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