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1.1. Current TrendsCurrent Trends

2.2. Results of Coronary Bypass SurgeryResults of Coronary Bypass Surgery

3.3. Results of Percutaneous RevascularizationResults of Percutaneous Revascularization

Surgery: Still the best treatment forSurgery: Still the best treatment for

multivessel diseasemultivessel disease


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0

100

200

300400

500

600

700

800

900

(# THOUSANDS)

2000 2001 2002 2003 2004

YEAR

TRENDS IN PCI vs.CABG

PCI

CABG


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Copyright 2006 American Heart Association

Radford, M. J. Circulation 2006;114:1229-1231

Coronary revascularization procedures in New York State, 1995 to 2004


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Co ri ht 2006 Elsevier Science B.V.

Kappetein, A. P. et al.; Eur J Cardiothorac Surg 2006;29:486-491

Procedures by region or country for three-vessel disease


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Co ri ht 2006 Elsevier Science B.V.

Kappetein A. P. et al.; Eur J Cardiothorac Surg 2006;29:486-491

Procedure by region or country for left main disease


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Transcatheter Cardiovascular Therapeutics ConfTranscatheter Cardiovascular Therapeutics Conf

Washington DC 2002Washington DC 2002

Speaking on the results of the trials evaluatingSpeaking on the results of the trials evaluating

DES, Dr. Marty Leon sends a message to theDES, Dr. Marty Leon sends a message to the

cardiothoracic surgeons of the world tocardiothoracic surgeons of the world to Get aGet anew day jobnew day job


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OriginalOriginal multicentermulticenter randomized controlled trials:randomized controlled trials:

medical therapy vs. surgical revascularizationmedical therapy vs. surgical revascularization

1.4%1.4%3.6%3.6%5.6%5.6%Op MortOp Mort

LVEF >50LVEF >50

in 74%in 74%

LVEF >50LVEF >50

in 100%in 100%

LVEF < 50LVEF < 50

in 55%in 55%

LV FunctionLV Function

>70%>70% >> 11>50%>50% >> 22>50%>50% >> 11CADCAD

19751975--1979197919731973--1976197619721972--19741974Time PeriodTime Period

780780768768686686No pts.No pts.

CASSCASSECSSECSSVA StudyVA Study


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RISK FACTORS FOR CORONARY BYPASS SURGERYRISK FACTORS FOR CORONARY BYPASS SURGERY

Ann Thor Surgery 2000; 70:84Ann Thor Surgery 2000; 70:84--9090

20.5%20.5%19.4%19.4%10.4%10.4%

LVEF < 35%LVEF < 35%

41.5%41.5%34.2%34.2%26.9%26.9%Urgent OpUrgent Op

17.1%17.1%9.3%9.3%7.3%7.3%Recent MIRecent MI

20.7%20.7%10.2%10.2%11.0%11.0%PVDPVD

8.5%8.5%2.7%2.7%2.2%2.2%Chronic renalChronic renal

failurefailure

26.7%26.7%23.6%23.6%18.6%18.6%DiabetesDiabetes

25.8%25.8%22.0%22.0%15.2%15.2%AgeAge >> 7070

63.463.462.862.860.760.7AgeAge

19961996--1998199819931993 -- 1995199519901990 -- 19921992


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DiffuseDiffuse coronary artery disease in 87 year old withcoronary artery disease in 87 year old with

dementia and chronic renal failuredementia and chronic renal failure


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Full Metal JacketFull Metal Jacket


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Co ri ht 2007 The Societ of Thoracic Sur eons

Hayward P. A.R. et al.; Ann Thorac Surg 2007;84:795-799

Comparative patencies of different in situ and free arterial conduits at 5 years


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Cleveland ClinicCleveland Clinic-- 10 year survival CABG10 year survival CABGNEJM 1986: 314: 1NEJM 1986: 314: 1--66


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Co ri ht 1998 Euro ean Association for Cardio-Thoracic Sur er . Published b Elsevier B.V. All ri hts reserved.

