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SECTION 1 Pathophysiology and investigation ofcoronary artery disease68
Lumen
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Fig.7.4.1 Normal and abnormal findings on OCT. (a)Normal artery:the bright– dark– bright, three- layered appearance corresponding to
intima, media, and adventitia (asterisk:guidewire shadow). (b)Fibrous plaques:homogeneous, signal- rich regions (asterisk). (c)Fibrocalcific
plaques:signal- poor regions with sharply delineated borders (arrows). (d)Lipid- rich plaques:signal- poor regions (lipid pools) with poorly defined
borders and overlying signal- rich band corresponding to fibrous cap (asterisk). (e)Intimal injury in RA induced by transradial PCI. (f)Anastomosis in
CABG:intraoperative assessment of 1, native coronary; 2, toe; and 3, mid- anastomosis. (g)Thin- cap fibroatheroma in SVG:without causing significant
stenosis on three- dimensional and longitudinal reconstructions (asterisk:lipid pool, arrow:thin fibrous cap). (h)De novo lesions and in- stent restenosis
in SVGs. Left- to- right and top- to- bottom:de novo calcification (arrows), in- stent restenosis (arrowheads:struts; arrows:delimiting neointima) with
homogeneous neointima in bare- metal stent and heterogeneous or lipid- rich neointima (asterisk) in drug- eluting stents. (i)Intimal thickening in the left
internal thoracic artery (arrows). (j)Marked concentric neointima formation in RA with string sign on angiography (white lines:neointima thickness).
(e) Reproduced from Di Vito L, Burzotta F, Trani C, Pirozzolo G, Porto I, Niccoli G, etal. Radial artery complications occurring after transradial coronary procedures using long
hydrophilic- coated introducer sheath:a frequency domain- optical coherence tomography study. Int J Cardiovasc Imaging. 2014;30(1):21– 9. doi:10.1007/ s10554- 013- 0284- 9 with
permission from Springer Nature.
(j) Reproduced from Adlam, D.and K.M. Channon, 2011. Radial artery graft string sign due to lumen obliteration by neointima:Insight from optical coherence tomography. JACC.
Cardiovascular interventions, 4(5):586– 587 with permission from Elsevier.
(a)
(e) (g) (h)(f)
Cavity
Lumen
Cavity
Lumen
Cavity
Thrombus
(c) (d)(b)
Lumen
Cavity
Intimal tear
Fig.7.4.2 OCT in ACS. (a)Red thrombus:high- backscattering protrusion casting a shadow (arrow). (b)White thrombus:signal- rich, low-
backscattering projection (arrow). (c, d) Plaque rupture:protrusion into lumen with moderate backscattering (mixed thrombus, arrowhead). Post
thrombectomy, disrupted fibrous cap creating an aperture (arrow) communicating lumen with a large plaque cavity is visualized. (e)Plaque erosion:a
plaque with irregularities (arrow) and no signs of rupture in a patient with ACS. (f, g) Culprits in SVGs:ruptured caps, cavity, thrombus and intimal tear.
(h)Friable tissue in SVG:adherent high- signal layer (arrows) over a signal- free zone.
7.4 Optical coherencetomography 69
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RA gra failure with the ‘string sign’ on angiography manifests as
thick neointima without plaques or calcication (Fig. 7.4.1j).
meta- analysis of 2,581 patients and 2,807 lesions. Am Heart J.
2015;169(5):663– 73.
4. Brown EN, Burris NS, Gu J, Kon ZN, Laird P, Kallam S, etal.
Optical coherence tomography inacute
coronarysyndromes
Nativecoronaries
By visualizing thrombus (Fig. 7.4.2a,b) and plaque rupture/ erosion (Fig. 7.4.2c– e), OCT can identify culprit lesions in ACS. Acute
thrombosis superimposed on ruptured brous cap constitutes
the majority of culprit lesions in ST- elevation myocardial infarction (STEMI); nevertheless, culprit plaques with intact brous cap
in more than one- quarter of STEMI population are identied by
OC T. Ano- stenting approach with aggressive antiplatelet therapy
in intact brous cap ACS may be safe and ecacious, but more denitive data are needed.
Bypassgrafts
Culprit lesions in SVGs demonstrate similarities to those in native
coronaries (thin- cap broatheromas and ruptured brous caps with
thrombus) (Fig. 7.4.2f). Features unique to lesions in SVGs are
larger cavities compared to native coronaries (bigger vessel size and
lipid pools), more frequent intimal tears, and concomitant presence
of aneurysms and tissue friability (signal- free zones with loosely adherent high- signal layers) (Fig. 7.4.2g,h).
inking inside the gra:applications of optical coherence
tomography in coronary artery bypass graing. J Biomed Opt.
