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8/11/2019 Left Main Revascularization in the United States- Guidelines, Appropriate Use Criteria, And Standards of Care
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Left Main Revascularization
in the US: Guidelines,Appropriate Use Criteria
and Standards of Care
Jeffrey W. Moses, MD
Columbia University Medical CenterThe Cardiovascular Research Foundation
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Disclosure Statement of Financial Interest
I, Jeffrey W. Moses, MD am a consultant
with BSC (Consulting Fees/Honoraria)
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Resources for Guidance
ACCF/AHA Guidelines UAP/NSTEMI SIHD PCI CABG STEMI
ESC Guidelines Revascularization ACS STEMI
Stable CAD
AUC Angiography Revascularization
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GNL 2011
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UPLM PCI to Improve Survival:
Setting of Acute Coronary Syndrome
Class Of Recommendation LOE
IIaFor UA/NSTEMI if not a
CABG candidate B
IIaFor STEMI when distal coronary
flow is
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Heart Team Approach for
UPLM (Unprotected Left Main)
or Complex CAD Revascularization
GNL 2011
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UPLM Revascularization
to Improve Survival
RevascMethod Class Of Recommendation
LOE
CABG I B
PCI IIaFor SIHD when low risk of PCI complications and high likelihood of good
long-term outcome (e.g., SYNTAX score of 22, ostial or trunk left main
CAD), anda signficantly increased CABG risk (e.g., STS-predicted risk of
operative mortality 5%)
B
IIbFor SIHD when low to intermediate risk of PCI complications and
intermediate to high likelihood of good long-term outcome (e.g., SYNTAX
score of 2%)
B
III: Harm
For SIHD in patients (versus performing CABG) with unfavorable
anatomy for PCI and who are good candidates for CABGB
IIaFor UA/NSTEMI if not a CABG candidate B
IIaFor STEMI when distal coronary flow is
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UPLM PCI to Improve Survival (SIHD)
RiskofPCI
Complication
Lik
elih
oodof
Good
Lon
g-termO
utcom
e
CAB
GMortality
Risk
Class Of RecommendationLOE
IIaFor SIHD when lowrisk of PCI complications
and highlikelihood of good long-term outcome (e.g.,SYNTAX score of 22, ostial or trunk left main CAD),
anda signficantly increased CABG risk (e.g., STS-
predicted risk of operative mortality 5%)
B
IIbFor SIHD when low to intermediate risk of PCI
complications and intermediate to high likelihood of
good long-term outcome (e.g., SYNTAX score of 2%)
B
III: HarmFor SIHD in patients (versus performing
CABG) with unfavorableanatomy for PCI and whoare goodcandidates for CABG
B
Low
Hi
Hi Hi
Low Low
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What About High
Risk for PCIandCABG?
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SIRTAX: SYNTAX Score Is Not a
Measure of Absolute Risk: Different
Stent, Different Outcomes
Girasis et al, Euro Heart J2011; in press
MACE1Y
P=0.21
DEATH1Y
P=0.35P=0.95
CSSLOWn=282
60
%
CSSMIDn=283
CSSHIGHn=283
P=0.001P=0.98P=0.4650
40
30
20
10
0
9.0
SES PES
23.9
8.67.57.36.6
CSSLOWn=282
60
CSSMIDn=283
CSSHIGHn=283
50
40
30
20
10
01.4
SES PES
4.92.10.00.71.5
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0
Months Months
2-year HR
0.63[0.49, 0.82]
p=
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Sirolimus
Everolimus
SCAAR: EES vs. Gen 1 DES Diabetes
Mortality
Kedhi et al, JACC2012;5:1141-1149
Vs. SES Vs. PES
HR 1.69; 95%CI: (1.06-2.72)
Time in months
Pacitaxel
Everolimus
0.00
0.02
0.04
0.06
0.08
0 3 6 9 12Cum
ulativeRiskofall-c
auseMortality
HR 2.02; 95%CI: (1.03-3.98)
Time in months
0.00
0.02
0.04
0.06
0.08
0 3 6 9 12
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Montalescot et al, Euro Heart J2013;34:2949-3003
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Indications for Revascularization in
Stable Angina or Silent Ischemia
* With documented ischemia or Fractional Flow Reserve (FFR) 50%* I A
Any proximal LAD >50%* I A
2VD or 3VD with impaired LV function* I B
Proven large area of ischemia (>10% LV) I B
Single remaining patent vessel >50% stenosis* I C
I VD without proximal LAD and without >10% ischemia III A
For
prognosis
For
symptoms
Subset of CAD by Anatomy Class Level
Any stenosis >50% with limiting angina or anginaequivalent, unresponsive to OMT
I A
