Best option in main stem and multivessel disease

CABG, PCI or medical therapy

Franz-Josef Neumann

Revascularisation vs conservative therapy

PCI vs CABG – The SYNTAX trial

Role of anatomic complexity

Role of left main involvement

Best option in main stem and multivessel disease

CABG, PCI or medical therapy

Revascularisation vs conservative therapy

PCI vs CABG – The SYNTAX trial

Role of anatomic complexity

Role of left main involvement

Best option in main stem and multivessel disease

CABG, PCI or medical therapy

CABG Superior to Conservative

• Left main disease

• Triple- or double-vessel disease involving the proximal LAD

• Triple- or double-vessel disease in the presence of severe

angina or large areas of ischemia on functional testing

• Triple-vessel disease associated with impaired LV-function

PCI equal to CABG?

• Left main disease

• Triple- or double-vessel disease involving the proximal LAD

• Triple- or double-vessel disease in the presence of severe

angina or large areas of ischemia on functional testing

• Triple-vessel disease associated with impaired LV-function

CABG Superior to Conservative

Hannan EL et al., Circulation 2006

Lower Adjusted Mortality with CABG vs. DES

Hannan EL et al., Circulation 2006

Lower Mortality with Complete Revascularisation

Complete revascularisation

Incomplete revascularisation

no chronic total occlusion

only one chronic total occlusion

chronic total occlusion + other lesion

0 2 4 6 8 10 12

8.6

10.5

11.2

11.3

3-year mortality (%)

P < 0.03

Who benefits from elective PCI?

Boden WE et al., N Engl J Med 2007

18.5 19

0

5

10

15

20

Incidence of death & MI (%)

Conservative PCI

PCI Superior to Conservative?

Shift in Paradigm:

From angiographic to functional guidance for PCI

FAME: Tonino PA et al., N Engl J Med 2009

Functional guidance (FFR)

Angiographic guidance

11.1

7.3

Death & MI

18.3

13.2

0

5

10

15

20

1-year incidence (%)

MACE

P = 0.02

P = 0.04

FAME II: De Bruyne B et al., N Engl J Med 2012

3.0

FFR-guided

conservative

0

5

10

15

1-year incidence of death, MI & urgent TVR(%)

4.3

FFR-guided

PCI

Shift in Paradigm:

From angiographic to functional guidance for PCI

12.7

Conservative

despite FFR < 0.8

P < 0.001n.s.

FAME II: De Bruyne B et al., N Engl J Med 2012

1.8

FFR-guided

conservative

0

5

10

15

1-year incidence of death & MI (%)

3.4

FFR-guided

PCI

Benefit of FFR-guided PCI?

3.9

Conservative

despite FFR < 0.8

n.s.n.s.

Large ischaemic area:

Improved survival with revascularisation

Hachamovitch R et al. Circulation 2003

0

2

4

6

8

10

0% 1-5% 5-10% 11-20% >20%

Mortality (%)

Ischaemic area (% of LV myocardium)

n=10627

Medical

therapy

PCI / CABG

Hachamovitch R et al. Circulation 2003

Cardiac death

Large ischaemic area:

Improved survival with revascularisation

Shaw LJ et al., Circulation 2008

Years to follow-up

Survival without myocardial infarction

Residual ischemic area (% of LV)

Best outcome with revascularisation

and no residual ischaemic area

Revascularisation vs conservative therapy

PCI vs CABG – The SYNTAX trial

Role of anatomic complexity

Role of left main involvement

Best option in main stem and multivessel disease

CABG, PCI or medical therapy

MACCE to 5 Years

TAXUS (N=903)CABG (N=897)

Serruys PW., ESC 2012

Repeat Revascularization to 5 Years

TAXUS (N=903)CABG (N=897)

Serruys PW., ESC 2012

CVA to 5 Years

TAXUS (N=903)CABG (N=897)

Serruys PW., ESC 2012

Myocardial Infarction to 5 Years

TAXUS (N=903)CABG (N=897)

Serruys PW., ESC 2012

TAXUS (N=903)CABG (N=897)

All-Cause Death to 5 Years

Serruys PW., ESC 2012

TAXUS (N=903)CABG (N=897)

Cardiac Death to 5 Years

Serruys PW., ESC 2012

4-year mortality (%)

10

5

0

20Bypass

PCI

8.8%

11.7%

P = 0.05

Losses to follow-up impact on outcome

8.2%

11.5%

P = 0.02

All non-evaluable patients

having survived

Non-evaluable

patients

similar survival as

evaluable patients

1516.9%

14.2%

P = 0.10

All non-evaluable

patients

having died

Revascularisation vs conservative therapy

PCI vs CABG – The SYNTAX trial

Role of anatomic complexity

Role of left main involvement

Best option in main stem and multivessel disease

CABG, PCI or medical therapy

Serruys PW., ESC 2012

CABG (n=275)

