Days alive and out of hospital for adult female and male cardiac surgery patients: a population-based cohort study.

BACKGROUND: Research shows women experience higher mortality than men after cardiac surgery but information on sex-differences during postoperative recovery is limited. Days alive and out of hospital (DAH) combines death, readmission and length of stay, and may better quantify sex-differences during recovery. This main objective is to evaluate (i) how DAH at 30-days varies between sex and surgical procedure, (ii) DAH responsiveness to patient and surgical complexity, and (iii) longer-term prognostic value of DAH. METHODS: We evaluated 111,430 patients (26% female) who underwent one of three types of cardiac surgery (isolated coronary artery bypass [CABG], isolated non-CABG, combination procedures) between 2009 - 2019. Primary outcome was DAH at 30 days (DAH30), secondary outcomes were DAH at 90 days (DAH90) and 180 days (DAH180). Data were stratified by sex and surgical group. Unadjusted and risk-adjusted analyses were conducted to determine the association of DAH with patient-, surgery-, and hospital-level characteristics. Patients were divided into two groups (below and above the 10th percentile) based on the number of days at DAH30. Proportion of patients below the 10th percentile at DAH30 that remained in this group at DAH90 and DAH180 were determined. RESULTS: DAH30 were lower for women compared to men (22 vs. 23 days), and seen across all surgical groups (isolated CABG 23 vs. 24, isolated non-CABG 22 vs. 23, combined surgeries 19 vs. 21 days). Clinical risk factors including multimorbidity, socioeconomic status and surgical complexity were associated with lower DAH30 values, but women showed lower values of DAH30 compared to men for many factors. Among patients in the lowest 10th percentile at DAH30, 80% of both females and males remained in the lowest 10th percentile at 90 days, while 72% of females and 76% males remained in that percentile at 180 days. CONCLUSION: DAH is a responsive outcome to differences in patient and surgical risk factors. Further research is needed to identify new care pathways to reduce disparities in outcomes between male and female patients.

Decision analysis in cardiac surgery: a scoping review and methodological primer.

OBJECTIVES: Randomized controlled trials are the gold standard for evidence generation in medicine but are limited by their real-world generalizability, resource needs, shorter follow-up durations and inability to be conducted for all clinical questions. Decision analysis (DA) models may simulate trials and observational studies by using existing data and evidence- and expert-informed assumptions and extend analyses over longer time horizons, different study populations and specific scenarios, helping to translate population outcomes to patient-specific clinical and economic outcomes. Here, we present a scoping review and methodological primer on DA for cardiac surgery research. METHODS: A scoping review was performed using the PubMed/MEDLINE, EMBASE and Web of Science databases for cardiac surgery DA studies published until December 2021. Articles were summarized descriptively to quantify trends and ascertain methodological consistency. RESULTS: A total of 184 articles were identified, among which Markov models (N = 92, 50.0%) were the most commonly used models. The most common outcomes were costs (N = 107, 58.2%), quality-adjusted life-years (N = 96, 52.2%) and incremental cost-effectiveness ratios (N = 89, 48.4%). Most (N = 165, 89.7%) articles applied sensitivity analyses, most frequently in the form of deterministic sensitivity analyses (N = 128, 69.6%). Reporting of guidelines to inform the model development and/or reporting was present in 22.3% of articles. CONCLUSION: DA methods are increasing but remain limited and highly variable in cardiac surgery. A methodological primer is presented and may provide researchers with the foundation to start with or improve DA, as well as provide readers and reviewers with the fundamental concepts to review DA studies.

One-month DAPT with ticagrelor and aspirin for patients undergoing coronary artery bypass grafting: rationale and design of the randomised, multicentre, double-blind, placebo-controlled ODIN trial.

