Surgical revascularization holds its ground in modern cardiac care
CABG remains the preferred treatment for patients with complex disease or certain other clinical characteristics.
Surgical coronary artery bypass grafting (CABG) remains the gold standard option for complex multivessel disease, with or without left main coronary artery blockages or for patients with severe left ventricular dysfunction. And even though less invasive care is generally preferred, in some cases CABG continues to offer advantages over percutaneous coronary intervention (PCI).
On Friday, at the session titled “Rethinking Coronary Revascularization: Less Invasive and More Strategic,” Judith Hochman, MD, will illuminate factors that impact decision-making in these cases. Hochman is the Harold Snyder Family Professor of Cardiology, associate director of the Leon H. Charney Division of Cardiology and senior associate dean for clinical sciences at the New York University Grossman School of Medicine.
“The patient-centered goals of revascularization are to improve quality of life and survival,” Hochman said. “For patients with angina, revascularization by each modality improves quality of life compared to medical therapy alone.” But patients’ individual anatomy, disease complexity and ventricular function all can make CABG the preferred revascularization strategy, she said.
During her presentation, "Does Anyone Need Surgical Coronary Revascularization? If So, Who Should Be Referred?" Hochman will share evidence from the ISCHEMIA trial that shows both CABG and PCI improve angina-related health status compared with medical therapy alone. CABG produced the highest long-term freedom-from-angina rates, while PCI delivered the fastest early symptom relief, she said.
In further addressing therapeutic indications for CABG, Hochman will discuss treating patients with stable chronic coronary disease who have preserved left ventricular function and an absence of left main coronary artery disease. Current evidence does not demonstrate a clear benefit for overall survival from routine CABG or PCI compared with guideline-directed medical therapy alone, Hochman said. However, cardiovascular death and myocardial infarction are reduced. CABG is recommended to improve survival for those with reduced ejection fraction.
“When revascularization is indicated, there are differences in the risk of major adverse cardiac events for CABG versus PCI,” she said. “For those with preserved ejection fraction, surgical revascularization is most strongly recommended for patients who have diabetes and multivessel disease, including left anterior descending artery (LAD), high-complexity disease, such as a high SYNTAX score, and complex left main disease, as long as they are surgical candidates.”
Although CABG carries a higher early risk of stroke, she said, PCI is associated with higher rates of spontaneous myocardial infarction and repeat revascularization procedures over time.
Given that revascularization decisions are evolving beyond anatomy alone, Hochman said her fellow panelists will support the shift by discussing research from studies such as FAME and FAME 2. These trials have found that fractional flow reserve (FFR)-guided PCI can improve outcomes and reduce unnecessary stenting, with this physiologic testing changing treatment decisions in 30% to 50% of cases.
Panelists will also discuss leveraging angiography-derived FFR, Hochman said. This emerging technique, which relies on computational modeling, obviates the need for a hyperemic agent and enables noninvasive functional assessment before catheterization, she said.
Coronary revascularization is increasingly a tailored strategy based on physiology- and imaging-guided lesion selection rather than visual stenosis assessment. Hybrid approaches combine the durability of the LIMA-LAD (left anterior mammary artery-left anterior descending artery) bypass procedure with the recovery advantages of PCI. More importantly, they include patient-centered health-status outcomes alongside hard endpoints.
When the optimal strategy is unclear, Hochman recommends multidisciplinary "heart team" decision-making. Collaborating surgeons, interventional cardiologists and other specialists are helpful in evaluating patient risk, anatomy, comorbidities, frailty and personal preferences before recommending a treatment strategy, she said.
Rethinking Coronary Revascularization: Less Invasive and More Strategic
4:45-6 p.m. | Friday, Nov. 6 | S105D
