2.1 Study Design and Population
This study compared consecutive patients prospectively referred to HT discussion in the Soroka University Medical Center from 2016 to 2017 (HT Group) and a matched retrospective cohort of patients who underwent coronary angiography between the years 2005 and 2015 (No HT Group).
The inclusion criteria for the registry were based on an institutional protocol specifically designed for selecting patients for HT discussion. In summary, patients were included if they presented with stable coronary artery disease (CAD) or with stabilized acute coronary syndromes (ACS), defined as hemodynamically stable patients, at least 48 hours since the last ischemic complaint, who were diagnosed with left main (LM) and/or multivessel coronary disease with low SYNTAX score (< 23) and low perioperative risk as assessed by the Society of Thoracic Surgeons (STS) score (<4%) [7]. Patients were also included if presenting with single vessel disease considered high risk for PCI due to left anterior descending (LAD) artery origin lesions or complex bifurcation lesions of the proximal LAD. Patients with LM and /or multivessel disease with an intermediate or high SYNTAX score (> 23) were discussed by the HT if they were classified as being of moderate or high perioperative risk (STS risk score >4%) or due to co-morbidities that could influence the clinical outcome after cardiac surgery. Patients presenting with ST elevation MI (STEMI) could be included if there were clinical and electrocardiographic signs of reperfusion and/ or if the patient presented in the evolved phase of STEMI and had been pain-free for at least 48 hours before admission.
If a patient met the institutional criteria for HT discussion after the diagnostic angiogram, the procedure was concluded, and the case brought for discussion within 24 hours. The HT was composed of interventional cardiologists, clinical cardiologists and cardiothoracic surgeons. A member of the clinical team treating the patient was also present. Afterwards, the treating physician presented the revascularization strategy recommended by the HT to the patient and their family, along with the advantages and disadvantages of both treatments. The patient then made an informed decision whether to proceed with the HT recommended therapy or to opt for the alternative, when feasible [8, 9].
The retrospective cohort was composed of patients that underwent coronary angiographies between the years 2005 and 2015 with matching diagnosis and complexity of coronary disease, identified from our institutional database. Angiographic data was individually reviewed by an unbiased interventional cardiologist to unsure appropriate matching.