PCI (n=299)

SYNTAX-Score < 23: Similar MACCE Rate

Bypass PCI

SYNTAX-Score < 23: Similar Outcomes

Serruys PW., ESC 2012

5-year incidence (%)

P = 0.11 P = 0.64 P = 0.11 P = 0.81

20

10

5

0

4.2%

7.8%

10.1%8.9%

Death

4.0%1.8%

Stroke

14.9%

16.1%

DeathMI, stroke

25

15

30

Myocardialinfarction

SYNTAX-Score 23-32: More MACCE with PCI

Serruys PW., ESC 2012

CABG (n=310)

PCI (n=300)

Bypass PCI

SYNTAX-Score 23-32: More Infarctions with PCI

Serruys PW., ESC 2012

5-year incidence (%)

P < 0.001 P = 0.68 P = 0.25 P = 0.42

20

10

5

03.6%

11.2%12.7%

13.8%

Death

3.6%2.0%

Stroke

18.0%

20.7%

DeathMI, stroke

25

15

30

Myocardialinfarction

SYNTAX-Score >32: More MACCE with PCI

Serruys PW., ESC 2012

CABG (n=315)

PCI (n=290)

Bypass PCI

4-year incidence (%)

P = 0.004 P = 0.005 P = 0.80 P = 0.007

20

10

5

03.9%

10.1%

Myocardialinfarction

11.4%

19.2%

Death

3.7% 3.5%

Stroke

17.1%

26.1%

DeathMI, stroke

25

15

SYNTAX-Score >32: More Deaths with PCI

Serruys PW., ESC 2012

30

Revascularisation vs conservative therapy

PCI vs CABG – The SYNTAX trial

Role of anatomic complexity

Role of left main involvement

Best option in main stem and multivessel disease

CABG, PCI or medical therapy

Bypass PCI

5-year MACCE (%)

50

20

30

10

0

31.5% 30.4%

P = 0.74

5-year mortality (%)

P = 0.11

15

10

5

0

26.8%

33.3%

P = 0.21

11.3%

7.0%

P = 0.28

20 40

3 vesselLeft main 3 vesselLeft main

9.3%10.2%

25

SYNTAX-Score < 23: Left main and 3-vd similar

Kappetein AP, TCT 2012

SYNTAX-Score > 32: Left main and 3-vd similar

5-year MACCE (%)

50

20

30

10

0

29.7%

46.5%

P = 0.003

5-year mortality (%)

14.1%

20.9%

P = 0.11

15

10

5

0

24.1%

41.9%

P < 0.001

8.8%

17.8%

P = 0.02

20 40

3 vesselLeft main

Bypass PCI

3 vesselLeft main

25

Kappetein AP, TCT 2012

SYNTAX-Score 23-32 : Left main and 3-vd different?

Bypass PCI

5-year MACCE (%)

50

20

30

10

0

32.7% 32.3%

P = 0.88

5-year mortality (%)

P = 0.040

15

10

5

0

22.6%

37.9%

P < 0.001

19.3%

8.9%

P = 0.047

20 40

3 vesselLeft main 3 vesselLeft main

9.6%

16.3%

25

Kappetein AP, TCT 2012

Leipzig Multicenter Left Main:

Similar Death & Infarction

Boudriot E et al., J Am Coll Cardiol 2011

Leipzig Left Main:

No significant increase in MACE

Boudriot E et al., J Am Coll Cardiol 2011

n = 100

n = 101

PRECOMBAT:

Similar death, infarction and stroke

Park SJ et al., N Engl J Med 2011

PRECOMBAT:

No significant increase in MACCE

Park SJ et al., N Engl J Med 2011

No difference in 5-year survival after PCI vs. CAGB

- MAIN-COMPARE -

Park DW et al., J Am Coll Cardiol 2010

Adjusted hazard ratio:

1.00 (0.73–1.37)

P=0.99

N = 1,474

DES

CABG

Differential outcome according to SYNTAX score

Park DW et al., J Am Coll Cardiol 2011

0.2 0.5 1 2 5 10 50PCI better CABG better

Adjusted Hazard Ratio

Death

Death, MI, stroke

Reintervention

SYNTAX score

< 23

23 – 32

> 32

Distal left main?

SYNTAX-Score

Proximal left main 12

Bifurcation 18Medina 1/1/1

> 20 mm

Severe calcification

left dominance

Trifurcation 21All branches involved

> 20 mm

Severe calcification

left dominance

SYNTAX-Score 23 – 32 Heart team

SYNTAX-Score > 32 CABG

SYNTAX-Score < 23 PCI

Best option in main stem and multivessel disease

CABG, PCI or medical therapy