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www.metcardio.org
Giuseppe Biondi Zoccai
University of Turin, Turin, ItalyMETCARDIO, Turin, Italy
Educational Fellowship in PCI for Young Interventionalists -
Certified Training Course (EAPCI, SCAI, GISE) - Bologna, 25/9/2008 – 14:30-17:30 (15’)
LEFT MAIN/MULTIVESSEL DISEASE: LEFT MAIN/MULTIVESSEL DISEASE:
WHEN PERCUTANEOUS CORONARY WHEN PERCUTANEOUS CORONARY
INTERVENTION, WHEN SURGERY?INTERVENTION, WHEN SURGERY?
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LEARNING GOALS
• Should I bother with left main (LM)/ multivessel disease (MVD)?
• Who is the winner between PCI and CABG in LM/MVD?
• When is surgery appropriate for LM/MVD?
• When is PCI appropriate for LM/MVD?
www.metcardio.org
LEARNING GOALS
• Should I bother with left main (LM)/ multivessel disease (MVD)?
• Who is the winner between PCI and CABG in LM/MVD?
• When is surgery appropriate for LM/MVD?
• When is PCI appropriate for LM/MVD?
www.metcardio.org
PREVALENCE AND PROGNOSIS OF LM/MVD DISEASE
Chaitman et al, Circulation 1981;64:360-367; Yusuf et al, Lancet 1994;344:563-570;
Melidonis et al, Angiology 1999;50:997-1006
• Out of 1000 pts undergoing coronary angio: 30-80 will have unprotected LM, 20-60 protected LM, a total of 300-700 will have MVD
• Unprotected LM has, historically, a 36% 5-year mortality rate with medical Rx only, which is reduced to 12% after CABG (p=0.004)
• Corresponding figures for 3VD are 18% vs 10% (p<0.001), and for 2VD are 12% vs 10% (p=0.45)
• Whenever LV function is abnormal, 5-year mortality with medical Rx only is 25%, which is reduced to 14% after CABG (p=0.02)
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LEARNING GOALS
• Should I bother with left main (LM)/ multivessel disease (MVD)?
• Who is the winner between PCI and CABG in LM/MVD?
• When is surgery appropriate for LM/MVD?
• When is PCI appropriate for LM/MVD?
www.metcardio.org
META-ANALYSIS OF RCTS OF CABG VS PCI: 5-YEAR-SURVIVAL WITH POBA VS BMS
Bravata et al, Ann Intern Med 2007;147:703-716
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META-ANALYSIS OF RCTS OF CABG VS PCI: 5-YEAR-SURVIVAL WITH POBA VS BMS
Bravata et al, Ann Intern Med 2007;147:703-716
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META-ANALYSIS OF RCTS OF CABG VS PCI: 5-YEAR-SURVIVAL IN DIABETICS
Bravata et al, Ann Intern Med 2007;147:703-716
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HOWEVER, PCI WITH BMS WAS INFERIOR TO CABG FOR THE
RISK OF REPEAT PCI/CABG
Biondi-Zoccai et al, Ital Heart J 2003;4:271-280
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RISK OF MACE AT MID-TERM FOLLOW-UP FOLLOWING PCI WITH DES FOR ULM
Biondi-Zoccai et al, Am Heart J 2008;155:274-283
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IMPACT OF LESION LOCATION AND PATIENT RISK FEATURES ON OUTCOMES OF ULM PCI
Biondi-Zoccai et al, Am Heart J 2008;155:274-283
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SYNTAX TRIAL: 12-MONTH RESULTS
Serruys et al, ESC 2008
%
P=0.37 P=0.11 P=0.003
P<0.001
P=0.0015
P=0.89
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LEARNING GOALS
• Should I bother with left main (LM)/ multivessel disease (MVD)?
• Who is the winner between PCI and CABG in LM/MVD?
• When is surgery appropriate for LM/MVD?
• When is PCI appropriate for LM/MVD?
www.metcardio.org
ESC 2005 GUIDELINES
Silber et al, Eur Heart J 2005;26:804-847
THUS CABG IS RECOMMENDED INSTEAD OF PCI IN MOST CASES OF CAD IN
DIABETICS, IN MOST CASES OF MVD, AND ALL BUT A FEW CASES OF ULM…however, the guidelines are based mainly on
differences in repeat revascularization rate
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MY SURGICAL MUST DOs• Concomitant compelling indication to
cardiothoracic surgery (eg MR)
• Absolute contraindications to antiplatelet therapy
• Previous failed PCI attempts (especially LAD)
• Multivessel CTO or CTO
involving proximal-mid LAD
• Very high SYNTAX score (?!)
