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Textbook of
INTERVENTIONAL
CARDIOLOGY
8 TH
EDITION
ERIC J. TOPOL, MD
PAUL S. TEIRSTEIN, MD
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
TEXTBOOK OF INTERVENTIONAL CARDIOLOGY, 8th EDITION ISBN: 978-0-323-56814-2

Copyright © 2020 by Elsevier, Inc. All rights reserved.
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Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

To the enormous number of interventional cardiologists,
scientists and engineers who, over the past 40 years,
have radically transformed the treatment of heart
disease and helped so many patients.
Contributors
William T. Abraham, MD, FACP, FACC, Stephen Balter, PhD Sergio Buccheri, MD
FAHA, FESC, FRCP Professor of Clinical Radiology (Physics) Interventional Cardiologist
Professor of Medicine, Physiology, and in Medicine Cardiac-Thoracic-Vascular Department
Cell Biology Radiology and Medicine Azienda Policlinico-Vittorio Emanuele
College of Medicine Distinguished Columbia University Associate Professor of Cardiology
Professor New York, New York University of Catania
Division of Cardiovascular Medicine Catania, Italy
David T. Balzer, MD
The Ohio State University
Professor, Pediatrics Robert A. Byrne, MB BCh, PhD
Columbus, Ohio
Division of Pediatric Cardiology Interventional Cardiologist
Marcelo Abud, MD Director, Cardiac Catheterization Deutsches Herzzentrum München
Fellow Laboratory Technische Universität
Interventional Cardiology and Washington University School of Munich, Germany
Endovascular Therapies Medicine
Davide Capodanno, MD, PhD
Cardiovascular Institute of Buenos Aires St. Louis, Missouri
Interventional Cardiologist
Buenos Aires, Argentina
Gregory W. Barsness, MD Cardiac-Thoracic-Vascular Department
Jung-Min Ahn, MD Assistant Professor Azienda Policlinico-Vittorio Emanuele
Associate Professor Departments of Internal Medicine, Associate Professor of Cardiology
Department of Cardiology Cardiovascular Medicine, and University of Catania
Asan Medical Center Radiology Catania, Italy
University of Ulsan College of Medicine Director, Cardiac Intensive Care Unit
Ivan P. Casserly, MD
Seoul, Republic of Korea Mayo Clinic
Professor of Medicine
Rochester, Minnesota
Takashi Akasaka, MD, PhD University College Dublin
Department of Cardiovascular Medicine Olivier F. Bertrand, MD, PhD Mater Misericordiae University Hospital
Wakayama Medical University Quebec Heart-Lung Institute Dublin, Ireland
Wakayama, Japan Interventional Cardiology
Matthews Chacko, MD
Quebec City, Canada
Ibrahim Akin, MD Assistant Professor of Medicine
Universitätsklinikum Mannheim Farzin Beygui, MD, MPH, PhD Division of Cardiology
Fakultät Heidelberg Professor of Cardiology Johns Hopkins University and Hospital
Abteilung Kardiologie Interventional Cardiology Unit Baltimore, Maryland
Mannheim, Germany Caen University Hospital
Derek P. Chew, MBBS, MPH, PhD
Caen, France
Waleed Alharbi, MD FRACP, FACC, FESC, FCSANZ
Complex Coronary, Structural and John A. Bittl, MD Professor of Cardiology
Endovascular Interventional Cardiology Interventional Cardiologist Department of Cardiovascular Medicine
Fellow AdventHealth Ocala Flinders University
Prairie Heart Institute Ocala, Florida Network Director of Cardiology
Springfield, Illinois Department of Cardiovascular Medicine
Nyal Borges, MD
Southern Adelaide Health Service
David W. Allen, MD Department of Cardiovascular Medicine
Adelaide, Australia
Assistant Professor of Cardiology Cleveland Clinic
Max Rady College of Medicine Cleveland, Ohio Leslie Cho, MD
University of Manitoba Section Head, Preventive Cardiology &
Vikram M. Brahmanandam, MD
Winnipeg, Manitoba, Canada Rehabilitation
Attending Cardiologist, Assistant
Director, Womens Cardiovascular Center
Alexandra Almonacid, MD Professor of Medicine
Cleveland Clinic
Associate Director Cardiology
Cleveland, Ohio
Beth Israel Deaconess Medical Center Montefiore-Einstein Center for Heart and
Cardiovascular Imaging Core Vascular Care Michael L. Chuang, MD
Laboratory Bronx, New York Assistant Director
Boston, Massachusetts Beth Israel Deaconess Medical Center
Éric Brochet, MD
Cardiovascular Imaging Core
Dominick J. Angiolillo, MD, PhD Cardiology Department
Laboratory
Professor of Medicine Hopital Bichat
Boston, Massachusetts
Director, Cardiovascular Research Paris, France
Program Director, Interventional Antonio Colombo, MD
Cardiology Fellowship EMO-GVM Centro Cuore Columbus
University of Florida College of Medicine San Raffaele Scientific Institute
Jacksonville, Florida Milan, Italy
vi
CONTRIBUTORS vii
Marco A. Costa, MD, PhD Vasim Farooq, MBChB, PhD Mario J. Gössl, MD
University Hospitals Harrington Heart & Newcastle upon Tyne Hospitals Director, Transcatheter Research and
Vascular Institute NHS Foundation Trust Education, Center for Valve and
Case Western Reserve University School Newcastle, United Kingdom Structural Heart Disease
of Medicine Co-chair, Valve Science Center
Miroslaw Ferenc, MD
Cleveland, Ohio Minneapolis Heart Institute
Head of Interventional Cardiology
Abbott Northwestern Hospital
Alain Cribier, MD Division of Cardiology and Angiology II
Minneapolis, Minnesota
Department of Cardiology University Heart Center Freiburg - Bad
Rouen University Hospital Krozingen Nilesh J. Goswami, MD, FACC, FSCAI,
Rouen, France Bad Krozingen, Germany FSVM
Director of Cardiac Catheterization
Fernando Cura, MD, PhD Kenneth A. Fetterly, PhD
Laboratory
Director Medical Physicist
Director of Structural Heart Interventions
Interventional Cardiology and Cardiovascular Diseases
Prairie Heart Institute
Endovascular Therapies Mayo Clinic and Foundation
Springfield, Illinois
Instituto Cardiovascular de Buenos Aires Rochester, Minnesota
Buenos Aires, Argentina Elliott M. Groves, MD, MEng, FACC,
Peter J. Fitzgerald, MD, PhD
FSCAI
Ingo Daehnert, MD, PhD Professor Emeritus of Medicine and
Director, Structural Heart Interventions
Department of Pediatric Cardiology Engineering
Department of Medicine, Division of
University of Leipzig, Heart Center Division of Cardiovascular Medicine
Cardiology
Leipzig, Germany Stanford University School of Medicine
University of Illinois at Chicago
Director, Center for Cardiovascular
Vishal Dahya, MD Chicago, Illinois
Technology
Chief Fellow
Stanford University Medical Center Giulio Guagliumi, MD
Cardiovascular Medicine Fellowship
Stanford, California Cardiovascular Department
Summa Health Heart and Vascular
ASST Papa Giovanni XXIII
Institute Marat Fudim, MD
Bergamo, Italy
Summa Health System Duke University Medical Center
Akron, Ohio Duke Clinical Research Institute Serge C. Harb, MD
Durham, North Carolina Department of Cardiovascular Medicine
Kimberly S. Delcour, DO, FACC
Cleveland Clinic
Director, Cardiac CT Mario J. Garcia, MD
Cleveland, Ohio
Clinical Assistant Professor Chief of Cardiology
Department of Internal Medicine, Medicine Trent Hartshorne, MBBS, FRACP,
Division of Cardiology Montefiore Medical Center FCICM, DDU
Heart & Vascular Center Bronx, New York Cardiologist and Intensive Care Physician
University of Iowa Hospitals & Clinics Intensive Care Consultant
Baris Gencer, MD
Iowa City, Iowa The Alfred Hospital
Cardiology Division
Melbourne, Australia
Robert S. Dieter, MD, RVT Geneva University Hospital
Loyola University Medical Geneva, Switzerland Grant Henderson, MD
Center/Hines VA Fellow, Cardiovascular Medicine
C. Michael Gibson, MD, MS
Maywood, Illinois Cleveland Clinic
CEO of Baim and PERFUSE Research
Cleveland, Ohio
John S. Douglas, Jr., MD Institutes
Professor Professor of Medicine Timothy D. Henry, MD, FACC, MSCAI
Department of Medicine Cardiovascular Division, Department of Medical Director, The Carl and Edyth
Director, Interventional Cardiology Medicine Lindner Center for Research and
Fellowship Program Beth Israel Deaconess Medical Center Education at The Christ Hospital
Emory University School of Medicine Harvard Medical School The Carl and Edyth Lindner Family
Emory University Hospital Boston, Massachusetts Distinguished Chair in Clinical
Atlanta, Georgia Research
Bryan H. Goldstein, MD
Director of Programmatic and Network
Helene Eltchaninoff, MD Associate Professor of Pediatrics
Development Heart and Vascular
Department of Cardiology University of Cincinnati College of
Service Line
Rouen University Hospital Medicine
The Christ Hospital Health Network
Rouen, France The Heart Institute
Cincinnati, Ohio;
Cincinnati Children’s Hospital Medical
Marvin H. Eng, MD Professor of Medicine
Center
Center for Structural Heart Disease University of Minnesota
Cincinnati, Ohio
Division of Cardiology Cedars-Sinai Heart Institute
Henry Ford Hospital Jeffrey Goldstein, MD University of California Los Angeles
Detroit, Michigan Director of Cardiology Department
Howard C. Hermann, MD
Prairie Heart Institute
Zaher Fanari, MD John W. Bryfogle Jr. Professor of
Springfield, Illinois
Heartland Cardiology/Wesley Medical Cardiovascular Medicine
Center Carlos A. Gonzalez Lengua, MD Health System Director for Interventional
University of Kansas School of Medicine Medicine-Cardiology Cardiology Program
Wichita, Kansas Mount Sinai St. Luke’s Hospital Perelman School of Medicine, University
New York, New York of Pennsylvania
Philadelphia, Pennsylvania
viii CONTRIBUTORS
Dominique Himbert, MD David E. Kandzari, MD, FACC, FSCAI John M. Lasala, MD, PhD
Cardiology Department Director, Interventional Cardiology Professor of Medicine
Hopital Bichat Chief Scientific Officer Director, Structural Heart Disease
Paris, France Piedmont Healthcare Washington University School of
Piedmont Heart Institute Medicine
Ravi S. Hira, MD, FACC, FAHA, FSCAI
Atlanta, Georgia St. Louis, Missouri
Assistant Professor of Medicine
University of Washington Samir R. Kapadia, MD Amir Lerman, MD
Seattle, Washington Professor of Medicine Professor
Director, Sones Catheterization Department of Cardiovascular Medicine
Russel Hirsch, MD
Laboratories Mayo Clinic
Professor of Pediatrics
Director, Interventional Cardiology Rochester, Minnesota
University of Cincinnati College of
Fellowship
Medicine Scott M. Lilly, MD, PhD
Department of Cardiovascular Medicine
The Heart Institute Associate Professor
Cleveland Clinic
Cincinnati Children’s Hospital Medical Department of Medicine, Division of
Cleveland, Ohio
Center Cardiology
Cincinnati, Ohio Adnan Kastrati, MD Ohio State University
Professor of Cardiology Columbus, Ohio
Kazuhiro Hisamoto, MD
Deutsches Herzzentrum and 1.
Clinical Assistant Professor Michael J. Lim, MD
Medizinische Klinik rechts der Isar
Department of Cardiothoracic Surgery Interim Director and Associate Professor
Technische Universität
NYU School of Medicine of Medicine
Munich, Germany
New York, New York Cardiology Division
Yuki Katagiri, MD Saint Louis University
Yasuhiro Honda, MD
Department of Cardiology St. Louis, Missouri
Clinical Professor of Medicine
Academic Medical Center
Division of Cardiovascular Medicine William L. Lombardi, MD, FACC, FSCAI
University of Amsterdam
Stanford University School of Medicine Director, Complex Coronary Artery
Amsterdam, Netherlands
Director, Cardiovascular Core Analysis Disease Therapies
Laboratory Athanasios Katsikis, MD, PhD University of Washington Medical Center
Center for Cardiovascular Technology Department of Cardiology Seattle, Washington
Stanford University Medical Center General Military Hospital of Athens
Phillipp C. Lurz, MD, PhD
Stanford, California Athens, Greece
Department of Internal Medicine/
Khalil Ibrahim, MD Dean J. Kereiakes, MD, FACC, FSCAI Cardiology
Department of Cardiology Medical Director, The Christ Hospital Leipzig Heart Center, University
Johns Hopkins School of Medicine Heart and Vascular Center Hospital
Baltimore, Maryland Medical Director, The Christ Hospital Leipzig, Germany
Research Institute
Bernard Iung, MD Kambis Mashayekhi, MD
The Christ Hospital Health Network
Professor of Cardiology Associate Head of Interventional
Cincinnati, Ohio
University of Paris VII Cardiology
Professor of Clinical Medicine
Hospital Doctor Division of Cardiology and Angiology II
Ohio State University
Cardiology Department University Heart Center Freiburg - Bad
Hopital Bichat Morton J. Kern, MD Krozingen
Paris, France Chief of Medicine Bad Krozingen, Germany
Department of Medicine
Hani Jneid, MD, FACC, FAHA, FSCAI Roxana Mehran, MD
VA Long Beach Health Care System
Associate Professor of Medicine The Zena and Michael A. Wiener
Long Beach, California
Director, Interventional Cardiology Cardiovascular Institute
Fellowship Program Ajay J. Kirtane, MD, SM, FACC, FSCAI Icahn School of Medicine at
Director, Interventional Cardiology Associate Professor of Medicine, Mount Sinai
Research Columbia University Medical Center New York, New York
Baylor College of Medicine Chief Academic Officer, Center for
Adrian W. Messerli, MD, FACC, FSCAI
Director, Interventional Cardiology Interventional Vascular Therapy
Associate Professor of Medicine
The Michael E. DeBakey VA Medical Director, NYP/Columbia Cardiac
Director, Cardiac Catheterization
Center Catheterization Laboratories
Laboratories
Houston, Texas New York, New York
Gill Heart Institute, University of
James G. Jollis, MD, FACC Serge Korjian, MD Kentucky
Professor of Medicine PERFUSE Study Group Lexington, Kentucky
Duke University Cardiovascular Division, Department of
Rodrigo Modolo, MD, PhD
Durham, North Carolina Medicine
Department of Cardiology
Beth Israel Deaconess Medical Center
Michael A. Jolly, MD, FACC, RPVI Amsterdam University Medical Center
Harvard Medical School
Interventional Cardiologist Amsterdam, Netherlands
OhioHealth Heart and Vascular Department of Internal Medicine
Columbus, Ohio Amar Krishnaswamy, MD Cardiology Division
Program Director University of Campinas (UNICAMP)
Interventional Cardiology Campinas, Brazil
Cleveland Clinic
Cleveland, Ohio
CONTRIBUTORS ix
Gilles Montalescot, MD, PhD Gjin Ndrepepa, MD Marc S. Penn, MD, PhD
Pitié-Salpêtrière University Hospital Professor of Cardiology Director of Research
Institut de Cardiologie Deutsches Herzzentrum München Director of Cardiovascular Medicine
Paris, France Technische Universität Fellowship
Munich, Germany Summa Health Heart and Vascular
Pedro R. Moreno, MD
Institute
The Zena and Michael A. Weiner Franz-Josef Neumann, MD, PhD
Summa Health System
Cardiovascular Institute Endowed Professor of Cardiovascular
Akron, Ohio;
The Marie-Josée and Henry R. Kravis Medicine
Professor of Medicine
Cardiovascular Health Center University of Frieburg
Integrative Medical Sciences
Icahn School of Medicine at Mount Sinai Medical Director
Northeast Ohio Medical University
New York, New York Division of Cardiology and Angiology II
Rootstown, Ohio
University Heart Center Freigurg - Bad
Jeffrey W. Moses, MD
Krozingen Jeffrey J. Popma, MD
Interventional Cardiology
Bad Krozingen, Germany Director, Interventional Cardiology
New York Presbyterian Hospital
Clinical Services
Columbia University Medical Center Christoph A. Nienaber, MD
Medicine (Cardiovascular Division)
New York, New York Imperial College
The Royal Brompton & Harefield NHS
Debabrata Mukherjee, MD Professor of Medicine
Trust
Chairman, Department of Internal Harvard Medical School
Cardiology and Aortic Centre
Medicine Boston, Massachusetts
London, England
Chief, Cardiovascular Medicine
Matthew J. Price, MD
Texas Tech University Yoshinobu Onuma, MD, PhD
Assistant Professor
El Paso, Texas Thoraxcenter, Erasmus Medical Center;
Director, Cardiac Catheterization
Cardialysis
Dale J. Murdoch, MBBS Laboratory
Rotterdam, Netherlands
Centre for Heart Valve Innovation Division of Cardiovascular Diseases
St Paul’s Hospital Igor F. Palacios, MD Scripps Clinic
University of British Columbia Associate Professor of Medicine La Jolla, California
Vancouver, Canada Director, Interventional Cardiology
Lorenz Räber, MD, PhD
Fellowship Program
Sahar Naderi, MD Cardiology Department
Director, Interventional Cardiology
Division of Cardiology Bern University Hospital
Research
Kaiser Permanente, San Francisco Bern, Switzerland
Baylor College of Medicine
Medical Center
Director, Interventional Cardiology Vivek Rajagopal, MD
San Francisco, California
The Michael E. DeBakey VA Medical Staff Cardiologist
Srihari Naidu, MD Center Piedmont Heart Institute
Director, Cardiac Catheterization Houston, Texas Atlanta, Georgia
Laboratory
Tullio Palmerini, MD Sunil V. Rao, MD
Division of Cardiology
Unità Operativa di Cardiologia Duke Clinical Research Institute
Winthrop University Hospital
Dipartimento Cardio-Toraco-Vascolare Durham, North Carolina
Mineola, New York
Policlinico S. Orsola
Associate Professor of Medicine Robert F. Riley, MD, MS, FACC, FAHA,
Bologna, Italy
SUNY Stony Brook School of Medicine FSCAI
Stony Brook, New York Duk-Woo Park, MD, PhD Medical Director, Complex Coronary
Associate Professor Therapeutics Program
Craig R. Narins, MD
Department of Cardiology Heart and Vascular Center
Associate Professor of Medicine and
Asan Medical Center The Christ Hospital, Lindner Center for
Surgery
University of Ulsan College of Medicine Research and Education
Divisions of Cardiology and Vascular
Seoul, Republic of Korea Cincinnati, Ohio
Surgery
University of Rochester Medical Center Seung-Jung Park, MD, PhD Madhur A. Roberts, MD
Rochester, New York Professor Interventional Cardiology Fellow
Department of Cardiology Cardiology
Nima Nasiri, MD
Asan Medical Center Westchester Medical Center
Research Fellow in Medicine
University of Ulsan College of Medicine Valhalla, New York
Division of Cardiovascular Medicine
Seoul, Republic of Korea
Beth Israel Deaconess Medical Center Marco Roffi, MD
Boston, Massachusetts Manesh R. Patel, MD Cardiology Division
Department of Medicine University Hospital
Eliano P. Navarese, MD, PhD
Duke University Medical Center Geneva, Switzerland
Interventional Cardiology and
Durham, North Carolina
Cardiovascular Medicine Jason H. Rogers, MD
Mater Dei Hospital and SIRIO Division of Cardiovascular Medicine
MEDICINE Research Network University of California, Davis
Bari, Italy; Sacramento, California
Faculty of Medicine
University of Alberta
Edmonton, Canada
x CONTRIBUTORS
R. Kevin Rogers, MD, MSc, RPVI Danielle N. Sin, MS On Topaz, MD, FACC, FACP, FSCAI
Associate Professor Senior Research Coordinator Professor of Medicine
Program Director, Vascular Medicine & Division of Adult Cardiac Surgery Duke University School of Medicine
Intervention NYU Langone Medical Center Chief, Division of Cardiology
Interventional Cardiology New York, New York Charles George Veterans Affairs Medical
University of Colorado Center
Gagan D. Singh, MD
Aurora, Colorado Asheville, North Carolina
Division of Cardiovascular Medicine
Jennifer A. Rymer, MD, MBA University of California, Davis Mark K. Tuttle, MD
Department of Medicine Sacramento, California Fellow, Division of Cardiovascular
Duke University Medical Center Medicine
Paul A. Sobotka, MD
Durham, North Carolina Beth Israel Deaconess Medical Center
Affiliated Clinical Professor
Clinical Fellow, Harvard Medical School
Bruno Scheller, MD Medicine/Cardiology
Clinical and Experimental Interventional The Ohio State University
Cardiology Columbus, Ohio Alec Vahanian, MD, FESC, FRCP (Edin.)
University of Saarland Professor of Cardiology
Nishtha Sodhi, MD
Homburg/Saar, Germany University of Paris VII
Structural Heart Disease & Interventional
Paris, France
Beth A. Schueler, PhD Cardiology Fellow
Professor of Medical Physics Cardiovascular Department Miguel Valderrábano, MD, FACC
Department of Radiology Barnes Jewish Hospital of Washington Lois and Carl Davis Centennial Chair,
Mayo Clinic University Methodist DeBakey Heart and Vascular
Rochester, Minnesota St. Louis, Missouri Center
Associate Professor of Medicine,
Joshua Seinfeld, MD Paul Sorajja, MD
Weill College of Medicine, Cornell
Department of Neurosurgery Roger L. and Lynn C. Headrick Chair,
University
University of Colorado School of Valve Science Center Director
Director, Division of Cardiac
Medicine Center for Valve and Structural Heart
Electrophysiology
Aurora, Colorado Disease
Department of Cardiology
Minneapolis Heart Institute, Abbott
Patrick W. Serruys, MD, PhD Houston Methodist Hospital
Northwestern Hospital
National Heart and Lung Institute, Houston, Texas
Minneapolis, Minnesota
Faculty of Medicine
Birgit Vogel, MD
Imperial College London Sabato Sorrentino, MD, PhD
The Zena and Michael A. Wiener
London, England The Zena and Michael A. Wiener
Cardiovascular Institute
Cardiovascular Institute
Margot M. Sherman Jollis, BS Icahn School of Medicine at Mount Sinai
Icahn School of Medicine at Mount Sinai
Denison University New York, New York
New York, New York
Granville, Ohio
Amit N. Vora, MD, MPH
Goran Stankovic, MD, PhD
Kunihiro Shimamura, MD Duke Clinical Research Institute
Clinic for Cardiology
Department of Cardiovascular Medicine Durham, North Carolina
Department for Diagnostic and
Wakayama Medical University
Catheterization Laboratories Robert Wagner, MD, PhD
Wakayama, Japan
Clinical Center of Serbia Department of Pediatric Cardiology
Satya S. Shreeniva, MD Faculty of Medicine University of Leipzig, Heart Center
Interventional Cardiologist University of Belgrade Leipzig, Germany
The Lindner Research Center Belgrade, Serbia
John G. Webb, MD
Division of Cardiology
Curtiss T. Stinis, MD Centre for Heart Valve Innovation
The Christ Hospital
Director, Peripheral Interventions St Paul’s Hospital
Cincinnati, Ohio
Program Director, Interventional University of British Columbia
Kevin H. Silver, MD Cardiology Fellowship Vancouver, Canada
Director, Coronary Intensive Care Unit Division of Interventional Cardiology
William S. Weintraub, MD
Director, Cardiac Catheterization Lab Scripps Clinic
MedStar Heart & Vascular Institute
Summa Health Heart and Vascular La Jolla, California
Georgetown University
Institute
Matthew Summers, MD Washington, DC
Summa Health System
Fellow Physician
Akron, Ohio Sandra Weiss, MD
Christiana Care Health System
Mitchell J. Silver, DO, FACC, FSVM, Cleveland Clinic Foundation
Newark, Delaware
RPVI Cleveland, Ohio
Interventional Cardiologist Christopher J. White, MD, MSCAI,
Paul S. Teirstein, MD
OhioHealth Heart and Vascular FACC, FAHA, FESC, FACP
Columbus, Ohio Professor and Chairman of Medicine
Scripps Clinic
The Ochsner Clinical School, University
Daniel I. Simon, MD La Jolla, California
of Queensland
University Hospitals Harrington Heart &
Chief of Medical Services
Vascular Institute
Ochsner Medical Center
Case Western Reserve University School
New Orleans, Louisiana
of Medicine
Cleveland, Ohio
CONTRIBUTORS xi
Wendy Whiteside, MD Paul G. Yock, MD, MA, AB Khaled M. Ziada, MD, FACC, FSCAI
Assistant Professor of Pediatrics Martha Meier Weiland Professor Professor of Medicine
University of Michigan Division of Bioengineering and Medicine Clinical Chief of Cardiology
Pediatric Cardiology Stanford University Director, Cardiovascular Interventional
C. S. Mott Children’s Hospital Stanford, California Fellowship Program
Congenital Heart Center Gill Heart Institute, University of
Katherine Yu, MD
Ann Arbor, Michigan Kentucky
Fellow
Lexington, Kentucky
R. Jay Widmer, MD, PhD University of Southern California
Assistant Professor of Internal Medicine Los Angeles, California David A. Zidar, MD, PhD
Baylor Scott and White University Hospitals Harrington Heart &
Alan Zajarias, MD
Temple, Texas Vascular Institute
Associate professor of Medicine
Case Western Reserve University School
Mathew R. Williams, MD Co-director, Center of Valvular Heart
of Medicine
Associate Professor of Cardiothoracic Disease
Cleveland, Ohio
Surgery & Medicine Cardiovascular Division
Chief, Division of Adult Cardiac Surgery Washington University school of Andrew A. Ziskind, MD
Director, Interventional Cardiology medicine Senior Vice President, Premier’s
Director, CVI Structural Heart Program St. Louis, Missouri Academic Health System Strategy
NYU Langone Medical Center Premier Inc.
Jeffrey D. Zampi, MD
New York, New York Charlotte, North Carolina
Assistant Professor of Pediatrics
Daaboul Yazan, MD University of Michigan Division of
Research Fellow Pediatric Cardiology
PERFUSE Study Group C. S. Mott Children’s Hospital
Cardiovascular Division, Department of Congenital Heart Center
Medicine Ann Arbor, Michigan
Harvard Medical School
Preface
The eighth edition of Textbook of Interventional Cardiology has the appropriateness or overuse of procedures. But hopefully, all
been more extensively updated than any previous edition. We of these challenges are outweighed by the immense gratification
have tried to fully capture the excitement and relentless matura- of helping a symptomatic patient with limitations in quality of
tion of the field of interventional cardiology, emphasizing rigor- life get back to his or her baseline. Nowhere in medicine is this
ous evidence-based approaches. New chapters have been added feeling more prevalent than in the transformative field of trans-
to address the diagnosis and treatment of coronary microvascular catheter aortic valve replacement.
disease, percutaneous tricuspid valve repair, and valve-in-valve This book is intended to serve as a resource for the interven-
interventions. Over the years, coronary intervention became tional cardiology community, which not only includes practicing
increasingly predictable and, in many ways, routine, with the cardiologists but also the team involved in procedures, referring
progressive maturation of stents and leaps forward in our adjunct physicians, and those training or who have aspiration to train
pharmacologic therapies. In some ways, the field of interventional in this awe-inspiring field. We have changed authors for many
cardiology lost a bit of its pioneering spark that had so character- chapters to provide a sense of newness and a fresh perspective,
ized this discipline from its inception in the 1980s. In those heady and in every chapter we have sought the authors who are widely
times, performing balloon angioplasty in the coronary artery was regarded as the true experts in the field. Going forward, we fully
unpredictable. The predictability provided by stents was replaced recognize that there needs to be increased cooperativity with car-
with the unpredictability of stent thrombosis. Interventional cardiac surgeons—the rising popularity of hybrid and collaborative
diologists and scientists had to not only rise to the challenge for valve procedures that capitalize on the best parts of percutaneous
each individual patient but also to discover the vital innovations and surgical approaches is clearly indicative of that collaboration.
that would perpetuate the prominence and importance of the We want to express our genuine and deep appreciation to the
specialty. authors from all over the world who have graciously contributed
Currently, the challenges continue, but they have morphed to this new edition. They represent a remarkable brain trust from
considerably. The profile of patients who undergo coronary whom we have learned so much in the review of their input. We
intervention has dramatically increased in complexity to include thank Mary Hegeler at Elsevier for her first-rate, professional
patients with advanced age and those with left main stem lesions, support of this endeavor, and we are especially grateful to the
chronic occlusions, and what would formerly have been consid- cardiovascular community of readers of this book who have sup-
ered prohibitive complexity. What ever happened to patients ported it as the primary reference textbook source for more than
with type A lesions? How can we break the maximal Synergy 30 years. That represents a large sense of responsibility for us
Between Percutaneous Coronary Intervention With Taxus and to maintain, and we hope to have lived up to that and perhaps
Cardiac Surgery (SYNTAX) score barrier for percutaneous cor- exceeded expectations with the eighth edition.
onary intervention? At the same time, the crisis in health care
economics has placed increased burdens on interventional cardi- Paul S. Teirstein, MD
ologists with respect to time, constraints in equipment selection, Eric J. Topol, MD
and fulfilling the responsibility of 24/7 coverage for such emer- La Jolla, California, 2019
gencies as acute myocardial infarction. There is also the incre-
mental pressure from scorecarding initiatives and challenges to
xii
SECTION I Patient Selection 1
1 Individualized Assessment for Percutaneous or

