c.h.t dr.salarifar 1 tehran heart center tehran university of medical sciences pci vs cabg m....
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C.H.TC.H.T Dr.SalarifarDr.Salarifar 11
Tehran Heart Center Tehran University of Medical Sciences
PCI VS CABG
M . SALARIFAR , MD
C.H.TC.H.T Dr.SalarifarDr.Salarifar 22
PCI VS CABG
From 1987 to 2003 326% increase in PCI
Now more than 90% stenting
C.H.TC.H.T Dr.SalarifarDr.Salarifar 33
Factors in patient selection
1. The need for mechanical revascularization as opposed to medical treatment & risk factor modification .
2. The likelihood of success ( vessel size , calcification , tortuosity , side branches )
3. The risk and potential consequences of acute failure of PCI ( Coronary anatomy % viable myocardium , LV function .
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 44
4.The likelihood of restenosis ( diabetes , prior restenosis , small vessel , long lesion , Total occlusion , SVG disease) .
5. The need for complete revascularization based on the extent of CAD , severity of ischemia ,
LV function .
6. The presence of comorbid conditions
7. Patient preference
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 55
Ideal cases of PCI
Significant symptoms despite intensive medical therapy
Low risk for complications
Technical success rate
No history of CHF
EF > 40%
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 66
Patients with increased risk for PCI
Advanced age
Female gender
Unstable angina
CHF
LM equivalent disease
Multivessel disease
DM
Renal failure
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 77
Current expectations for PCI
Procedural success at least 90%
Mortality < 1%
Q ware MI < 1.5%
Emergency by pass surgery 1 – 2 %
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 88
PCI and Medical therapy
RCT comparing PCI with medical therapy are few in number and < 5000 patients , enrolled patients with SVD and prior stenting and enhanced adjunctive pharmaco therapy.
* Results :
Better control of angina
Functional capacity
Quality of life
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 99
No RCT to date has demonsrated a reduction in death or MI with PCI compared with medical
thraphy for patient with chronic stable angina
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 1010
RITA – 2 showel excess of death and MI
62% Patients multivessed disease
COURAGE TRIAL :
2287 patients
PCI did not reduce the risk of death or MI over a medium 4.6 years follow up .
TIMe Trial : similar results in elderly patients .
PCI and Medical therapy PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 1111
Most patients with chronic stable angina and class I – II symptoms Medical treatment .
PCI for patients with severe symptoms despite medical
therapy or patients with high risk criteria on Noninvasive
tests .
PCI and Medical therapy Conclusion
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 1212
PCI in LV dysfunction
In hospital & long term mortality was higher in LV dysfunction .
EF ≤ 40% 11 % 1 Year Mortality
EF 41 – 49% 4.5 % 1 Year Mortality
EF ≥ 50% 1.9 % 1 Year Mortality
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 1313
CABG
Garrett , Dennis , DeBakey : Bailoat CABG in 1964
Fovoloro : late 1960 s
Kolessov : use of IMA 1967
Green : 1970
% 26 in CABG since 1997
In 2004 : 20% off – PUMP CABG
Minimally Invasive
Hybrid procedure
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 1414
Surgical outcomes
CABG
Patient population of CABG Higher risk
( older , 3VD , History of Revascularization , LV dysfunction Diabetes , Peripheral vascular disease )
Out comes with CABG Remain stable or improved
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 1515
Operative Mortality
Mortaliy of 503 , 478 CABG - only in the s td data
base 1997 – 1999: 3.05 %
2005 : 2 . 2 %
CABG PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 1616
In THC data base:
C.H.TC.H.T Dr.SalarifarDr.Salarifar 1717
CABG Complications
Mojor morbidity ( death , stroke , Renal failure sternal
infection : 13.4% in 30 days
MI : 3.9%
Respiratory complications
Bleeding : 2-6 % reparation for bleeding
Wound infection
Post operative HTN
Cerebrovascular complication
Stroke 2.6%
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 1818
CABG Complications
AF : One of the most frequent complications of CABG up to 40% Risk of stroke Use of beta blockers reoluces post operative AF
Brady arrhythmia : 0.8% need for permanent pacemaker Renal dysfunction
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 1919
Return to Employment
80% who were employed prior to CABG Return to work
Patient undergoing CABG return to work 6 W later than PCI
But long term employment is similar .
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 2020
SVG Patency
Early occlusion : 8 – 12 %
1 year occlusion : 15 – 30 % occlusion
1 – 6 y occlusion : 2% Annually
6 – 10 occlusion : 4% Annually
At 10 y :50% SVG occlusion and 20 -40%
significant stenosis in Remaining
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 2121
Arterial graft patency
IMA graft patency rate 95% 1 y 88% 5 y ,
83% 10 y .
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 2222
Indications for Revascularization CABG:
Significant left main disease : Regardless of the severity of symptoms or LV dysfunction
Patients with 3 VD that Includes LAD proximal lesion & LV dysfunction
Patients with 2 VD with LAD proximal lesion & LV dysfunction or high risk non invasive tests
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 2323
Indications for Revascularization
PCI:
In patients with SVD the aim of procedure is relief of symptoms or objective evidence of sever ischemia
In patients with angina who are not high risk , medical treatment , PCI & CABG are similar .
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 2424
C.H.TC.H.T Dr.SalarifarDr.Salarifar 2525
C.H.TC.H.T Dr.SalarifarDr.Salarifar 2626
C.H.TC.H.T Dr.SalarifarDr.Salarifar 2727
C.H.TC.H.T Dr.SalarifarDr.Salarifar 2828
PCI or CABG witch strategy ?