The optimal antiplatelet strategy after coronary artery bypass graft (CABG) surgery in patients with chronic coronary syndromes (CCS) is unclear. Adding the P2Y12 inhibitor, ticagrelor, to low-dose aspirin for 1 year is associated with a reduction in graft failure, particularly saphenous vein grafts, at the expense of an increased risk of clinically important bleeding. As the risk of thrombotic graft failure and ischaemic events is highest early after CABG surgery, a better risk-to-benefit profile may be attained with short-term dual antiplatelet therapy followed by single antiplatelet therapy. The One Month Dual Antiplatelet Therapy With Ticagrelor in Coronary Artery Bypass Graft Patients (ODIN) trial is a prospective, randomised, double-blind, placebo-controlled, international, multicentre study of 700 subjects that will evaluate the effect of short-term dual antiplatelet therapy with ticagrelor plus low-dose aspirin after CABG in patients with CCS. Patients will be randomised 1:1 to ticagrelor 90 mg twice daily or matching placebo, in addition to aspirin 75-150 mg once daily for 1 month; after the first month, antiplatelet therapy will be continued with aspirin alone. The primary endpoint is a hierarchical composite of all-cause death, stroke, myocardial infarction, revascularisation and graft failure at 1 year. The key secondary endpoint is a hierarchical composite of all-cause death, stroke, myocardial infarction, Bleeding Academic Research Consortium (BARC) type 3 bleeding, revascularisation and graft failure at 1 year (net clinical benefit). ODIN will report whether the addition of ticagrelor to low-dose aspirin for 1 month after CABG reduces ischaemic events and provides a net clinical benefit in patients with CCS. (ClinicalTrials.gov: NCT05997693).

European Association of Cardio-Thoracic Surgery (EACTS) expert consensus statement on perioperative myocardial infarction after cardiac surgery.

Cardiac surgery may lead to myocardial damage and release of cardiac biomarkers through various mechanisms such as cardiac manipulation, systemic inflammation, myocardial hypoxia, cardioplegic arrest and ischaemia caused by coronary or graft occlusion. Defining perioperative myocardial infarction (PMI) after cardiac surgery presents challenges, and the association between the current PMI definitions and postoperative outcomes remains uncertain. To address these challenges, the European Association of Cardio-Thoracic Surgery (EACTS) facilitated collaboration among a multidisciplinary group to evaluate the existing evidence on the mechanisms, diagnosis and prognostic implications of PMI after cardiac surgery. The review found that the postoperative troponin value thresholds associated with an increased risk of mortality are markedly higher than those proposed by all the current definitions of PMI. Additionally, it was found that large postoperative increases in cardiac biomarkers are prognostically relevant even in absence of additional supportive signs of ischaemia. A new algorithm for PMI detection after cardiac surgery was also proposed, and a consensus was reached within the group that establishing a prognostically relevant definition of PMI is critically needed in the cardiovascular field and that PMI should be included in the primary composite outcome of coronary intervention trials.

Do the Few Dictate Care for the Many? Revascularisation Considerations That Go Beyond the Guidelines.

The burden of coronary artery disease (CAD) is large and growing, commonly presenting with comorbidities and older age. Patients may benefit from coronary revascularisation with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), yet half of patients with CAD who would benefit from revascularisation fall outside the eligibility criteria of trials to date. As such, the choice of revascularisation procedures varies depending on the CAD anatomy and complexity, surgical risk and comorbidities, the patient's preferences and values, and the treating team's expertise. The recent American guidelines on coronary revascularisation are comprehensive in describing recommendations for PCI, CABG, or conservative management in patients with CAD. However, individual challenging patient presentations cannot be fully captured in guidelines. The aim of this narrative review is to summarise common clinical scenarios that are not sufficiently described by contemporary clinical guidelines and trials in order to inform heart team members and trainees about the nuanced considerations and available evidence to manage such cases. We discuss clinical cases that fall beyond the current guidelines and summarise the relevant evidence evaluating coronary revascularisation for these patients. In addition, we highlight gaps in knowledge based on a lack of research (eg, ineligibility of certain patient populations), underrepresentation in research (eg, underenrollment of female and non-White patients), and the surge in newer minimally invasive and hybrid techniques. We argue that ultimately, evidence-based medicine, patient preference, shared decision making, and effective heart team communications are necessary to best manage complex CAD presentations potentially benefitting from revascularisation with CABG or PCI.

Outcomes following coronary artery bypass grafting with multiple arterial grafting by pump status in men and women.

