cabg is superior to pci in heart failure patients with multivessel disease pro

CABG is, today, the best option in most multivessel coronary artery disease patients

José L. Pomar, MD, PhDProfessor of Surgery

Hospital Clinic and University of BarcelonaBarcelona, Spain

Vasilii I Kolesov (1904 –1992)Military surgeon in St. PeterburgLITA to marginal branch of LCX on 25 February 1964

Michael E DeBakey (1908-2008)SVG to the LAD on 23 November 1964Garrett HE et al. JAMA 1973;223:792-4

René G Favaloro (1923-2000)SVG to the RCA on 9 May 1967J Thorac Cardiovasc Surg 1969;58:178-85

Mason Sones, smoking and serendipity

1967 Cleveland Clinic

Evidence based myocardial revascularizationHead SJ & Davierwala PM et al. Eur Heart J 2014; online

Coronary Artery Bypass Graft Trialist Cooperation Yusuf et al. Lancet 1994;344:563-72

Time from randomization (years)

Mor

talit

y (%

)

N = 1325

Medical treatmentCABG

N = 1324

OR 0.61[0.48-0.77]P<0.0001

OR 0.83[0.70-0.98]

P=0.03

CABG VS MEDICAL TREATMENT

CABG VS MEDICAL TREATMENTCoronary Artery Bypass Graft Trialist Cooperation

(Individual Data from 7 Randomized Trials)

Yusuf S et al. Lancet 1994;344:563-72

CABG vs MM0.00

20.0040.0060.0080.00

100.00120.00

1VD / 2VD 3VD LM

CABG vs MM0.00

20.0040.0060.0080.00

100.00120.00

CABG vs MM0.00

20.0040.0060.0080.00

100.00120.00P=0.25 P=0.001 P=0.005

Interaction P = 0.02

Mea

n su

rviv

al (m

onth

s)

CABG VS MEDICAL TREATMENTNetwork meta-analysis of 100 revascularization trials with 93,553 patients and

262,090 patient-years

CABG

MM

Risk ratio (95% CI)

0.80 (0.70-0.91)DeathCABG vs MM

MICABG vs MM

Death or MICABG vs MM

Revasc.CABG vs MM

SES

0.1 0.3 1 3Favours CABG Favours MMWindecker S et al. BMJ 2014;348:g3859

0.81 (0.70-0.94)

0.16 (0.13-0.20)

0.79 (0.63-0.99)

RCTs on revascularization

Head SJ & Davierwala PM et al. Eur Heart J 2014; online

Hlatky M et al. Lancet 2009;373:1190-97

CABG VS PTCA/BAREMETALSTENTSPooled analysis of 10 RCTs with 7812 patients

(ARTS, BARI, CABRI, EAST, ERACI-II, GABI, MASS-II, RITA, SoS, FMS)

PTCA/BMSCABG

Mor

talit

y (%

)

10.0%8.4%N = 3923

N = 3889

Follow-up (years)

HR 0.92 [0.80-1.02]

P=0.121VD or 2VD

0.91 [0.78-1.06]

3VD0.91 [0.77-1.09]

RCTs on revascularization

Head SJ & Davierwala PM et al. Eur Heart J 2014; online

2014 ESC/EACTS Guidelines

TAXUS (N=546)CABG (N=549)

SYNTAX 3VD cohortAll-cause death to 5 years

ITT populationCumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates

0Months Since AllocationCu

mul

ativ

e Ev

ent R

ate

(%)

25

50 Before 1 year*

2.9% vs 4.5%P=0.18

1-2 years*

1.2% vs 2.1%P=0.25

2-3 years*

1.7% vs 3.2%P=0.12

3-4 years*

1.7% vs 2.5%P=0.40

4-5 years*

2.4% vs 2.8%P=0.74

0 12 6024 36 48

P=0.006

9.2%

14.6%

0Months Since AllocationCu

mul

ativ

e Ev

ent R

ate

(%)

25

50 Before 1 year*

2.7% vs 5.2%P=0.04

1-2 years*

0.2% vs 1.2%P=0.12

2-3 years*

0.4% vs 1.0%P=0.45

3-4 years*

0.0% vs 2.3%P=0.001

4-5 years*

0.0% vs 1.3%P=0.03

0 12 6024 36 48

SYNTAX 3VD cohortMyocardial infarction to 5 years

P<0.001

3.3%10.6%

TAXUS (N=546)CABG (N=549)

ITT populationCumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates

0Months Since AllocationCu

mul

ativ

e Ev

ent R

ate

(%)

25

50Before 1 year*

6.6% vs 8.0%P=0.39

1-2 years*

1.8% vs 3.7%P=0.07

2-3 years*

2.5% vs 4.4%P=0.10

3-4 years*

2.1% vs 4.4%P=0.053

4-5 years*

2.4% vs 3.7%P=0.29

0 12 6024 36 48

SYNTAX 3VD cohortDeath/Stroke/MI to 5 years

P<0.001

14.0%

22.0%

TAXUS (N=546)CABG (N=549)

ITT population

TAXUS (N=546)CABG (N=549)

Cumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates

0Months Since AllocationCu

mul

ativ

e Ev

ent R

ate

(%)

25

50Before 1 year*

11.5 vs 19.2%P<0.001

1-2 years*

4.4% vs 7.0%P=0.08

2-3 years*

4.6% vs 7.4%P=0.06

3-4 years*

2.8% vs 7.7%P<0.001

4-5 years*

4.5% vs 6.9%P=0.11

0 12 6024 36 48

SYNTAX 3VD cohortMACCE to 5 years

P<0.001

24.2%

37.5%

SYNTAX 3VD CohortMultivariate cox regression: PCI vs CABG

HR (95% CI)

MACCE

Death/stroke/MIDeath

0.5 1 2 5

HR 1.66 (1.32-2.09)

HR 1.81 (1.33-2.46)

HR 1.81 (1.24-2.67)

FavoursPCI

FavoursCABG

SYNTAX 3VD cohortSYNTAX score terciles

Death

Myocardialinfarction

Stroke

Repeat Revasc.

