To the Editor:
We have learned through maturing practices in aortic stenosis that deciding on transcatheter aortic valve replacement vs surgical aortic valve replacement by using only anatomic limitations and surgical risk is overly generalizing and may not offer the best for all patients. Instead, lifelong management of the valve is increasingly weighing in, especially in the younger patient. The index procedure is being designed to avoid a repeat intervention, or if necessary, to set up the patient for a successful repeat intervention during the expected lifetime. This is reflected in the joint American Heart Association and American College of Cardiology valvular guidelines, which include age and life expectancy as significant variables in the decision-making process.1
The case should not be different for coronary artery disease. In the SYNTAX (Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery) trial, 1 in 4 (25.9%) patients undergoing an index percutaneous coronary intervention (PCI) required repeat revascularization within 5 years, and 1 in 10 (9%) required more than 1 PCI.2 Those patients who required repeat revascularization after an index PCI had a 33.8% composite all-cause death, stroke, or myocardial infarction vs 16% for those patients not requiring repeat revascularization (P < .001). Repeat revascularization after index coronary artery bypass grafting (CABG) had a composite end point that was not significantly worse than that in patients who did not require repeat revascularization.2 This difference persisted at 10 years, with a significantly higher morality associated with repeat revascularization after an index PCI than after index CABG (32.7% vs 17.3%; P = .004).3
The foregoing indicates that an index PCI results not only in more repeat revascularizations, but also in revascularizations that are associated with more morbidity and mortality, when compared with patients after an index CABG. Age and life expectancy represent a cumulative likelihood of needing repeat revascularization. The American Heart Association, American College of Cardiology, and Society for Cardiovascular Angiography and Interventions 2021 joint guidelines document in its current form does not take this into consideration in the choice of revascularization strategy.4 A 45-year-old patient and an 85-year-old patient receive the same recommendation.
Given the rates of repeat revascularization and the discrepant risks of repeat revascularizations, both favoring index CABG, age and life expectancy should play a stronger role in the decision-making process. Younger patients should receive a stronger recommendation for CABG. This is regardless of whether multiple arterial grafts will be performed.
References
- 1.Otto C.M., Nishimura R.A., Bonow R.O., et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143:e72–e227. doi: 10.1161/CIR.0000000000000923. [DOI] [PubMed] [Google Scholar]
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- 4.Lawton J.S., Tamis-Holland J.E., Bangalore S., et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145:e18–e114. doi: 10.1161/CIR.0000000000001038. [DOI] [PubMed] [Google Scholar]