The next lecture will be presented by Dr. Selke. Frank has been a colleague, we participated in several committees together at AHA, has many titles at Brown where he practices, and we're delighted to listen about his presentation on complex disease and high-risk patients. Thank you, Frank. Thank you, Mauricio, for your kind invitation, and I'd like to thank the organizers also for inviting me. I was given the text of defining complex disease and high-risk surgical patients. So how do you define complex disease? The SynStax score is probably the most commonly used and reliable. It came up in a clinical trial, and you can ask, why does it matter? Next slide. Well, the complexity of the coronary artery lesion in part determines its short and potential long-term benefit and risk of percutaneous coronary intervention. Next slide. So there's another revascularization option, namely coronary bypass grafting. So if PCI is high-risk, you always have the option of bypass surgery. So I'm going to give you an example. This is actually a real patient that came in the week I brought up these slides. It's a 65-year-old attorney, he experienced sudden onset of chest pain and lightheadedness after taking Viagra for the first time. His symptoms resolved after one hour. I didn't ask him if he did anything after he took the Viagra other than trying to relieve his symptoms. But he was taken to a local hospital where EKG showed some mild T-wave inversions, and he underwent catheterization next morning. Now, he was totally asymptomatic after the hour of symptoms. And this is what the catheterization showed. Very tight left main lesion, a bifurcation lesion. You can almost say it was a trifurcation lesion. It's left dominant, the right coronary artery was small and non-diseased. And the guy did not want surgery. He was in extremely good condition on the outside. He was very athletic, worked out with weights. He did not want his body image to be disturbed. So Dr. Don Abbott actually referred him to me. He thought it was a bad candidate for bypass surgery for PCI, so he referred him for bypass surgery. Well, he didn't want the surgery. So I asked another interventional cardiologist, Paul Gordon, who was also extremely good, but he tends to intervene on a lot of lesions, which the surgeons think should have bypass surgery. Dr. Gordon also turned him down. So after he was transferred to our institution, I did a syntax score and it was 26, which is rather high. Anything above 23 is high risk. His STS score was one. He was in great shape. He had normal ejection fraction. So he was really low risk for bypass surgery. And he finally consented to having the operation. He went triple cabbage and was discharged three days after surgery. I did a mammary artery graft. I tried to talk him into a radial, but when I told him the potential risk of a radial artery graft, I said, you may have some weakness in your hand. He didn't like that. So he wanted all veins in the mammary artery. The syntax score looks a lot of considerations, the dominance of the circulation. This guy had left dominant system angulation, is there a bifurcation, trifurcation lesions, total occlusions, presence of thrombus and effuseness of disease. This is actually the first time ever myself came up with a syntax score. I came up at 26. So low complexity is less than 16, medium complexity at 16 to 22, and high complexity lesion is greater than 22. Now there's an added group of variables here that comes up with a syntax two score, which not only takes in the complexity of the coronary lesion, but also a factor such as the age of the patients, the creatinine clearance, ejection fraction. Is there a presence of the left main gender COP and peripheral vascular disease? And this gives you an indication of the four year survival. So you can see how many, the greater number of points you have, the lower the four year survival. Well, what about bypass surgery and why does it matter? Well, as I mentioned before, the risk of coronary artery bypass surgery in large part determines the short and potential long-term benefit of the therapy. And there is another option for revascularization, namely PCI. So you have two good options. Now when figuring the STS score, I'm not going to go through all these, but there are dozens of factors, including the age, gender, race, payer status, ejection fraction, do they have a balloon pump, the urgency of the operation, are they in shock, have they had cancer or radiation within the past five years? All of these go into the estimation of the CABG mortality, the STS score. And it's a percent predicted 30 day operative mortality. It's very similar to the Euro score. We tend to use the STS score in North America. What's not taken into consideration is the complexity of lesion. As surgeons, we don't really care how complex the lesion is. Even a very tight left vein, we give antigrade cardioplegia, then we get retrograde cardioplegia. We figured out we can very effectively preserve the heart. Also, the presence or quality of the conduit. Somebody has bilateral vein strippings or has severe peripheral artery disease, they have a negative valence test. You can't take the radial artery. The quality of the bypass targets and the diffuseness of disease, the frailty, the thinness of the skin, and the class of liver disease, these are not taken into consideration. So you have to really add these to the STS score. Somebody has a child, C, cirrhotic, they can be an STS1, but their mortality is greater than 90%. So again, you have to take these other factors into consideration. So in conclusion, it's important when deciding on the course of treatment of patients with coronary disease to take in consideration the relative risk and benefits of both PCI and CABG. And the best way to do this is estimating the STS score and Syntax score and taking a heart team approach, as Dr. Lawton mentioned earlier. You have to involve the patient, the family, and the referring physician preference into consideration. The patient I presented was very adamant that he not have bypass surgery, mainly for cosmetic reasons. But when two very good interventional cardiologists told him they did not think he should have a PCI, he finally gave consent for bypass surgery. However, there are factors not taken into consideration by either STS score or Syntax score, such as the presence of CABG conduit frailty, that need to be taken into consideration when deciding the next treatment option. Thank you.

complex disease

high-risk patients

coronary artery disease

SynStax score

percutaneous coronary intervention