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Click to edit Master title,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,3011246-,15,Click to edit Master title style,3011693-,*,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,3011719-,29,Percutaneous or Surgical Revascularization for Multivessel Coronary Artery Disease?,Verghese Mathew, MD, FACC,Consultant, Division of Cardiovascular Diseases and Department of Radiology,Professor of Medicine, Mayo Clinic College of Medicine,Revascularization Strategies,How do we decide?,AnatomyClinicalPatient,presentation preference,Risk vs. Benefit,Invasive Therapies,Low Risk Patient,High Risk Patient,Some acute risk,Less long-term risk reduction,Greater acute risk,Greater long-term risk reduction,12-Year Survival in Patients with CAD,5035-4935,Emond,M et al: Circ 90:2645, 1994,23,467 Medically-Treated Patients in CASS Registry,LVEF,CP1203018-2,12-Year Survival in Patients with CAD,No CAD1 vessel2 vessel3 vessel,Emond,M et al: Circ 90:2645, 1994,23,467 Medically-Treated Patients in CASS Registry,CP1203018-1,Clinical Presentation,Age,Acute ischemic syndrome versus chronic stable angina,Prior cardiac history (MI, CABG, intervention),Co-morbid conditions (diabetes, cerebrovascular disease, renal disease, lung disease),Functional impairment,Ischemic burden,Extension of Survival with CABG vs Medical Therapy After 10 Years,CP1203018-14,Extension of survival (mo),Yusuf S et al:Lancet 344:563, 1994,Overall,Vessel disease,1/2 vessels,3 vessels,Left main,LV function,NormalAbnormal,Exercise test,NormalAbnormal,Angina,Class 0, I, II,Class III, IV,Low,Moderate,High,Low,Moderate,High,VA risk score,Stepwise risk score,CABG vs Stenting for MVD Meta-Analysis of ARTS, ERACI-II, MASS-II and SOS,Circ 118, 2008,Days,Event-Free Survival Analysis of Death,1,5181,4721,4561,4401,4061,347,1,5331,4791,4571,4391,4121,349,Overall survival (%),P=0.78,Days,Repeat Revascularization,1,5181,204772740707665,1,5331,428927911882855,P0.0001,Overall survival (%),Days,Death, Stroke or MI,1,5181,381913896872846,1,5331,377908891868845,Overall survival (%),P=0.64,Days,Major Adverse Cardiac and Cerebrovascular Events,1,5181,153729691657616,1,5331,332867846812785,P0.0001,Overall survival (%),PCI 91.5%,CABG 91.8%,PCI 71.0%,CABG 92.1%,PCI 83.3%,CABG 83.1%,PCI 60.8%,CABG 77.0%,Increased Likelihood of Restenosis,Lesion/Patient Subsets,Small vessels,Bifurcations,Ostial,CTO,Bare metal ISR,SVG,AMI (thrombus),Diabetes mellitus,Hazard ratio 95% CI,CP1045415-3,SIRIUS,Clinical Restenosis (TLR) at 1 Year,SirolimusControl,Overall4.920.0,Male5.220.5,Female4.119.0,Diabetes8.426.4,No diabetes3.717.6,LAD6.023.0,Non-LAD4.118.0,Small vessel (13.5)6.021.9,Overlap5.723.2,No overlap4.518.6,P,0.0001,0.0001,0.0002,0.0002,0.0001,0.0001,0.0001,0.0001,0.0001,0.0001,0.0001,0.0001,0.0001,Eventsprevented/1,000 pt,152,153,149,180,138,170,140,157,151,146,158,175,141,Odds ratio,CABG vs Drug-Eluting Stents in Multivessel Coronary Disease,A Meta-Analysis on 24,268 Patients,Benedetto,et al: EJCTS 6958, 2009,Favors DES-PCI,Favors CABG,0.010.1110100,HR and 95% CI,Study name,Park,Hannan,Briguori,Yang JH,Lee,Yang ZK,Javaid,Varani,Tarantini,Left Main Disease,(isolated, +1, +2 or +3 vessels),3 Vessel Disease,(,revasc,all 3 vascular territories),SYNTAX Eligible Patients,De novo disease,Limited Exclusion Criteria,Previous interventions,Acute MI with CPK2x,Concomitant cardiac surgery,SYNTAX Inclusion Criteria,3-vessel disease and/or left main disease,Total occlusion without time limitation,Previous stroke 1 month,Renal and respiratory insufficiency,Decreased pump function,Myocardial ischemia (unstable-silent-stable),Patients with comorbidity,Real world patient population,PCI,n=198,TAXUS,*,n=903,CABG,n=897,vs,CABG,n=1077,no,f/u,n=428,5yr,f/u,n=649,Two Registry Arms,N=1275,Randomized Arms,N=1800,Heart Team (surgeon &,interventionalist,),Amenable for only one treatment approach,Amenable for both,treatment options,Stratification: LM and Diabetes,LM,33.7%,3VD,66.3%,LM,34.6%,3VD,65.4%,23 US Sites,62 EU Sites,+,SYNTAX