2007;12(5):051704.
5. Di Vito L, Burzotta F, Trani C, Pirozzolo G, Porto I, Niccoli G,
etal. Radial artery complications occurring aer transradial
coronary procedures using long hydrophilic- coated introducer
sheath:a frequency domain- optical coherence tomography study.
Int J Cardiovasc Imaging. 2014;30(1):21– 9.
6. Brazio PS, Laird PC, Xu C, Gu J, Burris NS, Brown EN, etal.
Harmonic scalpel versus electrocautery for harvest of radial
artery conduits:reduced risk of spasm and intimal injury on
optical coherence tomography. J orac Cardiovasc Surg.
2008;136(5):1302– 8.
7. Brown EN, Burris NS, Kon ZN, Grant MC, Brazio PS, Xu C,
etal. Intraoperative detection of intimal lipid in the radial
artery predicts degree of postoperative spasm. Atherosclerosis.
2009;205(2):466– 71.
8. Kotsia AP, Papafaklis MI, Michael TT, Rangan BV, Peltz M,
Roesle M, etal. Serial multimodality evaluation of aortocoronary
bypass gras during the rst year aer CABG surgery. JACC
Cardiovasc Imaging. 2015;8(11):1341– 3.
9. Adlam D, Antoniades C, Lee R, Diesch J, Shirodaria C, Taggart D,
etal. OCT characteristics of saphenous vein gra atherosclerosis.
JACC Cardiovasc Imaging. 2011;4(7):807– 9.
10. Davlouros P, Damelou A, Karantalis V, Xanthopoulou I,
Mavronasiou E, Tsigkas G, etal. Evaluation of culprit saphenous
Conclusion
vein gra lesions with optical coherence tomography in patients
with acute coronary syndromes. JACC Cardiovasc Interv.
2011;4(6):683– 93.
Despite oering additional diagnostic value in coronary artery disease, OCT remains underutilized in contemporary cardiovascular
practice. OCT has potential utility in guidance of bypass conduit selection and optimization of CABG, opening new avenues for application of this relatively novel technology in the surgical eld.
11. Roleder T, Pociask E, Wańha W, Dobrolińska M, Gąsior P, Smolka
G, etal. Optical coherence tomography of de novo lesions and
in- stent restenosis in coronary saphenous vein gras (OCTOPUS
study). Circ J. 2016;80(8):1804– 11.
12. Porto I, Gaudino M, De Maria GL, Di Vito L, Vergallo R, Bruno
P, etal. Long- term morphofunctional remodeling of internal
thoracic artery gras:a frequency- domain optical coherence
REFERENCES
1. Tearney GJ, Regar E, Akasaka T, Adriaenssens T, Barlis P, Bezerra
HG, etal. Consensus standards for acquisition, measurement,
and reporting of intravascular optical coherence tomography
studies:A report from the international working group for
intravascular optical coherence tomography standardization and
validation. J Am Coll Cardiol. 2012;59(12):1058– 72.
2. Karimi Galougahi K, Maehara A, Mintz GS, Shlofmitz RA,
Stone GW, Ali ZA. Update on intracoronary optical coherence
tomography:a review of current concepts. Curr Cardiovasc
Imaging Rep. 2016;9:16.
3. D’Ascenzo F, Barbero U, Cerrato E, Lipinski MJ, Omedè P,
Montefusco A, etal. Accuracy of intravascular ultrasound
and optical coherence tomography in identifying functionally
signicant coronary stenosis according to vessel diameter:a
tomography study. Circ Cardiovasc Interv. 2013;6(3):269– 76.
13. Gaudino M, Prati F, Caradonna E, Trani C, Burzotta F,
Schiavoni G, etal. Implantation in coronary circulation induces
morphofunctional transformation of radial gras from muscular
to elastomuscular. Circulation. 2005;112(9, Suppl):I208– 11.
14. Adlam D, Channon KM. Radial artery gra string sign due to
lumen obliteration by neointima:insight from optical coherence
tomography. JACC Cardiovasc Interv. 2011;4(5):586– 7.
15. Saia F, Komukai K, Capodanno D, Sirbu V, Musumeci G,
Boccuzzi G, etal. Eroded versus ruptured plaques at the
culprit site of STEMI:in vivo pathophysiological features
and response to primary PCI. JACC Cardiovasc Imaging.
2015;8(5):566– 75.