Surgical-Based Revascularization
Vasim Farooq, Rodrigo Modolo, Patrick W. Serruys
KEY POINTS
• Changes in the demographics of patients who present in • Clinical tools based on the Synergy Between Percutaneous
need of revascularization, advances in percutaneous and Coronary Intervention With Taxus and Cardiac Surgery
surgical revascularization techniques, and results from (SYNTAX) trial have evolved from purely anatomic
contemporary studies of percutaneous versus surgical factors (anatomic SYNTAX score) to anatomic factors
revascularization have made it essential that patients be augmented by clinical variables (culminating in the
assessed as individuals prior to selection of a treatment development of the SYNTAX score II) and tools to assess
strategy. a level of reasonable incomplete revascularization that
• Risk stratification plays an important role in the would not have an adverse effect on long-term morbidity
assessment of patients undergoing revascularization. and mortality (residual SYNTAX score). Validation of
many of these newly developed clinical tools is ongoing.
• Clinical tools used to assist the heart team in risk
stratifying patients and deciding the most appropriate • Clinical and anatomic factors have an impact on short-
revascularization modality can be broadly divided into and long-term morbidity and mortality following surgical
assessments based on clinical comorbidities, coronary or percutaneous revascularization and must be considered
anatomy, or a combination of the two. by the heart team in open dialogue with the patient during
the decision-making process.
Revascularization of patients with coronary artery disease (CAD) and consequently patients are more likely to present with more
has progressed exponentially since Andreas Grüntzig1 performed extensive CAD. The Arterial Revascularization Therapies Studies
the first balloon angioplasty in 1977. These developments, which (ARTS) parts I and II were separated by a period of 5 years, and
have been fueled by new technology, have blurred the boundary despite both studies having the same inclusion criteria, patients in
between what was once considered exclusively surgical disease ARTS-II had a significantly greater incidence of risk factors and
and what can be treated percutaneously. Consequently, there is overall increased disease complexity (Table 1.1).4
a greater need than ever to tailor revascularization appropriately, Patient comorbidities must be taken into consideration when
taking into consideration a patient’s comorbidities, coronary assessing patients for revascularization because they have the
anatomy, personal preferences, and individual perception of risk. potential to significantly influence patient outcomes; moreover,
This chapter will explore the increasing requirement for a more they may have a different impact depending on the underlying
individualized assessment of patients undergoing revasculariza- revascularization strategy selected. Notably in patients enrolled
tion, and it will review the clinical tools currently available to in the ARTS-I and II studies, patient age was shown to be a sig-
assist in this decision-making process. nificant independent correlate of major adverse cardiovascular
and cerebrovascular events (MACCEs) who were treated with
CABG.5 More recently, in the randomized all-comers SYNTAX
NEED FOR INDIVIDUALIZED PATIENT ASSESSMENT trial, increasing age was shown to favor PCI over CABG when
A number of confounding factors have made it imperative that adjustments were made for other anatomic and clinical factors.6–8
patients are assessed as individuals prior to the selection of revas- In addition, other anatomic and clinical factors were shown to
cularization strategy. have an impact on long-term mortality, and thereby decision
making between CABG and PCI (SYNTAX score II7,8), and this
topic is discussed later under “SYNTAX-Based Clinical Tools.”
Patient Comorbidities In a collaborative patient-level analysis of 10 randomized
The demographics of patients presenting to tertiary care services trials of patients with multivessel disease (MVD) treated with
in need of revascularization are constantly evolving. This has been PCI using bare-metal stenting (BMS) and CABG, Hlatky and
largely the consequence of increased longevity of the general pop- coworkers9 demonstrated comparable rates of 5-year mortality
ulation, a lower threshold to investigate patients who present with between both treatment groups in patients without diabetes.
symptoms suggestive of obstructive CAD, and increased resources Notably, when patients with diabetes were viewed as a whole,
that have made revascularization via percutaneous coronary inter- mortality was significantly higher in those treated with PCI, even
vention (PCI) or coronary artery bypass grafting (CABG) more after multivariate adjustment (Fig. 1.1). In the Future Revascu-
accessible. Together with increased age, patients in need of larization Evaluation in Patients With Diabetes Mellitus: Opti-
revascularization are currently more likely to have comorbidities mal Management of Multivessel Disease (FREEDOM) trial,10,11
such as diabetes, hypertension, and hyerlipidemia.2,3 These fac- it was shown that in patients with diabetes and advanced CAD,
tors are all implicated in accelerating the progression of CAD, CABG was superior to PCI in that it significantly reduced rates
1
2 SECTION I Patient Selection
TABLE 1.1 Changing Baseline Demographics of Patients Enrolled in Drug-Eluting Stent Trials
All-Comers Studies
SIRTAX24 Leaders25 Resolute27 Arts-I28 Arts-II172 SYNTAX13
Years of Enrollment 2003–2004 2006–2007 2008 1997–1998 2003 2005–2007
Stent Type DES DES DES BMS DES DES
Demographics
Age, years (mean ± SD) 62 ± 11 65 ± 11 64.4 ± 10.9 61 ± 10 63 ± 10 65 ± 10
Diabetes, % 20 24 23.5 19 26 26
Hypertension, % 61 73 71.1 45 67 69
Hypercholesterolemia, % 59 67 63.9 58 74 78
Previous myocardial infarction, % 29 33 28.9 44 34 32
Left ventricular function, % (mean ± SD) 57 ± 12 56 ± 12 61 ± 12 60 ± 12 59 ± 13
Lesion Characteristics (Per Patient)
Multivessel disease, % 59 23 58.4 96 100 92
Bifurcation lesions, % 8 22 16.9 35 34 72
Total occlusions, % 19 12 16.3 3 17 24
SYNTAX score (mean ± SD) 12 ± 7 14 ± 9 15 ± 9 – 21 ± 10 28 ± 12
Mean number of diseased lesions 1.4 1.5 1.5 2.8 3.6 3.6a
Procedural Characteristics (Per Patient)
Mean number of stents 1.2 ± 0.5 1.3 ± 0.7b 11.9 ± 7.5 2.8 ± 1.3 3.7 ± 1.5 4.6 ± 2.3
Total stent length, mm (mean ± SD) 25.9 ± 15.5 24.7 ± 15.5b 34.4 ± 24.5 47.6 ± 21.7 72.5 ± 32.1 86.1 ± 47.9

aTreatedlesions.
bPer
lesion.
BMS, Bare-metal stent; DES, drug-eluting stent; SD, standard deviation; SYNTAX, Synergy Between Percutaneous Coronary Intervention with Taxus and
Cardiac Surgery.

of death and myocardial infarction (MI) but at the expense of a

35
higher rate of stroke (Fig. 1.2).11 In addition, using the Ameri- CABG no diabetes
can College of Cardiology Foundation (ACCF) National Car- CABG diabetes
30
diovascular Data Registry (NCDR) and the Society of Thoracic PCI no diabetes
Surgeons (STS) Adult Cardiac Surgery Database, Weintraub PCI diabetes
and colleagues12 found that subjects who had elective inter- 25
vention for MVD had a long-term survival advantage among
Mortality (%)
patients who underwent CABG compared with PCI (Fig. 1.3). 20

Findings have been corroborated in the randomized, all-comers
SYNTAX trial,13–16 as discussed later. 15
In addition, within the randomized Evaluation of the Xience
Everolimus-Eluting Stent Versus Coronary Artery Bypass Sur- 10
gery for Effectiveness of Left Main Revascularization (EXCEL)
trial, in appropriately selected patients with left main (LM) CAD 5
(low-intermediate anatomic SYNTAX scores), PCI with evero-
limus-eluting stents was shown to be noninferior to CABG with 0
respect to the rate of the composite end point of death, stroke, or 0 1 2 3 4 5 6 7 8
MI at 3 years (Fig. 1.4A).17,18 Moreover, a substantially greater Number of patients* Years of follow-up
early benefit in quality of life (QOL) was evident with PCI at CABG no diabetes 3263 3169 3089 2877 2677 2267 1592 1380 1274
1 month, with a similar QOL improvement at 36 months with CABG diabetes 615 587 575 532 498 421 257 225 200
both PCI and CABG (see Fig. 1.4B).19 This corroborates find- PCI no diabetes 3298 3217 3148 2918 2725 2281 1608 1393 1288
PCI diabetes 618 574 555 508 475 373 218 179 160
ings originally made in the original landmark SYNTAX trial.20
Conversely, in the randomized NOBLE21 (Nordic-Baltic-British Fig. 1.1 Cumulative survival curve of long-term mortality strati-
left main revascularisation study) and BEST (The Randomized fied according to diabetic status among patients with multivessel
Comparison of Coronary Artery Bypass Surgery and Everoli- disease randomized to treatment with percutaneous coronary
mus-Eluting Stent Implantation in the Treatment of Patients intervention (PCI) or coronary artery bypass grafting (CABG). The
with Multivessel Coronary Artery Disease) trials22 investigating importance of diabetic status on outcomes are highlighted not only
patients with unprotected LM and MVD, respectively, CABG by the higher mortality among patients with diabetes compared
was shown to offer superior long-term clinical outcomes com- with nondiabetics but also by the greater impact diabetic status
pared with PCI with contemporary drug-eluting stents (DESs); had on patients treated with PCI compared with CABG.*Number of
notably in both trials, patients were not appropriately risk strati- patients available for follow-up. (From Hlatky MA, Boothroyd DB,
fied and appropriately selected as occurred in EXCEL. Conse- Bravata DM, et al. Coronary artery bypass surgery compared with
quently, an urgent need exists for clinical tools that account for percutaneous coronary interventions for multivessel disease: a col-
both anatomic and clinical factors and comorbidity to assist the laborative analysis of individual patient data from ten randomised
heart team in decision making in regard to the most appropriate trials. Lancet. 2009;373[9670]:1190–1197.)
revascularization modality in patients with complex CAD.
CHAPTER 1 Individualized Assessment for Percutaneous or Surgical-Based Revascularization 3
Primary outcome Evaluation of the Resolute Zotarolimus-Eluting Coronary Stent

60 System in the Treatment of De Novo Lesions in Native Coronary 1
Death, myocardial infarction, Arteries (RESOLUTE),27 and in studies of complex three-vessel
50 disease (3VD) and/or LM CAD, such as ARTS-I,28 ARTS-II,26
P = .005 by log-rank test
5-year event rate: 26.6% vs. 18.7%
and the SYNTAX trial (see Table 1.1).13–16 Further evidence
40 in support of this change comes from assessments of real world
or stroke (%)
clinical practice, which indicate that approximately one-third of

30 patients with complex CAD are currently treated with PCI.29
PCI This practice has been coupled with the expanding use of PCI,
20 driven largely through advances in PCI technology, with more
CABG deliverable newer-generation DESs, lower-profile balloons, new
10 guidewires, adjunctive devices to aid stent delivery, crossing and
reentry systems to aid total occlusion revascularization, functional
0 assessment of lesions, intravascular ultrasound (IVUS) guidance
0 1 2 3 4 5 to ensure adequate stent expansion, dedicated specialists for spe-
Years since randomization cific anatomic subsets including CTO operators with high suc-
No. at risk cessful revascularization rates, introduction of new adjunctive
PCI 953 848 788 625 416 219 pharmacologic therapies, and the increasing availability of percu-
A CABG 947 814 758 613 422 221 taneous extracorporeal circulatory support (eFig. 1.1).30–36 From
a technical perspective, a large subset of coronary lesions can cur-
Death rently be addressed with PCI; however, it is important to empha-
60 size that the percutaneous approach to revascularization requires
individual patient selection to ensure that it is appropriate.
Death from any cause (%)
50
P = .049 by log-rank test
40
5-year event rate: 16.3% vs. 10.9% HISTORIC (PRE-SYNTAX) CLINICAL TRIAL RESULTS
Historically, and prior to the publication of the SYNTAX trial,13–
30 16 randomized trials to compare CABG and PCI centered on
two major patient groups: either isolated proximal left anterior
20
descending (LAD) artery lesions or complex CAD (3VD and/or
PCI
10
LM disease). Although results of these studies suggest no differ-
CABG ences were found in the hard clinical outcomes of death and MI
0 between patients treated with PCI or CABG at short- and long-
0 1 2 3 4 5 term follow-up (Table 1.2),9,37–41 there was profound selection
bias in enrollment of patients prior to randomization. Specifically,
Years since randomization
No. at risk between 2% and 12% of screened patients were randomized in
PCI 953 897 845 685 466 243 most trials (Table 1.3), with patients with lesser comorbidities,
B CABG 947 855 806 655 449 238 such as impaired left ventricular function or coronary anatomy
Fig. 1.2 Kaplan-Meier Estimates of the Composite Primary Outcome
(predominantly single- or double-vessel disease) often “cherry-
of death, myocardial infarction (MI), or stroke (A) and death from any
picked” prior to randomization.42–44 Consequently, interpreting
cause (B) truncated at 5 years after randomization in the FREEDOM
and extrapolating these results to routine and contemporary clin-
trial. In FREEDOM, patients with diabetes and multivessel coronary
ical practice has been challenging.
artery disease were assigned to undergo either percutaneous coronary
intervention (PCI) with first-generation drug-eluting stents or coronary SYNTAX Trial
artery bypass grafting (CABG). Patients were followed for a minimum
of 2 years (median among survivors, 3.8 years), and CABG was
The landmark SYNTAX trial13–16 represents the largest (and
shown to be superior to PCI with first-generation drug-eluting stents
only) assessment of revascularization with PCI or CABG in
with significant reduced rates of death (10.9% vs. 16.3%, P = .049)
all-comers with complex CAD. SYNTAX aimed to supply evi-
and MI (6.0% vs. 13.9%, P < .001) but a higher rate of stroke (5.2%
dence to support the somewhat established but non–evidence-
vs. 2.4%, P = .03). (From FREEDOM Trial Investigators. Strategies for
based practice of performing PCI in patients with complex
multivessel revascularization in patients with diabetes. N Engl J Med.
CAD.29 In addition, SYNTAX also sought to identify which
2012;367(25):2375–2384.)
patients should be treated with CABG only. Through an all-
comers design, SYNTAX addressed the limitations of the ear-
lier CABG versus PCI trials, which were plagued by profound
TECHNOLOGIC ADVANCES selection bias as previously discussed (see Table 1.3),43,44 and
in doing so it was anticipated that the results would be more
The introduction in 2002 of DESs revolutionized the practice of relevant to contemporary routine clinical practice. Specifically:
interventional cardiology and was driven primarily through the
dramatic reduction in rates of repeat revascularization.23 The • To ensure results were applicable to routine practice, the
favorable results observed with DES use promptly resulted in an study was designed as an all-comers trial such that there were
expansion of the indications for PCI, such that bifurcation lesions, no specific inclusion criteria other than the need to have re-
chronic total occlusions (CTOs), and MVD were no longer in vascularization of de novo 3VD or unprotected LM CAD (in
the exclusive domain of surgical revascularization, and these were isolation or with CAD). Exclusion criteria were limited to
increasingly treated with PCI. Evidence of this expansion can be prior revascularization, ongoing MI, and patients requiring
seen in the changing baseline lesion characteristics of patients concomitant cardiac surgery.16 In contrast to the earlier stud-
enrolled in all-comers PCI trials such as the Sirolimus-Eluting ies, 70.9% of eligible patients were enrolled.
and Paclitaxel-Eluting Stents for Coronary Revascularization • The previously indicated problem of reporting outcomes from
(SIRTAX) trial,24 the Limus Eluted From a Durable Versus all patients with complex CAD together, irrespective of dis-
Erodable Stent Coating Study (LEADERS),25,26 the Clinical ease severity, was addressed in the SYNTAX trial through the
CHAPTER 1 Individualized Assessment for Percutaneous or Surgical-Based Revascularization 3.e1
A B
12F pump motor Inlet