BACKGROUND: Multiple arterial grafting (MAG) and off-pump surgery are strategies proposed to improve outcomes with coronary artery bypass grafting (CABG). This study was conducted to determine the impact of off-pump surgery on outcomes after CABG with MAG in men and women. METHODS: This cohort study used population-based data to identify all Ontarians undergoing isolated CABG with MAG between October 2008 and September 2019. The primary outcome was all-cause mortality. Secondary outcomes included major adverse cardiac and cerebrovascular events (MACCE; hospitalization for stroke, myocardial infarction hospitalization or heart failure, or repeat revascularization). Analysis used propensity-score overlap-weighted cause-specific Cox proportional hazard regression. RESULTS: A total of 2989 women (1188 off-pump, 1801 on-pump) and 16,209 men (6065 off-pump, 10,144 on-pump) underwent MAG with a median follow-up of 5.0 years (interquartile range, 2.7-8.0) years. Compared to the on-pump approach, all-cause mortality was not changed with off-pump status (hazard ratio [HR] in women: 1.25 [95% CI, 0.83-1.88]; in men: 1.08 [95% CI, 0.85-1.37]). In women, the risk of MACCE was significantly higher off-pump (HR, 1.45; 95% CI, 1.04-2.03), with nonsignificantly increased risk observed for all component outcomes. CONCLUSIONS: In patients undergoing CABG with MAG, this population-based analysis found no association between pump status and survival in either men or women. However, it did suggest that off-pump MAG in women may be associated with an increased risk of MACCE.

Race and Ethnicity in Cardiac Surgery: A Missed Opportunity?

BACKGROUND: Patients' race and/or ethnicity are increasingly being associated with differential surgical access and outcomes in cardiac surgery. However, deriving evidence-based conclusions that can inform surgical care has been difficult because of poor diversity in study populations and conflicting research methodology and findings. Using a fictional patient example, this review identifies areas of concern in research engagement, methodology, and analyses, as well as potential steps to improve race and ethnicity considerations in cardiac surgical research. METHODS: A narrative literature review was performed using the PubMed/MEDLINE and Google Scholar databases, with a combination of cardiac surgery, race, ethnicity, and disparities keywords. RESULTS: Less than half of the published cardiac surgery randomized control trials report the race and/or ethnicity of research participants. Racial and/or ethnic minorities make up <20% of most study populations and are significantly underrepresented relative to their proportions of the general population. Further, race and/or ethnicity of research participants is variably categorized based on ancestry, geographic regions, cultural similarities, or minority status. There is growing consideration of analyzing interrelated and confounding variables, such as socioeconomic status, geographic location, or hospital quality, to better elucidate racial and/or ethnic disparities; however, intersectionality considerations remain limited in cardiac surgery research. CONCLUSIONS: Racial and/or ethnic disparities are increasingly being reported in research engagement, cardiac pathologies, and surgical outcomes. To promote equitable surgical care, tangible efforts are needed to recruit racially and/or ethnically minoritized patients to research studies, be transparent and consistent in their groupings, and elucidate the impact of their intersectional social identities.

The Call for the "Interventional/Hybrid" Aortic Surgeon: Open, Endovascular, and Hybrid Therapies of the Aortic Arch.

Aortic arch pathology is relatively rare but potentially highly fatal and associated with considerable comorbidity. Operative mortality and complication rates have improved over time but remain high. In response, aortic arch surgery is one of the most rapidly evolving areas of cardiac surgery in terms of surgical volume and improved outcomes. Moreover, there has been a surge in novel devices and techniques, many of which have been developed by or codeveloped with vascular surgeons and interventional radiologists. Nevertheless, the extent of arch surgery, the choice of nadir temperature, cannulation, and perfusion strategies, and the use of open, endovascular, or hybrid options vary according to country, centre, and surgeon. In this review article, we provide a technical overview of the surgical, total endovascular, and hybrid repair options for aortic arch pathology through historical developments and contemporary results. We highlight key information for surgeons, cardiologists, and trainees to understand the management of patients with aortic arch pathology. We conclude by discussing training paradigms, the role of aortic teams, and gaps in knowledge, arguing for the need for wire skills for the future "interventional aortic surgeon" and increased research into techniques and novel devices to continue improving outcomes for aortic arch surgery.

Research Concepts and Opportunities for Early-Career Investigators in Cardiac Surgery.

Basic, translational or clinic, research is a key component of cardiac surgery. Understanding basic cellular and molecular mechanisms is key to improving patient outcomes, and cardiac surgical procedures must be compared with nonsurgical alternatives. However, guidance for early-career investigators interested in cardiac surgery research is limited. This opinion piece aims at providing basic guidance and principles based on the authors' experience.

Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology 2023 Focused Update of the Guidelines for the Use of Antiplatelet Therapy.

