Impact of European Society of Cardiology and European Association for Cardiothoracic Surgery Guidelines on Myocardial Revascularization on the activity of percutaneous coronary intervention and coronary artery bypass graft surgery for stable coronary artery disease.
Selected in Journal of Thoracic and Cardiovascular Surgery by S. Head
Yates MT, Soppa GK, Valencia O, Jones S, Firoozi S, Jahangiri M
J Thorac Cardiovasc Surg 2014;147:606-10
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There has been an increased emphasis on Heart Team decision-making for patients with complex coronary artery disease; defined by left main, proximal left anterior descending (proximal LAD), or three-vessel disease (3VD). The 2010 ESC/EACTS guidelines give a 1C recommendation to multidisciplinary teams, but little data on the implementation, decisions, and results of the Heart Team are available. This single-center study assessed the impact of these 2010 guidelines on referral patterns to cardiac surgery.
- All patients with severe disease undergoing percutaneous coronary intervention at one institution were identified 6 months before (January to June 2010) and 6 months after (January to June 2011) the introduction of the 2010 ESC/EACTS guidelines.
- Follow-up was completed at 6 months.
- During the two studies time points, there was no change in the activity of elective PCI (P=0.34) or CABG (p=0.40).
- Pre-and post-guidelines, respectively 67 (34%) and 38 (29%) of patients who underwent PCI had complex disease as defined by left main, proximal LAD, or three-vessel disease (P=0.26). The number of patients discussed in a Heart Team was 9 versus 17%.
- The majority of patients with complex disease pre- as well as post-guidelines not discussed in a Heart Team had proximal LAD disease (71 and 65%), and ~25% of patients had 3VD.
- Ad hoc stenting accounted for 14 and 26% of elective PCIs pre- and post-guidelines, respectively. Of these, ~65% had proximal LAD disease and the remainder 3VD. No patients with LM disease underwent ad hoc PCI.
The data presented in the study by Yates and co-authors provide useful information on the function of the Heart Team. It is unfortunate that the recommendation of the ESC/EACTS guidelines to implement the Heart Team has not been incorporated in clinical practice. However, this was a single-center experience with only a limited number of patients shortly after the publication of the guidelines. One should allow sufficient time and enough experience to produce a well-functioning Heart Team. Furthermore, the success of the Heart Team depends strongly on the collaborative environment in a center, the motivation of both cardiologists and surgeons, and the organization of meetings, which may be different in other institutions; undoubtedly the Heart Team functions well in these other institutions.