area
9F Outlet area
C
eFig. 1.1 Devices that are increasingly available to provide assistance during high-risk percutaneous coronary
intervention include percutaneous extracorporeal circulatory support devices such as the TandemHeart
(A and B) and the Impella device (C). (A) The TandemHeart removes oxygenated blood from the left atrium and
returns this blood into the peripheral arterial circulation; with the (B) aid of a centrifugal pump. (C) The Impella
left ventricular assist device is a miniaturized rotary blood pump that is placed retrograde across the aortic
valve, and it aspirates (inlet area) up to 2.5 L/min of blood from the left ventricular cavity and subsequently
expels this blood (outlet area) into the ascending aorta. (From Valgimigli M, Steendijk P, Serruys PW, et al. Use
of Impella Recover LP 2.5 left ventricular assist device during high-risk percutaneous coronary interventions;
clinical, haemodynamic and biochemical findings. EuroIntervention. 2006;2[1]:91–100; and Vranckx P, Meliga
E, De Jaegere PP, et al. The TandemHeart, percutaneous transseptal left ventricular assist device: a safe-
guard in high-risk percutaneous coronary interventions. The six-year Rotterdam experience. EuroIntervention.
2008;4[3]:331–337.)
1.0
0.8
1.00
Proportion surviving
0.95
0.6
0.90
CABG
0.85
0.4
0.80
0.75 PCI
0.2 0.70
0.00
0 500 1000 1500
0.0
0 500 1000 1500
Days since index revascularization
30-day 1-year 2-year 3-year 4-year
Mortality after CABG, % (95% CI) 2.07 (1.98–2.17) 6.00 (5.58–6.17) 8.76 (8.56–8.94) 12.1 (11.9–12.4) 16.0 (15.7–16.3)
Mortality after PCI, % (95% CI) 1.21 (1.14–1.27) 6.36 (6.22–6.51) 11.2 (11.0–11.4) 16.0 (15.7–16.2) 20.9 (20.6–21.3)
A Relative risk with CABG (95% CI) 1.72 (1.58–1.84) 0.94 (0.91–0.97) 0.78 (0.76–0.80) 0.76 (0.74–0.78) 0.76 (0.75–0.78)
1.0
0.8
1.00
Proportion surviving
0.95
0.6
0.90
CABG
0.85
0.4
0.80
0.75 PCI
0.2 0.70
0.00
0 500 1000 1500
0.0
0 500 1000 1500
Days since index revascularization
30-day 1-year 2-year 3-year 4-year
Mortality after CABG, % (95% CI) 2.25 (2.09–2.41) 6.24 (5.97–6.50) 8.98 (8.68–9.29) 12.4 (12.0–12.8) 16.4 (15.9–16.9)
Mortality after PCI, % (95% CI) 1.31 (1.21–1.41) 6.55 (6.35–6.76) 11.3 (11.0–11.6) 15.9 (15.6–16.3) 20.8 (20.4–21.2)
B Relative risk with CABG (95% CI) 1.72 (1.52–1.89) 0.95 (0.90–1.00) 0.79 (0.76–0.83) 0.78 (0.75–0.81) 0.79 (0.76–0.82)
Fig. 1.3 Incidence of survival in the coronary artery bypass grafting (CABG) and percutaneous coronary
intervention (PCI) cohorts, from unadjusted (A) and adjusted (B) analyses. Cumulative mortality with CABG and
PCI and the relative risk of CABG compared with PCI are shown. Data from the American College of Cardiol-
ogy Foundation and Society of Thoracic Surgeons Database Collaboration on the Comparative Effectiveness
of Revascularization Strategies registry, the American College of Cardiology Foundation National Cardiovascu-
lar Data Registry, and the Society of Thoracic Surgeons Adult Cardiac Surgery Database from 2004 through
2008. (From Weintraub WS, Grau-Sepulveda MV, Weiss JM, et al. Comparative effectiveness of revasculariza-
tion strategies. N Engl J Med. 2012;366[16]:1467–1476.)
use of the anatomic SYNTAX score (www.syntaxscore.com; TAX score for this group was 26.1 and 28.8 in patients
Fig. 1.5),13,45–49 which enabled CAD complexity to be objec- treated with CABG and PCI, respectively. 1
tively and prospectively quantified. 2. Nested CABG registry (n = 1077 [35.0%]): These patients
• To ensure assessment of patients on an individual level, all had CAD that was considered unsuitable for PCI, clearly
patients eligible for enrollment were discussed by the heart reflected in the high mean SYNTAX score (37.8) for this
team.50 An interventional cardiologist and cardiac surgeon group.
carried out a careful and comprehensive review of the patient 3. Nested PCI registry (n = 198 [6.4%]): These patients were
in terms of their anginal status, comorbidities, and coronary deemed unsuitable for CABG. The commonest reason for
anatomy using the respective Braunwald score, European Sys- this decision was the presence of multiple comorbidities13
tem for Cardiac Operative Risk Evaluation (EuroSCORE), reflected in the mean EuroSCORE, which was 2 points
and SYNTAX score (discussed under “SYNTAX-Based Clin- higher in this group than the mean in the randomized
ical Tools”). The consensus reached from this meeting was group (5.8 vs. 3.8).

subsequently used to allocate the patient into one of the three
arms of the trial. In total, 3075 patients were enrolled into one Overall, SYNTAX failed to meet the prespecified primary
of the following: end point of noninferiority in terms of 12-month MACCEs, a
1. Randomized group (n = 1800 [58.5%]; 897 CABG, 903 composite of death, stroke, MI, and repeat revascularization
PCI): These patients had CAD and were equally suitable (17.8% vs. 12.4%, P = .002). Final 5-year reporting of SYN-
for revascularization with PCI or CABG. The mean SYN- TAX demonstrated significantly higher incidence of MACCE
PCI (n = 948) CABG (n = 957)
(i) Death, stroke, or myocardial infarction (ii) Death from any cause
100 25 100 25
20 20
80 15 80 15
14.7%
10 Patients (%) 10 8.2%
Patients (%)
15.4%
60 60
5 5
5.9%
0 0
40 0 6 12 24 36 40 0 12 24 36
6
Hazard ratio, 1.00 (95% CI, 0.79–1.26) Hazard ratio, 1.34 (95% CI, 0.94–1.91)
20 20 P = .11
P = .98
0 0
01 6 12 24 36 01 6 12 24 36
No. at risk Month No. at risk Month

PCI 948 896 875 850 784 445 PCI 948 933 921 898 839 476
CABG 957 868 836 817 763 468 CABG 957 933 910 889 835 522
(iii) Stroke (iv) Myocardial infarction

100 25 100 25
20 20
80 15 80 15
10 10
Patients (%)
Patients (%)
8.3%
60 60
5 2.9% 5 8.0%
2.3%
0 0
40 0 12 24 36 40 0 6 12 24 36
6
Hazard ratio, 0.77 (95% CI, 0.43–1.37) Hazard ratio, 0.93 (95% CI, 0.67–1.28)
20 P = .37 20 P = .64
0 0
01 6 12 24 36 01 6 12 24 36
No. at risk Month No. at risk Month
A PCI 948 930 915 893 839 473 PCI 948 900 882 857 805 452
CABG 957 922 899 880 823 511 CABG 957 879 846 830 776 480
Fig. 1.4 Primary composite end point of death, stroke, or myocardial infarction and its components in the ongo-
ing EXCEL trial at 3 years, indicating similar clinical outcomes (A).17,18 In addition, both percutaneous coronary
intervention (PCI) and coronary artery bypass grafting (CABG) result in similar quality of life (QOL) improvement
at 36 months, with a substantially greater early benefit in QOL seen with PCI at 1 month (B).19 CI, Confidence
interval; SAQ, Seattle Angina Questionnaire. (Reproduced with permission from references 17 and 19.)
Continued
CENTRAL ILLUSTRATION: Disease-Specific Health Status After PCI Versus CABG as Measured by the SAQ
SAQ - Angina Frequency SAQ - Physical Limitations
100 90
90
80
80
70
70 ∆ = –0.8 ∆ = 16.1 ∆ = 0.7
∆ = 1.5 ∆ = –0.3 ∆ = 1.3
P = .03 P = .63 P = .21 P < .01 P = .24 P = .55
60 60
0 1 12 24 36 0 1 12 24 36
Months Months
SAQ - Treatment Satisfaction SAQ - Quality of Life
100 90
80
95
70
90 60
50
85 ∆ = 3.4
∆ = 1.3 ∆ = 1.0 ∆ = 0.3 40 ∆ = –2.4 ∆ = –1.9
P = .02 P = .08 P = .63 P < .01 P = .02 P = .07
80 30
0 1 12 24 36 0 1 12 24 36
Months Months
B PCI CABG
Fig. 1.4 cont’d
TABLE 1.2 Summary of Meta-Analyses Prior to Publication of the SYNTAX Trial Reporting Long-Term Outcomes in Patients With Isolated Proximal Left
Anterior Descending Coronary Artery Disease or Multivessel Disease Randomized to Percutaneous or Surgical Revascularization
First Number of Patients POBA/BMS/ Follow-Up Death (PCI vs. MI (PCI vs. Stroke (PCI vs. Repeat Revasc. MACCEs (PCI
Author (PCI/CABG) DES (%) (Months) CABG) CABG) CABG) (PCI vs. CABG) vs. CABG)
Isolated Proximal LAD
Aziz37 1952 (1300/652) 0/91/9 34 2.9% vs. 3.4% 2% vs. 1.1% 2.4% vs. 3.5% 14.3% vs. 4.4%a 21.4% vs.
11.1%a
Kapoor38 1210 (633/577) 22/59/19 60 9.4% vs. 7.2% NA NA 33.5% vs. 7.3%a NA
Multivessel Disease
Hlatky9 7812 (3923/3889) 63/37/0 5.9 10.0% vs. 8.4% 16.7% vs. – 24.5% vs. 36.4% vs.
15.4%b 9.9%a,b 20.1%a
Daemen40 3051 (1518/1533) 4/96/0 60 8.5% vs. 8.2% 2.5% vs. 2.9% 6.6% vs. 6.1% 25.0% vs. 6.3%a 34.2% vs.
19.6%a
Bravata41 9963 (5019/4944) 56/42/2 60 9.3% vs. 11.3% 0.6% vs. 1.2%a 11.9% vs. 10.9% 46.1% vs. 40.1% –
vs. 9.8%a,c

aP < .001.
bComposite with death.
cBalloonangioplasty versus PCI versus CABG.
BMS, Bare-metal stent; CABG, coronary artery bypass grafting; DES, drug-eluting stent; LAD, left anterior descending coronary artery; MACCEs, major
adverse cardiovascular and cerebrovascular events (a composite of death, stroke, MI, and repeat revascularization); MI, myocardial infarction; NA, not
available; PCI, percutaneous coronary intervention; POBA, plain old balloon angioplasty; Revasc., revascularization.

TABLE 1.3 Summary of 15 Randomized Control Trials Comparing Coronary Artery Bypass Grafting Against Percutaneous Coronary Intervention in the
Pre-SYNTAX Era
Trial Number of Patients Screened % Randomized Stent % 3VD Proximal LAD EF >50% % Diabetes
MASS39 142 69 – – 100 100 21
ERACI173 127 9 – 45 – 100 11
1
EAST174 392 4 – 40 70 100 25
GABI175 359 4 – 18 – – 10
CABRI176 1054 3 – 40 – 100 12
BARI177 1829 12 – 41 36 100 24
SIMA178 121 – – – 100 100 11
LAUSANNE179 134 3 – 0 100 – 12
RITA180 1011 4 – 12 – – 6
TOULOSE181 152 3 29 – – 14
AWESOME182 454 – + 45 – – –
ERACI-II183 450 2 + 56 – – 17
ARTS184 1205 5 + 32 – 100 19
SOS185 988 5 + 38 45 100 14
MASS II186 408 2 + 41 – – –
Summary 8826 5 35 41 100 16

3VD, Three-vessel disease; CABG, coronary artery bypass grafting; EF, ejection fraction; LAD, left anterior descending artery; PCI, percutaneous coronary intervention.
From Soran O, Manchanda A, Schueler, S. Percutaneous coronary intervention versus coronary artery bypass surgery in multivessel disease: a current
perspective. Interact Cardiovasc Thorac Surg. 2009;8(6):666–671.

The SYNTAX score algorithm
1. Arterial dominance Lesion 1

2. Arterial segments involved per lesion Segment 5: 5×2 10
+ Bifurcation type A 1
Lesion characteristics + Heavy calcification 2
3. Total occlusion Lesion 1 score: 13
i. Number of segments involved LM>50%

ii. Age of the total occlusion (>3 months)
iii. Blunt stump Lesion 2
iv. Bridging collaterals Segment 6: 3.5×2 7
v. First segment beyond the occlusion + Bifurcation type A 1
+ Angulation <70 1
visible by antegrade or retrograde filling + Heavy calcification 2
vi. Side branch involvement Lesion 2 score: 11
LAD>50%
4. Trifurcation
i. Number of segments diseased
5. Bifurcation Lesion 3
Segment 11: 1.5×5 7.5
i. Medina type
Age T.O. is unknown 1
ii. Angulation between the distal main vessel + Blunt stump 1
and the side branch <70 degrees + Side branch 1
6. Aorto-ostial lesion + Heavy calcification 2
Lesion 3 Score: 12.5
7. Severe tortuosity
8. Length >20 mm LCx 100%
9. Heavy calcification Lesion 4

Segment 1: 1×5 5
10. Thrombus Age T.O. is unknown 1
11. Diffuse disease/small vessels + Blunt stump 1
i. Number of segments with diffuse + Side branch 1
disease/small vessels First segment visualized by contrast:4
2
+ Tortuosity 2
+ Heavy calcification 2
RCA 100% Lesion 4 Score: 14
Fig. 1.5 The SYNTAX score algorithm is applied to each individual coronary lesion in a vessel larger than 1.5
mm in diameter that has a stenosis diameter greater than 50%; the individual lesion scores are added together
to give the final SYNTAX score.16,45-47 LAD, Left anterior descending; LCx, left circumflex artery; LM, left main;
RCA, right coronary artery. (Modified from Serruys PW, Onuma Y, Garg S, et al. Assessment of the SYNTAX
score in the SYNTAX study. EuroIntervention. 2009;5:50–56.)
All-cause mortality Myocardial infarction

50 P < .0001
P = .10
Cumulative event rate (%) CABG (n = 897)
PCI (n = 903)
25
13.9%
9.7%
11.4%
0 3.8%
0 12 24 36 48 60 0 12 24 36 48 60
Months since allocation Months since allocation
Number at risk
CABG 897 820 810 788 761 606 897 800 784 759 730 575
PCI 903 859 853 832 803 537 903 832 821 792 756 593
Stroke Death or stroke or myocardial infarction

50 P = .09 P = .03
Cumulative event rate (%)
25 20.8%
3.7% 16.7%
2.4%
0
0 12 24 36 48 60 0 12 24 36 48 60
Number at risk
CABG 897 806 790 763 732 579 897 787 776 749 717 566
PCI 903 854 842 815 782 622 903 830 824 792 756 592
Repeat revascularisation MACCE

50 P < .0001 P < .0001
37.3%
25.9%
25
26.9%
13.7%
0
0 12 24 36 48 60 0 12 24 36 48 60
Number at risk
CABG 897 778 760 717 677 532 897 751 739 694 654 512
PCI 903 760 740 688 644 495 903 747 733 681 634 483
Fig. 1.6 Five-year Kaplan-Meier cumulative event curves of major adverse cardiovascular and cerebrovascular
events (a composite of death, stroke, myocardial infarction and repeat revascularization) and its components
among the 1800 patients randomized to percutaneous coronary intervention (PCI) or coronary artery bypass
grafting surgery (CABG) in the SYNTAX trial. (From Mohr FW, Morice MC, Kappetein AP, et al. Coronary artery
bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main
coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet. 2013;381[9867]:629–638.)
with PCI compared with CABG (26.9% vs. 37.3%, P < .0001; Fig. 1.7, clinical outcomes between patients treated with PCI
Fig. 1.6).15 and CABG in SYNTAX differed according to the presence of
As indicated earlier, analyses of all patients irrespective of 3VD or unprotected LM CAD. With 3VD, a low SYNTAX
disease severity does not provide adequate information for cli- score (<23) allowed for similar outcomes between CABG and
nicians who are faced daily with patients who display a wide PCI, whereas higher SYNTAX scores (particularly in the high
variety of CAD complexity. To address this limitation of earlier SYNTAX score [>32] group) clearly favored CABG. With
studies, patient outcomes in SYNTAX were stratified accord- unprotected LM CAD, a low-intermediate SYNTAX score
ing to tertiles of the anatomic SYNTAX score. As shown in (<33) allowed for similar outcomes between CABG and PCI,
Overall Cohort Left Main Coronary Disease Subgroup Three-Vessel Disease Subgroup
Baseline SYNTAX score 0–22 Baseline SYNTAX score 0–22 Baseline SYNTAX score 0–22
1

50
CABG P = .43 P = .74 P = .21
PCI 32.1% 31.5% 33.3%
25
28.6% 30.4% 26.8%
0
0 12 24 36 48 60 0 12 24 36 48 60 0 12 24 36 48 60
Months since allocation Months since allocation Months since allocation
Number at risk
CABG 275 226 221 212 197 154 104 87 86 80 74 56 171 137 135 133 123 98
PCI 299 263 255 237 223 168 118 109 108 98 93 68 181 154 147 139 130 100
Baseline SYNTAX score 23–32 Baseline SYNTAX score 23–32 Baseline SYNTAX score 23–32
50
P = .008 P = .88 P = .0008 37.9%
36.0% 32.7%
25
32.3%
25.8%
22.6%
0
0 12 24 36 48 60 0 12 24 36 48 60 0 12 24 36 48 60
Number at risk
CABG 300 251 248 230 219 172 92 75 74 66 66 51 208 176 174 164 153 121
PCI 310 257 256 236 221 173 103 91 90 79 78 60 207 166 166 157 143 114
Baseline SYNTAX score ≥33 Baseline SYNTAX score ≥33 Baseline SYNTAX score ≥33
50
P < .0001 P = .003 P = .0005
44.0% 46.5%
41.9%
25
26.8% 29.7%
24.1%
0
0 12 24 36 48 60 0 12 24 36 48 60 0 12 24 36 48 60
Number at risk
CABG 315 272 267 251 237 185 149 130 127 118 112 86 166 142 141 133 125 99
A PCI 290 224 220 206 188 139 B 135 103 101 95 84 60 C 155 121 119 111 104 79
Fig. 1.7 The evidence supporting the use of the SYNTAX score as a tool to assist in revascularization decisions.
Five-year Kaplan-Meier cumulative event curves of major adverse cardiovascular and cerebrovascular events
(MACCEs; a composite of death, stroke, myocardial infarction and repeat revascularization) among the 1800 pa-
tients randomized to percutaneous coronary (PCI) or coronary artery bypass graft surgery (CABG) in the SYNTAX
trial (A) and stratified by the presence of unprotected left main coronary artery disease (B) or de novo three-vessel
disease (C). In patients with three-vessel disease (C), the incidence of MACCEs at 5-year follow-up was similar
among patients treated with PCI and CABG for low SYNTAX scores (≤22); for all other SYNTAX scores (>22), out-
comes were significantly better following CABG. (B) In patients with unprotected left main coronary artery disease,
clinical outcomes were similar among patients treated by PCI or CABG for all low to intermediate SYNTAX scores
(<33), whereas more complex disease (SYNTAX score >32) fared significantly better with CABG. (From Mohr FW,
Morice MC, Kappetein AP, et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention
in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical
SYNTAX trial. Lancet. 2013;381[9867]:629–638.)
whereas a high SYNTAX score (>32) clearly favored CABG. subjects in all tertiles of the anatomic SYNTAX score who had
Furthermore, the SYNTAX score II,7,8 essentially the ana- a long-term mortality that favored either CABG, PCI, or both
tomic SYNTAX score augmented with clinical variables shown revascularization modalities (discussed under “SYNTAX-
directly to affect decision making between CABG and PCI, Based Clinical Tools”).7,8,13–16
was developed in the randomized, all-comers SYNTAX trial The results of SYNTAX reiterate the importance of
and allowed for the identification of higher- and lower-risk assessing patients when selecting a revascularization strategy.
SYNTAX was able to identify those patients in whom either appropriate revascularization modality, which may be modified
CABG or PCI was appropriate or in whom CABG or PCI was by the heart team consensus. In addition to their role in the
the optimal treatment. Considering the distribution of CAD risk stratification of individual patients, these quantitative risk
in SYNTAX, overall one-third of patients with 3VD/LM dis- scores have increasing use in the wider context of overall health
ease were deemed to have CAD that could be treated safely care. They can provide a vital measure of overall patient care
and effectively with PCI or CABG, whereas in the remaining and can help to identify future directions to further improve
two-thirds, CABG remained the standard of care. Although outcomes. Clinical governance and the increasing requirement
these results helped further delineate the boundaries between to publicly report clinical performance and complications have
a percutaneous and surgical revascularization approach in also propelled the need to risk stratify patients, thereby allow-
patients with complex CAD, the validation of the anatomic ing a useful comparison of performance to be made between
SYNTAX score and development of the SYNTAX score II clinicians and institutions against the standards dictated by
notably facilitated a more objective assessment of patients regulatory authorities.67 In addition, calculation of risk using
by the heart team as discussed later under “SYNTAX-Based accepted risk scores may aid clinicians faced with an increasing
Clinical Tools.” need to be able to justify their clinical decisions to peers, regu-
latory bodies, and patients.
INDIVIDUAL ASSESSMENT FROM A PHYSICIAN’S In comparison with the qualitative risk scores, the use of a
finite number of variables results in these risk scores lacking the
PERSPECTIVE sensitivity to accurately predict risk in an individual, such that
There is no disputing the need for and potential benefits of select- they are more apt at predicting risk for a population of patients
ing a revascularization strategy following an individualized patient with similar comorbidities. The number of variables included in
assessment or risk stratification. Risk stratification is performed the score must strike a balance between sufficient numbers to
routinely and subconsciously by physicians in everyday clinical enable a meaningful prediction of risk to be calculated; however,
practice and is in essence behind all clinical decisions made by a the number must not be excessive so as to prevent use in rou-
physician. Stratification of risk is vital when assessing patients for tine practice. In addition, a minimal number of variables reduces
revascularization because this treatment is only considered appro- the chances of colinearity between independent variables, which
priate when “the expected benefits, in terms of survival or health can result in redundant information being collected62 while also
outcomes (symptoms, functional status, and/or QOL) exceed the increasing the chances of “overfitting” the score and thereby
expected negative consequences of the procedure.”51 However, it reducing the overall applicability and accuracy of the results to
should be emphasized that the SYNTAX-pioneered heart team conventional clinical practice.68
approach, consisting of at least an interventional/clinical cardi- The applicability of a risk score to contemporary practice must
ologist and a cardiac surgeon,50 carries a class I recommendation also take into consideration the time when the score was developed.
in international guidelines for assessing risk and is subsequently Risk scores rely on large patient databases to derive appropriate
the most appropriate revascularization modality in patients with weighting factors for variables in the score to enable the final calcu-
complex CAD.52–55 lation of risk. It follows that they are developed using retrospective
information that may no longer be relevant in the era when the risk
score is being used. For example, the EuroSCORE was developed
Qualitative Versus Quantitative Risk Assessment in 1999; however, there have been calls for its recalibration because
Qualitative risk stratification is subjective and relies on a clini- repeated evaluations indicate that it overestimates risk by a factor
cian’s experience. This subjective qualitative assessment also of 2 to 3, which has largely been attributed to improvements in
allows risk to be calculated and tailored to the expertise of the surgical techniques and lower perioperative mortality in the decade
physician performing the procedure, as opposed to a clinician following its construction.69,70 The updated EuroSCORE II cur-
in another region who may use different techniques and who rently addresses many of the limitations of the original EuroS-
may have different equipment available. In addition, assessments CORE.71–73 The STS score is also derived from a large patient
of patient frailty can be made that are frequently not captured database and is periodically recalibrated to ensure its results are
by conventional risk-scoring systems.56 This assessment does applicable to contemporary practice.74
not require a calculator or computer and can be “computed”
subconsciously very quickly. The major disadvantages of this
method of risk assessment are its dependence on the operator’s
Risk Scores in Contemporary Practice
prior experience, potential personal bias to undertake or with- Numerous risk scores are available to assist clinicians in strati-
hold potential revascularization, and its high interobserver vari- fying risk among patients undergoing revascularization. Some
ability. In addition, influences of local practice often dominate scores are appropriate for patients prior to the selection of a
clinical decision making, irrespective of the revascularization revascularization strategy, whereas some have been validated
guidelines. only in patients undergoing one form of revascularization.
Quantitative risk stratification can be performed using a vari- Nevertheless, the various risk scores can largely be categorized
ety of risk scores that frequently incorporate clinical variables according to the variables—clinical, angiographic, or a combina-
sourced from large patient registries,57–64 with the exception tion of both—used in the overall estimation of risk. Tables 1.4
of the SYNTAX score II,7,8 which was developed in the all- and 1.5 summarize the different risk scores used in contemporary
comers randomized SYNTAX trial to reduce unavoidable (but CABG and PCI practice (excluding SYNTAX-based tools), and
often appropriate) selection bias inherent to all registries no Table 1.6 summarizes SYNTAX-based clinical tools. A selection
matter their size. These risk scores largely incorporate objec- of these is described in more detail later.
tive variables to ensure adequate reproducibility of the score;
however, those risk scores—such as the American College of
Cardiology/American Heart Association (ACC/AHA) lesion
Clinical Scores
score65 or the anatomic SYNTAX score/newly developed These risk scores incorporate only clinical variables and do not
SYNTAX score II,7,8,46 which include angiographic variables— require any data from the angiogram. They offer the advantage
continue to have documented intraobserver and interobserver of being able to be computed relatively quickly, usually at the
variability.47,66 However, these tools do provide a more objec- bedside, and principally include variables that are not subject to
tive assessment of the patient risk and suitability for the most user interpretation, thereby ensuring excellent reproducibility.
TABLE 1.4 Summary of Contemporary Risk Scores for Assessment of Risk in Patients Undergoing Surgical Revascularization With the Exception of the
Anatomic SYNTAX Score 1
Number of Variables Used to Calculate Score Validated in PCI/CABG
Risk Score Clinical Angiographic PCI CABG
EuroSCORE13,57-59,75,76,80–84 17 0 + +
EuroSCORE II71–73 18 0 − +
ACEF62 3 0 − +
Society of Thoracic Surgery score64,74,87,104 40 2 − +
Anatomic SYNTAX score4,13,47,81,84,94,95,187–194 0 11 (per lesion) + +

