Catheterization and Cardiovascular Interventions 86:11 (2015)
Editorial Comment Being Reasonable During Coronary Revascularization Jorge A. Belardi,* MD, FACC, FSCAI and Mariano Albertal, MD, PhD, FACC Department of Interventional Cardiology and Endovascular Therapeutics, Instituto Cardiovascular De Buenos Aires, Buenos Aires, Argentina
ond, operators tend to overestimate the functional significance of the stenosis and thus, (direct or indirect) physiological lesion assessment is always necessary. Third, assessment of the SS and rSS requires proficiency to avoid excessive variability. Lastly, both scores provide only angiographic information, adding clinical variables clearly improve their predictive performance. Future prospective studies combining SS with physiological and clinical factors are needed to better determine the best revascularization strategy in patients with complex coronary artery disease.
Key Points
The SYNTAX score is an angiographically based tool useful for clinical decision-making prior to coronary revascularization. The residual SYNTAX score (after angioplasty) is an independent predictor of clinical long-term outcome in patients with complex coronary artery disease. Both scores require functional lesion assessment. Adding clinical risk factors to both scores enhances their performance.
The SYNTAX Score (SS) is an objective tool that improves decision-making between surgical and percutaneous coronary revascularization and it is currently advocated by both the European and US [1] revascularization guidelines. The presence of incomplete revascularization (IR) has a negative clinical impact [2], while an excessive attempt for revascularization can lead to major perioperative complications, suggesting the need for an acceptable level of revascularization or so called reasonable IR strategy [3]. The residual SS (rSS), measured after angioplasty, emerges as an independent predictor of long-term clinical outcome with a best cut-off value of 8 points [4]. In this issue of Catheterization and Cardiovascular interventions, Witberg et al. validated this cut-off point in a consecutive series of patients with triple vessel/left main disease undergoing routine angioplasty [5]. The systematic, widespread use of the rSS deserves some comments though. First, by combining information about both the amount of jeopardized myocardium and the degree of lesion complexity, it becomes challenging to separate their individual clinical predictive value. SecC 2015 Wiley Periodicals, Inc. V
REFERENCES 1. Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA. ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: A report of the American College of Cardiology Foundation appropriate use criteria task force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 2012;59:857–881. 2. Gussl M, Faxon DP, Bell MR, Holmes DR, Gersh BJ. Complete versus incomplete revascularization with coronary artery bypass graft or percutaneous intervention in stable coronary artery disease. Circ Cardiovasc Interv 2012;5:597–604. 3. De Bruyne B. Multivessel disease: From reasonably incomplete to functionally complete revascularization. Circulation 2012;125:2557–2559. 4. Genereux P, Palmerini T, Caixeta A, Rosner G, Green P, Dressler O, Xu K, Parise H, Mehran R, Serruys PW, Stone GW. Quantification and impact of untreated coronary artery disease after percutaneous coronary intervention: The residual SYNTAX (synergy between PCI with taxus and cardiac surgery) score. J Am Coll Cardiol 2012;59:2165–2174. 5. Witberg G, Lavi I, Assali A, Vaknin-Assa H, Lev E, Kornowski R. The incremental impact of residual SYNTAX score on longterm clinical outcomes in patients with multivessel coronary artery disease treated by percutaneous coronary interventions. Catheter Cardiovasc Interv 2015;86:3–10.
Conflict of interest: Nothing to report. *Correspondence to: Jorge Belardi, MD, Department of Interventional Cardiology and Endovascular Therapeutics, Blanco Encalada 1543, 4th floor, Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina. E-mail: [email protected] Received 11 May 2015; Revision accepted 11 May 2015 DOI: 10.1002/ccd.26044 Published online 27 May 2015 in Wiley Online Library (wileyonlinelibrary.com)
Editorial Comment Being Reasonable During Coronary Revascularization Jorge A. Belardi,* MD, FACC, FSCAI and Mariano Albertal, MD, PhD, FACC Department of Interventional Cardiology and Endovascular Therapeutics, Instituto Cardiovascular De Buenos Aires, Buenos Aires, Argentina
ond, operators tend to overestimate the functional significance of the stenosis and thus, (direct or indirect) physiological lesion assessment is always necessary. Third, assessment of the SS and rSS requires proficiency to avoid excessive variability. Lastly, both scores provide only angiographic information, adding clinical variables clearly improve their predictive performance. Future prospective studies combining SS with physiological and clinical factors are needed to better determine the best revascularization strategy in patients with complex coronary artery disease.
Key Points
The SYNTAX score is an angiographically based tool useful for clinical decision-making prior to coronary revascularization. The residual SYNTAX score (after angioplasty) is an independent predictor of clinical long-term outcome in patients with complex coronary artery disease. Both scores require functional lesion assessment. Adding clinical risk factors to both scores enhances their performance.
The SYNTAX Score (SS) is an objective tool that improves decision-making between surgical and percutaneous coronary revascularization and it is currently advocated by both the European and US [1] revascularization guidelines. The presence of incomplete revascularization (IR) has a negative clinical impact [2], while an excessive attempt for revascularization can lead to major perioperative complications, suggesting the need for an acceptable level of revascularization or so called reasonable IR strategy [3]. The residual SS (rSS), measured after angioplasty, emerges as an independent predictor of long-term clinical outcome with a best cut-off value of 8 points [4]. In this issue of Catheterization and Cardiovascular interventions, Witberg et al. validated this cut-off point in a consecutive series of patients with triple vessel/left main disease undergoing routine angioplasty [5]. The systematic, widespread use of the rSS deserves some comments though. First, by combining information about both the amount of jeopardized myocardium and the degree of lesion complexity, it becomes challenging to separate their individual clinical predictive value. SecC 2015 Wiley Periodicals, Inc. V
REFERENCES 1. Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA. ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: A report of the American College of Cardiology Foundation appropriate use criteria task force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 2012;59:857–881. 2. Gussl M, Faxon DP, Bell MR, Holmes DR, Gersh BJ. Complete versus incomplete revascularization with coronary artery bypass graft or percutaneous intervention in stable coronary artery disease. Circ Cardiovasc Interv 2012;5:597–604. 3. De Bruyne B. Multivessel disease: From reasonably incomplete to functionally complete revascularization. Circulation 2012;125:2557–2559. 4. Genereux P, Palmerini T, Caixeta A, Rosner G, Green P, Dressler O, Xu K, Parise H, Mehran R, Serruys PW, Stone GW. Quantification and impact of untreated coronary artery disease after percutaneous coronary intervention: The residual SYNTAX (synergy between PCI with taxus and cardiac surgery) score. J Am Coll Cardiol 2012;59:2165–2174. 5. Witberg G, Lavi I, Assali A, Vaknin-Assa H, Lev E, Kornowski R. The incremental impact of residual SYNTAX score on longterm clinical outcomes in patients with multivessel coronary artery disease treated by percutaneous coronary interventions. Catheter Cardiovasc Interv 2015;86:3–10.
Conflict of interest: Nothing to report. *Correspondence to: Jorge Belardi, MD, Department of Interventional Cardiology and Endovascular Therapeutics, Blanco Encalada 1543, 4th floor, Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina. E-mail: [email protected] Received 11 May 2015; Revision accepted 11 May 2015 DOI: 10.1002/ccd.26044 Published online 27 May 2015 in Wiley Online Library (wileyonlinelibrary.com)
