After 4 years the European Society of Cardiology (ESC) TAX) score is

appropriate for gauging the anatom-

and the European Association for Cardio-Thoracic ical complexity of
coronary disease and should be
Surgery (EACTS) have released an updated version of routinely calculated in
patients with left main or
the guidelines for myocardial revascularization from multivessel
disease for identifying the most appro-
2014 [1]. The present article summarizes the 10 key priate
revascularization strategy.
points of the new guidelines. 4. The
Society of Thoracic Surgery (STS) risk score

1. The heart team approach has received a class 1C should be calculated

for prediction of the patient’s

recommendation to identify the most optimal risk of

mortality and morbidity after CABG. The

treatment strategy for patients with ischemic heart EuroSCORE II for

assessment of in-hospital mor-

disease while taking the patients’ preferences into tality after

CABG has been downgraded to a class

account. This multidisciplinary heart team deci- IIbB

recommendation.

sion-making process is critical as interventional 5. Clinical and anatomical

aspects favoring PCI in-

cardiologists, clinical cardiologists and cardiac clude severe

comorbidities, advanced age, frailty,

surgeons are increasingly targeting the same pa- reduced life

expectancy, restricted mobility, condi-

tient population for medical treatment, percuta- tions that

affect the rehabilitation process, multi-

neous coronary intervention (PCI) and coronary vessel disease

with a SYNTAX score 0–22, porcelain

artery bypass grafting (CABG). aorta

or a poor quality of potential conduits. Fac-

2. Prior to myocardial revascularization prognostic tors favoring

the surgical approach are diabetes,

and symptomatic benefits should be estimated reduced left

ventricular function, contraindica-

in patients with stable angina or silent ischemia. tions to dual

antiplatelet therapy (DAPT), multi-

Left main or proximal left anterior descending vessel disease

with a SYNTAX score ≥23 and the
 coronary artery stenoses >50%, 2 or 3-vessel dis- need for
concomitant cardiac or aortic surgery.

ease with stenosis >50% with severely impaired 6. Radial access is preferred
over femoral access for

left ventricular function, a large area of myocar- any coronary

angiography and PCI regardless of

dial ischemia or a stenosis >50% of the last patent clinical

presentation, unless there are overriding

coronary artery are considered as prognostically procedural

considerations.

relevant. Other hemodynamically significant coro- 7. The use of drug-eluting

stents (DES) is recom-

nary stenoses should be treated in the presence of mended for any PCI
regardless of clinical or anatom-

limiting angina or angina equivalent, refractory to ical aspects.

Bioresorbable scaffolds should not be

optimized medical treatment. used

outside clinical studies.

3. The synergy between percutaneous coronary in- 8. Routine revascularization of

noninfarct-related ar-

tervention with TAXUS and cardiac surgery (SYN- terial lesions is

not recommended during primary

PCI in myocardial infarction complicated by car-

diogenic shock. In PCI of bifurcation lesions, stent

implantation should be in the main vessel followed

K. Distelmaier, MD, PhD, FESC (#)·A.Toma,MD
Department of Internal Medicine II, Medical University of by provisional
balloon angioplasty with or without
Vienna, Waehringer Guertel 18–20, 1090 Vienna, Austria stenting of the side
branch.
klaus.distelmaier@meduniwien.ac.at

K The top 10 messages of

the 2018 ESC guidelines on myocardial revascularization 347

2
commentary

9. In out-of-hospital cardiac arrest survivors present- Conflict of interest

K. Distelmaier and A. Toma declare that

they have no competing interests.

 ing with an electrocardiogram consistent with ST-
elevation myocardial infarction (STEMI), a pri-
mary PCI strategy is recommended. References
10. As individual operator experience strongly influ-
ences patient outcome, current guidelines recom- 1. Neumann FJ, Sousa-Uva
M, Ahlsson A, et al. 2018 ESC/
mend that the annual operator volume for PCI for EACTS Guidelines on
myocardial revascularization. Eur

acute coronary syndrome should be ≥75 cases per HeartJ.2019;40(2):87–

165.

year and for left main PCI ≥25 cases per year. Publisher’s Note
Springer Nature remains neutral with re-

gard to jurisdictional claims in published maps and institu-

tional affiliations.
348 The top 10 messages of the 2018 ESC guidelines on myocardial revascularization
K