CABG or PCI for CAD?

Recent years have seen an ongoing debate as to whether heart surgery using coronary artery bypass graft (CABG) or the non-surgical procedure of percutaneous coronary intervention (PCI) is the most appropriate revascularisation strategy for patients with coronary artery disease (CAD), the most common form of cardiovascular disease. During PCI, a cardiologist feeds a deflated balloon or other device on a catheter from the inguinal femoral artery or radial artery up through blood vessels until they reach the site of blockage in the heart. X-ray imaging is used to guide the catheter threading. At the blockage, the balloon is inflated to open the artery, allowing blood to flow. This is then combined with stenting, whereby a short-wired mesh tube (or stent) is placed at the site of blockage to permanently open the artery. In patients treated with PCI, improvements in technology and antiplatelet therapy coupled with landmark studies have effectively led to the replacement of balloon angioplasty with coronary artery stenting, which is the current preferred method of PCI.

The Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) study was conducted with the intention of defining the specific roles of each therapy in the management of de novo three-vessel disease or left main CAD. Interim results after 12 months show that PCI leads to significantly higher rates of major adverse cardiac or cerebrovascular events compared with heart surgeryusing CABG (17.8 versus 12.4; p=0.002), largely owing to increased rates of repeat revascularisation. However, CABG was much more likely to lead to stroke. Interestingly, categorisation of patients by severity of CAD complexity according to the SYNTAX score has shown that there are certain patients in whom PCI can yield results that are comparable to, if not better than, those achieved with CABG.  

For the practitioner, the most important message to take away from the SYNTAX study is that patients with three-vessel disease should no longer be treated using a generalised approach, but rather should undergo a careful clinical evaluation and comprehensive assessment of CAD severity, alongside application of the SYNTAX score. This will help practitioners in selecting the most suitable therapy for each individual CAD patient and optimise outcomes for this most common form of cardiovascular disease.

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Optimal imaging for interventional cardiology

Advances in the design and technology of medical devices and delivery systems, coupled with demand for alternative non-surgical therapies for common medical problems, cardiology diseases and heart failure, have led to an increase in the volume, variety and complexity of non-coronary cardiac interventional procedures performed.

The greater complexity of these newer procedures, particularly those involving heart valve intervention, necessitates more sophisticated and exacting imaging techniques, both to facilitate appropriate case selection and to provide procedural guidance, thus increasing the likelihood of successful outcome. Contemporary advances in echocardiography imaging techniques ensure these modalities are well suited to the imaging requirements of this exciting and expanding field of interventional cardiology. Realtime 3D imaging, made possible by the development of a full matrix transducer capable of acquiring pyramidal-shaped ultrasound data sets, has been a major advance in transthoracic echocardiography (TTE) for examining patients with suspected heart failure. Progress can also be seen in the development of transducers and systems capable of single-beat 3D acquisitions, thus eradicating stitching artefacts, are now available. Miniaturisation of this 3D technology has enabled coupling with a transoesophageal echocardiography (TEE) probe providing high-quality 3D TEE images for patients with cardiology diseases.

The ideal echocardiography modality would provide high-quality, realtime 3D imaging in a format easily comprehended by the interventional cardiologist, with minimal interference to the flow of the interventional procedure being performed. It would be safe, minimally invasive and widely available at low cost. Currently, no one echocardiography imaging modality fulfils all these criteria. Each has relative advantages and disadvantages compared with the others. Therefore, selection of the optimal imaging modality for any given interventional cardiac procedure must take into account both the specific requirements of the procedure and the relative strengths and weaknesses of the imaging modality to ensure the greatest likelihood of successful outcome.

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The future for cardiology stem cells

Myocardial infarction (MI) is the leading cause of death among people in the industrialised world and will become the leading cause of death in the world in 2020, according to the World Health Organization (WHO).

Whilst remarkable medical advances have been made during the second half of the 20^th Century to increase patient survival, new treatments for patients with cardiovascular disease from acute MI and ischaemic cardiomyopathies to bifurcation disease are needed.

Scientists believe that stem cells and their by-products could be the next major advance in the treatment of patients with cardiac disease. It is hoped that cardiac stem cell research may also one day reduce the need for coronary angioplasty in CAD including Bifurcation Disease.

Currently, basic research scientists and clinicians worldwide are investigating human embryonic stem cells, skeletal stem cells (myoblasts), adult bone marrow stem cells, cardiology stem cells and human umbilical cord stem cells for the treatment of patients with MIs and ischaemic cardiomyopathies. 

Whilst important progress is occurring in the use of stem cells for cardiac repair, the most optimal stem cell(s) for treatment of patients with infarcted myocardium is yet to be determined.

At present, there are no widely used stem cell therapies other than bone marrow transplant. Research is underway to develop various sources for cardiac stem cells and to apply them to heart disease and other conditions.

Cardiology stem cell therapy offers great hope and is the topic of much discussion. Anyone wanting to know more about this exciting area can attend the cardiology conference Cell Therapy for Cardiovascular Disease. The cardiology conference is designed for a wide ranging audience from clinicians and clinical investigators, interventional cardiologists, noninvasive cardiologists, cardiac surgeons, research associates, basic science investigators (cell and molecular biologists) to members of public.

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