Best optionin mainstemandmultivesseldisease CABG, PCI ... Neumann...CABG Superior toConservative •...
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Transcript of Best optionin mainstemandmultivesseldisease CABG, PCI ... Neumann...CABG Superior toConservative •...
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