SYNTAX-based tools are shown in Table 1.6.
ACEF, Age, creatinine, and ejection fraction; CABG, coronary artery bypass grafting; PCI, percutaneous coronary intervention.

EuroSCORE and EuroSCORE II Similarly, at intermediate follow-up of 23 months, Rodés-Cabau

The EuroSCORE is an established risk score that uses 17 clinical and colleagues83 identified a EuroSCORE of 9 or higher as the
variables used in cardiothoracic surgical practice for predicting best predictor of MACCE after PCI and CABG among 249 octo-
operative mortality, and it has been validated in many popula- genarians with LM disease. In the MAIN-COMPARE registry,
tions around the world.58,75–77 In use since 1999, the score was which enrolled more than 1500 patients with LM disease followed
derived from almost 20,000 consecutive patients from 128 hos- up for a median of 3.1 years, the EuroSCORE has been identified
pitals in eight European countries. The additive EuroSCORE as an independent predictor of death, MI, and stroke irrespective
assigns an individual score to 17 clinical variables (Table 1.7) with of revascularization strategy.84 In addition, in the same registry, a
a low-risk tertile that ranges from 1 to 2, an intermediate-risk ter- EuroSCORE of 6 or higher has been shown to be an independent
tile from 3 to 5, and a high-risk tertile of 6 and higher. However, predictor of mortality following either PCI or CABG.82
early validation studies suggested that the additive EuroSCORE More recently, the EuroSCORE II (Table 1.8) was devel-
underestimated risk in those at highest risk; this led to the developed to improve the risk prediction of the original EuroSCORE.
opment of the logistic EuroSCORE, which uses the same clini- EuroSCORE II was developed on newer data to reflect more con-
cal variables and requires use of an online calculator (available temporary surgical practice given that cardiac surgical mortality
at www.euroscore.org) to quantify risk.58,59,70,77 However, the has decreased significantly in the last 15 years, despite patients
logistic EuroSCORE has been shown to potentially overestimate being older and sicker, and that the previous additive and logistic
observed mortality, and its accuracy at predicting risk varies in EuroSCOREs were suggested to be representative of outdated
different surgical subgroups.70,78 surgical practices.71–73,85
In addition to the EuroSCORE’s assessment and validation The EuroSCORE II was shown to have improved calibra-
in patients undergoing surgical revascularization, Kim and col- tion (actual mortality 4.18%, predicted 3.95%) compared with
leagues79 first demonstrated that the high-risk tertile of the addi- the original EuroSCORE (actual 3.9%, additive predicted
tive EuroSCORE was an independent predictor of death/MI 5.8%, logistic predicted 7.57%) while preserving discrimina-
after unprotected LM intervention with sirolimus-eluting stents. tion (area under the receiver operating characteristic [ROC]
Subsequently, Romagnoli and coworkers80 applied the additive curve of 0.8095). However, it should be noted that regular
EuroSCORE to predict in-hospital mortality in 1173 consecu- revalidation of the EuroSCORE II will need to be continued
tive patients undergoing PCI in a single high-volume center and to identify calibration drift or clinical inconsistencies seen in
correlated the higher-risk tertiles of the EuroSCORE with in- previous versions.85,86
hospital mortality; the study population also included patients In summary, while acknowledging that most of these studies
who had undergone unprotected LM PCI. The EuroSCORE has have been nonrandomized observational studies, the findings do
since been evaluated in numerous studies of patients undergoing suggest that the EuroSCORE and EuroSCORE II are valuable
PCI, the majority of which specifically enrolled patients with LM tools in the individual assessment of risk prior to the selection of
disease.13,79,81–83 Notably, all studies, irrespective of disease sever- a revascularization strategy.
ity, have demonstrated the EuroSCORE to be an independent
predictor of mortality81,82 and/or MACCE at follow-up ranging New Mayo Clinic Risk Score
from 1 to 3 years.13,79,81–83 Importantly, those studies that also The new Mayo Clinic Risk Score (MCRS) was designed to replace
included a surgical control group—such as the SYNTAX study, the original MCRS by predominantly excluding angiographic vari-
the Revascularization for Unprotected Left Main Coronary ables, namely the presence of LM or MVD, and a few of the inter-
Artery Stenosis: Comparison of Percutaneous Coronary Angio- action effects of specific clinical variables (see Table 1.5).
plasty Versus Surgical Revascularization (MAIN-COMPARE) The new MCRS is based solely on baseline clinical and
study, and the registry by Rodés-Cabau and colleagues83—also noninvasive assessments and incorporates seven preprocedural
demonstrated the EuroSCORE to be an independent predictor variables (age, serum creatinine, left ventricular ejection frac-
of MACCE in surgical patients.81,84 Only one study has exam- tion [LVEF], MI within the past 24 hours, preprocedural shock,
ined the logistic EuroSCORE in PCI patients; however, little dif- congestive heart failure, and peripheral vascular disease). The
ferences were found in stratifying risk when compared with the risk score had a C-statistic (area under ROC curve) of 0.74
additive EuroSCORE.80 and 0.89 for major adverse cardiovascular events (MACEs) and
Specifically in the SYNTAX trial, which represents the only procedural death, respectively, in the population from whom
randomized study to assess the EuroSCORE, the additive Euro the risk score was derived.60,61 The risk score has since been
SCORE was shown to be an independent predictor of MACCE validated for in-hospital mortality in the NCDR61; however, it
at 1-year follow-up irrespective of the method of revasculariza- has not been validated for MACEs. The new MCRS has also
tion (odds ratio [OR]: 1.21; 95% confidence interval [CI]: 1.12 to been demonstrated to be predictive of in-hospital mortality
1.32; P < .001) in 705 patients undergoing LM revascularization.81 after CABG surgery.87
TABLE 1.5 Summary of a Selection of Established and Contemporary Risk Scores Categorized by Anatomic, Clinical, or Combined Types for the
Assessment of Risk in Patients Proposing to Undergo Percutaneous Coronary Intervention
Number of Variables Used
to Calculate Risk
Clinical Risk Score Clinical Angiographic PCI Outcomes (Surgical Outcomes in Italics)
Anatomic Scores
ACC/AHA lesion 0 11 (per lesion) Pre-DES era: predictive of angiographic success of PCI and prognostic effect on early and
classificationa late clinical outcomes. Conflicting results were yielded in the DES era.93,95,195–197
Myocardial Jeopardy Scores
Duke Jeopardy Score 0 Coronary tree divided into six segments: LAD, diagonal, septal perforating branches, LCx, OM, and PDA; a
segment distal to ≥70% is considered at risk. Each segment is assigned 2 points with a maximum of 12
points.96,97b
Myocardial Jeopardy Index 0 Distal terminating portions of LAD, LCx, RCA, and major branch vessels (diagonals, OM, ramus, PDA and
(BARI) LV branches) assigned units of 1, 2, or 3 on the basis of length and vessel size. Septal perforators are
arbitrarily assigned a maximum of 3 units. Extent of jeopardy defined by units jeopardized by ≥50% stenosis
summated and divided by total LV territory.97,98b
APPROACH lesion score 0 Based on principle from autopsy studies that the LAD generally subtends 41% of the LV, with the LCx and RCA
supplying the remainder, dependent on vessel dominance. Score is calculated by percent of myocardium
supplied by a vessel or its branches and jeopardized territories supplied by vessels with ≥70% stenosis
(≥50% in the LMS); the maximum score is 100.97b
Clinical Scores
New Mayo Clinic Risk Scorea 7 0 Procedural death and MACEs for PCI; score has been externally validated for death62,63
(in-hospital death with CABG).87
Parsonnet Score 14 0 Independent predictor of long-term MACEs after LMS PCI in two registry
populations198,199 (operative mortality after open-heart surgery)200
EuroSCORE (additive or 17 0 Evidence for predicting death or MACCEs in high-risk tertiles for PCI79,80,83,201 (operative
logistic) mortality for all forms of cardiothoracic surgery).58,61
NCDR CathPCI Risk Scorea 8 0 Developed from 181,775 procedures performed in Medicare patients; incidence of
in-hospital and 30-day mortality after all PCI patient types internally validated in two
separate cohorts.65
ACEF score (age, creatinine, 3 0 Predictor of cardiac death and MI at 1 year after PCI; inferior to the SYNTAX score at
ejection fraction) predicting overall MACEs and repeat revascularization in two separate populations90,122
(operative mortality in elective cardiac operations).62,88
Combined (Anatomic AND Clinical) Risk Scores
EuroHeart PCI Scorea 10 6 Developed from 46,000 patients from the Euro Heart Survey; in-hospital mortality in all
PCI patient types; internally validated. The score has strong applicability for European
practice.105
New Risk Stratification 17 Angiographic: 33 6-month cardiac death and cumulative MACEs after unprotected LMS PCI; although
Score (NERS) Procedural: 4c internally validated, application to larger all-comers population is required (see text).106
New York PCI Risk Scoreb 8 1 In-hospital death after PCI; developed based on data from 46,090 procedures in 2002
and validated from 50,046 procedures in 2003202; excellent predictive ability in
validation cohort (C-statistic 0.905).
The Texas Heart Institute 8 Angiographic: 2 Predictors of in-hospital MACEs after PCI or CABG; developed in 9494 patients (BMS era)
Risk Scorea Procedural: 1d and validated in 5545 patients (DES era).203
Mayo Clinic Risk Scorea 6 2 In-hospital death, Q-wave myocardial infarction, emergent or urgent CABG or CVA after
PCI; validated using the NHLBI registry.204

aRiskscores that include prediction of in-hospital mortality or MACEs. SYNTAX-based tools are shown in Table 1.6.
bAll
myocardial jeopardy scores were validated in one population-based cohort consisting of more than 20,000 patients and were predictive of 1-year
mortality in patients treated with PCI or medically.96–98
cNeed of intraaortic balloon pump, two-stent technique, intravascular ultrasound guidance.
dNumber of stents.
ACC/AHA, American College of Cardiology/American Heart Association; BMS, bare-metal stent; CABG, coronary artery bypass grafting; CVA,
cerebrovascular accident; DES, drug-eluting stent; LAD, left anterior descending artery; LCx, left circumflex artery; LMS, left main stem; LV, left
ventricular; MACCEs, major adverse cardiovascular and cerebrovascular event; MACE, major adverse cardiovascular event; MI, myocardial infarction;
NCDR, National Cardiovascular Data Registry; OM, obtuse marginal artery; PCI, percutaneous coronary intervention; PDA, posterior descending artery;
NHLBI, National Heart, Lung, and Blood Institute; RCA, right coronary artery.

TABLE 1.6 Outline of the Anatomic SYNTAX Score and the Progression of SYNTAX-Based Tools
1
Year Structure Remarks
Anatomic SYNTAX 2006 Score of angiographic variables (i.e., anatomic First reported to be useful for decision making between CABG
Score4,13-15,48,55,60,64–72,166 complexity); developed during the design and PCI in the SYNTAX trial in 200913; categories of anatomic
of the SYNTAX trial13,47 as a tool to force complexity (low, intermediate, and high), no clinical variables, no
the heart team to systematically analyze the individual predictions; adding a functional component shown to
coronary angiogram and agree equivalent improve accuracy13; noninvasive multislice computed tomography
anatomic revascularization (CABG and PCI) anatomic SYNTAX score in development,36 with integration of a
could be achieved noninvasive functional component.162
Development Phase: Augmenting the Anatomic SYNTAX Score With Clinical Variables and the Move Toward Individualized Decision Making
ACEF163 2009 Age, creatinine, ejection fraction Predicted individual in-hospital operative mortality post CABG;
shown to be at least comparable to the EuroSCORE (composed
of 17 variables) in predicting operative risk62,88,89; shown to aid in
long-term predictions of mortality after PCI or CABG.62,89
Clinical SYNTAX Score127 2010 Amalgamation of SYNTAX score with modified Similar to the SYNTAX score; categorized patient risk; could only
ACEF score (creatinine replaced with CrCl identify a high-risk group in PCI-treated patients; provided
shown to be more predictive of mortality121) little help in decision making between CABG and PCI; not
individualized.
Global Risk88,123 2010 Amalgamation of SYNTAX score with surgical Similar to the SYNTAX score; categorized patient risk; could identify
EuroSCORE (composed of 17 variables) a low-risk group with comparable outcomes with CABG and
PCI in LM and 3VD patients; not individualized; patients with
a high EuroSCORE were found to have a prognostic benefit in
undergoing CABG compared with PCI irrespective of the SYNTAX
score provided an acceptable threshold of operative risk was not
exceeded.
Logistic Clinical SYNTAX 2011 Combination of age, SYNTAX score, CrCl, Individual 1-year mortality predictions in all PCI patients (STEMI,
Score126,127 and LVEF shown to contain most of NSTEMI) irrespective of clinical presentation (except cardiogenic
the prognostic data for 1-year mortality shock); not designed to help decision making between CABG and
predictions after PCI PCI; cross-validated in seven contemporary stent trials and more
than 6000 patients and further externally validated.123
End Result of This Process Leading to the Development of the SYNTAX Score II
SYNTAX Score II124 2012 Augmenting SYNTAX score with clinical Individualized approach; threshold of the SYNTAX score in guiding
variables; based on the principle that age, decision making between CABG and PCI shown to alter based
CrCl, LVEF, and SYNTAX score contain most on the presence of other risk factors; validated in the DELTA
of the long-term prognostic data in CABG Registry7,8 containing LM and 3VD (25% of the population) with
and PCI patients; additional variables added almost a third (30%) with highly complex disease (SYNTAX scores
that directly influenced decision making ≥33); prospective validation studies are underway in the EXCEL
between CABG and PCI trial (LM), and SYNTAX II trial is ongoing (de novo 3VD).
Use of the SYNTAX Score as an Objective Marker of Completeness of Revascularization
Residual SYNTAX 2012 Recalculation of the SYNTAX score after PCI Developed and validated in the ACUITY146,147 and SYNTAX146 trials;
Score129 a residual SYNTAX score greater than 8 was shown to have an
adverse effect on long-term prognosis at up to 5-year follow-up;
further, prospectively run validation studies are awaited.
Post-CABG SYNTAX 2013 Recalculation of the SYNTAX score after CABG Pilot study in angiographic substudy of the SYNTAX trial
Score147 with points deducted based on the demonstrated the feasibility of this approach in identifying
importance of the diseased coronary artery subjects post CABG with an adverse long-term (5-year)
segment (Leaman score154,155) that has a prognosis109; validation studies are awaited.
functioning bypass graft anastomosed distally

3VD, Three-vessel disease; CABG, coronary artery bypass grafting; CrCl, creatinine clearance; LM, left main; LVEF, left ventricular ejection fraction;
NSTEMI, non–ST elevation myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST elevation myocardial infarction.

Value of Age, Creatinine, and Ejection Fraction Score From ACEF, a mortality risk can be calculated from a
Ranucci and colleagues62,88 demonstrated in a relatively simple risk graphical relationship of ACEF with an operative risk or an
score consisting of only three clinical variables—age, preoperative equation (Fig. 1.8).62,88 ACEF was developed from an initial
serum creatinine value, and LVEF—a risk score for assessing oper- dataset of 4557 patients and a subsequent validation series of
ative mortality risk in elective cardiac operations. Notably, despite 4091 patients from a single institution. The results demon-
the simplicity of the score, the clinical performance of the Age, strated a similar accuracy and calibration for the prediction of
Creatinine, and Ejection Fraction (ACEF) score appeared to be in-hospital mortality with ACEF when compared with other
comparable with either the additive or the logistic EuroSCORE. more complicated surgical risk scores such as the EuroSCORE
The ACEF score is calculated using the following formula: and the Cleveland Clinic Score. Subsequent validation studies
have shown ACEF to have an accuracy level at least compa-
ACEF = [Age/LVEF (%)] + [1 (if creatinine>2 mg/dL)]
rable with that of the EuroSCORE for operative mortality risk
TABLE 1.7 Components of the EuroSCORE and Relevant Weighting Factors of the Additive and Logistic EuroSCOREs
Patient Characteristics Additive Logistic β Coefficient
Age Per 5 years or part thereof over the age of 60 years 1 0.07
Sex Female 1 0.33
Chronic pulmonary disease Long-term use of bronchodilators or steroids for respiratory disease 1 0.49
Peripheral arteriopathy Claudication, carotid stenosis >50%, previous or planned intervention on 2 0.66
the abdominal aorta, limb arteries, or carotidsa
Neurologic dysfunction Severely affected mobility or day-to-day function 2 0.84
Previous cardiac surgery Previous opening of the pericardium 3 1.00
Serum creatinine Preoperatively greater than 200 μmol/L 2 0.65
Active endocarditis Antibiotic therapy at time of surgery 3 1.10
Critical preoperative state Preoperative cardiac arrest, ventilation, renal failure, inotropic support, 3 0.91
intraaortic balloon pump use, ventricular arrhythmiaa
Cardiac-Related Factors
Unstable angina Rest pain that requires IV nitrates 2 0.57
Left ventricular function Moderate (30%–50%) 1 0.42
Poor (<30%) 3 1.09
Recent MI Within 90 days 2 0.55
Pulmonary hypertension Systolic pulmonary pressure greater than 60 mm Hg 2 0.77
Operation-Related Factors
Emergency Operation performed before the start of next working day 2 0.71
Other than isolated CABG Major cardiac procedure other than or in addition to CABG 2 0.54
Surgery on thoracic aorta 3 1.16
Postinfarct septal rupture 4 1.46
Constant β0 −4.79

aAny of these.
The logistic EuroSCORE can be calculated at www.euroscore.org.
CABG, Coronary artery bypass grafting; IV, intravenous; MI, myocardial infarction.
From Singh M, Rihal CS, Lennon RJ, et al. Bedside estimation of risk from percutaneous coronary intervention: the new Mayo Clinic Risk Scores. Mayo
Clinic Proc. 2007;82:701–708; and Singh M, Peterson ED, Milford-Beland S, et al. Validation of the Mayo Clinic risk score for in-hospital mortality after
percutaneous coronary interventions using the National Cardiovascular Data Registry. Circ Cardiovasc Interv. 2008;1:36–44.

