Percutaneous versus Surgical Coronary Revascularization: The Heart Wins Either Way

“I was in the right place at the right time, with the right collaborators, the right mentors and mentees.” Eugene Braunwald Dear Editor, Bansal et al. have elegantly enumerated the Clinical Profile of Indian Patients Undergoing Percutaneous or Surgical Coronary Revascularization in the Modern Era – a nonrandomized, open-label, cross-sectional, retrospective, observational, parallel design, and single-center study.[1] They have shown that in the North Indian population (n = 2847) patients undergoing surgical revascularization – coronary artery bypass graft (CABG) were usually males, diabetic, with dyslipidemia, chronic stable triple-vessel disease (TVD) or left main disease (LMD). In sharp contrast, women were younger, nondiabetic, with single- or double-vessel coronary artery disease (CAD) and preferred percutaneous intervention (PCI) over CABG. The study also showed that PCI was generally preferred over CABG in most patients. However, in patients with TVD or LMD, the preferred option was CABG.[1] Analysis of larger, more diverse populations is possible with the help of recently designed adaptive clinical trials.[2] I would like to highlight the importance of robotics in revascularization, the landmark contributions of Eugene Braunwald and Frank Cole Spencer, and the evolution and logical ending of the gladiatorial fight between PCI and CABG. It is understandable that almost every patient, along with family and friends, must have spent sleepless nights – unspoken panic – when asked to decide between the more acceptable PCI versus the more efficacious CABG procedure. Treating physician/cardiologist/cardiac surgeon can only advise as per guidelines, but the decision is family-driven. In the coming future, robotics and artificial intelligence (AI) would be playing a greater role in coronary total arterial revascularization by way of PCI and/or CABG. Today, we are witnessing unprecedented spin offs not only in medical therapy, PCI, and CABG but also in other fields such as AI, robotics, three-dimensional printing, tissue engineered conduit grafts and valves, shape memory materials and cardiovascular imaging-four-dimensional echocardiography, cardiac catheterization, intravascular ultrasound, optical coherence tomography, near-infrared spectroscopy, and fractional flow reserve (FFR), echocardiography, cardiac computed tomography, cardiac magnetic resonance imaging, cardiac positron emission tomography, multi-source image fusion, etc. This is especially true with the availability of AI algorithms, soft robotics, wonder materials which are highly flexible, durable, and biocompatible, showing favorable hemodynamics with ability to withstand high pressures, good suture strength, low infectious risk, nonimmunogenic, noninflammatory, and most importantly hypothrombogenic. The ability to conduct an invasive procedure, through minimally invasive incision, is the holy grail of cardiology. Looking at today’s technology, I can envision and imagine how some of the open surgical operations can be turned into minimally invasive procedures. In this context the historical timelines of milestones in percutaneous revascularization and surgical revascularization are summarized in Tables 1 and 2.Table 1: Historical timeline of milestones in percutaneous revascularizationTable 2: Historical timeline of milestones in surgical revascularizationEugene Braunwald and Frank Cole Spencer, the icons of cardiology and cardiothoracic surgery, have contributed immensely to the science and art of coronary revascularization. Behind every scientific milestone or spin off, there will be a stratosphere of knowledge as well as interesting stories which can be jaw-dropping, eye-popping, and mind-blowing. It is beyond the scope of this letter to describe all such stories related to revascularization. However, I would like to quote one interesting story from the life of Frank Cole Spencer, the man who gave us the technique of coronary anastomosis. Milestones, neither happen randomly, nor do they fall from the sky; they appear to happen to those who deserve them and under circumstances which can be unimaginably difficult. Frank Cole Spencer, as a young surgeon at Johns Hopkins, learned how to repair arteries. He would not agree with and vehemently opposed the existing guideline of “vessel ligation” technique, followed by amputation as the treatment of choice for arterial injury to the leg. He preferred “vessel repair” technique and preservation of the limb to “vessel ligation” and amputation of the limb in such cases. While serving in the US Navy Medical Corp (1951–1953) during the Korean War, leg injuries were common, and he was “court martialed” for going against the guidelines by performing “vessel repair” instead of “vessel ligation” of lower limb arterial injuries to avoid leg amputation in more than 150 war veterans in the Mobile Army Surgical Hospital Unit. In that dire situation, something happened which was nothing short of a miracle by any measure – about 90% of the veterans operated by Frank Cole Spencer were saved of a limb amputation in the next 9 months – a stupendous success of “repair technique” over “ligature technique.” Overnight, the “court martial” order was retracted, and “Legion of Merit Award” was conferred to Frank Cole Spencer. The Korean War ended with a very high number of casualties (~ 3.25 million deaths), often dubbed as the “Forgotten War” as it was overshadowed by World War II and the Vietnam War. The war has ended but then originated the technique of Frank Cole Spencer’s “coronary arterial anastomosis.” In 1964, Frank Cole Spencer performed the first left internal thoracic artery anastomosis to the left anterior descending artery, the first coronary artery stapling procedure, and was the first to advocate off-pump coronary artery bypass graft over on-pump CABG. “I could not live with myself, if I was forced to take someone’s leg off when it was not necessary.” Frank Cole Spencer PERCUTANEOUS INTERVENTION VERSUS CORONARY ARTERY BYPASS GRAFT: THE GLADIATORIAL FIGHT Ever since the concept of CABG was introduced in 1967 by Vasilii I. Kolesov (who reported first successful clinical CABG) and PCI technique started in 1977 as Andreas Grüntzig performed the first Balloon angioplasty to treat CAD, the long battle between PCI and CABG continues (like the Roman Gladiator duels), and even after numerous meta-analysis, randomized controlled trials (RCTs), registries, observational studies [Table 3], involving large number of patients in many possible cohorts (N = 67,078; PCI = 36,323, CABG = 32,060) there appears to be no clear winner [Figure 1].Table 3: List of recent meta-analyses on percutaneous intervention versus coronary artery bypass graft[ 3-17 ]Figure 1: Even after numerous meta-analyses involving randomized controlled trials, registries, observational studies (N = 67,078; percutaneous intervention = 36,323, coronary artery bypass graft = 32,060), there appears to be no clear winner. At the time of writing, the overall advantages and disadvantages over a broad spectrum of patient cohorts appear to be in equipoise, resulting in a draw– ahoy! Both could be winners, analogous to the famous Gladiatorial Fight (Roman Colosseum, 80 AD). “As Priscus and Verus each drew out the contest and the struggle between the pair long stood equal … equal they fought, equal they yielded … to both Titus sent wooden swords … valor and skill had their reward … two fought and both won.”– Martial. Gladiatorial Fight (Roman Colosseum, 80 AD). EXCEL = Evaluation of XIENCE Everolimus Eluting Stent versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization, NOBLE = Coronary Artery Bypass Grafting versus Drug Eluting Stent Percutaneous Coronary Angioplasty in the Treatment of Unprotected Left Main Stenosis trials, FAME 3 = Fractional Flow Reserve (FFR) versus Angiography for Multivessel Evaluation, PRECOMBAT = PREmier of Randomized Comparison of Sirolimus-Eluting Stent Implantation versus Coronary Artery Bypass Surgery for Unprotected Left Main Coronary Artery Stenosis, SYNTAX Study = TAXUS Drug-Eluting Stent versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries, FREEDOM = Future Revascularization Evaluation In Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease, PCI = Percutaneous intervention, CABG = Coronary artery bypass graftSome important outcomes of landmark RCTs, meta-analyses, registries, and observational studies include: Fearon WF and Nico HJP, the Principal Investigators of the multi-center, international, randomized, controlled noninferiority trial, the “Fractional Flow Reserve (FFR) versus Angiography for Multivessel Evaluation” (FAME) 3, state the outcomes for patients with three-vessel disease (TVD) at 1, 2, 3, and 5 years, respectively, as follows:[3-7] FAME 1: FFR-guided PCI resulted in fewer major adverse cardiac events (MACEs) at 1 year and improved patient outcomes compared to angiography-guided PCI. Specifically, the study showed a significant reduction in the rate of MACE, with a 30% decrease in the combined endpoint of death, myocardial infarction (MI), or repeat revascularization in the FFR-guided group at 1 year. In addition, the risk of death or MI was reduced by 35% in the FFR group FAME 2: A novel paradigm shift in the diagnostic focus of coronary lesions from anatomical characteristics to a functional impact (FFR) on myocardial perfusion FAME 3: Outcomes were better in patients treated with CABG, and the gap appears to be widening in a linear fashion. In patients with TVD, FFR-guided PCI was not found to be noninferior to CABG with respect to the incidence of a composite of death, MI, stroke, or repeat revascularization at 1 year FAME 5: Astonishingly, at 5 years, there were no statistically significant differences between the PCI and CABG groups in the composite endpoint of death, stroke, or heart attack. The absolute difference was similar to what was noted at three years. This phenomenon is interesting and can be explained by rapid advances in PCI, CABG techniques, and optimal medical therapy.[8-12] Recent meta-analysis by various groups has revealed the following interesting facts regarding PCI versus CABG duel:[8-17] CABG leads to improved long-term survival (Jason et al.) In low-risk left main CAD (LMCAD), PCI offers a mortality benefit and improved quality of life compared to CABG. Repeat revascularizations are fewer with CABG (Afrasayab et al.) In LMCAD, the risk of stroke is similar to PCI and CABG. Higher rates of MI, all-cause death, repeated revascularization, major adverse cardiac and cerebrovascular events (MACCEs), and MACEs are noted with PCI as compared to CABG (Akemu et al.)[14] While in MVD and LMCAD, CABG is superior in event prevention, PCI is noninferior in general (Haridas et al.)[6] In LMCAD with prior CVD, PCI was associated with increased risk of MACCEs, MI as compared with CABG. However, no significant difference was noted in all-cause mortality, repeat stroke, and revascularization (Shuja et al.)[4] In LMCAD patients with or without ACS, who do not require emergent revascularization, there was no difference in all-cause mortality through 5 years in the PCI as well as the CABG group. This suggests that PCI and CABG are equally good options in this cohort of patients (Prakriti et al.) In unprotected LMCAD patients, PCI was associated with a higher risk of MACE in females and higher repeat revascularization in both sexes (Pierre et al.) In the Gladiatorial fight, there appears to be no clear winner; can it be called a draw; or can both be declared as winners without any losers! In the near future, it is very likely that AI and Robotics will play a bigger role in both PCI and CABG procedures. In my opinion, American College of Cardiology (ACC), American Heart Association (AHA), American Society of Echocardiography (ASE), American Society of Nuclear Cardiology (ASNC), Society for Cardiovascular Angiography and Interventions (SCAI), Society of Cardiovascular Computed Tomography (SCCT), Society for Cardiovascular Magnetic Resonance (SCMR), Society of Thoracic Surgeons (STS), European Society of Cardiology (ESC), European Association of Cardiovascular Imaging (EACVI), European Heart Society (EHS), European Association for Cardio-Thoracic Surgery (EACTS), Canadian Cardiovascular Society (CCS) as well as Cardiological Society of India (CSI) should come up with a consensus for maximum possible, mandatory, seamless inter-vendor collaboration regarding hardware / software compatibility between various Imaging, Robotic and AI platforms for cross registrability of data for smooth sustained rollout of complex robotic procedures. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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