Abstract
It has been debated whether patients with multivessel coronary artery disease should
undergo complete revascularization (CR). The benefit of CR is biologically plausible,
and numerous studies and large meta-analyses suggested that CR achievement was associated
with a substantial reduction of mortality and future coronary events. In patients
with multivessel coronary artery disease, the aim of myocardial revascularization
is to minimize residual ischemia. Therefore, CR of all significant coronary lesions
has been proposed as the first priority in decision-making for myocardial revascularization
between coronary artery bypass grafting and percutaneous coronary intervention (PCI).
Reflecting the contemporary practice of ischemia-based revascularization, a physiological/functional
approach, such as measurement of fractional flow reserve or instantaneous wave-free
ratio, is considered more reasonable and should be encouraged for appropriate CR.
In patients who present with acute ST-elevation myocardial infarction, current evidence
suggests that an immediate or staged CR strategy might be equivalent or superior to
culprit-only revascularization. There is still uncertainty on when and how to perform
CR in ST-elevation myocardial infarction patients; comprehensive studies dedicated
to this issue are required. Hybrid coronary revascularization includes the advantages
of minimally invasive bypass grafting for the left anterior descending artery and
PCI for non-left anterior descending arteries and has been proposed as a viable alternative
for coronary artery bypass grafting or PCI only for achieving CR. In clinical practice,
the extent of revascularization and strategy for CR should be individualized, taking
account of different aspects of the patients, lesions, and treating physicians. Collaboration
of coronary heart teams would confer balanced decision-making and advanced therapeutic
capabilities.
Résumé
L’utilité d’une intervention de revascularisation complète chez les patients atteints
de coronaropathie pluritronculaire est un sujet qui fait l’objet de débats. Les bienfaits
de telles interventions sont plausibles sur le plan biologique. Par ailleurs, de nombreuses
études et méta-analyses de grande envergure ont établi un parallèle entre la réalisation
d’interventions de revascularisation complète et une réduction considérable de la
mortalité et des incidents coronariens subséquents. Chez les patients atteints de
coronaropathie pluritronculaire, la revascularisation myocardique vise à réduire au
minimum l’ischémie résiduelle. C’est pourquoi la revascularisation complète de toutes
les lésions coronariennes d’importance a été proposée comme principale priorité à
prendre en compte au moment de décider laquelle des deux interventions que sont le
pontage aorto-coronarien et une intervention coronarienne percutanée (ICP) sera réalisée
pour revasculariser le myocarde. Reflétant la pratique actuelle en matière de revascularisation
motivée par une ischémie, une démarche physiologique et fonctionnelle faisant notamment
appel à la mesure de la réserve coronaire fractionnaire (FFR) ou à l’iFR (Instantaneous Wave-Free Ratio) est considérée comme plus valable et doit être encouragée pour pratiquer une revascularisation
complète appropriée. Pour ce qui est des patients atteints d’un infarctus du myocarde
avec élévation du segment ST, les données probantes actuelles portent à croire qu’une
stratégie de revascularisation complète immédiate ou réalisée en plusieurs temps pourrait
être équivalente, voire supérieure à une revascularisation visant uniquement les lésions
significatives sur le plan fonctionnel. L’incertitude plane toujours à propos du moment
propice et de la méthode pour réaliser une revascularisation complète chez ces patients.
Il faudra effectuer des études approfondies sur cette question. Une intervention de
revascularisation hybride comporte les avantages du pontage aorto-coronarien, une
intervention très peu invasive pour l’artère interventriculaire antérieure et ceux
de l’ICP pour d’autres artères hormis l’artère interventriculaire antérieure. Elle
a en outre été proposée comme solution de rechange viable au pontage aorto-coronarien
ou à l’ICP utilisés seuls pour réaliser une revascularisation complète. En pratique
clinique, l’étendue de la revascularisation et la stratégie de revascularisation complète
choisie doivent être dictées par la situation de chaque patient en tenant compte des
différents facteurs qui lui sont propres, de ses lésions et des médecins traitants.
La collaboration d’équipes spécialisées en médecine coronarienne serait un atout dans
la prise de décisions objectives et ferait bénéficier les patients de compétences
thérapeutiques de pointe.
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Article info
Publication history
Published online: January 03, 2019
Accepted:
December 30,
2018
Received:
November 8,
2018
Footnotes
See page 956 for disclosure information.
Identification
Copyright
© 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
