Interventionelle Therapie der koronaren Mehrgefäßerkrankung sowie der Hauptstammstenose – alles klar 5 Jahre nach SYNTAX?

Zusammenfassung

Während für Patienten mit akutem Koronarsyndrom sowie stabiler koronarer 1- und 2-Gefäß-Erkrankung die perkutane Koronarintervention (PCI) therapeutischer Standard ist, wird die optimale Revaskularisationsstrategie von Patienten mit koronarer 3-Gefäß-Erkrankung und/oder Hauptstammstenose weiterhin intensiv interdisziplinär diskutiert. Vor allem Registerdaten legen nahe, dass eine Revaskularisation mittels PCI einer chirurgischen Bypassoperation (CABG) hinsichtlich des Überlebens und des Auftretens von Myokardinfarkten nicht unterlegen ist, für die CABG-Gruppe allerdings ein höheres Schlaganfallrisiko zu verzeichnen ist, wohingegen eine hohe Revaskularisationsrate klare „Achillesferse“ der PCI ist. Die SYNTAX-Studie liefert als prospektive, randomisierte Studie 5-Jahres-Outcome-Daten zum Vergleich von PCI und CABG: Diese legen nahe, dass bei Patienten mit geringerer Stenosenkomplexität – repräsentiert durch einen niedrigen SYNTAX-Score – beide Interventionsstrategien vergleichbare Ergebnisse liefern, wohingegen Patienten mit komplexeren Läsionen von einer chirurgischen Therapie mehr zu profitieren scheinen. Wir sind aufgefordert, hierzu patientenindividuelle Strategien gemeinsam im „Heart Team“ zu diskutieren.

Abstract

While patients with acute coronary syndrome or single and double vessel disease should receive percutaneous coronary interventions (PCI), coronary artery bypass graft surgery (CABG) is considered to be the standard of care for patients with more advanced pattern of coronary artery disease (CAD). More recently however PCI with second generation drug-eluting-stents (DES) appears to challenge CABG in the treatment of coronary three-vessel-disease and/or left main stenosis. To date, randomized trial data demonstrated comparable results regarding procedural and mid-term survival as well as the incidence of myocardial infarction while stroke rates were lower in PCI patients. In contrast, consistently all studies demonstrated a significantly higher rate of repeat coronary revascularization when using PCI. Recently, 5-year results of the largest comparative randomized trial, the SYNTAX-trial were available. These data demonstrated comparably good results in patients with less complex coronary artery disease for PCI – applying a first generation DES – and CABG, while patients with more complex coronary pathologies had significantly better clinical outcome following CABG.

Schlüsselwörter

perkutane Revaskularisation - Bypassoperation - Hauptstammstenose - koronare Mehrgefäßerkrankung - SYNTAX-Studie

Key words

PCI - CABG - left main stenosis - multivessel disease - SYNTAX

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