Antiplatelet therapy (APT) is the foundation of treatment and prevention of atherothrombotic events in patients with atherosclerotic cardiovascular disease. Selecting the optimal APT strategies to reduce major adverse cardiovascular events, while balancing bleeding risk, requires ongoing review of clinical trials. Appended, the focused update of the Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology guidelines for the use of APT provides recommendations on the following topics: (1) use of acetylsalicylic acid in primary prevention of atherosclerotic cardiovascular disease; (2) dual APT (DAPT) duration after percutaneous coronary intervention (PCI) in patients at high bleeding risk; (3) potent DAPT (P2Y12 inhibitor) choice in patients who present with an acute coronary syndrome (ACS) and possible DAPT de-escalation strategies after PCI; (4) choice and duration of DAPT in ACS patients who are medically treated without revascularization; (5) pretreatment with DAPT (P2Y12 inhibitor) before elective or nonelective coronary angiography; (6) perioperative and longer-term APT management in patients who require coronary artery bypass grafting surgery; and (7) use of APT in patients with atrial fibrillation who require oral anticoagulation after PCI or medically managed ACS. These recommendations are all on the basis of systematic reviews and meta-analyses conducted as part of the development of these guidelines, provided in the Supplementary Material.

Identifying a target group for selenium supplementation in high-risk cardiac surgery: a secondary analysis of the SUSTAIN CSX trial.

BACKGROUND: Recent data from the randomized SUSTAIN CSX trial could not confirm clinical benefits from perioperative selenium treatment in high-risk cardiac surgery patients. Underlying reasons may involve inadequate biosynthesis of glutathione peroxidase (GPx3), which is a key mediator of selenium's antioxidant effects. This secondary analysis aimed to identify patients with an increase in GPx3 activity following selenium treatment. We hypothesize that these responders might benefit from perioperative selenium treatment. METHODS: Patients were selected based on the availability of selenium biomarker information. Four subgroups were defined according to the patient's baseline status, including those with normal kidney function, reduced kidney function, selenium deficiency, and submaximal GPx3 activity. RESULTS: Two hundred and forty-four patients were included in this analysis. Overall, higher serum concentrations of selenium, selenoprotein P (SELENOP) and GPx3 were correlated with less organ injury. GPx3 activity at baseline was predictive of 6-month survival (AUC 0.73; p = 0.03). While selenium treatment elevated serum selenium and SELENOP concentrations but not GPx3 activity in the full patient cohort, subgroup analyses revealed that GPx3 activity increased in patients with reduced kidney function, selenium deficiency and low to moderate GPx3 activity. Clinical outcomes did not vary between selenium treatment and placebo in any of these subgroups, though the study was not powered to conclusively detect differences in outcomes. CONCLUSIONS: The identification of GPx3 responders encourages further refined investigations into the treatment effects of selenium in high-risk cardiac surgery patients.

Barriers to Access to Cardiac Surgery: Canadian Situation and Global Context.

Cardiovascular disease is the leading cause of morbidity and mortality worldwide. Cardiovascular care spans primary, secondary, and tertiary prevention and care, whereby tertiary care is particularly prone to disparities in care. Challenges in access to care especially affect low- and middle-income countries (LMICs), however, multiple barriers also exist and persist across high-income countries. Canada is lauded for its universal health coverage but is faced with health care system challenges and substantial geographic barriers. Canada possesses 203 active cardiac surgeons, or 5.02 per million population, ranging from 3.70 per million in Newfoundland and Labrador to 7.48 in Nova Scotia. As such, Canada possesses fewer cardiac surgeons per million population than the average among high-income countries (7.15 per million), albeit more than the global average (1.64 per million) and far higher than the low-income country average (0.04 per million). In Canada, adult cardiac surgeons are active across 32 cardiac centres, representing 0.79 cardiac centres per million population, which is just above the global average (0.73 per million). In addition to centre and workforce variations, barriers to care exist in the form of waiting times, sociodemographic characteristics, insufficient virtual care infrastructure and electronic health record interoperability, and health care governance fragmentation. Meanwhile, Canada has highly favourable surgical outcomes, well established postacute cardiac care infrastructure, considerable spending on health, robust health administrative data, and effective health technology assessment agencies, which provides a foundation for continued improvements in care. In this narrative review, we describe successes and challenges surrounding access to cardiac surgery in Canada and globally.