stratification in a series of 29,659 patients undergoing elective

cardiac surgery.88,89
Angiography-Based Scores
In addition, ACEF was applied to PCI patients from the all- Two major angiography-based scores have been developed,
comers LEADERS population at 1-year follow-up.90 Despite both of which are independent of patient clinical variables, cal-
ACEF being demonstrated to be superior to the SYNTAX score culated using only angiographic data. As alluded to earlier, this
alone as a predictor of cardiac death and MI after PCI, ACEF was introduces a subjective element to the assessment of risk47,66 and
found to be inferior to the SYNTAX score at predicting overall consequently introduces a degree of intraobserver and interob-
MACE rates and the risk of repeat revascularization. This reflects server variability, which is notably absent from the clinical scores
the observation that anatomic and clinical variables appear to be described previously. In addition, these scores can be computed
necessary requirements for a comprehensive risk score in predict- only after diagnostic coronary angiography has been performed,
ing clinical outcomes after PCI. thereby moving assessment further down the treatment pathway.
National Cardiovascular Database Registry CathPCI Risk- American College of Cardiology/American Heart
Prediction Score Association Lesion Classification System
The NCDR CathPCI risk-prediction score is the most con- The ACC/AHA lesion classification system was one of the first
temporary clinical risk score currently available. It incorpo- angiographic scoring systems developed. Initially devised in 1986
rates information from nine clinical variables (Table 1.9), and modified in 1990, it uses 11 angiographic variables to catego-
which are assigned appropriate weighted values and are then rize lesions into four groups: types A, B1, B2, and C (Table 1.10).
added together to give a final score that can be translated into Historic studies prior to the arrival of DESs indicated that that
risk of in-hospital mortality (Fig. 1.9).63 The score was devel- the ACC/AHA lesion classification did have a prognostic impact
oped using data from more than 180,000 patients from the vol- on early and late outcomes.65,91,92
untary U.S. NCDR database and was validated in more than However, registry data from the DES era has shown con-
400,000 patients from the same database who underwent PCI flicting results. The German Cypher registry (n = 6755) failed
between March 2006 and March 2007. Notably, the C-statistic to show any definite relationship between clinical outcomes and
for the prediction of in-hospital mortality was consistently ACC/AHA lesion class at 6 months.93 These results are at vari-
greater than 0.90 for in-hospital mortality, whereas a lower but ance to the positive relationship identified between ACC/AHA
nevertheless adequate C-statistic of 0.83 was seen for 30-day lesion class and clinical outcomes in smaller studies of patients
mortality. with more complex disease.94,95
TABLE 1.8 Final Risk Factors by Multivariate Regression for the EuroSCORE II
1
Risk Factor Coefficient Standard Error z P ≥ |z| [95% Confidence Interval]
New York Hospital Association (NYHA)
II 0.1070545 0.1463849 0.73 0.465 [−0.1798547 to 0.3939637]
III 0.2958358 0.141466 2.09 0.037 [0.0185674 to 0.5731042]
IV 0.5597929 0.1697565 3.30 0.001 [0.2270763 to 0.8925095]
CCS4 0.2226147 0.1462888 1.52 0.128 [−0.0641061 to 0.5093356]
IDDM 0.3542749 0.145863 2.43 0.015 [0.0683887 to 0.6401611]
Age 0.0285181 0.0065954 4.32 0.000 [0.0155914 to 0.0414448]
Female 0.2196434 0.0953505 2.30 0.021 [0.0327599 to 0.4065269]
ECA 0.5360268 0.1106046 4.85 0.000 [0.3192458 to 0.7528079]
CPD 0.1886564 0.1232126 1.53 0.126 [−0.0528358 to 0.4301486]
N/M mob 0.2407181 0.1729494 1.39 0.164 [−0.0982564 to 0.5796927]
Redo 1.118599 0.1226272 9.12 0.000 [0.8782539 to 1.3589440]
Renal Dysfunction
On dialysis 0.6421508 0.3083468 2.08 0.037 [0.0378021 to 1.2464990]
CC ≤ 50 0.8592256 0.1446758 5.94 0.000 [0.5756663 to 1.1427850]
CC 50–85 0.303553 0.1240518 2.45 0.014 [0.0604159 to 0.5466901]
Active endocarditis 0.6194522 0.2046001 3.03 0.002 [0.2184433 to 1.0204610]
Critical 1.086517 0.147657 7.36 0.000 [0.797115 to 1.3759200]
Left Ventricular Function
Moderate 0.3150652 0.1036182 3.04 0.002 [0.1119773 to 0.5181530]
Poor 0.8084096 0.1498233 5.40 0.000 [0.5147614 to 1.1020580]
Very poor 0.9346919 0.2917754 3.20 0.001 [0.3628227 to 1.5065610]
Recent MI 0.1528943 0.136257 1.12 0.262 [−0.1141646 to 0.4199531]
Pulmonary Artery Systolic Pressure
31–55 mm Hg 0.1788899 0.1266713 1.41 0.158 [−0.0693812 to 0.4271611]
≥55 0.3491475 0.1676641 2.08 0.037 [0.0205318 to 0.6777632]
Urgency
Urgent 0.3174673 0.1174178 2.70 0.007 [0.0873326 to 0.5476020]
Emergency 0.7039121 0.1719835 4.09 0.000 [0.3668306 to 1.0409940]
Salvage 1.362947 0.33706 4.04 0.000 [0.7023221 to 2.0235730]
Weight of Procedure
1 non-CABG 0.0062118 0.1463574 0.04 0.966 [−0.2806434 to 0.2930670]
2 0.5521478 0.1268137 4.35 0.000 [0.3035975 to 0.8006980]
3+ 0.9724533 0.1463969 6.64 0.000 [0.6855206 to 1.2593860]
Thoracic aorta 0.6527205 0.221183 2.95 0.003 [0.2192097 to 1.0862310]
Constant −5.324537 0.1682446 −31.65 0.000 [−5.65429 to −4.9947830]

CABG, Coronary artery bypass grafting; CC, creatinine clearance; CCS, Canadian Cardiovascular Society; CPD, chronic pulmonary dysfunction; Critical,
critical preoperative state; ECA, extracardiac arteriopathy; IDDM, insulin-dependent diabetes mellitus; N/M mob, neurologic or musculoskeletal
dysfunction severely affecting mobility; MI, myocardial infarction; Redo, previous cardiac surgery.
Weight of procedure: 1, non-CABG, single major cardiac procedure (MCP) that is not isolated CABG; 2, two MCPs; 3+, three or more MCPs. For age, Xi =
1 if patient age is 60 or younger; Xi increases by one point per year thereafter (e.g., age 60 or less, Xi = 1; age 61, Xi = 2; age 62, Xi = 3, etc.).
From Nashef SA, Roques F, Sharples LD, et al. EuroSCORE II. Eur J Cardiothorac Surg. 2012;41(4):734–744.

Specifically, Valgimigli and colleagues94 reported that a higher objectively quantified. This is further discussed in the section on
ACC/AHA lesion score (derived by assigning 1, 2, 3, and 4 points SYNTAX-based scoring tools.
to type A, B1, B2, and C lesions, respectively) correlated with
poor clinical outcomes among 306 patients with 3VD undergoing Myocardial Jeopardy Scores
PCI with a DES. In addition, data from a small registry (n = 255) Myocardial jeopardy scores are a method of estimating the
were potentially predictive of mortality and MACEs in unpro- amount of myocardium at risk based on the assessment of both
tected LM stem PCI at 1-year follow-up.95 the severity of the coronary artery lesion and the volume of
myocardium it supplies. Examples of such scores include the
Anatomic SYNTAX Score Duke Jeopardy Score, the Myocardial Jeopardy Index from the
The anatomic SYNTAX score represents a comprehensive angi- Bypass Angioplasty Revascularization Investigation (BARI) score,
ographic scoring system that allows the complexity of CAD to be and the Alberta Provincial Project for Outcome Assessment in
72
70
68 Age (years)
ACEF score = + 1 (if serum creatinine ≥ 2 mg/dL)
66 EF (%)
64
62
60
58
56
54
52
50
48
Predicted mortality rate (%)
46
44
42
40
38
36
34
32
30
28
26
24
22
20
18
16
14
12
10
8
6
4
2
0
0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 2.2 2.4 2.6 2.8 3.0 3.2 3.4 3.6 3.8 4.0 4.2 4.4 4.6 4.8 5.0 5.2
ACEF score
Fig. 1.8 Univariate association (logistic regression) between age, creatinine, and ejection fraction (ACEF)
score—the value of age, creatinine, and ejection fraction—and mortality risk. (From Ranucci M, Castelvecchio
S, Menicanti L, et al. Risk of assessing mortality risk in elective cardiac operations: age, creatinine, ejection
fraction, and the law of parsimony. Circulation. 2009;119[24]:3053–3061.)
Coronary Heart Disease (APPROACH) score (Fig. 1.10; see SYNTAX-based tools to assess completeness of revasculariza-
Table 1.5). The Duke and BARI scores were developed and vali- tion (see Table 1.6) after CABG and PCI have been developed
dated in relatively small populations. All three scores have since and are discussed in the section on SYNTAX-based tools.
been validated in one population-based cohort consisting of more
than 20,000 patients and were predictive of 1-year mortality in
patients treated with PCI or treated medically; within this pop-
Combined Risk Scores
ulation, all three scores also had similar performance measures The previous discussion has reviewed risk scores that rely on
with only minor differences in C-statistics evident.96–98 either clinical or angiographic variables (with the exception
It has since been shown that the Duke Jeopardy Score is an of SYNAX-based clinical tools). There is no disputing that
independent predictor of adverse clinical outcomes, namely death for a complete individualized patient assessment, both fac-
and MI, in medically treated patients with acute coronary syn- tors must be taken into consideration. Moreover, current evi-
dromes (ACSs) at up to 1 year in a post hoc study of the Acute dence indicates that clinical and angiography-based risk scores
Catheterization and Urgent Intervention Triage Strategy (ACU- may be better suited to predict different patient outcomes.
ITY) trial.99 Clinical scores appear to be better at predicting clinical end
The BCIS-1 (balloon pump-assisted coronary intervention points such as death or MI, whereas angiography-based scores
study) Myocardial Jeopardy Score, a variant of the Duke Jeopardy appear to be superior for the prediction of angiographic suc-
Score that has been reported to be simpler to use, has recently cess and the risk of repeat revascularization. Of note, Peterson
been shown to have a strong correlation with the myocardial isch- and coworkers63 observed only a minimal improvement in the
emic burden as assessed by cardiac magnetic resonance perfusion ability of the NCDR CathPCI risk score to predict in-hos-
imaging.100,101 A BCIS-1 Jeopardy Score of 10 to 12 and a revas- pital mortality following the inclusion of angiographic vari-
cularization index (preprocedural minus postprocedural jeopardy ables. These findings are in line with previous reports, which
scores divided by preprocedural jeopardy score, with 1 indicating demonstrated that the MCRS was superior to the ACC/AHA
complete revascularization) of 0 to 0.33 were both shown to be lesion classification in the prediction of death, stroke, MI, and
highly predictive of mortality after contemporary PCI in a single emergent CABG but was inferior for the prediction of angio-
U.K. center experience that involved over 600 patients.102 graphic failure.103
TABLE 1.9 National Cardiovascular Database TABLE 1.10 American College of Cardiology/American Heart
Association Characteristics of Type A, B, and C Lesions 1
Variable Scoring Response Categories
Type A Lesions (high success, >85%; low risk)
Age <60 ≥60, <70 ≥70, <80 ≥80
Discrete (<10 mm length)
Weighted score 0 4 8 14 Concentric
Cardiogenic shock No Yes Readily accessible
Nonangulated segment (<45 degrees)
Weighted score 0 25 Smooth contour
Prior CHF No Yes Little or no calcification
Less than totally occlusive
Weighted score 0 5 Not ostial in location
Peripheral vascular disease No Yes No major branch involvement
Absence of thrombus
Weighted score 0 5
Type B Lesions (moderate success, 60%–85%; moderate risk)
Chronic lung disease No Yes
Tubular (10–20 mm in length)
Weighted score 0 4 Eccentric
GFR (mL/min) <30 30 to 60 60 to 90 >90 Moderate tortuosity of proximal segment
Moderately angulated segment, 45–90 degrees
Weighted score 18 10 6 0 Irregular contour
NYHA Class IV No Yes Moderate to heavy calcification
Ostial in location
Weighted score 0 4
Bifurcation lesions requiring double guidewires
PCI Status (STEMI) Elective Urgent Emergent Salvage Some thrombus present
Total occlusion less than 3 months old
Weighted score 12 15 20 38
Type B lesions are further subdivided into subtypes B1 (one type B
PCI Status (no STEMI) Elective Urgent Emergent Salvage characteristic) and B2 (two type B characteristics)
Weighted score 0 8 20 42 Type C Lesions (low success, <60%; high risk)

Diffuse (>2 cm length)
CHF, Congestive heart failure; GFR, glomerular filtration rate; NYHA, New
Excessive tortuosity of proximal segment
York Heart Association; PCI, percutaneous coronary intervention;
Extremely angulated segments (>90 degrees)
STEMI, ST elevation myocardial infarction.
Inability to protect major side branches
The risk of in-hospital mortality is derived using Fig. 1.11.
Degenerated vein grafts with friable lesions
Registry risk score from Peterson ED, Dai D, DeLong ER, et al. Contem-
Total occlusion more than 3 months old
porary mortality risk prediction for percutaneous coronary intervention:
results from 588,398 procedures in the National Cardiovascular Data Krone RJ, Laskey WK, Johnson C, et al. A simplified lesion classification
Registry. J Am Coll Cardiol. 2010;55:1923–1932. for predicting success and complications of coronary angioplasty. Reg-

istry Committee of the Society for Cardiac Angiography and Interven-
tion. Am J Cardiol. 2000;85:1179–1184.

According to the variables assessed in the risk score, these

100 differential outcomes have raised interest in combined risk
95 scores, which assess risk by considering both clinical and angi-
90 ographic variables. In view of this, several combined clinical
85 and angiographic risk scores have been developed. Other than
80 the STS score, the newer combined scores have yet to be vali-
Risk of in-hospital mortality (%)
75 dated in large patient populations, such that outcome data are

70
65
currently confined to small, retrospective studies with limited
60 follow-up. The most prominent combined risk scores are dis-
55 cussed here.
50
45 Society of Thoracic Surgery Score
40 The STS score predicts the risk of operative mortality and mor-
35 bidity after cardiac surgery and is calculated by means of an online
30
25 calculator (www.sts.org) that requests information on 40 clini-
20 cal and two angiographic variables (presence of LM lesion and
15 number of vessels diseased).64,74 As alluded to earlier, the STS
10 score undergoes periodic recalibration, which is vital to ensure
5 that its results remain applicable to contemporary practice. In
0 comparison with other clinical risk scores in patients undergoing
0 10 20 30 40 50 60 70 80 90 100
CABG, the STS score has been shown to be superior to both the
NCDR risk score MCRS87 and the EuroSCORE.104 However, notably, no evalua-
Fig. 1.9 The predicted risk of in-hospital mortality using the National tion has been done of the STS score in patients undergoing PCI,
Cardiovascular Database Registry (NCDR) risk score. (From Peterson nor has any comparison been made between the STS score and
ED, Dai D, DeLong ER, et al. Contemporary mortality risk prediction angiography-based scores. Consequently, the role of the STS
for percutaneous coronary intervention: results from 588,398 proce- score in the assessment of patients undergoing revasculariza-
dures in the National Cardiovascular Data Registry. J Am Coll Cardiol. tion is confined to those in whom surgical revascularization has
2010;55:1923–1932.) already been selected.
“LAD” high-risk group was demonstrated to be significantly more

anterolateral predictive of MACE compared with the intermediate or high
region SYNTAX score tertiles (Fig. 1.12). However, in the low-risk
4%
NERS group, outcomes were similar to the low SYNTAX
score group, suggesting at least from this study that anatomic
variables alone may be sufficient to be predictive of clinical
outcomes in the low-risk group. One of the main limitations of
NERS is that patient comorbidity was significantly less preva-
“Diagonal” lent compared with that of the all-comers SYNTAX popula-
anterolateral
region
tion,13,16 the latter of which was designed to overcome many of
13% the limitations and selection bias inherent in small registries.
A more simplified NERS II score consisting of 16 variables
LAD (seven clinical and nine angiographic) has been reported to
septum have a predictive accuracy similar to that of the original NERS
29% in a multicenter, prospective registry study in China.107
Apex Obtuse marginal
5% region SYNTAX-Based Tools
18%
The augmentation of the anatomic SYNTAX score with clini-
Anterior RV cal variables, culminating in the development and validation of
SYNTAX score II—in which objective and tailored decision
Posterior RV making could be made for the individual patient—is detailed in
PDA “PL branch” the next section.
septum posterolateral
13% region
13% SYNTAX-BASED CLINICAL TOOLS
In this section we systematically examine the widening applica-
tions of tools for clinical decision making that are based on the
SYNTAX score.
“PDA”
posterolateral
region Anatomic SYNTAX Score
5% The anatomic SYNTAX score (www.syntaxscore.com) has
Fig. 1.10 An example of a Myocardial Jeopardy Score. The AP- emerged as an anatomic-based tool to objectively determine
PROACH lesion score illustrating the weighting factors for myocardial the complexity of CAD and to guide decision making between
regions is illustrated. LAD, Left anterior descending artery; PDA, pos- CABG and PCI.45–48 Since the landmark SYNTAX trial13–15 to
terior descending artery; PL, posterolateral; RV, right ventricle. (From compare CABG with PCI in patients with complex CAD (unpro-
Graham MM, Faris PD, Ghali WA, et al. Validation of three myocardial tected left main coronary artery [ULMCA] or de novo 3VD),
jeopardy scores in a population-based cardiac catheterization cohort. numerous validation studies have confirmed the clinical validity
Am Heart J. 2001;142[2]:254–261.) of the SYNTAX score to identify higher-risk subjects and aid
decision making between CABG and PCI in a broad range of
patient types.48,49 The SYNTAX score is currently advocated in
EuroHeart Score both the European and U.S. revascularization guidelines52,54,55 as
A logistic regression score comprising 10 clinical variables and part of the SYNTAX-pioneered heart team approach.50 In addi-
6 anatomic variables was developed based on the Euro Heart tion, the U.S. Food and Drug Administration (FDA) mandates
Survey, a European PCI registry consisting of more than 46,000 the SYNTAX score as entry criteria in ongoing contemporary
patients from 176 European centers who underwent PCI for dif- stent and structural heart disease trials. Namely, the Evaluation
fering indications (Fig. 1.11).105 The risk score was shown to be of XIENCE PRIME or XIENCE V Everolimus-Eluting Stent
highly predictive of in-hospital mortality (C-statistic 0.91); the System Versus Coronary Artery Bypass Surgery for Effectiveness
strengths of this score were that it was internally validated within of Left Main Revascularization (EXCEL) trial (ClinicalTrials.gov
the registry population and that it retained its discriminatory ID# NCT01205776),108 and Safety and Efficacy Study of the
power (C-statistic 0.90); the score was also sufficiently calibrated Medtronic CoreValve System in the Treatment of Severe,
for the study and validation populations. Symptomatic Aortic Stenosis in Intermediate-Risk Subjects
Who Need Aortic Valve Replacement (SURTAVI) trial (ID#
New Risk Stratification Score NCT01586910).
The New Risk Stratification Score (NERS)106 is a risk score The anatomic SYNTAX score was developed during the
developed to predict outcomes for unprotected LM stem PCI design of the SYNTAX trial as a tool to force the interventional
from four centers in China (n = 260). Reflecting the long time cardiologist and cardiac surgeon to systematically analyze the
frame of this registry (approximately 10 years), the patients coronary angiogram and to specify the number of coronary
included either had bare-metal or DESs implanted. The lesions that require treatment and assess their angiographic
NERS was subsequently validated in a different consecutive location and anatomic complexity.13,45–49 The SYNTAX score
group of patients within the same registry, all treated with combines the importance of a diseased coronary artery seg-
DESs (n = 337). The NERS consists of 54 variables (17 clini- ment in terms of its severity (i.e., obstructive or occlusive),
cal, 4 procedural, and 33 angiographic features). A substan- anatomic location, and importance in supplying blood to the
tially higher C-statistic was evident for the NERS compared myocardium (vessel-segment weighting based on the Leaman
with the anatomic SYNTAX score (NERS 0.89 vs. SYNTAX Score),109 adverse lesion characteristics (ACC/AHA lesion
score 0.69), indicating that it had an excellent discriminatory classification),110 bifurcation lesion characteristics (Medina
ability. When the NERS score was separated into two groups classification),111 and total occlusion characteristics from
of risk (high and low) and clinical outcomes were assessed, the Recanalization of Total Coronary Occlusions Using a Laser
Characteristic Points
60% 1
PCI indication
Ongoing STE-ACS 8 50%
Ongoing NSTE-ACS 6
In-hospital mortality
Stabilized after ACS 4 40%
Age 30%
≥60–70 2
≥70–80 3 20%
≥80 6
10%
Haemodynamic instability 11
Ever smoker 1 0%
Diabetes mellitus 3 0 10 20 30 40
Female gender 2
Prior stroke 2 20%
No prior CABG 4
Valvular heart disease 2
In-hospital mortality
15%
BMI < 25 kg/m2 2
TIMI flow 0/1 before PCI 2
10%
3-vessel disease 1
Left main disease 3
Proximal LAD disease 2 5%
Bifurcation lesion 2
Type-C lesion 2
0%
+ 10 12 14 16 18 20 22 24 26 28 30
Euroheart PCI score
Euroheart PCI score
Fig. 1.11 EuroHeart PCI Score–assigned integer scores. ACS, Acute coronary syndrome; BMI, body mass
index; CABG, coronary artery bypass grafting; LAD, left anterior descending; NSTE, non-ST elevation; PCI,
percutaneous coronary intervention; STE, ST elevation; TIMI, thrombolysis in myocardial infarction. (From de
Mulder M, Gitt A, van Domburg R, et al. EuroHeart score for the evaluation of in-hospital mortality in patients
undergoing percutaneous coronary intervention. Eur Heart J. 2011;32[11]:1398–1408.)
Guidewire (the European TOTAL Surveillance Study).112 B recommendation for PCI. In subjects with ULMCA disease
Each vessel segment 1.5 mm in diameter or greater (Fig. 1.13, and low to intermediate SYNTAX scores (<33), a class I LOE A
labeled 1 through 16) with a 50% or more diameter stenosis recommendation is given for CABG and IIb B for PCI. Further-
by visual estimation is awarded a multiplication factor related more, U.S. guidelines currently give surgical revascularization for
to coronary lesion location and severity (see Fig. 1.13A). Fur- ULMCA disease a class I B recommendation54,55 compared with
ther characterization of the coronary lesions leads to the addi- a class I A recommendation in previous guidelines.113
tion of more points (see Fig. 1.13B), which includes features
of total occlusions (duration, length, blunt stumps, presence
of bridging collaterals or side branch), bifurcation (Medina
Functional SYNTAX Score
classification)111 or trifurcation (number of diseased branches PCI guided by the assessment of the functional significance of a
involved), side-branch angulation, aortoostial lesions, severe lesion has been shown to improve clinical outcomes.114–116 The
tortuosity, lesion length greater than 20 mm, heavy calcifica- functional SYNTAX score uses the principle of the functional
tion, thrombus, and diffuse or small-vessel disease. An online assessment of coronary lesions to determine the SYNTAX
SYNTAX score algorithm45 automatically summates each of score, rather than the angiographic determination of the
these features to calculate the total SYNTAX score. SYNTAX score based on visual assessment, as is undertaken
Within the SYNTAX trial,13 the distribution of the SYN- in conventional SYNTAX score calculations. In a retrospec-
TAX score was found to be normal (Gaussian) in the random- tive subanalysis of almost 500 patients (n = 497) from the FFR-
ized PCI and CABG populations with the curves almost being guided arm of the Fractional Flow Reserve Versus Angiography
superimposable on each other (eFig. 1.2). When the scores of the for Multivessel Evaluation (FAME) study, the primary benefit
randomized SYNTAX population were divided into tertiles, the appeared in reclassifying higher-risk groups into lower-risk cat-
upper boundary of the lowest tertile was 22 (low risk), the second egories without any adverse sequelae in terms of MACEs and
tertile ranged from 23 to 32 (intermediate risk), and the lower death or MI at 1 year.36
boundary for the highest tertile was equal to or greater than 33 It should be emphasized that subjects in the FAME study
(high risk). had substantially less complex CAD (mean SYNTAX score
Based primarily on the results of the SYNTAX trial,13–15 cur- 14.8 ± 6.0) compared with the PCI arm of the SYNTAX trial
rent European revascularization guidelines52 give subjects with (mean SYNTAX score 28.4 ± 11.5) and that subjects with LM
3VD and low SYNTAX scores (0 to 22) a class I recommenda- CAD were not investigated. Prospective validation studies of
tion, level of evidence (LOE) A, for CABG and a class IIa LOE the functional SYNTAX score in complex CAD are ongoing
25
1
CABG RCT
20 PCI RCT
CABG registry
PCI registry
% of patients 15
10
0
0 6 12 18 24 30 36 42 48 54 60 66 72 78 84
SYNTAX score
eFig. 1.2 The distribution of the SYNTAX score in the randomized and nested registry percutaneous coronary intervention (PCI) and coronary artery
bypass grafting (CABG) populations from the SYNTAX trial. Note how the distributions for both the randomized PCI and CABG populations are
almost superimposable on each other, whereas the nested registries are shifted to the right.13,48 RCT, Randomized controlled trials. (Reprinted with
permission from Serruys PW, Onuma Y, Garg S, et al. Assessment of the SYNTAX score in the SYNTAX study. EuroIntervention. 2009;5[1]:50–56.)
1.0 + 1.0
+
Cumulative survival rate free from

