treatment of multivessel coronary artery disease · left main disease cass study: circ 1990;...
TRANSCRIPT
T I MO T H Y S H A P I R O , MD , F A C C
D I R E C T O R , C A R D I A C C A T H E T E R I Z A T I O N L A B O R A T O R Y
D I R E C T O R , I N T E R V E N T I O N A L C A R D I O L O G Y F E L L O W S H I P
L A N K E N A U ME D I C A L C E N T E R
Treatment of Multivessel Coronary Artery Disease
Disclosures
None
RH
68 yo
nondiabetic
male with
exercise
intolerance and
a positive
stress test.
EF normal.
Syntax 19
RH
RH
Treatment of Multivessel and LM CAD
Medical Treatment
Percutaneous Coronary Intervention
Coronary Artery Bypass Surgery
Hybrid Coronary Revascularization
Heart Team Approach
Coronary Artery Bypass Surgery and Survival
Multivessel Coronary artery disease with involvement of proximal LAD
Multivessel disease with depressed left ventricular function
Left Main disease
CASS study: Circ 1990; 82:1647 European Coronary Surgery Study; NEJM 1988:319:322 STICH Trial: NEJM 2016; 374:1511
Studies Comparing PCI and CABG
Multivessel Disease SYNTAX
FREEDOM
Left Main
SYNTAX
EXCEL
NOBLE
SYNTAX MACCE to 5 Years
TAXUS (N=903) CABG (N=897)
0 Cu
mu
lati
ve E
ven
t R
ate
(%
)
Months Since Allocation
ITT population
Before 1 year* 12.4% vs 17.8%
P=0.002
1-2 years* 5.7% vs 8.3%
P=0.03
2-3 years* 4.8% vs 6.7%
P=0.10
3-4 years* 4.2% vs 7.9%
P=0.002
P<0.001
26.9% 25
50
37.3%
Cumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates
4-5 years* 5.0% vs 6.3%
P=0.27
0 12 60 24 36 48
Mohr et al. Lancet 2013; 381:629
SYNTAX 3 Vessel Disease Subset
Eur Heart J 2014; 35:2821
SYNTAX 3 vessel Disease Outcomes based on Syntax Score Tertiles
Eur Heart J 2014; 35:2821
FREEDOM Trial
Farkouh ME et al. NEJM 2012; 367:2375
FREEDOM Trial
NEJM 2012; 367:2375
FREEDOM Trial
NEJM 2012; 367:2375
Freedom Trial
Syntax 3 Vessel Disease Diabetic Subset
Eur Heart J 2014; 35:2821
L. David Hillis et al.
JACC 2011;58:2584-
2614
2011 ACC/AHA Guidelines for CABG Surgery
ACC/AHA Focused Update of patients with Ischemic Heart Disease 2014
Survival Improvement with Diabetics with complex multivessel disease: Class I: Heart team approach. LOE C
Class I: CABG generally recommended for complex CAD if patient is a reasonable candidate for surgery. LOE B
Circ 2014; 130:1749
SYNTAX 5 year Left Main Subset
Circ 2014; 129:2388
SYNTAX Left Main 5 Year Outcomes
Circ 2014; 129:2388
NEJM 2016; 375:2223
Primary Endpoint
Death, Stroke or MI at 3 Years
No. at Risk:
PCI
CABG
5%
25%
20%
15%
10%
0%
1 6 12 24 36
850
817
784
763
445
458
HR [95%CI] =
1.00 [95% CI: 0.79, 1.26]
P = 0.98
875
836
0
948
957
896
868
15.4% 14.7%
Dea
th,
str
ok
e o
r M
I (%
)
CABG (n=957)
PCI (n=948)
Months NEJM 2016;
375:2223
3-Year Death, Stroke or MI
HR [95% CI]
CABG
(N=957)
PCI
(N=948) Subgroup P (Int)
All patients 15.4% 14.7% 1.00 [0.79, 1.26]
1.5
Favors
PCI
Favors
CABG
5 1 0.1
Hazard Ratio [95% CI]
2 0.5 0.8
Left ventricular ejection fraction
0.99 - ≥50% 14.7% 14.4% 0.98 [0.75, 1.27] - <50% 20.4% 18.2% 0.98 [0.52, 1.83]
LM bifurcation or trifurcation stenosis ≥50%
0.82 - Yes 15.6% 15.3% 0.98 [0.75, 1.27] - No 14.8% 12.9% 1.05 [0.59, 1.87]
0.70
Syntax score (core lab assessment)
- ≤22 10.3% 13.3% 0.71 [0.44, 1.13] 0.49 - 23 - 32 17.6% 16.5% 1.02 [0.71, 1.47]
- ≥33 16.9% 14.3% 1.15 [0.71, 1.87]
Syntax score (site reported)
- 23 - 32 17.0% 15.4% 1.05 [0.73, 1.51]
- ≤22 14.3% 14.4% 0.95 [0.70, 1.31]
0.78 - 1 12.3% 16.0% 0.72 [0.46, 1.12] - 2 18.8% 12.7% 1.44 [0.96, 2.21] - 3 15.2% 16.8% 0.87 [0.50, 1.48]
- 0 14.6% 14.4% 0.99 [0.54, 1.79]
Non-LM diseased coronary arteries
NEJM 2016; 375:2223
Patients allocated to CABG in analysis (n=592)
567 received CABG 23 received PCI
Randomized (n= 1201)
Allocated to PCI (n=598) • Received PCI (n=585) • Did not receive PCI (n=13)
• Died before PCI (n=1) • Patient declined PCI (n=4) • PCI operator declined (n=4) • LMCA lesion not significant (n=4)
Allocated to CABG (n=603) • Received CABG (n=570 ) • Did not receive CABG (n=33)
• Died before CABG (n=1) • Patient declined CABG (n=15) • Not eligible for CABG (n=15) • Cross over by mistake (n=2)
Lost to follow-up (n=6) • Emigration (n=1) • Contact lost (n=2) • Withdrawal (n=3)
Lost to follow-up (n=11) • Emigration (n=0) • Contact lost (n=0) • Withdrawal (n=11)
Patients allocated to PCI in
analysis (n=592) 580 received PCI 7 received CABG
Lancet 2016; 388: 2743
Kaplan-Meier 5 year estimates by intention-to-treat
4.9%
1.9%
K-M estimates
Lancet 2016; 388: 2743
Results SYNTAX score subgroups
4.9%
1.9%
K-M estimates
HR 1·88 (1·23–2·89); p=0·0031 HR 1·16 (0·76–1·78); p=0·48 HR 1·41 (0·62–3·20); p=0·41
SYNTAX score assessed by independent corelab (CERC)
Lancet 2016; 388: 2743
L. David Hillis et al.
JACC 2011;58:2584-
2614
2011 ACC/AHA Guidelines for CABG Surgery
Hybrid Coronary Revascularization
Randomized trial of 200 patients with no difference in MACCE at one year JACC Cardiovasc Interv. 2014; 7:1277
NIH Hybrid Observational Trial JACC 2016; 68:356
NHLBI Randomized Trial of Hybrid revascularization versus PCI will begin enrolling in 2018. 2354 patients
RH
RH
RH
Heart Team Approach
AHA/ACC Guidelines Coronary Artery Bypass Surgery: Class I LOE C
Thank you