Survival Benefit of Multiple Arterial Revascularization With and Without Supplementary Saphenous Vein Graft.

Background It is unknown if the presence of saphenous vein grafting (SVG) adversely affects late survival following coronary surgery with multiple arterial grafting (MAG) versus single arterial grafting. Methods and Results A retrospective, observational, multicenter cohort study from 2001 to 2020 was conducted using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Database linked to the National Death Index. Patients undergoing primary isolated coronary artery bypass grafting with ≥2 grafts were included, and exclusions were patients aged <18 years, reoperations, concomitant or previous cardiac surgery, and the absence of arterial grafting. Demographics, comorbidities, medication, and operative configurations were propensity score matched between cohorts. The primary outcome was all-cause late death. Of 59 689 eligible patients, 35 113 were MAG (58.8%), and 24 576 were single arterial grafting (41.2%). Of the MAG cohort, 17 055 (48.6%) patients did not receive supplementary SVG (total arterial revascularization). Matching separately generated 22 764 patient pairs for MAG versus single arterial grafting, and 11 137 patient pairs for MAG with total arterial revascularization versus MAG with ≥1 supplementary vein grafts. At a median follow-up duration of 5.0 years postoperatively, the mortality rate was significantly lower for MAG than single arterial grafting (hazard ratio [HR], 0.79 [95% CI, 0.76-0.83]; P<0.001). The stratified MAG analysis found that MAG with total arterial revascularization had a lower risk of late death (HR, 0.85 [95% CI, 0.80-0.91]; P<0.001) compared with MAG with ≥1 supplementary vein grafts. Sensitivity analyses produced consistent outcomes as the primary analysis. Following adjustment for the presence of SVG in the Cox model, the survival advantage of incremental number of arteries was lost. Conclusions Multiple arterial grafting has significantly improved long-term survival compared with single arterial grafting. A further incremental survival benefit exists when no SVG is used.

Revascularization strategies for multivessel coronary artery disease based on sex and age.

OBJECTIVES: This study describes coronary revascularization strategies used by sex and age in the USA. METHODS: A sex-stratified cohort study from the National Inpatient Sample from the Agency for Healthcare Research and Quality (USA) including patients admitted for coronary revascularization with primary or secondary diagnoses of chronic coronary syndrome or non-ST elevation myocardial infarction who underwent ≥3-vessel coronary artery bypass grafting or percutaneous coronary intervention from January 2019 to December 2020. The primary outcome was the use rate of coronary artery bypass grafting or multivessel percutaneous coronary intervention. Prespecified subgroups included age and non-ST elevation myocardial infarction. RESULTS: Among 121 150 patients (21.7% women), there were no sex differences in age (women: 66.6 [66.5-66.7], men: 67.6 [67.5-67.7], standardized mean difference: 0.1) or non-ST elevation myocardial infarction incidence (women: 37.4%, men: 45.7%, standardized mean difference: 0.17). The majority of women (74.2%) and men (84.9%) underwent bypass grafting, which was unaffected by age, race or non-ST elevation myocardial infarction. Women were less likely to undergo bypass grafting than percutaneous intervention (adjusted odds ratio 0.49, 95% confidence interval 0.44-0.54; P < 0.001) and a disparity most pronounced in patients >80 years old (adjusted odds ratio 0.31, 95% confidence interval 0.22-0.45; P < 0.001). CONCLUSIONS: Most patients with multivessel coronary artery disease needing revascularization undergo bypass grafting, irrespective of sex, age or clinical presentation. The sex disparity in the use of bypass grafting is mostly seen among patients >80 years old.

Validating the SMART2 Score in a Racially Diverse High-Risk Nationwide Cohort of Patients Receiving Coronary Artery Bypass Grafting.

