Treatment of Triple Vessel Disease
CABG is the recommended treatment for patients with triple vessel disease, as it provides superior long-term survival, reduces myocardial infarction risk, and decreases the need for repeat revascularization compared to PCI. 1
Primary Treatment Recommendation
For patients with triple vessel disease and preserved left ventricular ejection fraction (LVEF >35%) without diabetes, CABG is recommended over medical therapy alone to improve symptoms, survival, and reduce cardiovascular mortality and spontaneous myocardial infarction. 1 This represents a Class I, Level A recommendation from the most recent 2024 ESC guidelines. 1
Special Consideration for Low-Complexity Disease
In patients with triple vessel disease of low-to-intermediate anatomical complexity (SYNTAX score ≤22) and preserved LVEF, PCI is recommended as an acceptable alternative to CABG, given its lower invasiveness and generally non-inferior survival, provided PCI can achieve similar completeness of revascularization. 1 However, this comes at the cost of significantly higher rates of repeat revascularization (25.4% vs 12.6% at 5 years). 2
Treatment Algorithm Based on Clinical Characteristics
Patients WITH Diabetes
In patients with diabetes and triple vessel disease, CABG (with LIMA to LAD) is strongly recommended over PCI to reduce mortality and repeat revascularizations. 1 This recommendation is based on Class I, Level A evidence showing CABG provides superior long-term outcomes in this population. 1
Patients WITH Reduced LVEF (≤35%)
In surgically eligible patients with triple vessel disease and LVEF ≤35%, CABG is recommended over medical therapy alone to improve long-term survival. 1 The decision should involve careful Heart Team evaluation of coronary anatomy, correlation between CAD and LV dysfunction, comorbidities, life expectancy, and individual risk-to-benefit ratio. 1
Patients WITHOUT Diabetes and Normal LVEF
CABG remains the preferred strategy, but PCI may be considered if the SYNTAX score is low (≤22) and complete revascularization can be achieved. 1
Risk Stratification Tools
Calculation of the SYNTAX score is mandatory to assess anatomical complexity of disease in patients with multivessel CAD. 1 The SYNTAX score directly influences treatment selection:
- Low SYNTAX score (0-22): PCI is an acceptable alternative with similar MACCE rates (33.3% vs 26.8%, P=0.21), though repeat revascularization remains higher. 2
- Intermediate SYNTAX score (23-32): CABG demonstrates clear superiority in MACCE, death, MI, and repeat revascularization. 2
- High SYNTAX score (≥33): CABG is strongly preferred with marked superiority over PCI. 2
Calculation of the STS score is recommended to estimate in-hospital morbidity and 30-day mortality after CABG. 1
Heart Team Approach
For complex clinical cases, a Heart Team discussion is recommended, including representatives from interventional cardiology, cardiac surgery, and non-interventional cardiology, to select the most appropriate treatment strategy. 1 This is particularly important when CABG and PCI hold the same level of recommendation. 1
Evidence Supporting CABG Superiority
The 5-year SYNTAX trial data in triple vessel disease patients demonstrated: 2
- Major adverse cardiac and cerebrovascular events (MACCE): 37.5% with PCI vs 24.2% with CABG (P<0.001) 2
- Death/stroke/MI composite: 22.0% with PCI vs 14.0% with CABG (P<0.001) 2
- All-cause death: 14.6% with PCI vs 9.2% with CABG (P=0.006) 2
- Myocardial infarction: 9.2% with PCI vs 4.0% with CABG (P=0.001) 2
- Repeat revascularization: 25.4% with PCI vs 12.6% with CABG (P<0.001) 2
- Stroke rates were similar: 3.0% with PCI vs 3.5% with CABG (P=0.66) 2
Intracoronary Assessment for PCI
If PCI is selected, intracoronary pressure measurement (FFR or iFR) or computation (QFR) is recommended to guide lesion selection for intervention in patients with multivessel disease. 1 Additionally, intracoronary imaging guidance by IVUS or OCT is recommended when performing PCI on anatomically complex lesions. 1
Common Pitfalls to Avoid
Do not select PCI for patients with diabetes and triple vessel disease, as CABG provides significantly better outcomes in this population. 1 The hazard ratio for MACCE in diabetics was 2.30 for PCI vs CABG compared to 1.51 in non-diabetics. 2
Do not proceed with PCI in patients with high SYNTAX scores (≥33), as CABG demonstrates clear superiority in all major endpoints. 2
Do not withhold CABG from patients with LVEF ≤35% who are surgical candidates, as this represents one of the few scenarios where revascularization provides survival benefit over medical therapy alone. 1
Avoid attempting PCI in diffuse distal disease with poor distal run-off, as this increases procedural complications without improving outcomes. 3