SVD : PCI
2VD
Multivessel disease : PCI as initial strategy especially in patients with good LV function , suitable anatomy and patient preference .
CABG : Severe LAD proximal lesion , DM LV dysfunction , LM lesion , Diffuse disease .
Advanced age and comorbidity : PCI is better
Younger patient < 50 y : PCI is initial strategy
CASS Registry : Impaired survivial in young patients
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 2929
PCI VS CABG
Observational studies :
Recent studies after stenting 60/000 patients with
multivessel disease treated with stenting or CABG
in the newyork state Registry (1997 – 2000 ) :
Higher survival with CABG after adjustment for
medical comorbidities .
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 3030
PCI VS CABG
Randomized trials :
ARTS trial ;
Death , MI , CVA and one – year mortality were similar .
CK – MB more than twice in CABG and was a predictor of poor outcome .
In PCI groupe DM was the main factor for poor out come
PCI was associated with a greater need for Repeat Revascularization .
TVR was Higher in stenting groupe .
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 3131
BARI
Diabetic patients with CABG had better
survival at two years .
PCI VS CABG
C.H.TC.H.T Dr.SalarifarDr.Salarifar 3232
PCI VS CABG
Recent Publications
NENGLJMED 358 : 4 January 2008
* DES VS . CABG in multivessel disease
Newyork state Registry ( oct 2003 – Dec 2004 )
More than 17000 patients ( 9963 DES , 7437 CABG )
CABG was associated with lower mortality , MI and repeat revascularization
C.H.TC.H.T Dr.SalarifarDr.Salarifar 3333
The – MAIN – COMPARE Registry
PCI VS CABG
Stenting VS . CAGB for LM
1102 stenting & 1138 CABG in Korea 2000 -2006
No significant difference in Death , MI , stroke
Higher Rate of TVR in stenting
C.H.TC.H.T Dr.SalarifarDr.Salarifar 3434
ACC/AHA Guidelines for Revascularization with PCI and CABG in Patients with Stable Angina
Class Indication Evidence
I (indicated) 1 .CABG for patients with significant left main coronary disease A2. CABG for patients with triple-vessel disease. The survival benefit is A greater in patients with abnormal LV function (ejection fraction <0.50) 3. CABG for patients with double-vessel disease with significant Aproximal LADCAD and either abnormal LV function(ejection fraction <50%) or demonstrable ischemia on noninvasive testing 4. PCI for patients with double- or triple-vessel disease with significant B proximal LAD CAD, who have anatomy suitable for catheter-based therapy and normal LV function and who do not have treated diabetes 5. PCI or CABG for patients with single- or double-vessel CAD without Bsignificant proximal LAD CAD but with a large area of viable myocardium and high-risk criteria on noninvasive testing
C.H.TC.H.T Dr.SalarifarDr.Salarifar 3535
Class Indication Evidence
I (indicated) 6 .CABG for patients with single- or double-vessel CAD without C significant proximal LAD CAD who have survived sudden cardiacdeath or sustained ventricular tachycardia
7. In patients with prior PCI, CABG or PCI for recurrent stenosis Cassociated with a large area of viable myocardium or high-risk criteria on noninvasive testing 8. PCI or CABG for patients who have not been successfully treated Bby medical therapy and can undergo revascularization with acceptable risk
C.H.TC.H.T Dr.SalarifarDr.Salarifar 3636
IIa ) good
supportive evidence)
1. Repeat CABG for patients with multiple saphenous Cvein graft stenoses, especially when there is significant stenosis of a graft supplying the LAD; it may be appropriate to use PCI for focal saphenous vein graft lesions or multiple stenoses in poor candidates for reoperative surgery 2. Use of PCI or CABG for patients with single- or double- Bvessel CAD without significant proximal LAD disease but with a moderate area of viable myocardium and demonstrable ischemia on noninvasive testing 3. Use of PCI or CABG for patients with single-vessel B disease with significant proximal LAD disease
Class Indication Evidence*
C.H.TC.H.T Dr.SalarifarDr.Salarifar 3737
IIb )weak
supportive evidence)
1.Compared with CABG, PCI for patients with double- B or triple-vessel disease with significant proximal LADCAD,who have anatomy suitable for catheter-based therapy and who have treated diabetes or abnormal LV function 2. Use of PCI for patients with significant left main C coronary disease who are not candidates for CABG 3. PCI for patients with single- or double-vessel CAD Cwithout significant proximal LAD CAD who have survivedsudden cardiac death or sustained ventricular tachycardia
Class Indication Evidence*
C.H.TC.H.T Dr.SalarifarDr.Salarifar 3838
III ) not
indicated (
1. Use of PCI or CABG for patients with single- or C double-vessel CAD without significant proximal LAD CAD, who have mild symptoms that are unlikely due to myocardial ischemia, or who have not received and adequate trial of medical therapy and a. have only a small area of viable myocardium Or b. have no demonstrable ischemia on noninvasive testing 2. Use of PCI or CABG for patients with borderline Ccoronary stenoses (50-60% diameter in locations other than the left main coronary artery) and no demonstrable ischemia on noninvasive testing 3. Use of PCI or CABG for patients with insignificant C coronary stenosis (<50% diameter) 4. Use of PCI in patients with significant left main Bcoronary artery disease who are candidates for CABG
Class Indication Evidence*
C.H.TC.H.T Dr.SalarifarDr.Salarifar 3939
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C.H.TC.H.T Dr.SalarifarDr.Salarifar 4040
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