3 Jahre nach SYNTAX – Stent oder Skalpell?

Die Sicht des Kardiochirurgen
Article

Zusammenfassung

Die koronare Bypassoperation gilt als Therapie der ersten Wahl in der Behandlung von Patienten mit Dreigefäßerkrankung und/oder linkskoronarer Hauptstammbeteiligung. Allerdings zeigt der klinische Alltag, dass an vielen europäischen Zentren inzwischen auch komplexe Formen der koronaren Herzerkrankung interventionell therapiert werden.

Die Überlegenheit der Bypassoperation ist durch große Registerstudien belegt und wurde zuletzt durch die multizentrische, randomisierte SYNTAX-Studie bestätigt. Letztere zeigt nach dem längsten derzeit verfügbaren Nachbeobachtungszeitraum nicht nur signifikante Vorteile für die Bypassoperation hinsichtlich der Notwendigkeit einer erneuten Koronarintervention, sondern auch bezüglich der Myokardinfarktrate oder der Rate kardialer Todesfälle. Andererseits scheint die interventionelle Therapie zumindest für weniger komplexe, isolierte Hauptstammläsionen der Operation ebenbürtig zu sein.

Eine wesentliche Schlussfolgerung aus diesen neu verfügbaren Daten ist die Betonung des interdisziplinären Therapieansatzes für Patienten mit komplexer koronarer Herzerkrankung. So wird in den neugefassten Leitlinien der Europäischen Gesellschaft für Kardiologie zur myokardialen Revaskularisierung explizit die Bildung eines sogenannten Heart-Teams empfohlen, das sich aus Kardiologen und Herzchirurgen zusammensetzt und im interdisziplinären Diskurs die optimale individuelle Therapiestrategie für Patienten mit fortgeschrittener koronarer Herzerkrankung festlegt.

Schlüsselwörter

Bypassoperation PCI Koronare Herzerkrankung Hauptstammbeteiligung Heart-Team 

3-year results of the SYNTAX trial—stent or surgery?

A surgeon’s perspective

Abstract

Coronary artery bypass grafting (CABG) is the standard of care for patients with three-vessel or left main coronary artery disease. However, clinical practice has proven to differ substantially with even the most complex coronary lesions being targeted by percutaneous coronary intervention (PCI) today.

An abundancy of both large registries and randomized clinical trials has demonstrated superiority of surgery over PCI in advanced coronary artery disease. Recently, these results have been confirmed by the landmark SYNTAX trial where CABG was found to be superior to PCI for three-vessel and/or left main coronary artery disease regarding repeat revascularization, rate of myocardial infarction, and cardiac mortality at the latest follow-up of 3 years. On the other hand, PCI proved to be a viable alternative for less complex forms of left main disease.

In conclusion, patients with three-vessel and/or left main coronary artery disease should be discussed in an interdisciplinary heart team consisting of cardiologists and cardiac surgeons within a heart center. Final decision making should be a formal process as recommended in the recently updated guidelines on myocardial revascularization by the European Society of Cardiology.

Keywords

Coronary surgery PCI Multi-vessel coronary artery disease Left main disease Heart Team 

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Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  1. 1.Klinik und Poliklinik für Herz- und GefäßchirurgieUniversitäres Herzzentrum HamburgHamburgDeutschland

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