1. My thoughts are why not reduce stroke risk and still provide enduring revascularization to the dominant coronary territory by a combo procedure with offpump LIMA to LAD esp for the LM or diffuse (esp proximal/ostial) LAD disease and DES multivessel stent the other territories thereby obtaining the best of both worlds and also treating the BARI type patients who had the best results with this strategy.
2. what was the proportion of offpump vs onpump bypass in SYNTAX vis a vis the implications for stroke rate?
3. also what percent of the conduits were veins versus artery conduits in SYNTAX? With no longer term 5-10 year follow up, one wonders if the benefits of potential vein graft failure ouweigh the risk of DES restenosis which is usually retreable.

appreciate this column

The results of SYNTAX trial are interesting but not suprising...and are related to previous trials comparing CABG with PTCA.

I think that we don't take into account the psycological impact of an open heart surgery and we must try to evaluate other situations to select the proper revascularization method such as the need to be ready quickly back to work, age, gender, diabetes and the future need of medication, although most patients need Aspirin, beta blockers, Statins and maybe other antihypertensive drugs.

An important issue is if the patient is going to be sent to surgery during the next year because of the withdrawl of Clopidogrel (in the PTCA group).

The patient must be part of the final decision.

I am personally impressed with the PCI outcomes, particularly in light of the total length and number of stents and the frequent LM stenting. I wonder whether the inability to establish noninferiority of PCI is equivalent to establishing the superiority of CABG for the composite endpoint. Probably not, due to power considerations. The whole composite endpoint approach including repeat TVR likely biased against noninferiority.

I also have difficulty with the meta-analysis in JACC. The COURAGE trial is the largest and provided the best medical therapy. I think it stands on its own. A recent JACC "state of the art" piece appeared somewhat biased in my opinion toward intervention.

  In INDAI we have lots of constrains for using multiple DES in a single patient , as CABG surgery is very cost effective , non the less repeat procedures?

  Probably there could be a vaible option of making ACS patients stabilize by using one DES at culprit vessel and making the subject stabilize to follow up as any one of COURAGE trial patient with optimal medical and life style approach. Thus taking the advantage of both the great trials in real world senario with the least discomfort to the patients.