Surgical Revascularization in Acute Coronary Syndrome
Main Article Content
Abstract
Purpose: This review evaluates surgical revascularization strategies in patients with acute coronary syndrome (ACS), focusing on optimal timing, patient selection criteria, and a comparative analysis with percutaneous coronary interventions (PCI). The study aims to provide a comprehensive overview of the indications, benefits, and limitations of surgical approaches in the context of multi-vessel disease and other complex ACS presentations.
Methods: A literature review was conducted, drawing from clinical trials, observational studies, and current guidelines on ACS management. Key studies examining outcomes of coronary artery bypass grafting (CABG) in ACS, including on-pump and off-pump techniques, were analyzed alongside PCI trials to assess the effectiveness and safety of these approaches.
Key Findings: Surgical revascularization, particularly CABG, offers advantages in selected ACS populations, such as those with multi-vessel disease or failed PCI, and is critical for patients with structural complications like ventricular septal rupture. Off-pump CABG (OPCAB) shows potential benefits in reducing systemic inflammation and perioperative complications, though patient selection remains essential. Guidelines recommend CABG for high SYNTAX score patients and in cases of left main disease, with emerging evidence supporting staged revascularization in multi-vessel disease to reduce adverse events. Comparatively, PCI offers rapid revascularization but may require repeat interventions, particularly in patients with complex coronary anatomy or comorbidities.
Conclusion: Surgical revascularization remains a crucial component of ACS management, particularly for complex cases where PCI is unsuitable or incomplete. This review underscores the importance of individualized patient assessment, the need for further comparative trials, and the role of the heart team approach in optimizing outcomes for ACS patients. Future research should focus on refining patient selection criteria and exploring hybrid revascularization approaches to improve clinical practice.
Article Details
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
2. Shroyer AL, Grover FL, Hattler B, et al. On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med. 2009;361(19):1827-1837. doi:10.1056/NEJMoa0902905.
3. Lamy A, Devereaux PJ, Prabhakaran D, et al. Five-year outcomes after off-pump or on-pump coronary-artery bypass grafting. N Engl J Med. 2016; 375(24):2359-2368. doi:10.1056/NEJMoa1601564.
4. Diegeler A, Börgermann J, Kappert U, et al. Off-pump versus on-pump coronary-artery bypass grafting in elderly patients. N Engl J Med. 2013;368 (13):1189-1198. doi:10.1056/NEJMoa1211666.
5. Holm NR, Mäkikallio T, Lindsay MM, et al. Percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: updated 5-year outcomes from the randomized, non-inferiority NOBLE trial. Lancet. 2020;395(10219):191-199. doi:10.1016/S0140-6736 (19)32972-1.
6. Jahangiri M, Mani K, Yates MT. The EXCEL trial: the surgeons' perspective. Eur Cardiol Rev. 2020;15. doi:10.15420/ecr.2020.34.
7. Kobayashi Y, Lønborg J, Jong A, et al. Prognostic value of the residual SYNTAX score after functionally complete revascularization in ACS. J Am Coll Cardiol. 2018;72(12):1321-1329. doi:10.1016/j.jacc.2018.06.069.
8. Généreux P, Campos CM, Yadav M, et al. Reasonable incomplete revascularization after percutaneous coronary intervention: the SYNTAX revascularization index. EuroIntervention. 2014; 10(5):546-554. doi:10.4244/EIJY14M10_05.
9. Vroegindewey MM, Schuurman AS, Oemrawsingh RM, et al. SYNTAX score II predicts long-term mortality in patients with one- or two-vessel disease. PLoS One. 2018;13(7). doi:10.1371/journal.pone.0200076.
10. O'Keefe JH Jr, Bailey WL, Rutherford BD, et al. Primary angioplasty for acute myocardial infarction in 1,000 consecutive patients: results in an unselected population and high-risk subgroups. Am J Cardiol. 1993;72(19). doi:10.1016/0002-9149 (93)90050
11. Koshal A, Beanlands DS, Davies RA, et al. Urgent surgical reperfusion in acute evolving myocardial infarction: a randomized controlled study. Circulation. 1988;78(1). doi:10.1161/01.cir.78.1.171.
12. Kim HH, Lee M, Yoo KJ. Optimal revascularization timing of coronary artery bypass grafting in acute myocardial infarction. Clin Cardiol. 2023;46(3):246-257. doi:10.1002/clc.24325.
13. Stähli BE, Varbella F, Linke A, et al.; MULTISTARS AMI Investigators. Timing of complete revascularization with multivessel PCI for myocardial infarction. N Engl J Med. 2023;389(15):1368-1379. doi:10.1056/NEJMoa2307823.
14. Diletti R, den Dekker WK, Bennett J, et al.; BIOVASC Investigators. Immediate versus staged complete revascularization in patients presenting with acute coronary syndrome and multivessel coronary disease (BIOVASC): a prospective, open-label, non-inferiority, randomized trial. Lancet. 2023; 401(10335):361-371. doi:10.1016/S0140-6736(23) 00351-3.
15. Lang Q, Qin C, Meng W. Appropriate timing of coronary artery bypass graft surgery for acute myocardial infarction patients: a meta-analysis. Front Cardiovasc Med. 2022;9:794925.
doi:10.3389/fcvm.2022.794925.
16. Bhatt DL, Pollack CV Jr, Mazer CD, et al.; REVERSE-IT Investigators. REVERSE-IT: effect of bentracimab on platelet inhibition and hemostasis in patients on ticagrelor with major bleeding or requiring urgent procedures. J Am Coll Cardiol. 2021;78(11):1127-1137. doi:10.1016/j.jacc.2021.10.005.
17. Valgimigli M, Bueno H, Byrne RA, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Eur Heart J. 2018;39(3):213-254. doi:10.1093/eurheartj/ehx419.
18. Hwang B, Williams ML, Tian DH,et al. Coronary artery bypass surgery for acute coronary syndrome: a network meta-analysis of on-pump cardioplegic arrest, off-pump, and on-pump beating heart strategies. J Card Surg. 2022;37(12):5290-5299. doi:10.1111/jocs.17149.
19. Liakopoulos OJ, Slottosch I, Wendt D, et al. Surgical revascularization for acute coronary syndromes: a report from the North Rhine-Westphalia surgical myocardial infarction registry. Eur J Cardiothorac Surg. 2020;58(6):1137-1144. doi:10.1093/ejcts/ezaa260.
20. Lawton JS, Tamis-Holland JE, Bangalore S, et al.; 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization Writing Committee. 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. 2021;144(14) . doi:10.1161/CIR.0000000000001038.
21. Valgimigli M, Bueno H, Byrne RA, et al.; ESC Clinical Practice Guidelines. 2023 ESC guidelines for the management of acute coronary syndromes. Eur Heart J. 2023;44(14):1103-1156. doi:10.1093/eurheartj/ehad320.