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HF, LVEF >40% and SR, when at high risk of stroke and with a low haemorrhagic risk.

12.2.2 Myocardial revascularization Data on the benefit of myocardial revascularization in patients with HF are limited. STICH compared coronary artery bypass grafting (CABG) with MT in patients with CAD, amenable by CABG, and with reduced LV function (EF <_35%). At a median follow-up of 56 months, there was no significant difference between the CABG group and the MT group in the rate of death from any cause, primary outcome of the trial.89 The extended follow-up report showed a significant reduction of death in the CABG group vs. the control group (58.9% vs. 66.1%; HR 0.84; 95% CI, 0.730.97; P = 0.02) over 10 years.581 CV death and the combined endpoint of all-cause death or hospitalization for CV causes were also significantly reduced after CABG at 10 years of follow-up.581 Post hoc analyses of the STICH trial suggested that neither myocardial viability, angina, nor ischaemia were related with outcomes after revascularization.92,93,582 The Heart Failure Revascularisation Trial (HEART) was under-powered, with only 138 of the planned 800 patients to be enrolled, and failed to show differences in outcomes between HF patients receiving CABG or MT.583 There are currently no reported RCTs comparing percutaneous coronary intervention (PCI) with MT in patients with HFrEF. However, the REVIVED-BCIS2 trial has finished recruitment (ClinicalTrials.gov Identifier: NCT01920048).584 There are also no randomized studies comparing PCI with CABG as such randomized trials excluded patients with HFrEF. In one prospective registry, including 4616 patients with multivessel disease and HFrEF, propensity-score matched comparisons showed similar survival (mean follow-up 2.9 years) in PCI vs. CABG group with PCIs associated with a higher risk of MI, particularly in patients with incomplete revascularization, and CABG associated with a higher risk of stroke.585 A propensity-matched analysis showed a significantly lower risk of death or major CV events in diabetic patients with LV dysfunction and multivessel disease treated with CABG compared with PCI.586 CABG was associated with better outcome than PCI also in patients with moderate or severe LV dysfunction and left main or complex coronary disease.587,588 Two meta-analyses confirmed that CABG is associated with better outcomes, including mortality, MI, and repeated revascularization, compared with PCI and/or MT.589,590

12.3 Valvular heart disease

12.3.1 Aortic stenosis Aortic stenosis may cause or worsen HF by increasing LV afterload and causing LV hypertrophy and remodelling.591 When HF symptoms occur in patients with severe aortic stenosis, prognosis is extremely poor. No MT for aortic stenosis can improve outcomes. HF medical treatment should be given to all HF patients with symptomatic severe aortic stenosis. Care must be taken using vasodilators to avoid hypotension. Importantly, possible improvement of symptoms after MT should not delay intervention. In the presence of suspected symptomatic and severe highgradient aortic stenosis (valve area <_1 cm2, mean gradient >_40 mmHg), other causes of high flow status must be excluded and corrected (i.e. anaemia, hyperthyroidism, arteriovenous shunts) before proceeding to aortic valve intervention.592 An aortic valve intervention is recommended in patients with HF symptoms and severe, high-gradient aortic stenosis, regardless of LVEF. Management of patients with low-flow low-gradient aortic stenosis is reported in Figure 16.592

Intervention is recommended in patients with a life expectancy >1 year, avoiding futility. Transcatheter aortic valve implantation (TAVI) has been shown to be non-inferior to surgical aortic valve replacement (SAVR) in reducing clinical events (including mortality and disabling stroke) in patients at high and intermediate risk for surgery.593600 In low-risk patients, mean age in the RCTs comparing TAVI and SAVR was >70 years and follow-up was restricted to 2 years. Therefore, SAVR is recommended in patients aged <75 years and at low surgical risk (STS-PROM score or EuroSCORE II <4%), whereas TAVI is recommended in those aged >75 years or at high/ prohibitive surgical risk (STS-PROM score or EuroSCORE II >8%). In all the other cases, the choice between TAVI and SAVR should be made by the Heart Team, weighing the pros and cons of each procedure, according to age, life expectancy, individual patient preference and other features including clinical and anatomical aspects. Aortic

Recommendations for myocardial revascularization in patients with heart failure with reduced ejection fraction

Recommendations Classa Levelb

CABG should be considered as the first-choice revascularization strategy, in patients suitable for surgery, especially if they have diabetes and for those with multivessel disease.581,587,588,590 IIa B Coronary revascularization should be considered to relieve persistent symptoms of angina (or an angina-equivalent) in patients with HFrEF, CCS, and coronary anatomy suitable for revascularization, despite OMT including anti-anginal drugs. IIa C In LVAD candidates needing coronary revascularization, CABG should be avoided, if possible. IIa C Coronary revascularization may be considered to improve outcomes in patients with HFrEF, CCS, and coronary anatomy suitable for revascularization, after careful evaluation of the individual risk to benefit ratio, including coronary anatomy (i.e. proximal stenosis >90% of large vessels, stenosis of left main or proximal LAD), comorbidities, life expectancy, and patient’s perspectives. IIb C PCI may be considered as an alternative to CABG, based on Heart Team evaluation, considering coronary anatomy, comorbidities, and surgical risk. IIb C

CABG = coronary artery bypass graft; CCS = chronic coronary syndrome; HFrEF = heart failure with reduced ejection fraction; LAD = left anterior descending artery; LVAD = left ventricular assist device; OMT = optimal medical therapy; PCI = percutaneous coronary intervention. aClass of recommendation. bLevel of evidence. ESC 2021

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