+
0.8 0.8
in-hospital MACE (%)
MACE (%)
0.6 0.6
+
0.4 0.4
Log rank (mantel-cox): P < .001 Log rank (mantel-cox): P = .001

0.2 0.2
NERS-higher, 89.1% NERS-higher, 45.9%
NERS-lower, 100% NERS-lower, 95.7%
0.0 0.0
0.00 5.00 10.00 15.00 20.00 25.00 30.00 0 500 1000 1500 2000
A Days after stenting procedure (d) B Days after stenting procedure (d)
1.0
1.0 +
+ +

+ +
0.8 +
0.8
in-hospital MACE (%)
++ +
+
0.6
0.6 MACE (%)
SYNTAX-lower vs. SYNTAX-higher or SYNTAX-lower vs. SYNTAX-higher or
0.4 SYNTAX-intermediate, log rank 0.4 SYNTAX-intermediate, log rank
(mantel-cox): P = .013 (mantel-cox): P < .001
0.2 SYNTAX-higher, 94% 0.2 SYNTAX-higher, 64.7%

SYNTAX-intermediate, 90.1% SYNTAX-intermediate, 74.6%
SYNTAX-lower 100% SYNTAX-lower 91.0%
0.0 0.0
0.00 5.00 10.00 15.00 20.00 25.00 30.00 0 500 1000 1500 2000
C Days after stenting procedure (d) D Days after stenting procedure (d)
Fig. 1.12 Comparison of freedom from in-hospital (A) and overall major adverse cardiac events (MACEs, B)
survival between New Risk Stratification (NERS) groups and in-hospital (C) and overall MACEs (D) survival
among SYNTAX groups. (From Chen SL, Chen JP, Mintz G, et al. Comparison between the NERS [New Risk
Stratification] score and the SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and
Cardiac Surgery) score in outcome prediction for unprotected left main stenting. JACC Cardiovasc Interv.
2010;3[6]:632–641.)
at the time of writing. Namely the SYNTAX II trial, in which variables—age, serum creatinine, and LVEF—for assessing
a noninvasive assessment of the functional SYNTAX is also operative mortality risk in elective cardiac operations (ACEF
being assessed with fractional flow reserve derived from com- score, see Fig. 1.8). Based on the law of parsimony, or “Occam’s
puted tomography angiography,117 and the FAME 3 trial razor,” whereby a simple model can explain a phenomenon
[NCT02100722]).118 with the same level of accuracy as complex models, ACEF was
shown to be least comparable to the EuroSCORE (composed
of 17 variables)58,59 in predicting in-hospital mortality after
Augmenting the Anatomic SYNTAX Score With CABG.62,89
Clinical Factors and the Personalization of Decision The three risk factors used in ACEF are natural continuous
variables that are objectively defined and not subject to personal
Making: Development of SYNTAX Score II estimation (e.g., whether the patient has diabetes or extracardiac
Since the anatomic SYNTAX score was developed, limitations of arteriopathy). In addition, the variables of ACEF were known
this scoring system to aid decision making between CABG and PCI independent risk factors for mortality, and it was subsequently
became evident—namely, the lack of clinical variables and lack of shown that the end-organ manifestations of the risk factor as
a personalized approach to decision making. Following is a brief identified in ACEF were more important for predicting long-
overview of the “development phase” leading to SYNTAX score II, term prognosis rather than the actual presence of the risk fac-
which was designed to overcome these limitations (see Table 1.6). tor.6,88,119,120
Age, Serum Creatinine, and Ejection Fraction Clinical SYNTAX Score/Logistic Clinical SYNTAX Score
As described earlier, Ranucci and devel- colleagues62,88,89 Based on the principle of ACEF, the clinical SYNTAX
oped a simple risk score that consisted of only three clinical score90,121,122 and subsequently the logistic clinical SYNTAX
score (eFig. 1.3)123,124 were developed and validated. Both the

clinical SYNTAX score and logistic clinical SYNTAX score
SYNTAX Score II 1
combined ACEF with the SYNTAX score and were shown to As previously discussed, the combination of the anatomic
improve mortality predictions, compared with the SYNTAX SYNTAX score with ACEF contained most of the prognos-
score alone, in subjects with complex CAD.90,121–124 Similar to tic information in predicting mortality after CABG (excluding
the conventional SYNTAX score, the clinical SYNTAX score the anatomic SYNTAX score)62,88,89,127 or PCI (including the
relied on categorization of risk into low, intermediate, and high anatomic SYNTAX score).123 SYNTAX score II7,8 augments
groups and was able to only identify a high-risk group after the purely anatomic SYNTAX score with anatomic and clini-
PCI.90,121,122 The logistic clinical SYNTAX score was designed cal factors that were shown to alter the threshold value of the
to individualize risk and provide 1-year mortality predictions in anatomic SYNTAX score for equipoise to be achieved between
an all-comers PCI population irrespective of clinical presentation CABG and PCI for long-term mortality. This was accomplished
(except cardiogenic shock).123,124 through building SYNTAX score II on the ACEF “skeleton”
The logistic clinical SYNTAX score was developed and with the addition of risk factors that were shown to directly
cross-validated (internal-external validation procedure125) in affect decision making between CABG and PCI through
more than 6000 subjects from seven contemporary coronary interaction effects (i.e., a risk factor being more predictive of
stent trials123 and was further externally validated in 2627 sub- mortality in patients undergoing PCI compared with CABG,
jects presenting with non–ST elevation ACS and undergo- or vice versa; Fig. 1.15). For example, the anatomic SYNTAX
ing PCI from the ACUITY trial.124 Notably, the addition of score aids decision making between CABG and PCI because it
six clinical variables, including diabetes, to the logistic clini- is more predictive of clinical outcomes in patients undergoing
cal SYNTAX score led to only a minor incremental benefit PCI, compared with patients undergoing CABG, in whom it
in improving risk predictions.123,124 Thus the logistic clinical is not predictive. Based on this principle, younger age, female
SYNTAX score was shown to follow the law of parsimony, as sex, and reduced LVEF favored CABG compared with PCI on
seen with the surgical ACEF score discussed previously,62,88,89 long-term prognostic grounds (eFig. 1.4). Thus in such patients
and the end-organ manifestations of the risk factor were found a lower anatomic SYNTAX score would be required for the
to be more important for predicting prognosis than the actual long-term mortality risk to be similar between CABG and PCI.
presence of the risk factor. By contrast, older age, ULMCA, or chronic obstructive pulmo-
nary disease (COPD) favored PCI compared with CABG (see
eFig. 1.4), and thus, in this type of patient, a higher anatomic
Global Risk SYNTAX score would be needed for the long-term mortality
In the SYNTAX trial, as well as the SYNTAX score in PCI risks to be similar.
subjects, it was shown that the EuroSCORE58,59 is an indepen- By adopting the individualized approach of SYNTAX score
dent predictor of MACEs in subjects undergoing surgical or II, augmented by clinical variables, it was shown that subsets of
percutaneous revascularization. Subsequently, it was hypoth- patients existed in all tertiles of the SYNTAX score in which
esized that the amalgamation of the anatomic SYNTAX CABG or PCI would confer a mortality benefit or offer a simi-
score with the EuroSCORE could improve decision making lar long-term prognosis (Fig. 1.16).7 A nomogram was developed
between CABG and PCI (Fig. 1.14).48 The feasibility of this (Fig. 1.17) that allowed for an accurate individualized prediction
“global risk” approach was demonstrated in a registry of 255 of 4-year mortality in patients proposing to undergo CABG or
subjects with LM CAD using tertiles of the SYNTAX score PCI to objectively aid decision making. For example, a 60-year-
and tertiles of the additive EuroSCORE that reflected the old man with an anatomic SYNTAX score of 30, ULMCA dis-
study population.126 Subsequently, the global risk was vali- ease, a creatinine clearance of 60 mL/min, an LVEF of 50%, and
dated in the SYNTAX trial using conventional tertiles of the COPD would have 41 points (predicted 4-year mortality 16.3%)
SYNTAX score and EuroSCORE,127 and compared with the and 33 points (predicted 4-year mortality 8.7%) to undergo
SYNTAX score alone, it was shown to substantially enhance CABG and PCI, respectively. The same example, without COPD
the identification of low-risk patients with ULMCA disease included, would lead to identical points (29 points) and identi-
or de novo 3VD who could safely and efficaciously be treated cal 4-year mortality predictions (6.3%) for CABG and PCI. An
with CABG or PCI. online version of SYNTAX score II, version 2.11 using the 4-year
One of the unexpected findings from the global risk was data, is currently available as a download along with the original
that higher-risk subjects (high additive EuroSCORE ≥6) in all SYNTAX score calculator (www.syntaxscore.com).
tertiles of the SYNTAX score were shown to have a potential
prognostic benefit from undergoing CABG compared with
PCI irrespective of the baseline SYNTAX score, provided an
Diabetics
acceptable threshold of operative risk was not exceeded.127 For Notably, diabetes was not included in the final SYNTAX score II
example, in the 3VD cohort of the SYNTAX trial, subjects with despite medically treated diabetes being prestratified at random-
a low SYNTAX score (<23) and a high EuroSCORE (≥6) had ization as a powered subgroup in the SYNTAX trial and present
a doubling of 3-year mortality when undergoing PCI (15.9%) in more than a quarter of the study patients (26%), and in spite of
compared with CABG (8.2%). Hypotheses to explain these find- diabetes being perceived as a specific high-risk group potentially
ings included that the bypass graft would potentially “protect” warranting a differing treatment strategy compared with that
the entire treated coronary vessel from future cardiac events for considering other risk factors.11,52,54,55 The primary reason was
the life span of the graft in high-risk subjects compared with that diabetes was shown not to be important for decision making
PCI, which would treat the individual lesion.43 Based on these between CABG and PCI because it lacked an interaction effect
observations, it was hypothesized by the investigators that sub- (i.e., it was equally predictive of mortality in the CABG and PCI
jects of opposite risk concealed each other; for example, low-risk arms after adjustment for other risk factors) (see Fig. 1.15). As
subjects were potentially concealed by high-risk subjects, and previously discussed in ACEF, the end-organ manifestations of
vice versa, in all tertiles of the SYNTAX score. This hypothesis diabetes are what affected long-term mortality in CABG and PCI
is what prompted the investigators to develop a more individu- populations.6,51,88,89,123 The findings of the lack of inclusion of
alized approach to decision making between CABG and PCI, diabetes in SYNTAX score II are supported by epidemiologic
and it is what subsequently led to the development of SYNTAX data, in which nondiabetics with chronic kidney disease and pro-
score II,7 as detailed later. teinuria had a stronger association with risk of MI and a higher
1
Points Score 20
1-year risk of death (%)

15
SYNTAX score see below
Age (years) see below
10
CrCl (mL/min) see below
LV ejection fraction see below
5
“SYNTAX-like” patienta 3
0
Sum score
0 5 10 15 20
Sum score
SYNTAX score ≤17 18–22 23–27 28–32 ≥ 33

0 1 2 3 4
Age (years) <50 50–54 55–59 60–64 65–69 70–74 75–79 ≥80
0 1 2 3 4 5 6 7
CrCl (mL/min) <30 30–59 60–89 ≥90
3 2 1 0
LV ejection fraction (%) <30 30–34 35–39 40–44 45–49 ≥50
10 8 6 4 2 0
eFig. 1.3 The Logistic Clinical SYNTAX score. CrCl, Creatinine clearance; LV, left ventricular. aSYNTAX-like patient defined as fulfilling the enrollment
criteria for the SYNTAX All-Comers trial: that is, left main stem (isolated or associated with 1-, 2-, or 3-vessel disease) or 3-vessel disease alone.
(From Farooq V, Vergouwe Y, Généreux P, et al. Prediction of 1-year mortality in patients with acute coronary syndromes undergoing percutaneous
coronary intervention: validation of the logistic clinical SYNTAX (Synergy Between Percutaneous Coronary Interventions With Taxus and Cardiac
Surgery) score. JACC Cardiovasc Interv. 2013;6(7):737–745.)
21.e2 SECTION I Patient Selection
Man without COPD or poor LVEF (<30%) Woman without COPD or poor LVEF (<30%)
Man with COPD Woman with COPD
Man with poor LVEF (<30%) Woman with poor LVEF (<30%)
LMS
Age <62 years SYNTAX score <23 Age <62 years SYNTAX score <23–32 Age <62 years SYNTAX score >32
3 Favours CABG Favours CABG Favours CABG
2
Log hazard PCI

1
0
-1
-2
Favours PCI Favours PCI Favours PCI
-3
Age 62–70 years SYNTAX score <23 Age 62–70 years SYNTAX score 23-32 Age 62–70 years SYNTAX score >32
3 Favours CABG
Favours CABG Favours CABG
2
Log hazard PCI
0
-1
-2
-3
Age >70 years SYNTAX score <23 Age >70 years SYNTAX score <23–32 Age >70 years SYNTAX score >32
3
Favours CABG Favours CABG Favours CABG
2
Log hazard PCI
0
-1
-2
-3
A 3VD
Age <62 years SYNTAX score <23 Age <62 years SYNTAX score 23–32 Age <62 years SYNTAX score >32
3
2
Log hazard PCI
0
-1
-2
-3
Age 62–70 years SYNTAX score <23 Age 62–70 years SYNTAX score <23–32 Age 62–70 years SYNTAX score>32
3
2
Log hazard PCI
0
-1
-2
-3
Age >70 years SYNTAX score <23 Age >70 years SYNTAX score <23–32 Age >70 years SYNTAX score>32
3 Favours CABG Favours CABG Favours CABG
2
Log hazard PCI
1
0
-1
-2
-3
-3 -2 -1 0 1 2 3 -3 -2 -1 0 1 2 3 -3 -2 -1 0 1 2 3
B Log hazard CABG Log hazard CABG Log hazard CABG
eFig. 1.4 Collective effect of the anatomic SYNTAX score and other anatomic and clinical variables on mortality predictions in the left main stem
(LMS, A) and three-vessel disease (3VD, B) cohorts of the SYNTAX trial (SYNTAX score II). Scatter plots are for illustrative purposes only. The diago-
nal line represents identical mortality predictions for coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). Individual
predictions plotted to the left of the diagonal line favor CABG (actual percentages shown in top left corner) and to the right favor PCI (actual percentages
shown in bottom right corner). COPD, Chronic obstructive pulmonary disease; LVEF, left ventricular ejection fraction. (From Farooq V, van Klaveren D,
Steyerberg EW, et al. Anatomical and clinical characteristics to guide decision making between coronary artery bypass surgery and percutaneous coro-
nary intervention for individual patients: development and validation of SYNTAX score II. Lancet. 2013;381[9867]:639–650.)
Right dominance Weighting

factor
1 5
9 +6
6
11 9a
12 +5
12a 7 10
13 +3.5
2 12b
14 10a
16 +2.5
16c 14a
3 16b +1.5
14b 8
4 16a
+1
Left dominance +0.5

1 5
9
6
11 9a
12
12a 7 10
13
2 12b
14 10a
14a
3 14b
8
A 15
Dise ent #
segm
on
lusi
ased
occ l
Tota
Do
m ion
ina c at
nc
e if ur
Tr
Diffuse small
SYNTAX Bifurcation
score
us Aor
mb ta o
o stia
Thr l
Se tuos
on
tor
ve ity
Length
ati
ca avy
re
fic
lci
He
B
Fig. 1.13 Coronary tree segments and their importance in supplying blood flow to the left ventricle (vessel
segment weighting factors; Leaman score154,155) based on the presence of a right or left dominant system
(A).109 A multiplication factor of two is used for nonocclusive lesions (50% to 99% diameter stenosis) and five
for occlusive (100% diameter stenosis) lesions. For example, a nonocclusive stenotic proximal left anterior
descending (LAD) coronary artery lesion (segment 6) would have a weighting factor of 3.5 × 2 (7 points) and
an occlusive proximal LAD lesion a weighting factor of 3.5 × 5 (17.5 points). Other adverse lesion character-
istics considered in the SYNTAX score have an additive value (B). #, Segment number. (Images courtesy the
SYNTAX Trial Investigators.)
since been directly contradicted by SYNTAX score II in the all-

SYNTAX score 1
comers SYNTAX trial in which the opposite was shown.7 Hence
EuroSCORE
≤22 23–32 ≥33
“randomized” or prospective validation of SYNTAX score II was
proposed7 in which further validation would be conducted in ran-
0–2 LOW LOW INT domized controlled trials or prospectively run studies.
Further retrospective validation of SYNTAX score II has
3–5 LOW LOW INT recently been undertaken in 3896 patients with 3VD and/or
ULMCA disease undergoing PCI (n = 2190) or CABG (n = 1796)
≥6 INT INT HIGH from the Japanese Coronary Revascularization Demonstrating
Outcome Study in Kyoto (CREDO-Kyoto) PCI/CABG multi-
LOW Global Risk: SYNTAX score <33 and EuroSCORE <6 center registry.133 In addition, the SYNTAX score II was externally
Int Global Risk: SYNTAX score <33 and EuroSCORE ≥6 validated in 1480 patients with multivessel and/or unprotected
OR EuroSCORE <6 and SYNTAX score ≥33 LM CAD in a pooled analysis of the BEST and PRECOMBAT
High Global Risk: SYNTAX score ≥33 and EuroSCORE ≥6 (Premier of Randomized Comparison of Bypass Surgery versus
Fig. 1.14 The Global Risk matrix. (From Serruys PW, Farooq V, Vranckx Angioplasty Using Sirolimus-Eluting Stent in Patients with Left
P, et al. A global risk approach to identify patients with left main or Main Coronary Artery Disease) randomized controlled trials.134
3-vessel disease who could safely and efficaciously be treated with Prospective validation of SYNTAX score II is being evaluated
percutaneous coronary intervention: the SYNTAX Trial at 3 years. JACC in the ongoing EXCEL17,18 and SYNTAX II135–137 trials. In addi-
Cardiovasc Interv. 2012;5[6]:606–617.) tion, prospective validation of decision making between CABG
and PCI based on noninvasive (computed tomography derived)
SYNTAX score II in patients with complex CAD is currently
rate of mortality compared with diabetics and that the relative being undertaken in the randomized SYNTAX III Revolution
risk of long-term mortality associated with chronic kidney disease trial and is discussed later under future directions.138,139
was “much the same irrespective of the presence or absence of
diabetes.”119,120
EXCEL Trial
The international multicenter EXCEL trial recently recruited
Impaired Left Ventricular Ejection Fraction 1905 patients with ULMCA disease and investigator-reported
Within SYNTAX score II, impaired LVEF favored CABG over SYNTAX scores less than 33, randomized to CABG (n = 957)
PCI on long-term prognostic grounds, findings supported by a or PCI with contemporary stents (n = 948),108 and reported
recent subanalysis of the Surgical Treatment of Ischemic Heart the composite primary end point of death, stroke, or MI at 3
Failure (STICH) trial128; namely, that in subjects with more years (see Fig. 1.4).17,18 As part of the prospective validation of
advanced ischemic cardiomyopathy with more extensive CAD SYNTAX score II, this tool was used to forecast and compare
and worse myocardial dysfunction and remodeling, a net longer- 4-year mortality in the PCI and CABG arms of EXCEL prior
term prognostic benefit was seen for CABG compared with opti- to the actual reporting of the primary outcome of EXCEL.140
mal medical therapy despite the short-term (30-day) mortality Based on 1000 4-year mortality simulations of the EXCEL trial
risk being higher with CABG. using the SYNTAX score II, 77.9% of trial simulations (n = 7790)
favored PCI and 22.1% of trial simulations (n = 2210) favored
CABG (Fig. 1.18). Thus the SYNTAX score II indicated at least
Validation of SYNTAX Score II an equipoise for long-term mortality between CABG and PCI in
Compared with existing revascularization guidelines using the subjects with ULMCA disease up to an intermediate anatomic
anatomic SYNTAX score,52,54,55 it was shown that if CABG or complexity. Longer-term follow-up of EXCEL is awaited to
PCI was selected based on a higher or lower expected survival allow validation of the SYNTAX score II.
(irrespective of the margin of difference) with SYNTAX score II
in the SYNTAX trial, SYNTAX score II would need to be used
in only 110 patients to have one more patient alive at 4 years.8
SYNTAX II Trial
External validation of SYNTAX score II7 was performed In the ongoing SYNTAX II trial (NCT02015832),135 the
in the multinational Drug-Eluting Stent for Left Main Coro- SYNTAX score II is being used as a tool to recruit subjects with de
nary Artery Disease (DELTA) registry (14 centers in Europe, novo 3VD (without LM involvement) on the grounds of patient
the United States, and South Korea)129 composed of subjects safety (i.e., subjects with a similar long-term mortality between
with ULMCA disease with or without MVD (26% of the study CABG and PCI) in conjunction with the heart team (Fig. 1.19).
population had 3VD). All variables in SYNTAX score II inter- Notably, subjects from all tertiles of the SYNTAX score are eli-
acted in a similar way and therefore influenced decision making gible. The PCI procedure uses the state-of-art SYNTAX II PCI
between CABG and PCI in the SYNTAX trial and DELTA reg- strategy of appropriate patient selection with the SYNTAX score
istry with the exception of age and LVEF, which had minimal II, newer-generation metal stent platform with a biodegradable
interactions in the DELTA registry—findings that may relate to polymer,36 contemporary CTO revascularization strategies and
the unavoidable selection bias inherent to all registries because functional and IVUS-guided PCI of all three vessels.141,142 The
decision making between CABG and PCI has already been made PCI and CABG arms of the original SYNTAX trial15,33 acted as
and would be difficult to control for.130 Even randomized tri- control arms.
als that lack an all-comers design, with restrictive inclusion and Notably, the use of functional guided PCI in SYNTAX II led
exclusion criteria, can potentially make application to clinical to a deferral of almost one-third of lesions (31%), with two-thirds
practice questionable.43,44,131 This was exemplified in a recent of lesions intervened on with PCI (69%) (Fig. 1.20A). In addi-
meta-analysis of randomized trials undertaken prior to SYNTAX tion, 87% of attempted CTOs were successfully revascularized
that compared PCI against CABG, where in most trials, 2% to (compared with 53% in the original SYNTAX trial), and IVUS
12% (see Table 1.3) of screened subjects were randomized due guidance was used in 84.1% of patients (compared with 4.8%
to the highly restrictive inclusion and exclusion criteria.132 In this patients in the original SYNTAX trial) (see Fig. 1.20B and C).
meta-analysis, CABG was shown to be favored in older subjects, At 2-year follow-up of SYNTAX II, the SYNTAX II PCI
and PCI was favored in younger subjects,132 findings that have strategy led to substantially improved clinical outcomes compared
SYNTAX score Age (years) CrCl (mL/min) LVEF (%)