TAXUS (N=546)CABG (N=549)

SYNTAX 3VD cohortSYNTAX score terciles

Head SJ & Davierwala PM et al. Eur Heart J 2014; online

TAXUS (N=546)CABG (N=549)

Death/stroke/MIMACCE

CABG PCI

SYNTAX 3VD cohortCompleteness revascularization

Incomplete revasc.Complete revasc.P = 0.010

P = 0.17

MA

CC

E (%

)Head SJ & Davierwala PM et al. Eur Heart J 2014; online

Completness revascularization

PCIN=63,945

CABGN=25,938

Incomplete revasc.Complete revasc.

75%

44%56%

25%

SXS<23

SXS23-32

SXS>32

Patients (%)0 10 20 30 40 50 60 70

CompleteResid SXS 0-4Resid SXS 4-8Resid SXS >8

Farooq V et al. Circulation 2013;128:141-51Garcia S et al. JACC 2013;62:1421-31

SYNTAX PCI cohortResidual SYNTAX score

Resid SXS 0-4Resid SXS 4-8Resid SXS >8

Haz

ard

ratio

(95%

CI)

7.0

6.0

5.0

4.0

3.0

2.0

1.0

0.0 MACCE DeathDeath/stroke/MI

Farooq V et al. Circulation 2013;128:141-51

SYNTAX 3VD CohortDiabetic patients

0.3 1 3 10Hazard Ratio

(95% CI)

MACCE: Diabetes

No diabetes

Death/stroke/MI: Diabetes

No diabetes

All-cause death: Diabetes

No diabetes

Interaction

P=0.095

P=0.44

P=0.37

Head SJ & Davierwala PM et al. Eur Heart J 2014; online

Favours CABG

FREEDOM TrialSimilar results as SYNTAX

Dea

th/S

trok

e/M

I (%

)

Follow-up (years)D

eath

/(%)

Follow-up (years)

26.6%

18.7%

P=0.005

16.3%

10.9%

P=0.049

SYNTAX 3VD:24.9% vs 13.2%P = 0.021

SYNTAX 3VD:20.2% vs 10.1%P = 0.027

SYNTAX II ScoreRisk score predicting 4-year mortality

84.2%Favours CABG

15.8%Favours PCI

Annual Cumulative

SYNTAX TrialEconomics

Cohen DJ & Osnabrugge RL, et al. Circulation 2014; online

Δ cost = $10,036

Δ cost = $5619

-$20 000

-$10 000

$0

$10 000

$20 000

-2 -1 0 1 2

$50,000 per QALY

84.7% below

∆ Cost = $5081 ∆ QALY = 0.307

ICER = $16,537/QALY

∆ QALYs (CABG-PCI)

∆ L

ong-

term

cost

(C

ABG

-PCI

) Cost QALY

Cost QALY

Cost QALY

Cost QALY

SYNTAX Cost-effectiveness

∆ Cost = $3350 ∆ QALY = 0.68

ICER = $4,905/QALY

$50,000 per QALY

94.3% below

3VDcohort

Multivessel disease (MVD)

CABG

Diabetics with MVD

FREEDOM

Left main disease

SYNTAX

Decision-making and

assessing riskHeart Team

PCI/CABG ratios worldwideCountry PCI/CABG CABG : PCI (per 100,000 of population)

MexicoNew ZealandCanadaUnited KingdomIrelandAustraliaDenmarkPortugalLuxembourgFinlandNetherlandsNorwaySwedenBelgiumOECDCzech RepublicIcelandSwitzerlandPolandGermanyHungaryUnited StatesItalyFranceSpain

200 100 0 100 200 300 400 500 600

0.67 ???1.401.872.032.152.192.242.332.342.372.413.093.203.213.293.363.563.673.804.184.305.175.265.988.63

Head SJ et al. Eur Heart J 2013;94:1954-60

Evidence based myocardial revascularization

CABG is clearly superior to Medical Management

SYNTAX trial shows superior survival with CABG over first-generation, paclitaxel-eluting stents for 3VD

Guidelines favours CABG for complex MV disease

Differences between PCI and CABG appear particularly with higher degree of incomplete revascularization

Evidence based myocardial revascularization

Surgery, since the beggining showed better results when patients had an LV dysfunction

PCI is an alternative to CABG for low SYNTAX score, but still more repeat revascularizations are required

CABG is economically attractive

Conclusions to take home

1• In 2015, CABG turned 50 years old…Many, many patients benefited.

2• SYNTAX trial and others show superior survival with CABG over first-

generation stents for 3VD

3• Differences between PCI and CABG appear particularly with higher

degree of incomplete revascularization

6• CAD patients with poor LV function or HF are better treated by

surgery, but Heart Team assessment is, in 2015, mandatory

4• CABG is superior to PCI in diabetic patients, irrespective of insulin

dependence

5• PCI provides similar outcomes as CABG 3VD patients with low or

intermediate SYNTAX scores

Thanks to Dr. Stuart Head for some few slides and apologieson behalf of Dr. David Taggart