Читать книгу Practical Cardiovascular Medicine - Elias B. Hanna - Страница 209

In a patient with multivessel disease where CABG or PCI is considered, two risk scores are used: (i) SYNTAX score to determine PCI outcomes, and (ii) STS score or EuroSCORE to assess surgical mortality (Table 3.4).^91,92 The average CABG mortality is 1.5-2%, but increases to >5% with the combination of several risk factors, especially combined CABG and valve surgery, redo CABG, age >80, prior disabling stroke, severe lung disease, acute MI, HF or hemodynamic compromise. Patients who are at a high surgical risk, much higher than the 2% seen in randomized trials (e.g., > 5%), may be better served with PCI (class IIa for low-SYNTAX left main disease, IIb for low-SYNTAX 3-vessel CAD). Thus, in the era of an aging population with comorbidities, multivessel complex PCI still has a role. A heart team discussion is warranted for these patients.

In addition to high-surgical risk patients, patients with small vessels and diffuse distal disease that is severe or calcified may not have appropriate distal targets for CABG and may not be CABG candidates, especially when the LAD cannot be grafted. They may undergo PCI of focal, critical, proximal disease. A third reason that may preclude CABG is the lack of conduits, in particular venous conduits in patients with large varicose veins and venous insufficiency.

The use of LIMA necessitates surgical dissection through the pleural cavity, with a high risk of pleural effusion and deterioration of pulmonary function in patients with severe lung disease.