Enrico Romagnoli Comparison of Coronary Artery Bypass Surgery versus Percutaneous Coronary...

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Transcript of Enrico Romagnoli Comparison of Coronary Artery Bypass Surgery versus Percutaneous Coronary...

  • Slide 1
  • Enrico Romagnoli Comparison of Coronary Artery Bypass Surgery versus Percutaneous Coronary Intervention With Drug-Eluting Stents in Patients with Chronic Kidney Disease Interventional Cardiology Unit Policlinico Casilino, Rome, Italy enromagnoli@gmail.com Interventional Cardiology Unit Policlinico Casilino, Rome, Italy enromagnoli@gmail.com
  • Slide 2
  • Background I The patient with Chronic Kidney Disease (CKD) and Coronary Artery Disease (CAD) represents special challenge for interventionalists and cardiologists in general. The patient with Chronic Kidney Disease (CKD) and Coronary Artery Disease (CAD) represents special challenge for interventionalists and cardiologists in general. Indeed, CKD is associated to worse outcomes both with percutaneous and surgical coronary revascularization with an increased incidence of both in-hospital and long-term clinical events. Indeed, CKD is associated to worse outcomes both with percutaneous and surgical coronary revascularization with an increased incidence of both in-hospital and long-term clinical events.
  • Slide 3
  • Background II A post-hoc analysis of patients with CKD enrolled in the Arterial Revascularization Therapies Study (ARTS) trial comparing CABG versus PCI showed equivalent mortality and morbidity at 5 year, but the requirement for repeat procedures remained significantly higher after PCI treatment. A post-hoc analysis of patients with CKD enrolled in the Arterial Revascularization Therapies Study (ARTS) trial comparing CABG versus PCI showed equivalent mortality and morbidity at 5 year, but the requirement for repeat procedures remained significantly higher after PCI treatment. More recently, the non-randomized ARTS II study demonstrated a comparable need for repeat revascularization both with PCI and CABG in general population. More recently, the non-randomized ARTS II study demonstrated a comparable need for repeat revascularization both with PCI and CABG in general population.
  • Slide 4
  • Rationale of the study At present, available data on DES safety and efficacy in patients with CKD are limited to small single-center registries, therefore it is not known whether the improved At present, available data on DES safety and efficacy in patients with CKD are limited to small single-center registries, therefore it is not known whether the improved outcomes in PCI with DES will be extended to patients with CKD disease. With this study we sought to compare the impact of DES introduction on clinical outcome of patients with CKD, when compared to CABG.
  • Slide 5
  • Methods I: end-points We retrospectively identified all patients with Chronic kidney disease who underwent coronary revascularization at San Raffaele Hospital between 2002 and 2006. We retrospectively identified all patients with Chronic kidney disease who underwent coronary revascularization at San Raffaele Hospital between 2002 and 2006. Primary end-point of the study was freedom from cerebrovascular accident, non fatal MI, or death. Primary end-point of the study was freedom from cerebrovascular accident, non fatal MI, or death. The Secondary end-point was the need for repeat revascularization by percutaneous or surgery. Additional clinical end-points were post-operative acute renal failure or contrast induced nephropathy, sepsis and bleeding complication rates. Additional clinical end-points were post-operative acute renal failure or contrast induced nephropathy, sepsis and bleeding complication rates.
  • Slide 6
  • Methods II: patients selection For the purposes of this study, only patients who received DES stents were included in the percutaneous revascularization group. For the purposes of this study, only patients who received DES stents were included in the percutaneous revascularization group. Patients who had a prior PCI or CABG, with valvular heart disease, congenital heart disease, obstructive or restrictive cardiomyopathy, and candidate for cardiac or renal transplantation were excluded. Patients who had a prior PCI or CABG, with valvular heart disease, congenital heart disease, obstructive or restrictive cardiomyopathy, and candidate for cardiac or renal transplantation were excluded. In general, patients who were thought not to be equal candidates for either CABG or PCI with DES (e.g. limited life expectancy, intolerance to aspirine or ticlopidine) were not included in the final analysis. In general, patients who were thought not to be equal candidates for either CABG or PCI with DES (e.g. limited life expectancy, intolerance to aspirine or ticlopidine) were not included in the final analysis.
  • Slide 7
  • Methods III: CKD definition Creatinine levels were measured the day before the time of the procedure, and renal function was assessed based on the CrCl using the Cockcroft-Gault formula*: (140-age) x weight (Kg) CrCl (ml/min) = (x 0.85 for females) 72 x serum creatinine (mg/dl) Renal impairment was defined as a calculated creatinine clearance
  • Slide 8
  • CABG group PCI group 407317 275 patients included in the final analysis 275 patients included in the final analysis138137 724 patients with CKD (
  • Slide 9
  • Overall PCI group CABG group p Male gender (%) 72.870.575.20.42 Age (year) 758738777
  • MAEGFR >25% GFR>75% (dialysis) SepsisPCICABG Major bleeding Results: in-hospital outcome P=