https://orcid.org/0000-0002-8266-3689
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Pierre T Le Page, Nick G Bellenger, Completeness of revascularization: should we not consider assessment before and after coronary artery bypass grafting?, European Heart Journal, Volume 40, Issue 41, 1 November 2019, Page 3435, https://doi.org/10.1093/eurheartj/ehz497
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This commentary refers to ‘2018 ESC/EACTS Guidelines on myocardial revascularization’, by N. Franz-Josef et al., 2019;40:87–165.
We commend the guideline authors in assimilating such a large amount of data into a well-structured, easy to read document that provides practising cardiologists with a useful day-to-day reference for a wide-ranging number of clinical scenarios.
New emphasis is placed on prioritizing the completeness of revascularization when considering coronary artery bypass grafting (CABG) vs. percutaneous intervention (PCI), with a concise figure outlining situations in which each are favoured.1 In clinical practice, however, there are situations where neither CABG nor PCI may be able to achieve complete revascularization. In such cases would the authors advocate an up-front hybrid approach of CABG with PCI of vessels predicted to be ungrafted, or a strategy of post-CABG functional assessment to identify areas thought not to be fully revascularized at the time of the bypass? For example, it may be possible to predict that proximal side branches would be trapped between the bypassed distal stenosis and a more proximal stenosis; such as a native ostial left anterior descending (LAD) stenosis and a mid-LAD stenosis receiving a distal graft may have trapped septal or diagonal branches that receive insufficient blood supply from the retrograde left internal mammary artery (LIMA) flow or the anterograde native LAD flow. Incomplete revascularization can also occur if technical issues arise during surgery such that it deviates from the proposed operation. In such circumstances would the authors advocate that an ischaemic burden of >10% of the left ventricle would warrant further revascularization?
