Left Main PCI vs. CABG: Real World

Transcription

1 Management of Patients with Stable CAD Left Main PCI vs. CABG: Real World Marco Roffi, MD, FESC University Hospital Geneva, Switzerland

2 SYNTAX-LMT The SYNTAX trial included a pre-specified subgroup of 705 patients with predominant distal LM disease, who were randomly assigned to CABG or PCI using early generation drug eluting stent (paclitaxel-eluting stent). At 5 years of follow-up, the primary end point was the composite of major adverse cardiovascular and cerebrovascular events (MACCE), which included all-cause death, cerebrovascular accident/stroke, MI, and repeat revascularizations Morice MC et al Circulation. 2014;129:

3 Morice MC et al Circulation. 2014;129:

4 SYNTAX-LMT At 5 years follow-up CABG PCI CABG PCI P=NS P< % 36.9% 31.0% 15.5% P= % 12.8% 4.3% 1.5% 4.8% 8.2% Death Stroke MI Repeat Revascularization MACCE n:705 MACCE: All-cause death, cerebrovascular accident/stroke, MI, and repeat revascularizations

5 MACCE 31.5% SYNTAX-LMT CABG PCI P=NS 32.3% 32.7% 30.4% Low SYNTAX Score Mohr FW Lancet 2013; 381: Intermediate SYNTAX Score low 22, intermediate 23 32, and high 33

6 SYNTAX SCORE 33 MACCE CABG CABG PCI 34.1% PCI P=0.11 P= % 14.1% 29.7% 11.6% 46.5% P<0.001 P= % 1.6% Mortality Repeat revascularization Stroke Morice MC et al Circulation. 2014;129: MACCE: All-cause death, cerebrovascular accident/stroke, MI, and repeat revascularizations

7 PRECOMBAT The PRECOMBAT trial randomized 600 patients with LM disease and a mean SYNTAX score of 25 to CABG or PCI using early generation DES (sirolimus-eluting stent). At 5 years of follow-up, the primary endpoint was death, MI, stroke, or target vessel repeat revascularization Ahn JM Am Coll Cardiol 2015 May 26;65(20):

8 14.3% PRECOMBAT CABG The incidence of stroke was similar for PCI (0.7%) and 17.5% CABG (0.7%) in contrast to the findings in SYNTAX n:600 PCI P=NS 9.6% 8.4% Primary Endpoint PE: Death, MI, stroke, or target vessel repeat revascularization Death, MI or Stroke Ahn JM Am Coll Cardiol 2015 May 26;65(20):

9 Ahn JM Am Coll Cardiol 2015 May 26;65(20):

10 Pooled analysis of SYNTAX and PRECOMBAT At 5 years of follow-up 15.1% P=NS 14.0% CABG PCI 19.5% P< % Death, MI and Stroke Repeat revascularization Cavalcante R et al J Am Coll Cardiol Sep 6;68(10):

11 EXCEL The EXCEL trial compared CABG with PCI using new generation DES (everolimus-eluting stent) among 1905 patients with significant LM disease on coronary angiography with evidence of invasive or non invasive ischaemia treated between 2010 and Although complex LM disease defined as a SYNTAX score > 32 constituted an exclusion criterion, the distribution of SYNTAX score tertiles according to the Core laboratory evaluation were 36%, 40% and 24% for low ( 22), intermediate (23 32) and high ( 33) SYNTAX scores, respectively. At 3 years of follow-up, the primary endpoint was death, stroke or MI Stone GW N Engl J Med 2016 Dec 8;375(23):

12 N=1905 P=NS EXCEL CABG PCI From % days to 3 years 14.7% At 3 years of follow-up 11.5% P=0.02 P<0.001 Primary endpoint: 12.9% death, stroke or MI 7.9% P= % P= % 4.3% 2.7% 7.6% Death, stroke and MI Peri-procedural Primary Endpoint Spontaneous MI MI Repeat Revascularization Stone GW N Engl J Med 2016 Dec 8;375(23):

13 Stone GW N Engl J Med 2016 Dec 8;375(23):

14 NOBLE The NOBLE trial compared CABG with PCI using new generation DES (biolimus-eluting stent*) among 1201 patients with significant LM disease (mean SYNTAX score of 23) treated between 2008 and At a median follow-up of 3.1 years, the primary endpoint was death, non-procedural MI, stroke and repeat revascularization. Mäkikallio T et al Lancet 2016; 388:

15 NOBLE No significant differences in the incidence of all-cause CABG PCI and cardiac death At a median follow-up of 3.1 years CABG 28.0% PCI P=0.03 P=0.004 n: % P= % 15.0% 6.0% 2.0% Primary Endpoint Non procedural MI Death, non-procedural Repeat MI, stroke and repeat revascularization Mäkikallio T et al Lancet 2016; 388:

16 Mäkikallio T et al Lancet 2016; 388:

17 Meta analysis SYNTAX (LMCA Cohort) PRECOMBAT EXCEL NOBLE Primary Endpoint: Composite of allcause death, myocardial infarction, or stroke Giacoppo D et al. JAMA Cardiol. 2017;2(10):

18 Meta analysis All-cause death, myocardial infarction, or stroke at long-term follow-up Giacoppo D et al. JAMA Cardiol. 2017;2(10):

19 Impact of Operator Experience/Volume on Outcomes After LMT PCI Pts treated by experienced operators had more complex/extensive CAD Adjusted risks for cardiac death lower for pts treated by experienced operators Unprotected LM PCI at a single institution Experienced/high-volume 30-day HR 0.22 (95% LM CI: operator: 0.09 to > ), LM p PCI/y = for >3 consecutive years 1948 patients treated in 8 y = 243 pts/y! 3-year HR: 0.49 (95% CI: 0.29 to 0.84); Xu B et p = al J Am Coll Cardiol Intv 2016;9:

20 IVUS Guidance for LMT PCI: Pooled Analysis of Patient-Level Data 4 registries, N=1,670, analysis on N=505 (30.2%) with PCI under IVUS guidance and matched with N=505 without IVUS guidance de la Torre Hernandez JM et al. J Am Coll Cardiol Intv 2014;7:244 54

21 IVUS Guidance for LMT PCI: Pooled Analysis of Patient-Level Data Pooled analysis suggests an association of IVUS guidance with better outcomes in LMT PCI de la Torre Hernandez JM et al. J Am Coll Cardiol Intv 2014;7:244 54

22 IRIS-MAIN registry A total of 3,504 consecutive patients with LMCAD treated with CABG (n = 1,301) or PCI with DES (n = 2,203) Matched cohorts (N=2x950) Lee PH et al. Am Heart J 2017;193:76-83

23 ESC 2014 Recommendations in patients with SCAD, LMT disease, suitable anatomy for both procedures and low predicted surgical mortality Windecker at al. Eur Heart J. 2014;35: