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Die Bedeutung der SYNTAX-Studie für die moderne Koronarchirurgie

Impact of the SYNTAX study on future surgical coronary revascularization

  • Evidenzbasierte Medizin
  • Published:
Zeitschrift für Herz-,Thorax- und Gefäßchirurgie Aims and scope

Zusammenfassung

Bis heute gilt die chirurgische Koronarrevaskularisation als Therapieoption der Wahl für Patienten mit koronarer 3-Gefäßerkrankung und/oder Hauptstammstenose. Neue perkutane Stent- und Interventionstechnologien (PCI) und dabei insbesondere die Etablierung medikamentenbeschichteter Stents (DES) fordern die Bypassoperation jedoch seit mehreren Jahren als primäres Revaskularisationsverfahren für diese prognostisch relevanten Formen der KHK neu heraus. In den bislang verfügbaren randomisierten Vergleichsstudien zeigte sich eine Überlegenheit der Operation einheitlich bezüglich der Notwendigkeit einer erneuten Koronarintervention, während Überlebens- und Myokardinfarktraten lediglich einen Trend zugunsten der Operation ergaben. Größere Registerdaten belegen hingegen bislang auch bei diesen Formen der KHK weiterhin einen Überlebensvorteil der Operation gegenüber der PCI.

Im Rahmen der bislang größten an diesem Patientenkollektiv durchgeführten randomisierten Untersuchung, der SYNTAX-Studie, zeigte sich, dass die Operation der PCI bezüglich des kombinierten Endpunkts aus gravierenden kardialen und zerebrovaskulären Ereignissen innerhalb von bis zu zwei Jahren nach dem Eingriff weiterhin signifikant überlegen ist. Dies ist zwar überwiegend einer geringeren Inzidenz wiederholter Koronarinterventionen geschuldet, nach zwei Jahren aber auch durch eine geringere Myokardinfarktrate und eine niedrigere kardial bedingte Mortalität erkärt. Es zeichnet sich jedoch ein Trend ab, dass die PCI bei Patienten mit weniger komplexer KHK eine vergleichbare Behandlungsoption darstellen könnte, wohingegen aber Patienten mit komplexer Koronarpathologie unverändert eindeutig von der Bypassoperation profitieren. Die Ergebnisse der SYNTAX-Studie werden derzeit intensiv innerhalb und zwischen den verschiedenen Fachgesellschaften diskutiert und haben Leitliniendiskussionen angestoßen, deren abschließende Bewertung abgewartet werden muss.

Abstract

Coronary artery bypass graft surgery (CABG) is still considered to be the standard of care for patients with a prognostically relevant pattern of coronary artery disease. New stent designs, including drug-eluting stents (DES) and improvements in percutaneous coronary intervention (PCI) technologies during recent years, challenge CABG in the treatment of coronary three-vessel disease and/or left main stem stenosis. To date, randomized trials have demonstrated significantly higher repeat revascularization rates in PCI patients but comparable results regarding procedural and mid-term survival as well as adverse events like myocardial infarction. In contrast, real world registry data demonstrated a survival benefit of CABG over PCI as the primary treatment option.

Recently, 2-year results of the largest comparative randomized trial to date, the SYNTAX trial, were made available. These data demonstrated the superiority of CABG over PCI regarding the combined endpoint of death and major adverse cardiac and cerebrovascular events, including repeat revascularization. There were comparable results in patients with less complex coronary artery disease between PCI and CABG, while patients with more complex coronary pathologies had significantly better results after surgical intervention. These results have led to controversies in all major medical societies and have resulted in intensive and ongoing guideline discussions.

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Authors and Affiliations

  1. Abteilung für Herzchirurgie, Herzzentrum der Universität Leipzig, Struempellstr. 39, 04289, Leipzig, Deutschland

    F.W. Mohr &  A.J. Rastan

  2. Klinik für Herz- und Gefäßchirurgie des Universitätsklinikums Schleswig-Holstein am Campus Kiel, Kiel, Deutschland

    J. Cremer

  3. Klinik für Herz- und Gefäßchirurgie der Universität Hamburg Eppendorf, Hamburg Eppendorf, Deutschland

    H. Reichenspurner

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  1. F.W. Mohr
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  4. H. Reichenspurner
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Correspondence to A.J. Rastan.

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Mohr, F., Rastan, A., Cremer, J. et al. Die Bedeutung der SYNTAX-Studie für die moderne Koronarchirurgie. Z Herz- Thorax- Gefäßchir 24, 49–57 (2010). https://doi.org/10.1007/s00398-009-0761-6

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