Loop F. D.; Eur J Cardiothorac Surg 1998;14:554-571

(A) Twenty-year event-free survival after left internal thoracic artery grafting for single

vessel anterior descending disease compared with age and gender matched US population


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Co ri ht 1999 The American Association for Thoracic Sur er

Lytle B. W. et al.; J Thorac Cardiovasc Surg 1999;117:855-872

Bilateral vs. Single Mammary Artery Grafting


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Adjusted cumulative event curves during 20 years inpatients who received internal mammary artery grafts

to multiple systems (solid line) versus a single system(dashed line)

Rankin J. S. et al.; Ann Thorac Surg 2007;83:1008-1015


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ACC/AHA Guidelines CABG 2004ACC/AHA Guidelines CABG 2004

Class I:Class I:

-- LMCAD 50%LMCAD 50%

-- Anatomically equivalent LMCAD with 70%Anatomically equivalent LMCAD with 70%proximal left anterior descending coronary arteryproximal left anterior descending coronary artery

and left circumflex arteryand left circumflex artery

-- TripleTriple--vessel CAD, particularly in the setting ofvessel CAD, particularly in the setting ofimpaired left ventricular ejection fractionimpaired left ventricular ejection fraction

-- Proximal LAD stenosis with impaired ventricularProximal LAD stenosis with impaired ventricularfunctionfunction


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Stenting is highly effectiveStenting is highly effective

1.1. Acute MIAcute MI

2.2. Unstable coronary syndromesUnstable coronary syndromes

3.3. Cardiogenic shockCardiogenic shock

4.4. Stenting in multivessel disease???Stenting in multivessel disease???


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37% of patients have a Troponin elevation37% of patients have a Troponin elevation

28% have MRI defined mean loss of 6 gm of LV muscle28% have MRI defined mean loss of 6 gm of LV muscle

(5% LV mass)(5% LV mass)

10% of patients have a significant MI with each PCI10% of patients have a significant MI with each PCI


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Copyright 2006 American Heart Association

Porto, I. et al. Circulation 2006;114:662-669

Frequency of angiographically determined side branch impairment and closed

microvasculature after stenting (TMPG 0 to 1) according to the magnetic

resonance-defined pattern of delayed hyperenhancement (HE)


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EPIC STUDY:EPIC STUDY: PeriproceduralPeriprocedural myonecrosismyonecrosis andand

subsequent mortalitysubsequent mortalityCirc. Aug 2005 112: 906Circ. Aug 2005 112: 906--915915


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Contrasting Mechanisms of Obstruction of Bare


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Shuchman M. N Engl J Med 2006;355:1949-1952

Contrasting Mechanisms of Obstruction of Bare-Metal Stents and Drug-Eluting Stents


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FDA Circulatory System Devices Advisory PanelFDA Circulatory System Devices Advisory Panel

Dec 2006Dec 2006

1) increase in stent thrombosis with DES at one1) increase in stent thrombosis with DES at one

year (mortality 50year (mortality 50--80%)80%)2) increase in adverse events when DES used off2) increase in adverse events when DES used off

labellabel

3) data for off label use is limited3) data for off label use is limited4) longer duration of Plavix treatment may be4) longer duration of Plavix treatment may be

beneficial (beneficial (d/cd/c Plavix rate 7.3%)Plavix rate 7.3%)


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BASKET TrialBASKET Trial


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Copyright 2006 American College of Cardiology Foundation. Restrictions may apply.

Pfisterer, M. et al. J Am Coll Cardiol 2006;48:2584-2591

Late stent thrombosis and related clinical events


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What is the evidence for PCI/Stenting inWhat is the evidence for PCI/Stenting in

MultiMulti--vessel disease?vessel disease?

Randomized TrialsRandomized Trials


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Long-Term Outcomes of Coronary-Artery Bypass

Grafting versus Stent Implantation

Edward L. Hannan, Ph.D., Michael J. Racz, Ph.D., Gary Walford, M.D., Robert H.

