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Giuseppe Biondi Zoccai

University of Turin, Turin, ItalyMETCARDIO, Turin, Italy

gbiondizoccai@gmail.com

Educational Fellowship in PCI for Young Interventionalists -

Certified Training Course (EAPCI, SCAI, GISE) - Bologna, 25/9/2008 – 14:30-17:30 (15’)

LEFT MAIN/MULTIVESSEL DISEASE: LEFT MAIN/MULTIVESSEL DISEASE:

WHEN PERCUTANEOUS CORONARY WHEN PERCUTANEOUS CORONARY

INTERVENTION, WHEN SURGERY?INTERVENTION, WHEN SURGERY?

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LEARNING GOALS

• Should I bother with left main (LM)/ multivessel disease (MVD)?

• Who is the winner between PCI and CABG in LM/MVD?

• When is surgery appropriate for LM/MVD?

• When is PCI appropriate for LM/MVD?

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LEARNING GOALS

• Should I bother with left main (LM)/ multivessel disease (MVD)?

• Who is the winner between PCI and CABG in LM/MVD?

• When is surgery appropriate for LM/MVD?

• When is PCI appropriate for LM/MVD?

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PREVALENCE AND PROGNOSIS OF LM/MVD DISEASE

Chaitman et al, Circulation 1981;64:360-367; Yusuf et al, Lancet 1994;344:563-570;

Melidonis et al, Angiology 1999;50:997-1006

• Out of 1000 pts undergoing coronary angio: 30-80 will have unprotected LM, 20-60 protected LM, a total of 300-700 will have MVD

• Unprotected LM has, historically, a 36% 5-year mortality rate with medical Rx only, which is reduced to 12% after CABG (p=0.004)

• Corresponding figures for 3VD are 18% vs 10% (p<0.001), and for 2VD are 12% vs 10% (p=0.45)

• Whenever LV function is abnormal, 5-year mortality with medical Rx only is 25%, which is reduced to 14% after CABG (p=0.02)

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LEARNING GOALS

• Should I bother with left main (LM)/ multivessel disease (MVD)?

• Who is the winner between PCI and CABG in LM/MVD?

• When is surgery appropriate for LM/MVD?

• When is PCI appropriate for LM/MVD?

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WHO’S THE WINNER BETWEEN PCI AND SURGERY IN LM-MVD?

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ARE THEY ENEMIES OR FRIENDS?

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LET’S LOOK AT THE PAST…

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META-ANALYSIS OF RCTS OF CABG VS PCI: 5-YEAR-SURVIVAL WITH POBA VS BMS

Bravata et al, Ann Intern Med 2007;147:703-716

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META-ANALYSIS OF RCTS OF CABG VS PCI: 5-YEAR-SURVIVAL WITH POBA VS BMS

Bravata et al, Ann Intern Med 2007;147:703-716

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META-ANALYSIS OF RCTS OF CABG VS PCI: 5-YEAR-SURVIVAL IN DIABETICS

Bravata et al, Ann Intern Med 2007;147:703-716

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HOWEVER, PCI WITH BMS WAS INFERIOR TO CABG FOR THE

RISK OF REPEAT PCI/CABG

Biondi-Zoccai et al, Ital Heart J 2003;4:271-280

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WHAT ABOUT THE PRESENT…

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RISK OF MACE AT MID-TERM FOLLOW-UP FOLLOWING PCI WITH DES FOR ULM

Biondi-Zoccai et al, Am Heart J 2008;155:274-283

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IMPACT OF LESION LOCATION AND PATIENT RISK FEATURES ON OUTCOMES OF ULM PCI

Biondi-Zoccai et al, Am Heart J 2008;155:274-283

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SYNTAX REGISTRIES

Mohr et al, ESC 2008

PCI REGISTRY (N=192) CABG REGISTRY (N=644)

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SYNTAX TRIAL: 12-MONTH RESULTS

Serruys et al, ESC 2008

%

P=0.37 P=0.11 P=0.003

P<0.001

P=0.0015

P=0.89

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SYNTAX TRIAL: 12-MONTH MACES

Serruys et al, ESC 2008

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SYNTAX TRIAL: DM VS NON-DM

Serruys et al, ESC 2008

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LEARNING GOALS

• Should I bother with left main (LM)/ multivessel disease (MVD)?

• Who is the winner between PCI and CABG in LM/MVD?

• When is surgery appropriate for LM/MVD?

• When is PCI appropriate for LM/MVD?

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ESC 2005 GUIDELINES

Silber et al, Eur Heart J 2005;26:804-847

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ESC 2005 GUIDELINES

Silber et al, Eur Heart J 2005;26:804-847

THUS CABG IS RECOMMENDED INSTEAD OF PCI IN MOST CASES OF CAD IN

DIABETICS, IN MOST CASES OF MVD, AND ALL BUT A FEW CASES OF ULM…however, the guidelines are based mainly on

differences in repeat revascularization rate

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MY SURGICAL MUST DOs• Concomitant compelling indication to

cardiothoracic surgery (eg MR)

• Absolute contraindications to antiplatelet therapy

• Previous failed PCI attempts (especially LAD)

• Multivessel CTO or CTO

involving proximal-mid LAD

• Very high SYNTAX score (?!)