16. Souteyrand G, Arbustini E, Motre P, Gatto L, Di Vito L, Marco
V, etal. Serial optical coherence tomography imaging of ACScausing culprit plaques. EuroIntervention. 2015;11(3):319– 24.
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SECTION 2
Treatment ofcoronary
artery disease
Section editors:Patrick W.Serruys, David R.Holmes, and Vasim Farooq
8. Heart Team management in coronary
revascularization:present reality and future
opportunities 73
Stuart J.Head, Michael J.Mack, David R.Holmes,
and David P.Taggart
9. Evidence basis for decision- making between
coronary artery bypass grafting and percutaneous
coronary intervention:present and future
perspectives 79
Vasim Farooq, John D.Puskas, Patrick W.Serruys,
and David P.Taggart
10. Lifestyle management and secondary prevention
of coronary artery disease 97
Mansoor Ahmad, Sandra A.Weiss, and William S.Weintraub
11. Optimal medical therapy for coronary artery
disease 103
David R.Holmes and Valentin Fuster
12. Differences and similarities between American
and European myocardial revascularization
guidelines 115
Milan Milojevic, Philippe Kolh, Stephen E.Fremes,
and Miguel Sousa- Uva
13. Comprehensive secondary cardiovascular
prevention and cardiac rehabilitation after
coronary artery bypass graft surgery 121
Suegene K.Lee, Jay Khambhati, Pratik Sandesara,
Danny Eapen, Gina Lundberg, Basil Margolis, Neil Gordon,
Barry Franklin, and Laurence Sperling
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8
Heart Team management
incoronaryrevascularization
Present reality and future opportunities
Stuart J. Head, Michael J. Mack, David R. Holmes, and David P. Taggart
Introduction
Multidisciplinary team decisions in medicine are thought to improve decision- making and to raise the level of care in situations
where there may be multiple treatment options for a particular patient or patient group. Aparticularly prominent example of this is
in oncology, where patients with cancer treated by a multidisciplinary team had signicantly improved care and clinical outcomes
as well as geographically more consistent therapy and treatment
recommendations.
Multidisciplinary Heart Teams for the treatment of cardiovascular
diseases have received emphasis over recent years with increasingly
overlapping treatment options for patients with coronary artery
disease or valvular heart disease. First with the introduction of percutaneous coronary intervention (PCI) and more recently with the
development of transcatheter aortic valve implantation (TAVI) and
mitral valve interventions, surgery is no longer the only treatment
for patients with advanced cardiovascular disease.
In the case of myocardial revascularization, Heart Teams were originally founded in the setting of randomized trials. In the BARI and
EAST trials, cardiovascular surgeons and interventional cardiologists had to agree on whether there was clinical equipoise between
both treatment strategies to enrol patients in a trial. Aer the results of the SYNTAX trial, the Heart Team, consisting of a clinical/
non- invasive cardiologist, interventional cardiologist, and cardiac
surgeon, has even been included in North American and European
clinical guidelines with a classIrecommendation.,
e current 2018 European Society of Cardiology (ESC)/
European Association for Cardio- oracic Surgery (EACTS)
guidelines continue to emphasize the desirability of a Heart
Team approach in recommending interventions. Clearly, while
decision- making for patients with acute indications or less complex coronary disease may be straightforward, the Heart Team is
considered the best method to evaluate which patients with stable
multivessel or le main disease are best treated with coronary artery bypass graing (CABG) or PCI, based on the risk:benet ratio
of both treatments.
Rationale forHeart Team decision- making
ere is strong evidence to suggest that the decision- making for
patients requiring myocardial revascularization can be improved.
Although decision- making should be objective and unbiased, there
are patient- , physician- , and institution- related factors that may play
a role in the decision to opt for PCI or CABG. ere is also evidence to suggest that patients are oen incompletely informed about
the risks and benets of dierent treatment strategies. In a study by
Chandrasekharan and Taggart, the alternative revascularization
strategy was not discussed with 68% of patients who underwent
PCI and 59% who underwent CABG. Moreover, the benets of
revascularization are oen overestimated by patients, particularly
for PCI, despite improved methods for information transfer through
audiovisual presentations., e Heart Team should not only help
determine the most appropriate treatment strategy for patients with
coronary artery disease, but it should also reinforce the central role
of physicians to better communicate the risks and benets of treatments to give patients more realistic expectations of their treatment.