Jones, M.D., Thomas J. Ryan, M.D., Edward Bennett, M.D., Alfred T. Culliford, M.D.,O. Wayne Isom, M.D., Jeffrey P. Gold, M.D. and Eric A. Rose, M.D.

37,212 CABG Pts

22,012 Stent Pts

N Engl J MedVolume 352;21:2174-2183

May 26, 2005

HannanHannan E. et al : NEJM 2005; 352: 2174E. et al : NEJM 2005; 352: 2174--21832183


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NY State Data:NY State Data: HannanHannan et alet al..


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Percentage of Patients Undergoing a Second Revascularization


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Hannan E et al. N Engl J Med 2005;352:2174-2183

g g gProcedure within Three Years


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6033 risk matched patients6033 risk matched patients

PCI increased 5 year mortality x 2.3PCI increased 5 year mortality x 2.3

Relative excess mortality at 3 years with initial stenting versus


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Guyton R. A.; Ann Thorac Surg 2006;81:1949-1957

Relative excess mortality at 3 years with initial stenting versus

initial coronary artery bypass graft surgery (CABG)

Northern New England RegistryNorthern New England Registry

Long term survival in patients with multivesselLong term survival in patients with multivessel


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Long term survival in patients with multivesselLong term survival in patients with multivessel

disease after CABG or PCI Circ. 2005 112: Idisease after CABG or PCI Circ. 2005 112: I--371371--II--

376376

Duke Registry: 18,000 pts; Era 1:1986Duke Registry: 18,000 pts; Era 1:1986--1990; Era 2:1990; Era 2:

19911991--1995;1995; Era 3:1996Era 3:1996--2000/ 33% survival2000/ 33% survival


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1991 1995;; Era 3:1996 2000/ 33% survivaladvantage at 5 years in TVDadvantage at 5 years in TVD

Ann ThorAnn Thor SurgSurg 2006 82: 14202006 82: 1420--14291429


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Adjusted Curves for Long-Term Survival and Survival Freefrom Myocardial Infarction According to the Number of


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from Myocardial Infarction According to the Number of

Diseased Vessels

Hannan E et al. N Engl J Med 2008;358:331-341


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Why is PCI replacing CABG for theWhy is PCI replacing CABG for the

treatment of multivessel diseasetreatment of multivessel diseaseagainst all available evidence?against all available evidence?


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1. When given the choice of1. When given the choice of

equivalentequivalent therapies, the patient willtherapies, the patient willalways choose the nonalways choose the non--surgicalsurgical

treatmenttreatment


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It is likely that most people undergoing coronaryIt is likely that most people undergoing coronaryangiography are not told the entire story when aangiography are not told the entire story when a

decision is made about undergoing a percutaneousdecision is made about undergoing a percutaneous

intervention.intervention.


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2. Cardiologist is the gate keeper2. Cardiologist is the gate keeper--

conflict of interest (selfconflict of interest (self--referral)referral)


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Never hold discussions with the monkey when theNever hold discussions with the monkey when the

organ grinder is in the roomorgan grinder is in the room

Sir Winston Churchill (1874Sir Winston Churchill (1874--1965)1965)


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4. A multibillion dollar industry vs.4. A multibillion dollar industry vs.evidence based medicine?evidence based medicine?


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Future Trends for the Treatment of CoronaryFuture Trends for the Treatment of Coronary

Artery DiseaseArtery Disease


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Angioplastys Golden Era May Be Fading

Kenneth Kent performs a "routine" angioplasty atWashington Hospital Center in Washington, D.C.Angioplasty involves guiding a tiny balloon to a blockedartery supplying the heart. Inflating the balloon clears theblockage and restores blood flow.

By Steve Sternberg, USA TODAY

By Andrew Councill for USATODAY

MarchMarch 26, 200826, 2008


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Number of active thoracic surgeons, 1990 to 2004


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Grover F. L.; Ann Thorac Surg 2008;85:8-24

Number of active thoracic surgeons, 1990 to 2004


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