Interventional cardiology and cardiac surgery indications
The exam tests whether you can select revascularisation or valve strategy for the right patient, and whether you understand the heart team concept.
PCI
- Indications: STEMI, high-risk NSTE-ACS, and stable angina with refractory symptoms or a large ischaemic burden.
- Drug-eluting stents are standard; DAPT for 6-12 months, shortened for high bleeding risk.
- FFR/iFR for intermediate lesions; IVUS/OCT for left main and complex bifurcation work.
CABG
- Left main stenosis above 50%, three-vessel disease especially with diabetes or reduced ejection fraction, high SYNTAX score, and multivessel disease with proximal LAD involvement favour surgery.
- Left internal mammary artery to LAD is the benchmark graft.
- Heart team discussion is mandatory for complex multivessel and left main disease.
Valve intervention
- TAVR for severe symptomatic AS at high or prohibitive surgical risk; SAVR for younger low-risk patients.
- Mitral repair is preferred to replacement when durable repair is feasible; mechanical valves require warfarin, bioprostheses have limited durability.
Advanced therapy
- Mechanical circulatory support: IABP, percutaneous ventricular assist devices, ECMO as bridge to decision, bridge to transplant or destination therapy.
- Transplant candidacy requires absence of irreversible end-organ damage and adherence to follow-up.
Worked example
A 66-year-old with diabetes, three-vessel disease, SYNTAX score 30 and ejection fraction 40% should be discussed by the heart team, with CABG favoured over multivessel PCI.
Traps
- Choosing PCI for left main disease without heart team input.
- Stopping DAPT prematurely without a bleeding reason.
- Ignoring contrast nephropathy risk and access-site complications.