Dyspnoea/CHF and >10% LV ichemic/viability suppliedby >50% stenotic artery IIa B
No limit symptoms with OMT III C
European Heart Journ al ,2010;31:2501-2555
European Journ al of Cardio-thoracic Surgery, 2010;38:S1-S52
Joint 2010 ESCEACTS
Guidelines on MyocardialRevascularization
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Indications for CABG vs. PCI in Stable Patients with
Lesions Suitable for Both Procedures and Low
Predicted Surgical Mortality
In the most severe patterns of CAD, CABG appears to offer asurvival advantage as well as a marked reduction in the need for
repeat revascularization Joint 2010 ESCEACTSGuidelines on Myocardial
Revascularization
Subset of CAD by Anatomy Favors CABG Favors PCI
1 VD or 2VDnon-proximal LAD IIb C I C
1 VD or 2VDproximal LAD I A IIa B
3VD simple lesions, full functional revascularization
achievable with PCI, SYNTAX score 22
I A III A
Left main (isolated or 1 VD, ostium/shaft) I A IIb B
Left main (isolated or 1 VD, distal bifurcation) I A IIb B
Left main + 2VD or 3VD, SYNTAX score 33 I A III B
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Montalescot G, et al.Eur Heart J2013;
34:2949-3003
PCI or CABG in SIHD with Ischemia
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PCI or CABG in SIHD with LM Disease
Montalescot G, et al.Eur Heart J2013;
34:2949-3003
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CABG PCI
Subset of CAD by anatomy ESC ACC ESC ACC
Heart team Approach for LM or complex CAD I C I C I C I C
LM (isolated or 1VD, ostium/shaft) I A I B IIa B IIa B
LM (isolated or 1VD, distal bifurcation) I A I B IIb B IIb B III BLM + 2VD or 3VD, SYNTAX scores 32 I A I B III B IIb B III B
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Appropriate Use Criteria
J Am Col l Cardio l 2012
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AUC and Multivessel Revascularization
Patel et al, JACC2012;59:857-881
Method of Revascularization of Multivessel Coronary Artery Disease
Assumes CCS >2 or int/high risk non-invasives
CABG PCI
Two-vessel CAD with proximal LAD stenosis A A
Three-vessel CAD with low CAD burden (i.e., three focal
stenosis, low SYNTAX score)A A
Three-vessel CAD with intermediate to high CAD burden(i.e., multiple diffuse lesions, presence of CTO, or high
SYNTAX score)
A U
Isolated left main stenosis A U
Left main stenosis and additional CAD with low CAD
burden (i.e., one to two vessel additional involvement,low SYNTAX score)
A U
Left main stenosis and additional CAD with intermediate
to high CAD burden (i.e., three vessel involvement,
presence of CTO, or high SYNTAX score)
A I
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Symptoms Med. Rx
Class llI or
lV Max Rx U A A A AClass I or lI
Max Rx U U A A AAsympto-matic Max
RxI I U U U
Class llI or
lV No/minRx
I U A A A
Class
I or lINo/min Rx
I I U U U
Asympto-matic
No/min RxI I U U U
Coronary
Anatomy
CTO of 1
vz.
no other
disease
1-2 vz.
disease
no
prox.
LAD
1 vz.
disease
of prox.
LAD
2 vz.
disease
with
prox.
LAD
3 vz.
disease
no Left
Main
Low-Risk Findings on Non-invasive Study
Patel et al JACC2009 53(February): 530-553
Asymptomatic
Stress Test Med. Rx
High Risk
Max Rx U A A A AHigh Risk
No/min
Rx U U A A AInt. Risk
Max Rx U U U U AInt. Risk
No/min
RxI I U U A
Low Risk
Max Rx I I U U ULow RiskNo/min
RxI I U U U
Coronary
AnatomyCTO of 1
vz.
no other
disease
1-2 vz.
disease
no
prox.
LAD
1 vz.
disease
of prox.
LAD
2 vz.
disease
with
prox.
LAD
3 vz.
disease
no Left
Main
Appropriateness Ratings by Low-Risk Findings on
Noninvasive Imaging Study and Asymptomatic
Whither Left Main?
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The AUC Have Changed
J Am Coll Cardio l2013;61:130517.
Appropriate Appropriate
Uncertain May be appropriate
Inappropriate Rarely appropriate
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Advanced CADMethod of
RevascularizationAngina Class III, and/or evidence of intermediate or
high risk non-invasive features
Note: 2009 rating s created pre-
SYNTAX And ISAR Left Main2012 AUC Revasc Update
M
R
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Criticisms of the AUC Lack of adequate
representation of
interventional cardiology onthe technical panel
Lack of specific criteria for
stress testing
Inability to link stress test
results to coronary anatomy
Overdependence on pre-
procedure stress testing
Inadequate use of
angiographic variables
No accounting for FFR
and IVUS
Validity of NCDR
self-reported data
J Am Col l Cardiol Intv2012;5:229-235.
