Cardiology Division, NYU Langone Health and NYU School of Medicine, New York, NY, USA.
Department of Medicine, Baylor College of Medicine, Houston, TX, 77030, USA.
Curr Cardiol Rep. 2024 Sep;26(9):919-933. doi: 10.1007/s11886-024-02090-x. Epub 2024 Jul 10.
The optimal revascularization strategy for coronary artery disease depends on various factors, such as disease complexity, patient characteristics, and preferences. Including a heart team in complex cases is crucial to ensure optimal outcomes. Decision-making between percutaneous coronary intervention and coronary artery bypass grafting must consider each patient's clinical profile and coronary anatomy. While current practice guidelines offer some insight into the optimal revascularization approach for the various phenotypes of coronary artery disease, the evidence to support either strategy continues to evolve and grow. Given the large amount of contemporary data on revascularization, this review aims to comprehensively summarize the literature on coronary artery bypass grafting and percutaneous coronary intervention in patients across the spectrum of coronary artery disease phenotypes.
Contemporary evidence suggests that for patients with triple vessel disease, coronary artery bypass grafting is preferred over percutaneous coronary intervention due to better long-term outcomes, including lower rates of death, myocardial infarction, and target vessel revascularization. Similarly, for patients with left main coronary artery disease, both percutaneous coronary intervention and coronary artery bypass grafting can be considered, as they have shown similar efficacy in terms of major adverse cardiac events, but there may be a slightly higher risk of death with percutaneous coronary intervention. For proximal left anterior descending artery disease, both percutaneous coronary intervention and coronary artery bypass grafting are viable options, but coronary artery bypass grafting has shown lower rates of repeat revascularization and better relief from angina. The Synergy Between PCI with Taxus and Cardiac Surgery score can help in decision-making by predicting the risk of adverse events and guiding the choice between percutaneous coronary intervention and coronary artery bypass grafting. European and American guidelines both agree with including a heart team that can develop and lay out individualized, optimal treatment options with respect for patient preferences. The debate between coronary artery bypass grafting versus percutaneous coronary intervention in multiple different scenarios will continue to develop as technology and techniques improve for both procedures. Risk factors, pre, peri, and post-procedural complications involved in both revascularization strategies will continue to be mitigated to optimize outcomes for those patients for which coronary artery bypass grafting or percutaneous coronary intervention provide ultimate benefit. Methods to avoid unnecessary revascularization continue to develop as well as percutaneous technology that may allow patients to avoid surgical intervention when possible. With such changes, revascularization guidelines for specific patient populations may change in the coming years, which can serve as a limitation of this time-dated review.
冠心病的最佳血运重建策略取决于多种因素，如疾病的复杂性、患者的特征和偏好。在复杂病例中纳入心脏团队至关重要，以确保获得最佳结果。经皮冠状动脉介入治疗和冠状动脉旁路移植术之间的决策必须考虑每位患者的临床特征和冠状动脉解剖结构。尽管当前的实践指南为冠心病的各种表型提供了一些关于最佳血运重建方法的见解，但支持这两种策略的证据仍在不断发展和增长。鉴于当代有关血运重建的大量数据，本综述旨在全面总结冠心病各表型患者经皮冠状动脉介入治疗和冠状动脉旁路移植术的文献。
当代证据表明，对于三支血管病变患者，由于长期预后更好，包括死亡率、心肌梗死和靶血管血运重建率更低，冠状动脉旁路移植术优于经皮冠状动脉介入治疗。同样，对于左主干冠状动脉疾病患者，经皮冠状动脉介入治疗和冠状动脉旁路移植术均可考虑，因为它们在主要不良心脏事件方面的疗效相似，但经皮冠状动脉介入治疗的死亡率可能略高。对于前降支近端病变，经皮冠状动脉介入治疗和冠状动脉旁路移植术均为可行选择，但冠状动脉旁路移植术显示重复血运重建率更低，心绞痛缓解更好。SYNTAX 评分可帮助预测不良事件风险并指导经皮冠状动脉介入治疗和冠状动脉旁路移植术之间的选择，从而有助于决策。欧洲和美国指南均同意纳入心脏团队，以便根据患者的偏好制定和制定个体化的最佳治疗方案。随着两种手术的技术不断改进，冠状动脉旁路移植术与经皮冠状动脉介入治疗在多种不同情况下的争论将继续发展。两种血运重建策略的风险因素、术前、术中和术后并发症将继续得到缓解，以优化那些从冠状动脉旁路移植术或经皮冠状动脉介入治疗中获益最大的患者的结果。避免不必要血运重建的方法也在不断发展，可能使患者在可能的情况下避免手术干预的经皮技术也在不断发展。随着这些变化，特定患者人群的血运重建指南可能会在未来几年发生变化，这可能是本综述的一个局限性。
