Lessons learned from the SYNTAX trial for multivessel and left main stem coronary artery disease.

PURPOSE OF REVIEW: The SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) trial is the most important trial of surgery and stents in patients with severe coronary artery disease (CAD) and reflects real clinical practice. This review describes its key findings at 3 years with particular reference to what is already known on this topic. RECENT FINDINGS: Taking together the SYNTAX randomized trial and its registry component, almost 79% of patients with three-vessel CAD and almost two-thirds of patients with left main stem (LMS) disease have a survival benefit and marked reduction in the need for repeat revascularization with coronary artery bypass grafting (CABG) in comparison to stents, implying that CABG is still the treatment of choice for most of these patients. This conclusion, at odds with results of previous trials of stenting and surgery but consistent with findings of large propensity-matched registries, can be explained by the fact that SYNTAX enrolled 'real life' patients rather than the highly select patients in previous trials. SYNTAX also shows that for patients with less severe CAD there is no difference in survival between CABG and stents but a lower incidence of repeat revascularization with CABG. SUMMARY: The results of the SYNTAX trial confirm that at 3 years CABG remains the treatment of choice for most patients with three-vessel and LMS disease and especially in those with the most severe disease. SYNTAX will have a profound effect on practice recommendations for the foreseeable future and already has had a major effect on the new European Society for Cardiology/European Association for Cardiothoracic Surgery guidelines for myocardial revascularization.