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Appropriateness Use Criteria Developed
Using a Modified Rand/Delphi Methodology
Define Appropriateness
for Coronary Revascularization
Coronary revascularization is appropriate
when the expected benefits, in terms of
survival or health outcomes (symptoms,
funct ional status, and /or qual ity o f l i fe) exceedthe expected negative consequences of the
procedure
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How Do Patients Weigh Outcomes?
i.e., Who Defines Negative Consequences
224 respondents SYNTAX eligible for3VD revascularization
Tong et al, Am Thor Surg2012;94:1908
Relative Weight
Death 0.23
Stroke 0.18
Longevity 0.17
MI 0.14
Revascularization 0.11
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Scenario Presented
Blinded17% PCI
OPEN27% PCI
PCI Choice: more familiarity
High socioeconomic status
PCI CABG
Hospital stay 2 day 4 day
Recovery 1 week 6 weeks
Death 6% 3%
MI 7% 3%CVA 3% 2%
Revasc 20% 10%
Life expectancy 0 1 year
Tong et al, Am Thor Surg2012;94:1908
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The Expanded Heart Team
Joint 2010 ESCEACTS Guidelineson Myocardial Revascularization
Clinical
Cardiologist(non interventional)
The patient with
complex CADand
comorbidity
Referring physician
General
practitionerGeriatrician
Nephrologist
Rehabilitation
Specialist
NeurologistDiabetologist
Anesthesiologist
PneumologistWhere is the patient?
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Will We Even
Identify LMDisease?
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Algorithm for Risk Assessment of Patients
With SIHD
Consider coronary
revascularization to
improve survival
Consider coronaryrevascularization to
improve symptoms
Regular
Monitoring
Test results suggest
high-risk coronary
lesion(s)?
Observe responseto Guideline-
Directed Medical
Therapy
Yes
Pharm MPI,
Echo, CCTA or
CMR
MPI or
Echo with
exercise
Indeterminate result
from functional
testing
Yes
No
No
YesNo
No
Yes
YesLBBB on ECG?
Known stenosis of
unclear significance
being considered for
revascularization
CCTA
Successful
Treatment?
Special circumstances
(irrespective of ability
to exercise)
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Algorithm for Guideline-Directed Medical
Therapy for Patients With SIHD
Consider
revascularization to
improve symptoms
Anginal Symptoms? No
Sublingual NTG
No
Successful
Treatment?
Yes
Yes
Yes
Yes
Yes
Serious
contraindication
Serious
contraindication
Persistent symptoms despite adequate trial ofGuideline-Directed Medical Therapy Yes
No
Successful
Treatment?
Yes Yes
No
Successful
Treatment?
Add/substitute
CCB and/or long-acting
nitrate if no
contraindication
Add/substitute ranolazine
Beta blocker if no
contraindication(Esp. if prior MI, heart failure or
other indication)
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ESC Algorithm for Initial Evaluation of Patients with
Clinical Symptoms of Angina
ESC Slide-set2010 European Society of Cardiology
Algorithm for Initial Evaluation of Patients with Clinical Symptoms of Angina (2)
Medical Therapy +Coronary
arteriography
Depending on level of
symptoms and
clinical judgment
Medical Therapy
Low risk
Annual CV mortality 3%
per year
Coronary
arteriography if not
already performed
If symptomatic control unsatisfactory,
consider suitability for
revascularization (PCI or CABG)
Evaluate response to medical therapyHigh risk coronary
anatomy known to benefit
from revascularization?
NO
YES
Revascularize
Medical TherapyAND
Coronary arteriography for
more complete risk
stratification and
assessment of need for
revascularization
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AUC for Diagnostic Cath
Patel et al, JACC2012;59:857-881
Low Intermediate High
Asymptomatic Global CAD Risk I I U
Symptomatic Pretest Probability I U A
Suspected CAD: No Prior Noninvasive Stress Imaging
Risk Assessment
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How to Treat: Pick Your Algorithm
50-year-old male hypertension withtypical angina class II
Pretest likelihood for CAD = 93%
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Next Steps
US guidelinesstress if not high risk GDMT
ESC guidelines: quantitative MPI ,if
>10% or intermediate risk risk: Cath ordirect cath
AUC: Cath
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Conclusions: LM Best Practices
Surgery remain the default strategy UPLM stenting is NEVER appropriate in
low risk patients according to US
guidelines
ESC guidelines leave a bit more wiggleroom to the Heart Team
The US AUC are internally ambiguousand conflict to some extent with the
guidelines (i.e., CTO, intermediate SS)
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