Coronary Artery Bypass Grafting vs Percutaneous...
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Controversies in Cardiovascular Medicine - Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention Skipper : Stoll Debate Eric R. Skipper, MD, FACS Chief, Adult Cardiovascular Surgery Surgical Director of Cardiac Transplantation and Mechanical Circulatory Support
Transcript of Coronary Artery Bypass Grafting vs Percutaneous...
Controversies in Cardiovascular Medicine -Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention
Skipper : Stoll Debate
Eric R. Skipper, MD, FACSChief, Adult Cardiovascular Surgery
Surgical Director of Cardiac Transplantationand Mechanical Circulatory Support
“KISS” Principle – Keep It Simple for Skipper
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CABG vsPCILow Risk MVD
• 15+ RCT’s – most were from the pre-stent era5 using stents < 5% of pt’s screened were enrolledAll had LVEF’s over 50% Incidence of 3 vessel CAD << 50%Excluded high-risk pt’s
» DM» Low EF» 3VD or left main disease
Conclude that both groups have similar outcomes• Caution re: generalizing these results to all CAD pt’s
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CABG vsPCI in Low Risk MVD
Trial # Scr % Ran
% 3VD
ProxLAD
EF >50
% DM
AWESOME 454 - 45 - - -ERACI-II 450 2 56 - - 17ARTS 1205 5 32 - 100 19SOS 988 5 38 45 100 14MASSII 408 2 41 - -
SUMMARY 3505 3.5 42.4 - - 17
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CABG vsPCILow Risk MVD
• 15+ RCT’s – most were from the pre-stent era5 using stents < 5% of pt’s screened were enrolledAll had LVEF’s over 50% Incidence of 3 vessel CAD << 50%Excluded high-risk pt’s
» DM» Low EF» 3VD or left main disease
Conclude that both groups have similar outcomes• Caution re: generalizing these results to all CAD pt’s
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CABG vsPCILow Risk MVD
• Appropriate conclusions:Both are reasonable options in single or double
vessel CAD with normal LVEFCABG may offer a slight long-term mortality benefit
over balloon angioplasty which is nullified with use of stents
Repeat procedures are significantly greater in pt’s initially treated with stents (~ 4x)
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CABG vsPCIHigh Risk Multivessel
• Brener et al – Circ 2004; 109: 2290-2295Propensity analysis6033 pt’sMVD and high risk features (DM or low LVEF)PCI 2.3 x higher mortality at 5 years
• Niles et al – JACC 2001; 37: 1008-10152766 risk matched diabetic pt’sPCI 1.5-3.9 x higher mortality at 5 years
• Pell et al – Diabet Med 2004; 21: 790-792PCI 2.6 x higher mortality at 2 years w DM
• New York Registry – NEJM 2005; 352: 2174-218337212 CABG and 22102 PCI pt’s w > 2 VDAfter 3 years, CABG significantly reduced mortality
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CABG vsPCIHigh Risk Multivessel
CABG vs PCI trial – using DES•SYNTAX - Synergy between PCI w TAXUS and CABG
Presented at European Society of Cardiology Congress 2008 – Munich
62 sitesAll-comers design
» Exclusions – prior PCI, acute MI w CKMB > 2x, or concomitant cardiac surgery
Avg stent implantation per pt + 4.6PCI carried a higher MACCE rate at 12 months
(PCI:CABG 18%:12:%; p = 0.0015)PCI was inferior in pt’s w DM, isolated 3 VD, LM +
2 or 3 VD
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CABG vsPCIHigh Risk Multivessel
• Conclusion: CABG remains the first-line therapy in pt’s with
high-risk MVDDMLV dysfunction
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CABG vsPCI in Left Main Disease
• LM stenosissignificant if > 50% diameterOccurs as an isolated lesion in 6-9% of pt’s40-90% occur in the distal LM segment and extend
into the proximal LAD or LCX branchesConcomitant MVD occurs in 70-80% of pt’s
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CABG vsPCI in Left Main Disease
• LEMANS trial – JACC 2008; 51: 538-545Unprotected Left Main Stenting vs CABG52 PCI vs 53 CABG pt’s60% distal LM stenoses3 VD – 60% PCI vs 75% CABGCABG more short-term complicationsPCI and CABG similar MACE rate at 1 year
Problem: only 75% of CABG pt’s received LIMA grafts thus questioning the “quality” of the surgery as LIMA useage is >98% in most contemporary cardiac surgery practices
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CABG vsPCI in Left Main Disease
• SYNTAX trial outcomes analysisOverall 12 month MACE favors CABG (PCI:CABG
15.8%:13.7%) Isolated LM dz and LM dz + single vessel CAD
favor PCI (7.1%:8.5%)CABG is favored with
» LM dz + 2 VD (19.8%:14.4%) » LM dz + 3 VD (19.4%:15.4%) » 3 VD alone (19.2%:11.5%)
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CABG vsPCI in Left Main Disease
• Conclusion: PCI with DES can be a future alternative to CABG
in pt’s with: » isolated, unprotected LM dz, or» LM dz + 1 VD
Catastrophic consequences of LM PCI, including stent restenosis, acute and late thrombosis must be a part of the informed consent discussion
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Cost Effectiveness CABG vsPCI
• Hill et al - Health Technology Assessment 2004; 8: 1242-1245
1720 pt’s allocated to PCI, CABG or both followed for 7 yearsConclusion using a conventional quality-
adjusted life year of $60,000» Medical therapy and CABG were cost-effective» PCI was not» The additional benefit of stenting over best
medical therapy was “to small to justify the additional cost”
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Cost Effectiveness CABG vsPCI
• Griffin et al – Br Med J 2007; 334: 624-627UK Health Technology Asssessment Group
warning that widespread use of DES might » reduce the gain in quality, and » possibly the duration of life arising for CABG in
the long term
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Conclusions
• “Multivessel disease” must be accurately defined as 2VD or 3VD.
• CABG remains an excellent and in many instances superior long-term form of revascularization in select groups of 2VD, and most groups with 3VD.
• Collaboration with a multidisciplinary team approach is going to be a key driver for the future success of these patients as we move into a Value Driven, Quality and Outcomes Oriented Healthcare Model.
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Selection is Key
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Not the Best Model…..
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Thank you
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