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chronic total occlusion lesions) focused on ‘anatomically’ complex lesions, ILUMIEN IV made the choice to define ‘complexity’ by the clinical context (DM and STEMI/NSTEMI) and/or by the anatomical characteristics of the lesions. In RENOVATE-COMPLEX PCI, intravascular imaging-guided PCI led to a lower risk of a composite of death from a cardiac cause, target vessel-related MI, or clinically driven target-vessel revascularization than angiography-guided PCI by 2 years (7.7% vs. 12.3%; HR 0.64; 95% CI, 0.45–0.89; P = .008).840 In OCTOBER, OCT-guided PCI led to a lower risk of a composite of death from a cardiac cause, target-lesion MI, or ischaemia-driven target-lesion revascularization than angiography-guided PCI by 2 years (10.1% vs. 14.1%; HR 0.70; 95% CI, 0.50–0.98; P = .035).810 In ILUMIEN IV, OCT-guided PCI failed to decrease the rate of the primary efficacy endpoint of target-vessel failure, defined as death from cardiac causes, target-vessel MI, or ischaemia-driven target-vessel revascularization (7.4% vs. 8.2%; HR 0.90; 95% CI, 0.67–1.19; P = .45), while the incidence of definite/probable stent thrombosis was significantly reduced by OCT guidance vs. angiography guidance (0.5% vs. 1.4%; HR 0.36; 95% CI, 0.14–0.91; P = .02).841

4.4.5.7 Hybrid revascularization in multivessel coronary artery

disease patients Arterial grafting with left internal mammary artery (LIMA) to the LAD system and multiple arterial grafting reduces the risk of graft occlusion, thus increasing the longevity of revascularization efficacy after CABG.842,843 Hybrid revascularization of multivessel CAD with minimally invasive direct coronary artery bypass (MIDCAB)-LAD plus PCI of the remaining arteries may represent an alternative option. Hybrid offpump revascularization seems a suitable option for patients at moderate-to-high risk for surgery by avoiding the use of cardiopulmonary bypass. Despite this attractive concept, the frequency of hybrid revascularizations remains extremely modest, with about 0.1% of surgical revascularizations.844 Few data are available comparing hybrid revascularization vs. conventional CABG or PCI. Large registry data report higher rates of bleeding, renal failure, MI, and HF with hybrid revascularization compared with PCI alone,844 while a very small randomized trial reported similar clinical outcomes at long-term follow-up.845 It seems challenging to perform larger RCTs to investigate this question. The recent National Heart, Lung, and Blood Institute-funded Hybrid Trial (Hybrid Coronary Revascularization Trial; NCT03089398) was prematurely discontinued due to slow enrolment, with only 200 patients in 5 years.

4.4.6 Patient–physician shared decision-making to

perform and select revascularization modality Shared decision-making between patients and healthcare professionals, based on patient-centred care, is considered a paramount process in defining the appropriate therapeutic pathway. Essential aspects of shared decision-making are: a complete and accurate explanation of the disease; presentation and description of therapeutic options; discussion of potential risks, benefits, and impact on QoL for each procedure; considering patient preferences and goals; and carefully explaining each step of the post-procedural course and follow-up. Poor shared decision-making is associated with worse physical and mental outcomes, lower adherence to therapy, and an increased number of emergency department visits.846–848 Shared decision-making and family meetings involving relatives increase patient trust in the physicians, with greater adherence to therapeutic decisions. Shared decisionmaking and patient medical education, considering the patient’s characteristics, mental status, cultural beliefs, and educational level, are therefore associated with increased patient knowledge and better QoL and with lower levels of anxiety and depression.849–851

Using lay language and discussion with patients and relatives of shortterm procedure-related and long-term risks and benefits—such as survival, relief of angina, QoL, the potential need for late reintervention, the need for prevention measures, and uncertainties associated with different treatment strategies—are of great importance. Although current recommendations are primarily based on the ability of treatments to reduce adverse events, including improved survival, there is growing interest in PROMs.852 Patients are not only interested in knowing how recommended treatment impacts prognosis but also their QoL in the way they perceive it.853 The patient’s right to decline the treatment option recommended by the Heart Team must be respected. Patient refusal of a recommended treatment should be acknowledged in a written document after the patient has received the necessary information. In this case, the Heart Team may offer the patient an alternative treatment option. The multidisciplinary Heart Team, on site or with partner institutions (Hub-Spoke institutions)—comprising clinical or non-invasive cardiologists, cardiac surgeons and interventional cardiologists, as well as anaesthetists or other specialists and healthcare professionals, if deemed necessary—should provide a balanced multidisciplinary decisionmaking process. Transparency in informed consent is critical, particularly when treatment options are debated. Complex cases, such as patients with CAD of high anatomic complexity and significant non-cardiac comorbidities, should be discussed in the Heart Team, taking into consideration other characteristics not always included in traditional databases, such as frailty. Heart Team/guideline discordance is common in complex CAD patients undergoing revascularization, especially in elderly patients, those with complex coronary disease, and those treated at centres without cardiac surgery service. These patients have a higher risk of mid-term mortality.854 In all cases, it is necessary to allow sufficient time to assess all available information and clearly explain and discuss the findings with each patient. The rationale for a decision and consensus on the optimal revascularization treatment should be documented on the patient’s chart. While the Heart Team decision is mainly driven by long-term survival benefits with a certain modality of revascularization, patient’s preferences must be respected.853,855,856

4.4.7 Institutional protocols, clinical pathways, and

quality of care Institutional protocols, developed by the Heart Team and aligned with the current guidelines, should delineate specific anatomical and functional criteria of disease complexity and specific clinical subsets of patient’ risk for cardiac surgery or intervention that may or may not be treated ad hoc. These protocols should be incorporated into clinical pathways, with regular meetings to assess the applied indications for myocardial revascularization and monitor the safety and effectiveness of the procedures, ensuring the quality of delivered patient care. Collaborative protocols are necessary when cardiac surgery isn’t available on site, and remote Heart Team meetings should be established.

ESC Guidelines                                                                                                                                                                                          3475

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