Dr. Gardner raises several excellent points. As Syntax follow up has increased we are seeing two main issues:

1) PCI for left main disease has a more beneficial role then was previously believed. 2) Surgery continues to be the standard of care in the treatment of triple vessel disease, particularly that which is complex.

In my opinion one of the best lessons from the SYNTAX trial was the SYNTAX Score. It basically demonstrated what we all felt to be true. Namely, multi-vessel disease is not the same entity among all patients. Having spent extensive time in both the cath lab and the OR I see lesions that involve the same segment of coronary artery, one may be excellent for a stent and another preferable for a bypass. As Dr. Gardener discusses, this is the benefit of having a multi-disciplinary team make the decision. This committee needs to make a decision that is in the best interest of the patient. Both the surgeons and interventionalists need to consider this important point. The discussion should not be centered around which approach is technically feasible but rather on the expected patient benefit. As an example, I recently saw a case in a patient with multi-vessel disease and a SYNTAX score that would have been in the middle range. While on one hand the data might suggest this patient would best benefit from surgery, he also had an LAD that had very diffuse mid and distal disease. In the proximal portion he had a very discrete simple lesion. While not entirely data driven, it was my feeling that the benefit he would gain from a LIMA-LAD was less than our typical bypass patient. In this case the patient was taken off the table and a thorough discussion had as to the appropriate treatment option. Not only did this involve a multi-disciplinary approach, but also, most importantly it allowed the patient to play a role in this decision. Ultimately this patient chose PCI and in this case I think that was certainly appropriate though surgery would also have been acceptable.

As a final note, SYNTAX compares all surgery vs. all PCI. Clearly there are benefits to each. In surgery it seems to be the durability and in PCI it is the safety profile. I think this provides the rationale for hybrid revascularization. With this strategy the patient generally gets a LIMA to the LAD, which is likely the survival benefit of CABG. This can frequently be done via a MIS approach and almost always off-pump. The other targets are then treated with a DES. Not only is this less invasive but I would argue is also the most durable option. I do not believe there is a better revascularization option than a mammary artery but I do think in most cases a DES will provide a more durable option than a saphenous vein or even a radial artery. I look forward to continuing to follow the results of the SYNTAX trial and other similar trials in the future.