Trial Design,*,TAXUS Express,Cumulative rate (%),SYNTAX: Outcomes,NEJM 360(10), 2009,Cumulative rate (%),Death from Any Cause,Death from Any Cause, Stroke, or MI,Repeat Revascularization,Major Adverse Cardiac or Cerebrovascular Event,Months since randomization,Cumulativerate (%),Cumulative rate (%),Months since randomization,P=0.37,P=0.99,3.5,P0.001,P=0.002,Months since randomization,Months since randomization,PCI,CABG,4.4,PCI,7.7,7.6,CABG,PCI,CABG,13.5,5.9,17.8,12.4,PCI,CABG,SYNTAX CABG/PCI Registries,SYNTAX appendix: NEJM, 2009,Reasons for CABG,Complex anatomy70.9%,Untreatable chronic22.0% total occlusion,Unable to take 0.9%anti-platelet medications,Patient refused PCI 0.5%,Other 5.7%,Reasons for PCI,Comorbidity70.7%,No graft material 9.1%,Patient refused CABG 5.6%,Small or poor quality 1.5%of distal vessel,Other13.1%,n=644,n=192,SYNTAX Score,Number & location of lesions,Tortuosity,Thrombus,Bifurcation,Total Occlusion,Diffuse,Left Main,Dominance,SYNTAX,Score,Calcification,EuroInterv,2005;1:219-227,Outcomes Stratified by SYNTAX Score,NEJM 360:970, 2009,Cumulative rate of major adverse cardiac or cerebrovascular events,P=0.71,Cumulative rate of major adverse cardiac or cerebrovascular events,P=0.10,Months since randomization,Months since randomization,Cumulative rate of major adverse cardiac or cerebrovascular events,P,33),14.7,13.6,CABG,PCI,16.7,12.0,CABG,PCI,23.4,10.9,PCI,CABG,Procedural Differences Between SYNTAX CABG Randomized vs Registry,CABG RCTCABG registry,Variablen=897n=644,Complete,revasc,(%)63.2 (550/870) 74.7 (481/644),Graft revascularization (%),At least 1 arterial graft97.3 (831/854) 96.7 (623/644),Arterial graft to LAD95.6 (816/854) 94.7 (610/644),Double LIMA/RIMA27.6 (236/854) 16.1 (104/644),Complete arterial18.9 (161/854)11.2 (72/644) revascularization,Venous grafts only2.6 (22/854) 3.3 (21/644),Cardiac-Related Medications Given after the Study Procedure*,Medication,PCI,CABG,p,Value,percent,Any,98.9,98.6,0.62,Aspirin,At discharge,96.3,88.5,0.001,6 mo after randomization,93.2,82.7,0.001,Thienopyridine,At discharge,96.8,19.5,0.001,6 mo after randomization,91.3,16.1,0.001,Any antiplatelet drug,At discharge,97,23.7,0.001,6 mo after randomization,91.4,18.4,0.001,Warfarin derivative,2.6,7.1,0.001,Statin,86.7,74.5,0.001,Beta-blocker,81.3,78.6,0.17,ACE inhibitor,55.1,44.6,0.001,Angiotensin IIreceptor antagonist,13.3,7,100 mm) (%),SYNTAX,Stent Thrombosis and Symptomatic Graft Occlusion,CP1294833-1,Stent Thrombosis,Symptomatic,Graft Occlusion,IncidenceMortality,T Feldman,EuroPCR,2009,Percutaneous or Surgical Revascularization for Multivessel Coronary Artery Disease?,Spectrum of risk (anatomic, clinical) in patients with stable multivessel CAD,Patients with more extensive, diffuse CAD (higher SYNTAX score) fare better with CABG than PCI due to repeat revascularization rates,Lower SYNTAX score patients do well with PCI,There are some patients too high risk for CABG,Limitations of PCI,TLR remains higher with PCI than CABG,Long segments of stents,Post-dilation, IVUS,Dual antiplatelet therapy,Stent thrombosis,PCI still has a significant acute failure rate in specific lesion subsets:,CTO,Bifurcation,SVG,Severe calcification/tortuosity,Limitations of CABG,Long-term graft attrition; total arterial revascularization still uncommon,Native vessel progression,CABG not curative,PCI frequently utilized for symptom relief in post-CABG,Selection of Revascularization Modality- What Should We Emphasize Moving Forward?,Careful assessment of anatomic and clinical risk,Meticulous stent deployment techniques,Prolonged dual antiplatelet therapy for DES,Bioabsorbable stents,Device/equipment development to contend with lesion subsets in which PCI fails,Optimize adjuvant medical therapy (antiplatelet, statin, ACE-I) particularly in post CABG patients,Total arterial revascularization,Explore The Best Of Both Worlds?,Hybrid approaches to minimize morbidity, recovery, pain and maximize durability,Robotic IMA to LAD,PCI with DES to non-LAD disease,
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