Background We tested the potential of the Secondary Manifestations of Arterial Disease (SMART2) risk score for use in patients undergoing coronary artery bypass grafting. Methods and Results We conducted an external validation of the SMART2 score in a racially diverse high-risk national cohort (2010-2019) that underwent isolated coronary artery bypass grafting. We calculated the preoperative SMART2 score and modeled the 5-year major adverse cardiovascular event (cardiovascular mortality+myocardial infarction+stroke) incidence. We evaluated SMART2 score discrimination at 5 years using c-statistic and calibration with observed/expected ratio and calibration plots. We analyzed the potential clinical benefit using decision curves. We repeated these analyses in clinical subgroups, diabetes, chronic kidney disease, and polyvascular disease, and separately in White and Black patients. In 27 443 (mean age, 65 years; 10% Black individuals) US veterans undergoing coronary artery bypass grafting (2010-2019) nationwide, the 5-year major adverse cardiovascular event rate was 25%; 27% patients were in high predicted risk (>30% 5-year major adverse cardiovascular events). SMART2 score discrimination (c-statistic: 64) was comparable to the original study (c-statistic: 67) and was best in patients with chronic kidney disease (c-statistic: 66). However, it underpredicted major adverse cardiovascular event rates in the whole cohort (observed/expected ratio, 1.45) as well as in all studied subgroups. The SMART2 score performed better in White than Black patients. On decision curve analysis, the SMART2 score provides a net benefit over a wide range of risk thresholds. Conclusions The SMART2 model performs well in a racially diverse coronary artery bypass grafting cohort, with better predictive capabilities at the upper range of baseline risk, and can therefore be used to guide secondary preventive pharmacotherapy.

2022 Joint ESC/EACTS review of the 2018 guideline recommendations on the revascularization of left main coronary artery disease in patients at low surgical risk and anatomy suitable for PCI or CABG.

In October 2021, the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) jointly agreed to establish a Task Force (TF) to review recommendations of the 2018 ESC/EACTS Guidelines on myocardial revascularization as they apply to patients with left main (LM) disease with low-to-intermediate SYNTAX score (0-32). This followed the withdrawal of support by the EACTS in 2019 for the recommendations about the management of LM disease of the previous guideline. The TF was asked to review all new relevant data since the 2018 guidelines including updated aggregated data from the four randomized trials comparing percutaneous coronary intervention (PCI) with drug-eluting stents vs. coronary artery bypass grafting (CABG) in patients with LM disease. This document represents a summary of the work of the TF; suggested updated recommendations for the choice of revascularization modality in patients undergoing myocardial revascularization for LM disease are included. In stable patients with an indication for revascularization for LM disease, with coronary anatomy suitable for both procedures and a low predicted surgical mortality, the TF concludes that both treatment options are clinically reasonable based on patient preference, available expertise, and local operator volumes. The suggested recommendations for revascularization with CABG are Class I, Level of Evidence A. The recommendations for PCI are Class IIa, Level of Evidence A. The TF recognized several important gaps in knowledge related to revascularization in patients with LM disease and recognizes that aggregated data from the four randomized trials were still only large enough to exclude large differences in mortality.

2022 Joint ESC/EACTS review of the 2018 guideline recommendations on the revascularization of left main coronary artery disease in patients at low surgical risk and anatomy suitable for PCI or CABG.

Task Force structure and summary of clinical evidence of 2022 ESC/EACTS review of the 2018 guideline recommendations on the revascularization of left main coronary artery disease. CABG, coronary artery bypass grafting; PCI, percutaneous coronary intervention; LM, left main; SYNTAX, Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery. a'Event' refers to the composite of death, myocardial infarction (according to Universal Definition of Myocardial Infarction if available, otherwise protocol defined) or stroke. In October 2021, the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) jointly agreed to establish a Task Force (TF) to review recommendations of the 2018 ESC/EACTS Guidelines on myocardial revascularization as they apply to patients with left main (LM) disease with low-to-intermediate SYNTAX score (0-32). This followed the withdrawal of support by the EACTS in 2019 for the recommendations about the management of LM disease of the previous guideline. The TF was asked to review all new relevant data since the 2018 guidelines including updated aggregated data from the four randomized trials comparing percutaneous coronary intervention (PCI) with drug-eluting stents vs. coronary artery bypass grafting (CABG) in patients with LM disease. This document represents a summary of the work of the TF; suggested updated recommendations for the choice of revascularization modality in patients undergoing myocardial revascularization for LM disease are included. In stable patients with an indication for revascularization for LM disease, with coronary anatomy suitable for both procedures and a low predicted surgical mortality, the TF concludes that both treatment options are clinically reasonable based on patient preference, available expertise, and local operator volumes. The suggested recommendations for revascularization with CABG are Class I, Level of Evidence A. The recommendations for PCI are Class IIa, Level of Evidence A. The TF recognized several important gaps in knowledge related to revascularization in patients with LM disease and recognizes that aggregated data from the four randomized trials were still only large enough to exclude large differences in mortality.