multivessel coronary artery disease 3v cad pci vs...
TRANSCRIPT
Multivessel Coronary Artery Disease3V CAD
PCI vs CABG
Michael Zairis, MD, PhD, FESC
Interventional Cardiologist
Director at Metropolitan Hospital
What is our goal of therapy?
• Prevent complications of CAD in effort to
prolong life
• Decrease cardiac morbidity
• Alleviate symptoms
What are the indications for revascularization?
• Activity limiting symptoms despite maximal medical therapy
• Not tolerating medication well or need to increase activity level
• Anatomy favors survival benefit (significant LMCA disease or multivesselCAD with decreased LVEF)
Will the debate go on forever?
• Balloon angioplasty vs CABG
– BARI
– RITA
– GABI
– EAST
– CABRI
Will the debate go on forever?
• Bare metal stent vs CABG
– ERACI - II
– ARTS
– SOS
• Drug eluting stents vs CABG
– ARTS - II
– ERACI – III
– SYNTAX
SYNTAX Trial
• CABG vs PCI in 3 vessel or LMCA disease
– 60% patients were 3V CAD
– 40% LMCA disease
– Paclitaxel was the DES used
Patient 1
Patient 1 Patient 2
Patient 2
SYNTAX SCORE 21 SYNTAX SCORE 52
LCx 70-90%
LAD 70-90%
RCA2 70-90%
RCA3 70-90%
LM 99%
LCx 100%
LAD 99%
RCA 100%
There is ‘3-vessel disease’ and ‘3-vessel disease’
• How the score was calculated– Amount of segments involved– If a CTO was present and if so
what type– Bifurcation vs trifurcation lesions– Ostial lesions– Tortuosity– Long segment disease– Small vessel disease
SYNTAX Trial
• Composite primary endpoint was higher in PCI vs CABG (17.8% vs 12.4%)
– Death/MI/Repeat revascularization
– This was driven by revascularization (13.5% vs 5.9%)
– Death/Stroke/MI were comparable
– At 3 and 5 year follow up, primary endpoint remained higher in PCI group (driven by revascularization)
SYNTAX Trial
• Outcomes were then broken down by disease complexity• SS < 23 - no difference in composite
endpoint
• SS 23-32 - endpoint was higher with PCI (37.9% vs 22.6%)
• SS > 33 - endpoint was higher with PCI (41.9% vs 24.1%)
SYNTAX Trial
• Criticisms
• No clinical variables
• Use of paclitaxel (increased rate of angiographic and clinical restenosis than later generations)
• Bypass patients were often not on “maximal” medical therapy
SYNTAX Trial
SYNTAX II• Additional scoring factors
• Anatomical syntax score• Age• Creatinine clearance• LVEF• Presence of unprotected LMCA disease• PAD• Female sex• COPD
SYNTAX II• Additional PCI Developments
• (SYNERGY™ and/or SYNERGY II™ DES)
• (iFR/FFR) to allow for ischemia-driven revascularisation and
• IVUS guidance to optimise stent deployment.
• If present, chronic total occlusion (CTO) lesions will be treated with contemporary techniques.
• 2 vessel CAD especially if LAD is not involved
• Older patients with significant comorbidities
• Patients who refuse surgery
• Patients with low complexity disease that do not have diabetes
PCI preferred
PCI or CABG
• If patients are equally suited• Decision should be made by joint team
• Patients willingness to undergo repeat procedures should be assessed
• Patients should be aware of slightly higher stroke risk with CABG vs PCI
• Should not be attempted by low volume operators
• Assess ability to take DAPT for a long period of time
The Future?