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WHAT ABOUT ITALIAN INTERVENTIONISTS?
Sheiban et al, Int J Cardiol 2008 – in press
Results of run-in survey for the RITMO Study on the management of unprotected left main disease in Italy (data limited to 2006)
RESPONDERSRESPONDERS NON-RESPONDERSNON-RESPONDERSNumber of centers 45 195Total coronary angiographies 61,370 198,906Coronary angiographies per center 1363±866 1036±630Total PTCA 31,699 92,392PTCA per center 704±479 499±308Total multivessel PTCA 7,870 19,947Multivessel PTCA per center 183±163 109±106Total PTCA with stenting 28,961 85,732PTCA with stenting per center 673±428 465±288Total PTCA with drug-eluting stenting 18,357 46,498PTCA with drug-eluting stenting per center 426±350 261±200ULM diagnosed at angiography per center, of total angio 5.0% (1.9-15.8) -ULM treated with CABG per center, out of total ULM at angio 50.0% (9.3-99.1) -ULM treated with PTCA per center, out of total ULM at angio 20.0% (0-80.8) -
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LEARNING GOALS
• Should I bother with left main (LM)/ multivessel disease (MVD)?
• Who is the winner between PCI and CABG in LM/MVD?
• When is surgery appropriate for LM/MVD?
• When is PCI appropriate for LM/MVD?
www.metcardio.org
CAN YOU DO IT?
85-year-old 85-year-old ♂ with with non-STEMI and non-STEMI and true trifurcational true trifurcational unprotected LM unprotected LM disease, high disease, high
surgical risk and surgical risk and LVEF 45%LVEF 45%
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ACTUALLY, IT CAN BE DONE,
BUT SHOULD I DO IT?
BEFORE PCIBEFORE PCI AFTER PCI WITH AFTER PCI WITH 4 STENTS4 STENTS
Sheiban et al, Catheter Cardiovasc Interv 2008 – in press
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ESC 2005 GUIDELINES
Silber et al, Eur Heart J 2005;26:804-847
THUS THE ROLE OF PCI IS LIMITED IN MOST CASES OF CAD IN DIABETICS, IN MOST CASES OF MVD, AND ALL BUT A FEW CASES OF ULM
…however, the guidelines are based mainly on differences in repeat revascularization rates
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MY PCI MUST DOs• Previous CABG (especially if redo already
performed and/or LIMA already there)
• Prohibitive surgical risk (with compelling indication)
• FFR unmasks MVD as just SVD
• Ongoing STEACS with culprit lesion amenable to primary PCI
• Patients refuses CABG (?!)
but provided patient and referring colleagues are consenting!
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MY EQUIPOISE• Non-bifurcational ULM with high surgical risk
• Multivessel but focal disease with only A-B2 lesions, or non-challenging C lesions
• Good LV function
• Very young or very old
• Depending also on need for and likelihood of completeness of revascularization
but still provided patient and referring colleagues are consenting!
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MY PRACTICAL FLOWCHARTULM or 3VD with any of the following unfavorable features:•True bifurcational disease of ULM•1 or > clinically relevant CTO•LV dysfunction (LVEF<40%)•Inexperienced operator (<1000 PCI)•Other surgical indications
CABG as first choice! Attempt PCI only if:• CABG contraindicated and• Patient/family and cardiac surgeon
agree on PCI
CABG favored, but PCI reasonableULM or 3VD without unfavorable features
Risk-benefit balance supports PCI, but CABG should still be
considered and discussed with patient and family
Protected LM/2VD with any of these “favorable” features :•Ostial LAD is ok•Lack of diffuse disease•No true bifurcations•No CTO•Ongoing STEACS
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A. 1ST STEP IN CRISIS MANAGEMENT IS PREVENTING THE CRISIS: FOLLOW
GUIDELINES UNLESS YOU ARE JUSTIFIED …
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B. COLLABORATIVE DECISON-MAKING IN ALL BUT CLEAR-CUT CASES: INVOLVE OTHER INTERVENTIONAL COLLEAGUES, NON-INVASIVE CARDIOLOGISTS, AND SURGEONS
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C. NEVER FORCE TOO MUCH…EITHER INDICATIONS, DEVICES, TECHNIQUES, OR ANCILLARY THERAPY (EG ANTI-THROMBOTIC RX)