Wars and scientific debates do not end that easily. Parallel to the Vietnam war days of 1970s to the current Ukraine-Russia conflict of 2025, one silent academic war is going on, in the conflict-ridden corridors of cardiology and cardiac surgery. (The CASS study of 1970s to the ORBITA era of 2025) Any amount of scientific literature, debates, guidelines, failed to tick the right choice of revascularisation in chronic CAD. Ironically, as our knowledge increased the decision making process got more murky.(Largely due to non academic factors)
To find an answer to this, CTSNET, a hugely popular cardiac surgery forum orgainsed a seminar trying to create a globally unifying approach. This is an hour long seminar , I am sure will enlighten us further. Please make yourself free for 60 minutes. Better , not to go to the summary, without watching the video.
Observation and brief summary
1.First and foremost, academic guidelines are created primarily, to make us understand the disease process fully, which would help us make a good decision. Interpretation of these guidelines can vary widely . As a professional physician , we are supposed to use the official guidlines judiously, at no time, we can be slaves to them.
2. It is possible ,the term myocardial revascularisation itself is largely misunderstood. What is being vascularised ? & What is the impact of that vascularisation are the right questions to be asked.I feel this seminar genuinely adds some sense to the flawed understanding of the prevailing concept of myocardial revascularization.
3.Think mechanistically and extrapolate the potential benefits and risks .Try to sort out the issue individually. Recall the classic truth that, revascularisation rarely improve contractility in chronic LV dysfunction to the desired levels.(Inspite of the patchy benefits shown by CABG-PATCH/ REVIVED BCIS-2 trials)
4. Realise, the confusion in choice of revascularisation is more in chronic coronary syndromes. PCI has an edge in acute situations if done in a timely fashion.
5. It is a open secret ,there is a big conflict of interest in the guideline writing committee. A huge transatlantic academic gap exists with American guidelines of 2021, 2023 favoring more PCI, while ESC recommends more CABG in complex lesions and left main. The big controversy ,that brewed was when Indication 2A was confered for both PCI and CABG in left main and multivessel CAD.
6.Global experts unanimously endoresed the European guidelines ,which favors for more liberal CABG . Still, they were hesitant to denounce the American guildelines.
7. Curiously, I believe the debate question itself is not fair.We should not be debating PCI vs. CABG at all ? This makes GDMT not a standalone option at all. In both hindsight and foresight, this may be the best option in the majority of patients, as indicated by many landmark studies of revascularization.(There is an Interesting comment made by the panelist relevant to the above point)
8.Every CAD patient should have an option finalising his decision with a heart team comprising of a clinical cardiologist, an Interventional cardiologist and the cardiac surgeon .
9.Quality and expertise of surgeons and PCI team is vitally important.We can’t bring the same trial outcomes in any neigbourhood hospitals, especailly in less well developed countries.
10. Finally, most importantly, it is agreed by more experts that CABG has more potential to prevent a future MI than PCI in most subsets of patients. This is because, CABG gives realtive immunity to potential the disease progression in the proximal segments which are the original high risk zones .
Final message
I have shared some key personal observations triggered by this extrodinary seminar. It can be called as a personlised version and a summary .Please listen to it completely and try to find whether these observations are good enough.
Dr.S.Venkatesan MD 