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Page 4 of 17 Ghunaim et al. Vessel Plus 2023;7:29 https://dx.doi.org/10.20517/2574-1209.2023.112

[23]
follow-up . Simultaneously, improvements in PCI techniques have resulted in improved outcomes over
time. The SYNTAX II trial (NCT02015832) compared contemporary vs. historical PCI techniques, finding
lower composite rates of all-cause mortality, stroke, myocardial infarction, or repeat revascularization at two
[24]
years of follow-up for modern vs. older PCI techniques (13.2% vs. 21.9%; P < 0.001) . However, this trial
did not enroll patients with reduced LVEF, requiring further study in this patient population.

More recently, the REVIVED-BCIS2 trial (NCT01920048) compared stable patients with LVEF of 35% or
less and no history of hospitalization two years prior to enrollment undergoing PCI (n = 347) vs. OMT
[25]
alone (n = 353) . At a median follow-up of 41 months, the primary composite outcome of all-cause
mortality or hospitalization for heart failure was comparable between groups (HR 0.99 [0.78-1.27]). LVEF
was similar between the two groups at 6 and 12 months, while quality-of-life scores appeared to initially
favor PCI at 6 and 12 months, but there was no significant difference at 24 months. Despite publication
before the trial, the most recent 2021 American College of Cardiology (ACC)/American Heart Association
(AHA)/Society for Cardiovascular Angiography and Interventions (SCAI) guidelines recommendations
reflect the findings from the REVIVED-BCIS and STICH(ES) trials [Table 1].

While the role of PCI is not described in detail in the American guidelines, European and Canadian
guidelines recommend that PCI may be considered as an alternative revascularization modality in patients
with high surgical risk or the presence of one- or two-vessel disease with the potential for complete
revascularization . In recent years, advances in PCI, such as later-generation drug-eluting stents, intra-
[33]
coronary imaging, radial access, physiology-guided PCI, bifurcation techniques, and advances in chronic
total occlusion recanalization, have resulted in improved short- and long-term outcomes, and may explain
why PCI rates in this patient population have grown over time despite existing trial evidence . These
[34]
[33]
improvements in techniques and outcomes require direct comparison with CABG . Nevertheless,
contemporary trials directly comparing PCI and CABG often exclude patients with (very) reduced LVEF,
such as in the case of FAME 3 Trial (NCT02100722), where only patients with LVEF > 30% were
included . The upcoming STICH3.0 International Consortium (NCT05427370) will provide contemporary
[35]
insights into the comparative effectiveness of CABG and PCI to manage patients with CAD and LV
dysfunction [33,36] . Meanwhile, the Revascularization Choices Among UnderRepresented Groups Evaluation
(RECHARGE):Women and RECHARGE:Minorities aim to specifically investigate PCI vs. CABG in
populations that are underrepresented in existing revascularization trials . Even with increasing research
[37]
into the nuances of different patient populations, there are limitations to applying trial-derived
recommendations to real-world scenarios. Clinical trials abide by strict eligibility criteria that challenge the
generalizability of their findings, with half to three-quarters of all real-world patients meeting clinical
criteria that would make them ineligible for enrolment in contemporary trials [38,39] . This is one of many
benefits of a Heart Team approach, as it interprets multidisciplinary evidence in the context of the patient’s
[40]
unique clinical profile to facilitate shared decision-making and personalized care . However, even with the
increasing adoption of Heart Teams, some disparities in clinical outcomes persist.

SURGICAL CONSIDERATIONS IN CAD WITH REDUCED LVEF [Figure 2]
Diagnosis
Initial investigations of reduced LVEF should distinguish isolated ICM from non-ischemic cardiomyopathy.
Mixed cardiomyopathy is suspected if the extent of CAD on coronary angiography is disproportionate to
the clinical picture or symptom severity. In patients who are minimally symptomatic, inducible ischemia is
identified with stress testing. Viability assessment clarifies the benefit of revascularization through late
gadolinium enhancement-cardiac magnetic resonance (LGE-CMR) imaging to assess the scar burden and
[41]
F-18-fluorodeoxy glucose positron emission tomography to rule out systemic inflammatory disease .