2
PCI
CABG
1
Log HR
–1
–2
0 20 40 60 60 70 80 90 0 30 60 90 120 10 20 30 40 50 60
Left main Sex COPD PVD

2
PCI
CABG
1
Log HR
–1
–2
3VD LMS F M No Yes No Yes
Diabetes
2
1
Log HR
–1
–2
No Yes
Fig. 1.15 Predictor effects for coronary artery bypass surgery (CABG) and percutaneous coronary intervention
(PCI) in the SYNTAX score II. These are represented visually as a log hazard ratio (HR) for CABG and PCI on
the y-axis for each predictor. Each predictor is expressed on the x-axis continuously (upper) or categorically
(lower), for a person of mean baseline characteristics. Diabetes is included (highlighted in red) to illustrate its
absence of interaction when included in the analyses. Note the differing gradients of the hazards for PCI and
CABG, leading to the hazards crossing at an anatomic SYNTAX score of 15. At this crossover point of haz-
ards, the mortality risk is comparable between CABG and PCI. This threshold of crossover of hazards will vary
according to the level of other variables, namely, being lower for female sex, reduced left ventricular ejection
fraction (LVEF) and younger age, and higher for chronic obstructive pulmonary disease (COPD), unprotected
left main coronary artery disease, and older age. As both peripheral vascular disease (PVD; P = 1.00) and
diabetes (P = .67) lacked an interaction effect, as indicated by almost parallel HRs (i.e., a comparable increase
in mortality risk), their presence would have no impact on decision making between CABG and PCI. CrCl, Cre-
atinine clearance. (From Farooq V, van Klaveren D, Steyerberg EW, et al. Anatomical and clinical characteristics
to guide decision making between coronary artery bypass surgery and percutaneous coronary intervention for
individual patients: development and validation of SYNTAX score II. Lancet. 2013;381[9867]:639–650.)
with the PCI strategy adopted in SYNTAX I (Fig. 1.21A). More- (anatomic SYNTAX score >22), in which current revasculariza-
over, clinical outcomes were similar in 3VD patients with a tion guidelines support CABG (see Fig. 1.21B). In addition, the
low anatomic SYNTAX score (≤22), in which revascularization SYNTAX II PCI strategy demonstrated equipoise to CABG at
guidelines currently support PCI or CABG-based revascular- 2-year follow-up for MACCE (exploratory end point) (see Fig.
ization52–55—compared with more anatomically complex 3VD 1.21C). Longer (5 year) follow-up of SYNTAX II is awaited.
LMS 3VD
3
Predicted 4-year mortality Predicted 4-year mortality
favors CABG: 50·1% favors CABG: 84·2%
(11·5% of predictions (40·7% of predictions
lie outside 95% CI) lie outside 95% CI)
2 1
1
Log hazard PCI
–1
–2
Predicted 4-year mortality for Predicted 4-year mortality favors Predicted 4-year mortality for Predicted 4-year mortality favors
CABG and PCI lying within PCI: 49·9% (8·8% of predictions CABG and PCI lying within PCI: 15·8% (0·5% of predictions
95% CI: 79·7% lie outside 95% CI) 95% CI: 58·8% lie outside 95% CI)
–3
–3 –2 –1 0 1 2 3 –3 –2 –1 0 1 2 3
Log hazard CABG
Log hazard CABG
LMS, SYNTAX score <23 LMS, SYNTAX score 23–32 LMS, SYNTAX score >32
3 37·2% (2·7%) 38·3% (10·2%) 68·2% (19·2%)
2
Log hazard PCI
–1
–2
78·5% 62·8% (18·8%) 80·6% 61·7% (9·2%) 80·1% 31·8% (0·7%)

–3
3VD, SYNTAX score <23 3VD, SYNTAX score 23–32 3VD, SYNTAX score >32
3 70·9% (19·2%) 87·1% (37·8%) 95·0% (68·1%)
2
Log hazard PCI
–1
–2
79·4% 29·1% (1·4%) 60·0% 12·9% (2·2%) 31·9% 5·0% (0·0%)

–3
–3 –2 –1 0 1 2 3 –3 –2 –1 0 1 2 3 –3 –2 –1 0 1 2 3
Log hazard CABG Log hazard CABG Log hazard CABG
Fig. 1.16 Mortality predictions for coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) for each individual patient in the
randomized SYNTAX trial. The SYNTAX trial included 1800 participants, separated into left main stem (LMS) cohort and three-vessel disease (3VD) cohort
(upper panels), and by tertiles of the anatomic SYNTAX score (lower panels). The diagonal line represents identical mortality predictions for CABG and PCI.
Individual predictions plotted to the left of the diagonal line favor CABG (actual percentages shown in top left corner) and to the right favor PCI (actual per-
centages shown in bottom right corner). Individual mortality predictions for CABG or PCI that could be separated with 95% confidence (P < .05) are colored
blue (actual percentage shown in parentheses in respective corners). Mortality predictions that could not be separated with 95% confidence (P > .05) are
highlighted in green and identify patients with similar 4-year mortality. Percentages of patients in each category are shown. CI, Confidence interval. (From
Farooq V, van Klaveren D, Steyerberg EW, et al. Anatomical and clinical characteristics to guide decision making between coronary artery bypass surgery
and percutaneous coronary intervention for individual patients: development and validation of SYNTAX score II. Lancet. 2013;381[9867]:639–650.)
100
80
4-year mortality (%)
60 58.4%
40
31.5%
20
15.1%
6.8%
1.3% 3%
0.6%
0
0 20 40 60 80 100
Total points
CABG PCI
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30
Points
SYNTAX score
0+ 0 10 20 30 40 50 60
Age (years)
40 50 60 70 80 40 50 60 70 80
CrCl (mL/min)
90 60 30 90 60 30
LVEF (%)
50 40 30 20 50 40 30 20
1 0
Left main
0 1
M F
Sex*
F M
1 1
COPD
0 0
1 1
PVD
0 0
Fig. 1.17 The SYNTAX score II nomogram for bedside application. Total number of points for eight factors can
be used to accurately predict 4-year mortality for the individual patient proposing to undergo coronary artery
bypass grafting (CABG) or percutaneous coronary intervention (PCI). COPD, Chronic obstructive pulmonary
disease; CrCl, creatinine clearance; LVEF, left ventricular ejection fraction; PVD, peripheral vascular disease.
*Because of the rarity of complex coronary artery disease in premenopausal women, mortality predictions in
younger women are predominantly based on the linear relation of age with mortality. The differences in mortality
predictions in younger women between CABG and PCI will therefore be affected by larger 95% CIs than those
in older women. (From Farooq V, van Klaveren D, Steyerberg EW, et al. Anatomical and clinical characteristics
to guide decision making between coronary artery bypass surgery and percutaneous coronary intervention for
individual patients: development and validation of SYNTAX score II. Lancet. 2013;381[9867]:639–650.)
Tools for Assessment of Completeness of trial, complete revascularization was defined as the treatment of any
lesion with more than 50% diameter stenosis in vessels 1.5 mm or
Revascularization larger as estimated on the diagnostic angiogram during the local
Interpreting the long-term prognostic impact of incomplete heart team conference and deemed appropriate for revasculariza-
revascularization in patients with complex CAD has historically tion.144,145 In SYNTAX, incomplete revascularization was shown
remained difficult.143 The lack of standardized definitions of to be linked to adverse long-term clinical outcomes, including
incomplete revascularization has confounded this issue and has mortality, in surgical and percutaneously treated patients (Fig.
made comparisons between studies difficult. In the SYNTAX 1.22). The residual and post-CABG SYNTAX scores were
0.20
Favors CABG:22.1 % 1
With P < .05: 4.3% With P > .05:
55.2 %
0.15
4-year mortality PCI
0.10
0.05
Favors PCI:77.9%
With P < .05: 40.4%
0.00
0.00 0.05 0.10 0.15 0.20

4-year mortality CABG
SYNTAX Score <= 22 SYNTAX Score 23-22

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7
Favors CABG:16.0 % Favors CABG:41.3 %

With P < .05: With P < .05:
With P < .05: 2.1% With P < .05: 4.6%
54.2% 84.2%
4-year mortality PCI
Favors PCI:84.0% Favors PCI:58.7%

With P < .05: 43.7% With P < .05: 11.3%
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7
4-year mortality CABG
Fig. 1.18 First 1000 4-year mortality simulations of the EXCEL trial using the SYNTAX score II. Each dot represents one simulated trial mortality in
both randomization arms based on individual predictions. The diagonal line represents identical mortality for coronary artery bypass grafting (CABG)
and percutaneous coronary intervention (PCI). A dot plotted to the left of the diagonal line favors CABG (actual percentages shown in top left cor-
ner), and to the right favours PCI (actual percentages shown in bottom right corner). Simulated trials with a significant (P ≤ .05) mortality difference
between CABG and PCI are colored black (actual percentage shown in parentheses in respective corners). Simulated trials with a nonsignificant (P
> 0.05) mortality difference between CABG and PCI are colored gray. (Reproduced with permission from Campos CM, van Klaveren D, Farooq V,
et al.; EXCEL Trial Investigators. Long-term forecasting and comparison of mortality in the Evaluation of the Xience Everolimus Eluting Stent vs. Coro-
nary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial: prospective validation of the SYNTAX Score II. Eur Heart J.
2015;36[20]:1231–1241.)
designed to quantify the degree of incomplete revascularization and it provides an objective quantitative measure of the degree
and allow for a threshold of incomplete revascularization that and complexity of residual stenosis after revascularization. More
would not have a negative impact on long-term clinical outcomes proximal CAD scores higher on the residual SYNTAX score
(i.e., reasonable incomplete revascularization). because this is dependent on the vessel segment weighting as
previously discussed (see Fig. 1.13), particularly if the obstructive
disease is more complex.146,147
Residual SYNTAX Score Généreux and colleagues146 first demonstrated that a residual
The residual SYNTAX score is based on the principle of being SYNTAX score greater than 8 after PCI was associated with
a measure of the myocardial ischemic burden dependent on the adverse 1-year mortality in a post hoc analysis of the ACUITY
location of the coronary disease, its importance in supplying trial, which consisted of subjects with moderate to high-risk ACS
blood to the myocardium, and the anatomic complexity (e.g., cal- undergoing PCI and substantially less complex CAD (median
cification, bifurcation, long lesion) associated with the obstruc- SYNTAX score 9.0, interquartile range [IQR] 5.0 to 16.0) com-
tive disease. The residual SYNTAX score is essentially the pared with those in the SYNTAX trial (median SYNTAX score
anatomic SYNTAX score recalculated after the PCI procedure, 28, IQR 20.0 to 36.0).
SYNTAX Trial II
Inclusion: All-Comers, angiographic, de-novo 3-vessel disease without
left main involvement (visual % diameter stenosis ≥50%)
Low (0–22) anatomical Interm (23–32) anatomical High (≥33) anatomical

SYNTAX Score SYNTAX Score SYNTAX Score
Screening according to
SYNTAX Score II
Heart Team Discussion

Confirm SYNTAX Score II calculation, and that recruitment of patients for PCI is based on
safety (long-term mortality comparisons between CABG and PCI)
SYNTAX Score II SYNTAX Score II Not

Offers equipoise for PCI and CABG a
Favors CABGa “eligible”
Index revascularisation
procedure type collected
for PCI
(CABG, PCI or medical,
Can “equivalent” anatomical revascularisation be or refusal)
achievedb NO
b
Surgeon and interventional cardiologist in agreement
YES
Patient “Signed Off” by Heart Team for PCI
Exploratory study: MSCT scan non-invasive computation of FFRCT
Fig. 1.19 Study flow chart of the SYNTAX II trial—using the state-of-art SYNTAX II percutaneous coronary
intervention (PCI) strategy of appropriate patient selection with the SYNTAX score II, newer-generation stent
platform with a biodegradable polymer, contemporary CTO revascularization strategies and functional and
intravascular ultrasound–guided PCI. CABG, Coronary artery bypass grafting; CTO, chronic total occlusion;
FFRCT, fractional flow reserve derived from computed tomography; MSCT, multislice computed tomography.
(From Escaned J, Banning A, Farooq V, et al. Rationale and design of the SYNTAX II trial evaluating the short to
long-term outcomes of state-of-the-art percutaneous coronary revascularisation in patients with de novo three-
vessel disease. EuroIntervention. 2016;12[2]:e224–e234.)
The residual SYNTAX score was subsequently validated in implantation, functionally incomplete revascularization was associ-
the randomized, all-comers SYNTAX trial, which comprised sub- ated with a higher rate of 2-year MACEs compared with functional
jects with complex CAD (ULMCA or de novo 3VD) at the final complete revascularization (functional incomplete revascularization
5-year follow-up.147 The previous findings, of residual SYNTAX vs. functional compete revascularization, 14.6% vs. 4.2%; hazard
score greater than 8 being associated with adverse long-term clini- ratio: 4.09; 95% CI: 1.82 to 9.21; P < .001). In addition, functional
cal outcomes in the ACUITY trial,146 were found to be of equal incomplete revascularization was shown to be an independent pre-
importance in SYNTAX patients who underwent 5-year follow-up. dictor of MACEs (adjusted hazard ratio: 4.17; 95% CI: 1.85 to 9.44;
Notably, as the baseline SYNTAX score increased, the frequency of P < .001), with the newly devised functional residual SYNTAX score
a residual SYNTAX score greater than 8 increased in unison, with appearing to better identify lower and high-risk patients. One of the
an associated increase in long-term mortality (Fig. 1.23). In addi- main limitations of this study was that predominantly low anatomic
tion, progressively higher residual SYNTAX scores were shown complex disease patients were recruited, with only 28.8% having
to be a surrogate marker of sicker patients,145 with greater base- 3VD. At the time of writing, prospective validation of the functional
line clinical comorbidity and anatomic complexity and consequent residual SYNTAX score is awaited from further studies investigating
adverse long-term clinical outcomes, including all-cause mortality. more complex CAD, including the ongoing SYNTAX II trial.
Stratified analyses in the powered subgroups of ULMCA disease In summary, the residual SYNTAX score (with possible func-
and medically treated diabetes showed that a residual SYNTAX tional assessment) allows for the quantification of the degree of
score greater than 8 was associated with adverse long-term clinical revascularization and for determination of an objective level of
outcomes, including mortality. Stratified analyses in subjects with reasonable incomplete revascularization,143 whereby a threshold
reduced LVEF also showed the results to be equally applicable, value could be determined that would not have a negative impact
whereas in subjects with total occlusions, a more modest effect was on long-term mortality and other clinical outcomes.
shown that did not reach statistical significance. The latter perhaps
implied that a higher level of a residual SYNTAX score was required
in patients with total occlusions with MVD and/or that appropriate
Post–Coronary Artery Bypass Grafting SYNTAX Score
viability assessment was required to ensure that revascularization of The CABG equivalent of the residual SYNTAX score, the post-
the total occlusion was appropriate and clinically justified.148 CABG SYNTAX score, has been shown to be linked to adverse
Subsequently, several validation studies from registries have fur- 5-year clinical outcomes, including mortality, in the angiographic
ther supported the use of the residual SYNTAX score in complex substudy of the SYNTAX trial (SYNTAX–LE MANS [Left Main
CAD.149–152 Specifically in one registry of 1043 patients with MVD Coronary Artery Stenting]; Fig. 1.24).154,155 Because of the inher-
and at least one CTO,151 a higher cutoff value for the residual SYN- ently differing mechanisms of treatment of CAD with CABG and
TAX score (≤12) value was demonstrated, in which a reasonable PCI, calculation of the residual SYNTAX score (i.e., the burden
level of incomplete revascularization was achieved that had similar of coronary disease removed by PCI) differs from that of the
outcomes to complete revascularization. These latter findings thus post-CABG SYNTAX score (i.e., coronary disease bypassed with
corroborated the effect of total occlusions on the residual SYNTAX a graft). The basic principle of the post-CABG SYNTAX score is
score in the original SYNTAX trial as discussed in the last paragraph. that it deducts points from the “native” baseline SYNTAX score
More recently, the prospect of a functionally guided incomplete based on the level of “protection” conferred by the bypass grafts,
revascularization has been proposed.153 Notably in 385 patents through deduction of the vessel-segment weighting (Leaman
who underwent three-vessel functional assessment following stent score, see Fig. 1.13)109 that the bypass graft provides (eFig. 1.5).
Native syntax score: 39
Inverse LIMA Y Graft LAD, OM 1-3:

deduct occluded segments 6 and 11
weighting: (3.5 × 5) + (2.5 × 5)= –30 points
CABG SYNTAX Score: 9
eFig. 1.5 Example of the calculation of the post–coronary artery bypass grafting (CABG) SYNTAX score. Occluded left main (#) in a left dominant
system gave a native SYNTAX score of 39 (upper image). A patent left internal mammary artery (LIMA) inverse Y graft anastomosed to the mid left
anterior descending (LAD) coronary artery (upper white arrow), with sequential anastomoses to the first, second, and third obtuse marginal (OM)
branches (lower three white arrows) are shown. Based on the vessel segment weighting (refer to Fig. 1.12 in text), 17.5 (occluded proximal LAD),
and 12.5 (occluded proximal left circumflex artery [LCx]) points were deducted from the native SYNTAX score. Post-CABG SYNTAX score was there-
fore 39 − 17.5 − 12.5 = 9 points. (Reprinted with permission from Farooq V, Girasis C, Magro M, et al: The CABG SYNTAX Score: an angiographic
tool to grade the complexity of coronary disease following coronary artery bypass graft surgery: from the SYNTAX Left Main Angiographic [SYNTAX-
LE MANS] substudy. EuroIntervention. 2013;8[11]:1277–1285.)
Impact of Coronary Physiology 1

Lesion evaluated by iFR/FFR Lesions treated per patient (n) Cases of three-vessel PCI (%)
interrogation (n =1177) in SYNTAX II and SYNTAX I in SYNTAX II and SYNTAX I
P < .001 100 P < .001

SYNTAX II
83.3%
4.02
80
PCI
deferred
2.64 60
31%
PCI 37.2%
performed 40
69%
20
0
A SYNTAX II SYNTAX I SYNTAX II SYNTAX I
Impact of CTO Revascularisation
CTO revascularisation in
CTO PCI procedural success rate in
SYNTAX II and SYNTAX I
SYNAX II:87% (n = 108)
P < .0001
100%
80%
n = 94
Success
60%
Failed
87%
n = 14 40%
53%
20%
0%
B SYNTAX II CTO PCI SYNTAX II SYNTAX I
Impact of Intravascular Ultrasound (IVUS)

SYNTAX II IVUS use in SYNTAX II and SYNTAX I
(patient level, % of cases)
Patient level Lesion level
100%
15.9% P < .0001

80%
23.6%
60%
84.1%
40%
84.1% 76.4%
20%
IVUS 4.8%
no IVUS 0%
SYNTAX II SYNTAX I
Post-implantation IVUS led to further