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WHAT ABOUT ITALIAN INTERVENTIONISTS?

Sheiban et al, Int J Cardiol 2008 – in press

Results of run-in survey for the RITMO Study on the management of unprotected left main disease in Italy (data limited to 2006)

RESPONDERSRESPONDERS NON-RESPONDERSNON-RESPONDERSNumber of centers 45 195Total coronary angiographies 61,370 198,906Coronary angiographies per center 1363±866 1036±630Total PTCA 31,699 92,392PTCA per center 704±479 499±308Total multivessel PTCA 7,870 19,947Multivessel PTCA per center 183±163 109±106Total PTCA with stenting 28,961 85,732PTCA with stenting per center 673±428 465±288Total PTCA with drug-eluting stenting 18,357 46,498PTCA with drug-eluting stenting per center 426±350 261±200ULM diagnosed at angiography per center, of total angio 5.0% (1.9-15.8) -ULM treated with CABG per center, out of total ULM at angio 50.0% (9.3-99.1) -ULM treated with PTCA per center, out of total ULM at angio 20.0% (0-80.8) -

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LEARNING GOALS

• Should I bother with left main (LM)/ multivessel disease (MVD)?

• Who is the winner between PCI and CABG in LM/MVD?

• When is surgery appropriate for LM/MVD?

• When is PCI appropriate for LM/MVD?

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CAN WE CAN DO WHATEVER THE SURGEON DOES?

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CAN YOU DO IT?

85-year-old 85-year-old ♂ with with non-STEMI and non-STEMI and true trifurcational true trifurcational unprotected LM unprotected LM disease, high disease, high

surgical risk and surgical risk and LVEF 45%LVEF 45%

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ACTUALLY, IT CAN BE DONE,

BUT SHOULD I DO IT?

BEFORE PCIBEFORE PCI AFTER PCI WITH AFTER PCI WITH 4 STENTS4 STENTS

Sheiban et al, Catheter Cardiovasc Interv 2008 – in press

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ESC 2005 GUIDELINES

Silber et al, Eur Heart J 2005;26:804-847

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ESC 2005 GUIDELINES

Silber et al, Eur Heart J 2005;26:804-847

THUS THE ROLE OF PCI IS LIMITED IN MOST CASES OF CAD IN DIABETICS, IN MOST CASES OF MVD, AND ALL BUT A FEW CASES OF ULM

…however, the guidelines are based mainly on differences in repeat revascularization rates

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MY PCI MUST DOs• Previous CABG (especially if redo already

performed and/or LIMA already there)

• Prohibitive surgical risk (with compelling indication)

• FFR unmasks MVD as just SVD

• Ongoing STEACS with culprit lesion amenable to primary PCI

• Patients refuses CABG (?!)

but provided patient and referring colleagues are consenting!

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MY EQUIPOISE• Non-bifurcational ULM with high surgical risk

• Multivessel but focal disease with only A-B2 lesions, or non-challenging C lesions

• Good LV function

• Very young or very old

• Depending also on need for and likelihood of completeness of revascularization

but still provided patient and referring colleagues are consenting!

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TAKE HOME MESSAGES

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MY PRACTICAL FLOWCHARTULM or 3VD with any of the following unfavorable features:•True bifurcational disease of ULM•1 or > clinically relevant CTO•LV dysfunction (LVEF<40%)•Inexperienced operator (<1000 PCI)•Other surgical indications

CABG as first choice! Attempt PCI only if:• CABG contraindicated and• Patient/family and cardiac surgeon

agree on PCI

CABG favored, but PCI reasonableULM or 3VD without unfavorable features

Risk-benefit balance supports PCI, but CABG should still be

considered and discussed with patient and family

Protected LM/2VD with any of these “favorable” features :•Ostial LAD is ok•Lack of diffuse disease•No true bifurcations•No CTO•Ongoing STEACS

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A. 1ST STEP IN CRISIS MANAGEMENT IS PREVENTING THE CRISIS: FOLLOW

GUIDELINES UNLESS YOU ARE JUSTIFIED …

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B. COLLABORATIVE DECISON-MAKING IN ALL BUT CLEAR-CUT CASES: INVOLVE OTHER INTERVENTIONAL COLLEAGUES, NON-INVASIVE CARDIOLOGISTS, AND SURGEONS

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C. NEVER FORCE TOO MUCH…EITHER INDICATIONS, DEVICES, TECHNIQUES, OR ANCILLARY THERAPY (EG ANTI-THROMBOTIC RX)

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