Long-term forecasting and comparison of mortality in the Evaluation of the Xience Everolimus Eluting Stent vs. Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial: prospective validation of the SYNTAX Score II

Campos, Carlos M.; Klaveren, David van; Farooq, Vasim; Simonton, Charles A.; Kappetein, A. Pieter; Sabik, Joseph F.; Steyerberg, Ewout W.; Stone, Gregg W.; Serruys, Patrick W.

doi:10.1093/eurheartj/ehu518

Cited by 104 publications

(75 citation statements)

References 22 publications

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“…55) Moreover, there are few data in the literature because meta-analyses have rarely been performed on the elderly population, 56) and clinical prospective randomized trials or multicenter studies did not generally study elderly patients, or included only a small proportion of these patients. [57][58][59] The evidence for the optimal revascularization procedure in octogenarians is thus reported mainly from observational studies, mostly singlecenter series comparing PCI and CABG with SITA grafting. 3,[60][61][62][63] It remains a matter of debate whether the use of bi-lateral IMA further displays the superiority of CABG over PCI, because no study has been specifically designed with this aim in the elderly population.…”

Section: Discussionmentioning

confidence: 99%

Coronary Artery Bypass Grafting with Arterial Conduits in the Elderly

Nicolini

Vezzani²,

Romano

et al. 2017

Int. Heart J.

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SummaryAlthough improved long-term outcomes obtained with the use of arterial grafts for coronary revascularization in comparison with the traditional association of a single arterial and saphenous vein grafts have been demonstrated in the overall population, the efficacy of this newer technique in the elderly is difficult to prove because their shorter life expectancy due to advanced heart disease, associated with severe comorbidities. Moreover, more widespread use of this technique is limited by the concerns on the potential morbidity, particularly the longer time required to perform the operation and the possibility of deep sternal wound infection in case of bilateral internal thoracic artery harvesting due to the decreased blood supply to the sternum and surrounding tissues.The review of the recent literature indicates that the use of bilateral internal thoracic arteries in very elderly patients should not be considered routinely. It seems reasonable to avoid it in octogenarians in the presence of well-known predictors of sternal complications such as diabetes, morbid obesity, and severe chronic lung disease.There is also still controversy about the superiority of the radial artery over the saphenous vein graft as a second or third conduit for surgical myocardial revascularization, although the majority of recent studies seem to support more liberal use of the radial artery as second arterial conduit in the elderly. Although a clinical benefit of arterial graft revascularization cannot be formally excluded for elderly patients, the increased complexity of this technique suggests that careful clinical judgment is necessary to select grafts for individual patients.(Int Heart J 2017; 58: 647-653) Key words: Coronary artery disease, Old patients, Arterial grafts N owadays a growing number of patients are older at the time of coronary artery bypass grafting (CABG) and present with a clinical history characterized by more comorbidities than in the past. However, despite the increasing proportions of elderly patients with a worse risk profile for elective CABG, mortality in elderly patients over recent decades has dramatically declined.1) In fact, recent studies on elderly patients operated with CABG reported a 30-day mortality rate ranging between 3.7 and 16.8%, a 1-year mortality between 8% and 10.8% and a 5-year mortality ranging from 28.4% to 31%. 2-6)It is well recognized that octogenarians have a higher risk of post-operative complications, 7) require greater clinical and economic resources, and have worse but acceptable short and long-term survival in comparison with younger patients. However, improvements in technical management, particularly the development of innovative extracorporeal circulatory systems, the use of off-pump CABG and the increased use of pedicled arterial conduits have been proven effective in improving outcomes, although they have not completely eliminated the morbidity in this high-risk population. [8][9][10][11][12][13][14] Although improved long-term outcomes obtained with the use of ...

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Section: Discussionmentioning

confidence: 99%

Coronary Artery Bypass Grafting with Arterial Conduits in the Elderly

Nicolini

Vezzani²,

Romano

et al. 2017

Int. Heart J.

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“…The anatomical SYNTAX score, with low (<23), intermediate (23)(24)(25)(26)(27)(28)(29)(30)(31)(32) or high (>32) categories, 8,12 became a sentinel tool in the SYNTAX trial and pioneered the now-popular "Heart Team" approach, in which a cardiac surgeon and interventional cardiologist determine the optimal revascularization modality for patients with 3VD/ULMCA disease. It combines the importance of diseased vessel segment weighting (Leaman score), adverse lesion characteristics (American College of Cardiology/American Heart Association lesion classification, and total occlusion characteristics from the European TOTAL Surveillance Study) and the Medina classification system for bifurcation lesions.…”

Section: After Syntaxmentioning

confidence: 99%

“…Both anatomical and clinical characteristics had a clear impact on long-term mortality predictions and decision-making between CABG and PCI. 31 In this issue of Journal of Patient-Centered Research and Reviews, Nfor et al 32 report on the clinical outcomes after PCI with newer-generation DES (everolimus or zotarolimus in ~80% patients) versus CABG in 3VD/ULMCA on a nonrandomized "high risk" surgical cohort of select patients in their tertiary care institution. These patients were identified as "high risk" based on Society of Thoracic Surgeons (STS)-predicted operative mortality of > 5%.…”

Section: After Syntaxmentioning

confidence: 99%

A Tale of Two Techniques: Demystifying the Myth

Jan¹

2015

Journal of Patient-Centered Research and Reviews

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“…Advances in the drug eluting stent (DES) have made the percutaneous coronary intervention (PCI) more acceptable therapy as an alternative to CABG [3]. Randomised trials demonstrated comparable efficacy and safety between PCI and CABG for significant LMCA disease [3,4,26,31].…”

Section: Introductionmentioning

confidence: 99%

“…Besides clinical predictors, anatomical factors are taken into account while making decision for type of revascularisation [31]. Presence or absence of bifurcation lesion, bifurcation type, distal bifurcation angle (BA) and characteristics of stenosis are generally used for anatomical score calculation in LMCA lesions [4,31]. In the SYNTAX score, presence of LMCA distal BA < 70° is an adverse lesion characteristics due to the anticipated difficulty in covering the ostium of the side branch when a stent become necessary after main branch stenting [28].…”

Section: Introductionmentioning

confidence: 99%