Scalpels Versus Balloons in Failing Hearts

While there is a preference for surgery regarding coronary revascularization for patients with coronary artery disease (CAD) and left ventricular (LV) systolic dysfunction, this issue still attracts attention due to limited hard evidence. Our decision-making in this field is dominated by the STICH (Surgical Treatment for Ischemic Heart Failure) trial, a landmark study that, however, compared surgical treatment with medical therapy. Unfortunately, randomized controlled studies comparing coronary artery bypass grafting (CABG) with contemporary percutaneous coronary intervention (PCI) are lacking. In search of available evidence, in this issue of Angiology, Zhang et al performes a meta-analysis comparing CABG and PCI in such patients. Four prospective and 5 retrospective studies, involving 6082 patients, were included. The authors conclude that CABG was associated with significantly lower long-term death, myocardial infarction, and repeat revascularization rates. On the other hand, the short-term death rate was comparable between the 3 options. The explanation behind these results most likely lies in the higher level of complete revascularization achieved with surgery, and an analogy can be drawn with the FREEDOM (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease) trial in which CABG was superior to PCI in diabetic patients with multivessel disease. The authors are to be complemented for following a rigorous analytical approach, and from this standpoint, the study lends support to current guidelines and offers reassurance regarding the tactics that we follow in our everyday clinical practice. However, as every good research, while it provides answers, it also creates questions. First, it becomes apparent that, with the exception of repeat revascularization, results favoring CABG are driven primarily by retrospective, and not prospective, studies. Second, there is no randomized study comparing the 2 therapeutic options. Finally, while surgical techniques have reached a peak, the world of PCI is continuously evolving. Not only stents have dominated interventional procedures but also drug-eluting stents prevail over bare-metal stents. And there is more: Second-generation stents are more effective, modern techniques, such as fractional flow reserve, intravascular ultrasound, and optical coherence tomography, are available to ensure a good post-PCI result, and more potent antiplatelet agents, such as ticagrelor and prasugrel, may improve outcomes in the general context of acute coronary syndromes. Accordingly, some of the older studies included in the meta-analysis of Zhang et al may contribute to a dilution effect that potentially draws away from realistic, updated potential of the current interventional procedures. Furthermore, questions that are not related to the technical or procedural issues remain to be answered. We currently do not know whether results would be different in moderately impaired (ejection fraction <50% and >35%), in comparison to severely impaired left ventricles (<35%). Theoretically, a preponderant technique would be given more likelihood to unfold its benefits in a condition where there is more myocardium to express its benefit, but additional evidence is needed. This also leads to another source of questioning related to the appropriate selection of patients. Conceptually, revascularization, which is precisely targeted and is performed following meticulous identification of viable myocardium, would yield more benefit. However, viability has not been identified beyond doubt as a factor that determines outcome after revascularization. The need for strong clinical data as opposed to theoretical advantages are also highlighted by the case of ventricular reconstruction. This reconstruction constitutes a conceptual advantage of surgery by attempting to remove scar tissue from the LV wall by an endoventricular patch plasty, thereby restoring physiological volume and to restore an elliptical rather than spherical shape. However, the STICH trial failed to show a difference in the primary outcome (death from any cause or hospitalization for cardiac causes) between CABG and the combined procedure (CABG and ventricular reconstruction). Given the lack of strong evidence and the wide spectrum of patient characteristics (related to comorbidities, clinical status