Guidelines recommend heart team (HT) decision-making for CABG versus PCI in complex coronary artery disease (CAD) with high SYNTAX scores (>32), but real-world outcomes remain unclear. This study evaluates adherence to HT recommendations and patient outcomes based on revascularization strategy.

A retrospective analysis was conducted on 274 cases with left main coronary artery disease (LM-CAD) or multi-vessel CAD with SYNTAX scores >32, discussed by the HT between August 2019 and December 2021. We assessed concordance with HT recommendations and rates of major adverse cardiac and cerebral events (MACCE), including mortality, non-fatal myocardial infarction (MI), stroke, and repeat revascularization.

Patients averaged 64 years old, 73% were male, 50% had diabetes, and 41% had LM-CAD. SYNTAX II scoring favored PCI in 7.7%, CABG in 65.3%, and equipoise in 27%. PCI was performed in 33.2% (concordant PCI: 12.4%, discordant PCI: 20.8%) and CABG in 66.8% (concordant CABG: 66.1%, discordant CABG: 0.7%), with 78.5% concordance to HT recommendations. After a median follow-up of 3.6 years, PCI and CABG showed no significant differences in mortality, MI, or stroke, though PCI had a higher rate of repeat revascularization (MACCE rates: PCI 17.6% vs. CABG 8.7%, P=0.032). Concordant PCI patients were older, had higher LM-CAD prevalence, more heart failure, and lower LVEF, with 76.5% meeting criteria for high-risk PCI (CHIP).

This study supports the HT approach, showing high concordance with recommendations and favorable outcomes. CABG is preferred in complex cases, though CHIP PCI provides a viable option for high-risk surgical candidates.