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The recent report from the ARTS trial focuses on the effect of completeness of revascularization on the outcome within each cohort (1). In the previous report from the trial, on the basis of a small difference in the cost of treatment during the first year in favor of stented angioplasty, but in the absence of difference in the rate of major complications and with a repeat revascularization rate more than five times greater among the stented patients, the investigators concluded that there is no advantage to surgery over angioplasty in patients with multivessel disease (2). Now we learn that when the interventional cardiologists estimated that, using stented angioplasty, they could achieve a degree of revascularization equal to surgical revascularization, they were, in fact, able to provide this degree of completeness to a substantially lower number of patients (70.5% vs. 84.1%). The significantly better revascularization in the surgical group was accomplished without increased incidence of stroke, myocardial infarction, or death. Patients in this trial, who were randomized to stented angioplasty and received incomplete revascularization (30%), could have much better freedom from death and other major complications, reducing the need for subsequent bypass surgery from 10% to only 0.2% to 1.1%, with only minimal effect of completeness of revascularization. However, the investigators elected to emphasize the effect of complete revascularization; the fact that even with complete revascularization, the stented patients had a one-year event-free survival much inferior to their surgical counterparts does not appear, as it should, in the conclusions of their report.
Another unanswered question is what happened to the left ventricle (LV) using an approach that resulted in the need for repeat revascularization in every fifth patient. Were all the ischemic episodes indicating the need for further revascularization procedures free of irreversible myocardial damage? And was the subsequent procedure, carrying a 5% to 6% infarction rate in the index procedure, free of damage the second time? Has LV function remained unchanged in both groups?
The researchers conclude that the effectiveness and cost-effectiveness of angioplasty can be further enhanced by careful selection of patients. The cohort assigned to this study consisted of lesser proportion of patients with totally obstructed vessels, small or multilesion vessels, and at least two lesions in arteries >2.75 mm, leading to two different territories. Such patients are almost ideal candidates for angioplasty. Careful selection of candidates from among these patients will further limit the application of the study results to the entire population of patients with multivessel disease.
As surgical collaborators in this study, we think that it shows that the most appropriate approach to patients with multivessel disease is apparent from this and the previous report from the ARTS trial. This could not have been expressed better than in the last sentence in the Results section, which should have been moved to the Conclusions section of the report.
- American College of Cardiology Foundation
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- Serruys P.W.,
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