C optimisation of the stented lesion in 30.2%.
Fig. 1.20 Impact of the SYNTAX II PCI strategy—coronary physiology (A), chronic total occlusion (CTO) revascularization (B), and intravascular ultrasound
(IVUS) (C)—in the SYNTAX II trial135–137 compared with the original SYNTAX I trial. FFR, Fractional flow reserve; PCI, percutaneous coronary intervention.
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whenever we stopped Mansing pathetically conversed with the dog, who
seemed almost to understand all the coolie was telling him.
A Tibetan Camp of Black Tents
It was rather a puzzle to me why this dog followed us so long, for we had so little
food that we could but seldom spare him any. He slept near us at night with his
head on the lap of one of us, and during the march he showed quite sporting
instincts by chasing antelopes and kiang (wild horse) when we encountered
herds of hundreds of them. Curiously enough, when we entered a Tibetan
encampment he always avoided being seen in our company. It seemed almost
as if he realised that we were not welcome guests in the country, and feared the
consequences. Possibly [139]he only temporarily left us to see what he could pick
up in the way of food, but whenever we came across him in the encampment, he
never would show signs of recognition, much less of affection, as was the case
when he would rejoin us some miles beyond on the march, when he made
ample efforts to reingratiate himself. He seemed almost to want to express:
“Sorry I had to cut you in the encampment, but I really had to!”
At last the day came when we were captured, and underwent several kinds of
tortures, as I have already described in In the Forbidden Land. The dog had
vanished, and, to tell the truth, we did not give him much of a thought, as we
were somewhat concerned about ourselves.
One day, when Mansing and I were stretched, or rather suspended, on a

primitive kind of rack, and we were for some time left to ourselves—the soldiers
and Lamas having retired some distance off into the huge tent of the Pombo, a
high official—the dog sadly walked towards us, sniffing us, and rubbing himself
against Mansing and me. He was particularly affectionate to Mansing, whose
face he licked several times; then with a pathetic movement of his head as if to
express his sorrow, he gave us a parting sad look, turned his back, [140]and
walked slowly and sorrowfully away. That was his last mark of friendship and the
last we saw of him.
Tibetan encampments have no great interest except for the peculiar shape of
the black tents—a pattern of shelter most suitable for the climate of their country.
The two sides of the tent are separate, and when the tent is put up it leaves an
aperture all along its highest ridge. This is for various reasons. First, because
the Tibetans light fires inside their tents, and an opening is necessary to let the
smoke out; also as a means of ventilation, the cold air not penetrating so quickly
as when it comes in at the sides, owing to the warmed atmosphere inside. The
black tents are woven of a coarse and waterproof fabric of yak hair. Through the
slit at the top generally protrude the props of the matchlocks bundled against
one of the tent poles.
Every man in Tibet owns one of these weapons, and is considered a soldier in
time of war.
Interior of a Tibetan Tent, showing Churn for mixing Tea with Butter
The inside of a large Tibetan tent is quaint enough when you have reached it by
skipping over masses of dirt and refuse which surround its outside. Only, when
you peep in, the odour is rather strong of the people, old and young, all since
[141]birth innocent of washing, and the smell of badly-prepared skins, and stores
of chura (cheese). Nor must I forget to mention the wall of yak-dung erected
right round the tent inside to serve the double purpose of protection against the
wind where the tent meets the ground, and of fuel, being gradually demolished
to feed the double mud-stove erected in the centre of the tent. Mud alone is also
occasionally used for the inside wall.
As you know, dung is practically the only fuel obtainable in the highest parts of
Tibet, although occasionally a few low shrubs are to be found. The fuel is
constantly collected and conveyed from one camp to the next, when changing in
order to find more suitable grazing for the sheep and yaks.
The centre mud-stove is built according to the most practical notions to make it
draw properly, and upon it can nearly always be seen one or two large raksangs,
brass vessels in which brick-tea is being stewed and stirred with a long brass
spoon. But the operation of tea-making is rather complicated in Tibet. After the
leaves have been stewed long enough the liquid is poured into a dongbo, or
cylindrical wooden churn, in which have been deposited several balls of butter
with copious [142]sprinkling of salt. A piston which passes through the movable
lid is then vigorously set in action, and when well stirred and steaming the
mixture is served all round and avidly drunk in wooden bowls, one of which
every one carries about the person. Tsamba, a kind of oatmeal, is frequently
mixed with the tea in the bowls, where it is made into a paste with the fingers.
A Little Boy learning to Pray
No matter how much non-Tibetan folks may find merriment in the idea of tea
being brewed with butter and salt, there is no doubt that for a climate like Tibet it
is “the drink” par excellence. It warms, nourishes, and is easily digested. I very
often indulged in the luxury myself, when I could obtain butter, only, my digestion
working rather rapidly owing to the amount of roughing we daily endured, I left
out the salt so that I should not digest the mixture too quickly.
The richer owners of tents generally have a sort of folding shrine, with one or
more images of Buddha, which occupies the place of honour in the tent.
Numerous brass bowls and ornaments are displayed in front of these images
and also offerings of tsamba and butter. Wicks, burning in butter, are
occasionally lighted around and upon the shrine. Decrepit old women seem to
[143]spend most of their time revolving their prayer-wheels and muttering prayers
in front of these altars, and when occasion arises thus teaching little children to
do the same. The younger folk, too, are very religious, but not to the fanatical
extent of the older ones.
It is quite amusing to see little mites—children are always quaint in every country
—try to master the art of revolving the prayer-wheel. It must be revolved from left
to right, to pray in the proper fashion,—not that if you revolved it the other way
you would necessarily be swearing, only, according to the laws of Tibetan
Buddhism, prayers spun in the wrong direction would have no effect and bring
no benefit. In a similar way circumambulations, either round hills for pilgrimages,
or round a tent, or round a sacred lake, must always follow a similar direction to
the revolving of the prayer-wheel.
In Lhassa and many other sacred places fanatical pilgrims make these
circumambulations, sometimes for miles and miles, and for days together,
covering the entire distance lying flat upon their bodies, then placing the feet
where the head was and stretching themselves full length. Inside temples a
central enclosure is provided, round [144]which these circumambulations are
performed, special devotions being offered before Buddha and many of the
other gilt or high-coloured images which adorn the walls of the temple.
As can be seen by the coloured plate illustrating one of these scenes, from the
ceiling of the temple hang hundreds of long strips, Katas, offered by pilgrims to
the temple and becoming so many flying prayers when hung up—for mechanical
praying in every way is prominent in Tibet. There is, after all, no reason why
praying should not be made easy like everything else. Thus, instead of having to
learn by heart long and varied prayers, all you have to do is to stuff the entire
prayer-book (written on a roll in Tibet) into the prayer-wheel, and revolve it while
repeating as fast as you can go these four words: “Om mani padme hum,”—
words of Sanscrit origin and referring to the reincarnation of Buddha from a lotus
flower, literally “O God, the gem emerging from the lotus flower.”
Interior of Tibetan Temple
Worshippers circumambulating the inner enclosure lying flat full length.
The temples of Tibet, except in Lhassa itself, are not beautiful in any way—in
fact, they are generally very tawdry and dirty. The attention of the pilgrims is
directed to a large box, or often a big bowl, where they may deposit whatever
[145]offerings they can spare, and it must be said that their religious ideas are so
strongly developed that they will dispose of a considerable portion of their
money in this fashion.
Large monasteries, of red or yellow Lamas, are attached to these temples,

where proselytes are also educated. These Lamas, whatever their colour, are
very clever in many ways, and have a great hold over the entire country. They
are, ninety per cent of them, unscrupulous scamps, depraved in every way, and
given to every sort of vice. So are the women Lamas. They live and sponge on
the credulity and ignorance of the crowds; and it is to maintain this ignorance,
upon which their luxurious life depends, that foreign influence of every kind is
strictly kept out of the country. Their abnormal powers have been grossly
exaggerated. They practise, it is true, hypnotism, but that is all. They can
perform no more marvellous feats than any one can do in England who is able
to mesmerize. As for the Mahatmas, who, our spiritualistic friends tell us, live in
Tibet, they are purely imaginary, and do not exist. The Tibetans have never
heard of them nor about their doings.
Personally—and I am glad that the few men [146]who know Tibet from personal
knowledge and not from political rivalry agree with me—I believe that the
intrigues of the Lamas with Russia are absolute nonsense. Tibet, it must be
remembered, was not forbidden to Englishmen only, but to everybody from
every side, whether native or white, certain Nepalese and Chinamen, only,
having the privilege of entering the country. It was a fight against Western ways
in general which the Lamas were carrying on, quite successfully owing to the
geographical position of their country, and the natural difficulties of reaching it,
and not a fight against one race more than another. The accounts of the Lhassa
Mission to the Czar were possibly the best diplomatic practical jokes which have
been played upon this credulous country; and the mythical and much-feared
Dorjeff is possibly—at least as far as power is concerned—nothing more than
the creation of hysterical Anglo-Indian officials who, everybody knows, seem to
see the treacherous hand of Russia in everything.
Tibetan Women weaving
Perhaps no other country but England would be so rash as to go and sink

millions of pounds sterling good money on a country that is, for all practical
purposes, absolutely useless and worthless. [147]This does not detract from its
pictorial, nor from its geographical or ethnological interest; from these points it is
most interesting indeed.
Agriculturally, as I have stated, nothing grows there; no very wealthy mines have
so far been discovered, the only mines that are plentiful being of borax, which
has not sufficient market value to pay for the expensive carriage from Tibet to
the coast. Regarded as a climate for a sanatorium for our sick soldiers in India—
for which Tibet is frequently recommended by Anglo-Indian papers—I believe
that such an establishment would be a very quick way of disposing altogether of
all the sick men sent there. And as for such gigantic schemes as the
construction of railways, say from India to the upper waters of the Yangtze-
Kiang, or to Pekin, the expense of taking a railway over the Himahlya range and
keeping it in working order during the wintry months—nine out of twelve—would,
I think, never be remunerative. In Tibet itself the construction of a railway would
be comparatively easy, as great stretches of the country are almost flat. Stations
of imported fuel would have to be provided for the entire distance across Tibet,
and the engines would have to be constructed specially to suit the great altitude.
[148]
For trade and commerce with the natives themselves, the population of the
country is so small, so deplorably poor and so lacking in wants, and the country
is so large that, personally, I do not see how any large commercial venture in
such a country can turn out successful. It is very difficult to get money where
there is none. Small native traders, of course, can make small profits and be
satisfied. Besides, the intercourse between Tibet and the neighbouring
countries, particularly those to the south, can only take place with comfort during
three months of the summer when the high snow-passes are open.
So that, much as I would like to see Tibet open in a proper way to travellers, I
cannot quite understand the necessity of the Government spending millions of
money and butchering thousands of helpless and defenceless natives in a
manner most repulsive to any man who is a man, and of which we can but be
ashamed—and all this to obtain a valueless commercial treaty. It is true, the
Tibetans had been very impudent in every way on our frontier, but for this we
only have to blame ourselves and our incompetent officials. If, instead of giving
way to their bluff, we had kept a firm hand, matters would have been different.
Tibetan Women cleaning Wool
[149]
Even in the case of my capture and torture on my first expedition into Tibet I
never had a feeling of resentment towards the Tibetans for what they did to me.
It was very exciting and interesting for me to endeavour to reach their sacred
city, but I did so at my own risk and against their repeated warnings and threats,
and I got nothing more for it in the end than I expected, in fact, bad as it was,
considerably less. Highly amusing as it was to me to give them endless trouble,
it was undoubtedly equally enjoyable to them to torture me, when once they
succeeded in effecting my capture. Possibly, if I now have any feelings at all
towards the Tibetans, it is a feeling of gratitude towards them for sparing my life
in the end, which, by the way, they came within an ace of taking as they had
promised to do.
As a punishment for what they did to me—because, after all, my men and I
suffered a great deal more than the average man could stand—the Government
of India practically ceded, as we have said, all the rights to Tibet of an immense
district of British territory at the frontier. Can you blame the Tibetans for doing
worse if they had a chance? [150]
[Contents]
CHAPTER XIV
In heart and soul the Tibetan is a sportsman; but if you look for grace in his
movements you will be sorely disappointed. Indeed, more fervour and
clumsiness combined are hardly to be paralleled anywhere. Perhaps the Tibetan
is seen to advantage on his pony, and some of his feats on the saddle I will here
describe.
A Lama Standard-Bearer
Horse races are quite a favourite form of amusement, and are run in a sensible
manner. Only two ponies at a time go round the course, the final race being run
between the winners of the two best heats. Praying is usually combined, in
some form or other, with everything people do in Tibet, and so even races are
run round the foot of an isolated hill or around an encampment of tents; for, as
you know, circumambulation of any kind, if in the right direction, is equivalent to
prayer, and pleases God. Thus, just as with their prayer-wheels, a rotatory
[151]motion is kept up from left to right, so races are run in the same way from the
standpoint of the spectator.
A Tibetan race would astonish an English crowd—the means adopted by the

well-matched couples being very effective, if somewhat primitive. Such simple
devices as seizing one’s opponent’s reins, or lashing him in the face to keep him
back, or pushing or pulling him off his saddle, are considered fair and legal
means in order to win the race. The last heat is usually the most exciting,
especially for the spectators, for blows with the lash are exchanged in
bewildering profusion by both riders taking part in it, their respective ponies
sharing unsparingly in the punishment. Occasionally the race becomes a regular
hippic wrestling match, when both riders, clinging tightly together, tumble over
and roll to the ground. When the ponies are recaptured, the bruised horsemen
remount and continue the race as if nothing had happened.
The heavy sheepskin coats worn by the Tibetans are some protection when the
lash is applied, and the pain inflicted is not always in proportion to the noise
made by the blow; but such is not the case when they catch one another across
the face. [152]
The winner is presented with a kata by the umpire—a high Lama or a military
officer, a most picturesque creature in a brilliant red coat and fluffy hat, who has
a peculiar standard with hundreds of long, vari-coloured strips of cloth, or flying
prayers. Sitting on a handsome pony, with gaudy harness of green leather inlaid
with brass, a valuable Chinese rug upon the saddle, and many tinkling bells
round the pony’s neck, the umpire and his pony certainly produce a gay
ensemble. This gentleman takes himself very seriously, and seldom
condescends to smile.
The kata, or “scarf of love and friendship,” which is given to the winner is a long
piece of silk-like gauze, the ends of which have been trimmed into a fringe. As I
have elsewhere described at greater length, these katas play quite an important
part in the social intercourse of Tibetans. They can be purchased or obtained
from the Lamas of any monastery, or where no monastery exists the natives
manufacture them themselves, for they are constantly needed. No gift can be
sent nor accepted without “a veil of friendship” accompanying it, and no stranger
ever enters a tent without offering, with outstretched hands, a kata, which he
quickly lays at the feet of [153]his host. Diminutive katas are enclosed in letters;
sweethearts exchange katas on every possible occasion—until they are actually
married. Polyandry being prevalent in Tibet, when one of the several husbands
returns to his wife after the customary absence, he never fails to bring a kata
with him. Not to offer a kata to an honoured visitor is as palpable a breach of
manners, and as great a slight as can possibly be offered in the Forbidden Land.
Necessarily, when a kata has been blessed by the Lamas, or is won in a race
before high officials, it has additional value, and these simple folks value it more
than a gift of money or food. It is stored away in the tent among the heirlooms,
and is handed down to posterity.
A slightly more difficult feat, very common in a similar form in most countries, is
the picking up of a kata by horsemen at full gallop. One horseman, a high
official, revolves the kata seven times in the wind, and then darts full gallop in
one direction, followed by twenty, thirty, or more horsemen riding wildly, and
each trying to push his neighbours out of the way. The official, some thirty yards
ahead, flies the kata in the wind, and when fancy takes him lets it drop out of his
hand. The kata eventually settles on the ground, and the horde [154]of riders
gallops away from it, yelling and quarrelling. At a signal from the officer the
horsemen turn round and make a dash for the scarf, towards which all the
ponies are converging. Clinging to the saddle with one hand and hanging over,
each rider attempts to pick up the kata without dismounting. Collisions and nasty
falls are numerous, and this sport generally partakes of the character of an all-
round fight among the ponies’ legs. Somebody, however, always succeeds in
picking up the scarf and getting clear of the others, when he triumphantly rides
round the camp fluttering the prize in the wind.
Some of the younger fellows are clever at this sport, and when one rider at a
time does the feat, he seldom misses picking up the kata at the first swoop.
A Race for the Kata
An interesting and more difficult feat of horsemanship I witnessed in Tibet was

the loading and firing of a matchlock while at full gallop—a performance which
requires a firmer seat on the saddle than appears. The heavy and cumbersome
weapons had to be unslung from the shoulders, the props let down, the fuse
lighted by flint and steel, some gunpowder placed and kept in the small side
receptacle, and last, but not least, the shot fired off—that [155]is to say, when it
would go off! The full use of both hands was required in this exercise, and
therefore the horsemen held the reins with their teeth. When firing they lay
almost flat on the ponies’ backs in order to prevent being thrown by the sudden
bucking of the frightened ponies.
Another exercise consists in bodily lifting a person on the saddle while the pony
is at full gallop. The pedestrian is seized as low near the waist as possible, and
the impetus of the pony’s flight, not the rider’s actual strength, is utilised in
raising the person on the saddle.
The women seemed particularly interested in this sport, because a practical

application of this exercise is used by enterprising lads of Tibet to overcome the
scruples of reluctant maids who do not reciprocate their love. At a suitable
opportunity the doomed young lady is abducted bodily in that fashion, and
conveyed in all haste to the suitor’s tent, with the honourable intention, of
course, of making her his happy bride.
Women are scarce in Tibet, and actual raiding parties, I was told, occasionally
take place against neighbouring tribes in order to obtain a fresh supply of wives.
Taking things all round, there are few men and [156]women in Tibet who cannot
ride well, yet there are few who can claim exceptional skill in that line. The
Tibetan generally values his bones too much to indulge in fancy tricks upon his
pony. Some young fellow, more ambitious than others, will master the art of
standing erect upon the saddle while going full speed, his feet being inserted
into the stirrups, which have for the purpose been shortened as high as they
could go. By pressing with his ankles against the saddle he manages to
maintain his balance, in the familiar way of the Cossacks and tribes of Central
Asia, who all excel in this game.
Tibetan saddles, as you know, are in appearance not unlike a cross between a
Cossack saddle and a rude Mexican saddle, and as good as neither, but quite
suited to the country where they are used. Men and women ride astride, with
exceptionally short stirrups, so that the leg is bent at the knee at a right or even
an acute angle. In order to maintain one’s equilibrium when riding fast some
additional stability is obtained by stretching out the arms sideways.
Tibetan Soldier at Target Practice
Taking all things into consideration, there is no doubt that in a rugged,

mountainous country like Tibet, and for a Tibetan, his is the most practical
[157]and useful type of saddle, and his fashion of riding the most sensible—
evidently the outcome of practical experience. When riding in caravans, driving
herds of laden yaks or ponies, the advantages of legs doubled up high upon the
saddle are soon apparent, avoiding the danger of crushing one’s lower limbs or
having them partly torn off. In the English way of riding, when among obstacles,
one’s legs are always in the way; in the Tibetan fashion they are always out of
the way, or, at any rate, can easily and quickly be moved over from one side to
the other of the saddle. Also, when tired of riding in one position, altering one’s
position to side-saddle is quite convenient and easy.
The blocks of the saddles are of wood imported mainly from India, Nepal, or
China, with bindings of hammered iron or brass, often inlaid with silver and gold.
Lizard skin and coloured leather adorn the front and back of the saddles, and a
substantial pad covers the central part and the otherwise very angular seat. For
extra comfort rugs—occasionally valuable and always decorative in blue and red
tints—are spread, while to leather laces behind the saddle are slung double
bags containing tsamba, chura, or cheese, a brick of compressed tea, and
whatever sundry articles may be used on a journey. [158]The last, but not least
attachment on a Tibetan saddle is a long coiled rope of yak hair with a wooden
peg at the end for tethering the pony at night.
Whatever one may say of Tibetans, the best-inclined could not compliment them
on their shooting. Their matchlocks—their only firearms, made in Lhassa and
Shigatz—are weapons so clumsy and heavy and badly made, that when fired it
is truly more dangerous to be behind them than in front of their muzzle. During
my captivity in Tibet in 1897, indeed, I was fired upon twice—by distinguished
marksmen who took accurate aim only a few paces from me—but neither time
was I hit. Nor in all my experience of Tibet have I any remembrance of ever
seeing a Tibetan hit with a projectile from his matchlock anything which he
intended, although the range was never more than twenty or thirty yards. Few
are the matchlocks in the Forbidden Land which will carry as far as fifty or a
hundred yards.

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Textbook of Interventional Cardiology

8th Edition Eric J. Topol

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TEXTBOOK OF INTERVENTIONAL CARDIOLOGY, 8th EDITION ISBN: 978-0-323-56814-2

Library of Congress Control Number: 2019943784

Content Strategist: Robin Carter

Last digit is the print number: 9 8 7 6 5 4 3 2 1

1 Individualized Assessment for Percutaneous or

of death and myocardial infarction (MI) but at the expense of a

patients who underwent CABG compared with PCI (Fig. 1.3). 20

Primary outcome Evaluation of the Resolute Zotarolimus-Eluting Coronary Stent

clinical practice, which indicate that approximately one-third of

12F pump motor Inlet

PCI (n = 948) CABG (n = 957)

No. at risk Month No. at risk Month

(iii) Stroke (iv) Myocardial infarction

No. at risk Month No. at risk Month

SAQ - Angina Frequency SAQ - Physical Limitations

SAQ - Treatment Satisfaction SAQ - Quality of Life

Fig. 1.4 cont’d

The SYNTAX score algorithm

1. Arterial dominance Lesion 1

i. Number of segments involved LM>50%

9. Heavy calcification Lesion 4

All-cause mortality Myocardial infarction

Stroke Death or stroke or myocardial infarction

Repeat revascularisation MACCE

Cumulative event rate (%)

EuroSCORE and EuroSCORE II Similarly, at intermediate follow-up of 23 months, Rodés-Cabau

stratification in a series of 29,659 patients undergoing elective

According to the variables assessed in the risk score, these

75 dated in large patient populations, such that outcome data are

“LAD” high-risk group was demonstrated to be significantly more

Cumulative survival rate free from

Log rank (mantel-cox): P < .001 Log rank (mantel-cox): P = .001

Cumulative survival rate free from

0.2 SYNTAX-higher, 94% 0.2 SYNTAX-higher, 64.7%

score (eFig. 1.3)123,124 were developed and validated. Both the

1-year risk of death (%)

SYNTAX score ≤17 18–22 23–27 28–32 ≥ 33

Log hazard PCI

Right dominance Weighting

Left dominance +0.5

since been directly contradicted by SYNTAX score II in the all-

SYNTAX score Age (years) CrCl (mL/min) LVEF (%)

Left main Sex COPD PVD

78·5% 62·8% (18·8%) 80·6% 61·7% (9·2%) 80·1% 31·8% (0·7%)

79·4% 29·1% (1·4%) 60·0% 12·9% (2·2%) 31·9% 5·0% (0·0%)

0.00 0.05 0.10 0.15 0.20

SYNTAX Score <= 22 SYNTAX Score 23-22

Favors CABG:16.0 % Favors CABG:41.3 %

Favors PCI:84.0% Favors PCI:58.7%

TEXTBOOK OF INTERVENTIONAL CARDIOLOGY, 8th EDITION ISBN: 978-0-323-56814-2