Consequently, consistency and generality of recommendations is
best approached by Heart Team– based care.
e previously mentioned factors all heavily impact the actual
numbers and types of revascularization procedures that are performed. Because these factors vary among dierent specialties,
cultures, and healthcare systems, there is a large variation in PCI- toCABG ratios. is variation is so marked that it cannot be explained
by dierences in baseline characteristics alone. Among countries
that provide data to the Organization of Economic Cooperation and
Development (OECD), PCI- to- CABG ratios were in the range of
SECTION 2 Treatment ofcoronary artery disease 74
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0.70 in Mexico to 19.4 in Korea, while the mean PCI- to- CABG ratio
was 3.9. Even in Europe alone, PCI- to- CABG ratios show a wide
range (Fig. 8.1).
e choice of which treatment strategy is most appropriate for a
specic patient with coronary artery disease may be quite complex,
because it is dependent on a number of variables. Consequently,
the treatment chosen may not be the most optimal strategy according to the appropriate use criteria. Issues with inappropriate
PCIs for non- acute indications led to the publication in 2009 of an
outline on what diagnostics are required before a decision on treatment for coronary artery disease should be reached. Treatment is
either (1)appropriate if all diagnostic information is available and
the indication is correct, (2)may be appropriate depending on either lack of specic clinical or physiological information or if there
is not enough diagnostic information to determine whether invasive treatment is necessary, or (3)rarely appropriate if treatment is
performed without enough diagnostic information or for an incorrect indication. Areview of more than 500,000 PCIs performed
in the United States through 2009– 2010 showed that 12% were
performed inappropriately for non- acute indications. In dierent
studies the rate of inappropriate PCI has been found to be approximately 15%, while for CABG the rate is about 1%., Importantly,
revascularization was shown to signicantly reduce the rate of
death or myocardial infarction over 3- year follow- up if performed
appropriately (hazard ratio (HR) 0.61; 95% condence interval (CI)
0.42– 0.88), but not if revascularization was deemed ‘uncertain’ (HR
0.57; 95% CI 0.28– 1.16) or when performed inappropriately (HR
0.99; 95% CI 0.48– 2.02).
Because of this type of evidence, attempts are increasingly being
made to reduce the rate of inappropriate revascularization procedures. In the state of NewYork, the Department of Health has even
announced plans to potentially withhold reimbursement for inappropriate PCIs. An analysis of 2.7million PCI procedures performed between 2009 and 2014 showed that, according to the 2012
appropriate use criteria, the proportion of non- acute PCIs that were
classied as inappropriate decreased from 26% to 13%. ere was
still considerable variation in this rate at dierent hospitals, ranging
between 6% and 23%, suggesting that decision- making can furthermore be improved.
ese studies have only classied the appropriateness of
revascularization in patients that have actually been treated with
PCI or CABG. However, there is considerable evidence to suggest
that specic patients may also be denied revascularization when this
would have been appropriate; older studies suggest this rate varies
from 18% to 34% for PCI and 25% for CABG. Several studies demonstrated that patients who were denied surgery had signicantly
1–2.4
2.5–3.9
4.0–5.4
5.5–6.9
>6.9
Fig.8.1 PCI- to- CABG ratios in Europe as reported in 2015 Health at a Glance report from the OECD.
Source data from 2015 Health at a Glance report from the OECD.
8 Heart Team management incoronaryrevascularization 75
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higher rates of angina and an increased risk of death or myocardial
infarction during follow- up.–
especially involving the proximal LAD) and which should not
(e.g. single- vessel disease of the right coronary artery). Electronic
teleconferencing technologies are now ubiquitous and can greatly
Information forthe HeartTeam
facilitate Heart Team conversations at centres without on- site cardiac surgery.
In the area of Rotterdam, the Netherlands, a collaboration beTo allow appropriate and substantiated decision- making, the Heart
Team should consider all available evidence. In addition to knowledge of the severity of symptoms and whether there is indeed signicant coronary artery disease, preferably measured by means of
fractional ow reserve in addition to angiography, the Heart Team
should know (1)relevant clinical factors such as diabetes, chronic
kidney disease, and previous coronary interventions, which can
be summarized in risk prediction scores, such as the STS score or
EuroSCORE (II); (2)the coronary lesion complexity, preferably with
tween sites with and without on- site cardiac surgery led to a wellfunctioning Heart Team approach. Of 1000 Heart Team case
discussions with 86% being referred from other centres or discussed at those centres, treatment by either PCI or CABG was
initiated within 6 weeks aer referral in 90%. According to the
most recent guideline recommendations, this time interval is optimal for reducing adverse events that may occur when awaiting
revascularization, and is thus usually not exceeded when Heart
Team meetings are held.
calculation of the SYNTAX score; (3)echocardiographic data on the
function of the le ventricle as well as potential valvular heart disease; and (4)medication that the patient is already taking.
