Distal protection devices should be considered for PCI of SVG IIa B
lesions.
PCI of the bypassed native artery should be considered over PCI IIa C
of the bypass graft.
13
Repeat revascularization for restenosis
Restenosis
DES are recommended for the treatment of in-stent restenosis of
I A
BMS or DES.
Drug-coated balloons are recommended for the treatment of in-
I A
stent restenosis of BMS or DES.
In patients with recurrent episodes of diffuse in-stent restenosis,
CABG should be considered by the Heart Team over a new PCI IIa C
attempt.
IVUS and/or OCT should be considered to detect stent-related
IIa C
mechanical problems leading to restenosis.
14
15
Technical aspects of CABG
Minimize aortic manipulation IB

Off-pump if calcified aorta IB LIMA to LAD IB
Off-pump if high-risk IIaB BIMA if low risk of sternal
complications IIaB
Skeletonize if risk of
Complete revascularization IB sternal complications IB
Graft flow measurement IIaB
Radial artery
in high-grade
stenosis IB
Endoscopic vein harvesting IIaA

No-touch vein harvesting IIaB
16
17
What’s new in relation with CABG?
Calculation of the Syntax Score if Completeness of revascularization

left main or multivessel prioritized, when considering CABG
revascularization is considered. vs PCI.
Systematic re-evaluation of No-touch vein technique, if open
patients after myocardial vein harvesting for CABG.
revascularization.
Stabilised NSTEMI-ACS patients:
revascularization strategy DOWNGRADES
according to principles for SCAD.
PCI for MVD with diabetes and SYNTAX score <23
Use of the radial artery grafts Platelet function testing to guide antiplatelet
over saphenous vein grafts in therapy interruption in patients undergoing
patients with high-degree cardiac surgery.
stenosis. EuroSCORE II to assess in-hospital mortality after
CABG.
18
www.escardio.org/guidelines
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2018 ESC/EACTS Guidelines on

myocardial revascularization – part 2

 Decision-Making and Patient Information

 Revascularization in Heart Failure

 Technical Aspects of CABG

 What’s New in Relation With CABG

This accompanying article is online – free to read

Windecker S et al., Eur Heart J 2018, in press

 Decision-Making and Patient Information

 Revascularization in Heart Failure

 Technical Aspects of CABG

 What’s New in Relation With CABG

 Decision-Making and Patient Information

 Revascularization in Heart Failure

 Technical Aspects of CABG

 What’s New in Relation With CABG

 Decision-Making and Patient Information

 Revascularization in Heart Failure

 Technical Aspects of CABG

 What’s New in Relation With CABG

 Decision-Making and Patient Information

 Revascularization in Heart Failure

 Technical Aspects of CABG

 What’s New in Relation With CABG

Minimize aortic manipulation IB

Endoscopic vein harvesting IIaA

 Decision-Making and Patient Information

 Revascularization in Heart Failure

 Technical Aspects of CABG

 What’s New in Relation With CABG

Calculation of the Syntax Score if Completeness of revascularization

www.escardio.org/guidelines 2018 ESC/EACTS Guidelines on myocardial revascularisation

• All ESC Pocket Guidelines

• Over 145 interactive tools

• Summary Cards & Essential Messages

• Online & Offline

www.escardio.org/guidelines 2018 ESC/EACTS Guidelines on myocardial revascularisation

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