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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.)
CHAPTER 1 Individualized Assessment for Percutaneous or Surgical-Based Revascularization 5
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
Cumulative event rate (%)
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,
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6. That a commission be appointed by the Mayor to make a careful

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JOHN D. ROCKEFELLER, JR.,

Foreman.
GEO. F. CRANE, Secretary.
Dated, June 9, 1910.

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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

6. That a commission be appointed by the Mayor to make a careful

JOHN D. ROCKEFELLER, JR.,

GEO. F. CRANE, Secretary.

Dated, June 9, 1910.

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