Hybridrevascularization
e SYNTAX II score has been proposed as a score that weighs
both clinical variables as coronary complexity to estimate 4- year
mortality aer PCI and CABG. is may help aid decisionmaking. However, although such risk scores may indeed be helpful,
decision- making should not be based only on these scores as each
score has limitations and does not integrate patient preferences, nor
account for local interventional or surgical experience/ expertise.
Hybrid coronary revascularization (HCR) is a true embodiment of
the Heart Team. e work of the surgeon and interventional cardiologist is integrated by the combination of a le internal thoracic
artery gra to the LAD through a minimally invasive approach,
with stents to the remaining non- LAD lesions for patients with
multivessel disease. is treatment has a major potential to disrupt
the current treatment strategies, with a survey in 2015 among 200
Current reality and evidence ofthe
HeartTeam
cardiologists and surgeons reporting that about 75% believed that
HCR will expand within the next 10years. e role of HCR at the
moment is limited. Large randomized trials are not yet available to
provide a substantiated basis for widespread, routine use of HCR.
Yates and co- authors analysed patients with le main disease,
proximal le anterior descending artery (LAD) disease, or threevessel disease to determine the impact of the 2010 ESC/ EACTS
guidelines on myocardial revascularization recommendations for
Heart Team discussions. ey found that 9% of patients were
discussed in a Heart Team in the 6 months before the guideline
was published, while 17% of patients were discussed in the Heart
Team in the 6months aer the guideline was published (P- value
not signicant).
Evidence to support the Heart Team concept is limited but
growing. Anumber of dierent centres have reported reproducible
and implementable treatment recommendations in 93– 95% of cases
discussed in the Heart Team, which may lead to greater uniformity
of care.– Moreover, in 299 out of 301 patients those treatment
recommendations as produced by the Heart Team were consistent
Absence of large studies is most likely the reason why adoption of
HCR has been slow. In an analysis of 198,622 patients treated with
CABG between 2011 and 2013 in the United States, only 0.5% of
patients underwent HCR while a more recent study estimated that
about 12% of patients undergoing cardiac catheterization may be
eligible for HCR.
However, because the particular benet of HCR is the minimally
invasive surgical incision, it is a more technically and logistically demanding procedure than conventional CABG. Currently, HCR is
reserved for specic patients in whom (1)a proximal LAD lesion
is graable with a minimally invasive direct coronary artery bypass
(MIDCAB) or robotic MIDCAB procedure, (2)the complexity of
residual non- LAD lesions is feasible for PCI (e.g. the SYNTAX score
should be intermediate at most), and (3)there is no contraindication
for dual antiplatelet therapy.
with the appropriate use criteria, which ultimately leads to reduced
rates of inappropriate revascularization.
Importantly, whereas critique of the Heart Team concept is oen
Futurestudies
directed to the logistics of including multidisciplinary discussion
in clinical decision- making, one study reported that cases could be
discussed by a Heart Team within 72 hours of diagnostic coronary
angiography and thus did not introduce longer waiting times for
revascularization. Clearly, this may be more cumbersome in
centres without on- site cardiac surgery. For those centres it will
be crucial to collaborate with other centres to provide institutional
or regional protocols that include details on which cases should
be discussed in the Heart Team (e.g. two- or three- vessel disease
Although clinical guidelines provide a classIof recommendation for
the Heart Team, the level of evidence is limited to ‘expert opinion’.
erefore, studies are required to determine at least whether Heart
Team decision- making (1)provides treatment decisions that better
concur with recommendations in clinical guidelines, (2)increases
uniformity of care between geographic regions with similar and
dierent healthcare systems, and (3)improves outcomes aer both
CABG and PCI.
SECTION 2 Treatment ofcoronary artery disease 76
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Conclusion
Both cardiology and cardiac surgery societies recommend a multidisciplinary Heart Team to discuss patients with coronary artery disease and propose the most appropriate treatment strategy
to the patient. is recommendation comes forth from evidence
of suboptimal and biased information provided to patients about
revascularization strategies, and a lack of global consistency of care.
Evidence to support Heart Team decision- making is scarce but
growing. It is crucial that strong evidence is generated so that clinical
guidelines can upgrade the level of evidence for the Heart Team recommendation, resulting in a stronger basis for healthcare providers
and insurance companies to demand Heart Team decision- making
for optimization of care.
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