When should we indisputably perform CABG? Quand faut-il indiscutablement opérer? Dr Hakim BENAMER

Transcription

1 When should we indisputably perform CABG? Quand faut-il indiscutablement opérer? Dr Hakim BENAMER ICPS, Massy ICV-GVM La Roseraie, Aubervilliers Hôpital FOCH, Suresnes

2 Disclosure Statement of Financial Interest I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company : - Terumo, Medtronic, Abbott, - General Electric, - Proctoring Edwards.

3 European Heart Journal (2014) 35,

4 RETREAT OF SURGERY FOR MYOCARDIAL REVASCULARIZATION TECHNICAL ISSUES Less and less PCI RESTENOSIS TLR < 5% THROMBOSIS Acute ST < 1%

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6 When should we indisputably perform CABG? Quand faut-il indiscutablement opérer?

7 When should we indisputably perform CABG? Quand faut-il indiscutablement opérer?

8 Recommend a formal collaborative interaction between the patient and the heart team comprised of noninterventional cardiologist, interventional cardiologist, cardiac surgeon, and other, care providers. With the use of evidencebased data of risk and benefit and appropriateness, this team aims to objectively inform and advise the patient of all treatment options to ensure a fully informed consent and shared decision making. (1) Reviewing the patient s coronary anatomy and disease burden (including SYNTAX score); (2) Reviewing the patient s coexisting medical morbidities that influence periprocedural and long-term outcome and survival; (3) Proposing and integrating medical therapies (eg, smoke cessation, exercise regimen, diet modification, and diabetes and lipid management); (4) Assessment of individual patient s priorities and goals such as survival, angina relief, freedom from MI or repeat revascularizations; (5) Balancing patient s goals with preferences to limit the invasiveness of the procedure and enhancing postprocedural recovery (convalescent) time (6) Containing (societal) health care costs. Ann Thorac Surg 2016;101:801 9

9 EMERGENCY European Heart Journal (2014) 35,

10 When should we indisputably perform CABG? Extensive and Complex Coronary Artery Disease

11 SYNTAX Trial Design 62 EU Sites + 23 US Sites De novo 3VD and/or LM (isolated, +1,2,3 VD) Limited Exclusion Criteria Previous interventions, Acute MI with CPK>2x, Concomitant cardiac surgery Heart Team (Surgeon & Interventional Cardiologist Amenable for both treatment options Stratification: LM and Diabetes Amenable for only one treatment approach Randomized Arms N=1800 Two Registry Arms N=1275 ESC 2009 Two-year Outcomes of the SYNTAX Trial Kappetein Slide 11

12 Patient Profiling Local Heart team (surgeon & interventional cardiologist) assessed each patient with regards to: Patient s operative risk (euroscore & Parsonnet score) Coronary lesion complexity (Newly developed SYNTAX Score) Goal: SYNTAX Score to provide guidance on optimal revascularization strategies for patients with high risk lesions Sianos et al, EuroIntervention 2005;1: Valgimigli et al, Am J Cardiol 2007;99: Serruys et al, EuroIntervention 2007;3:450-9 ESC 2009 Two-year Outcomes of the SYNTAX Trial Kappetein Slide 12 Coronary tree segments AHA classification and modified for the ARTS study, Circulation 1975; 51:5-40 & Semin Interv Cardiol 1999; 4: Modified Leaman score, Circ 1981;63: Lesions classification ACC/AHA, Circ 2001;103: Bifurcation classification, CCI 2000;49: CTO classification, J Am Coll Cardiol 1997;30:649-56

13 LCx 70-90% Patient 1 TC 99% Patient 2 IVA 99% IVA 70-90% LCx 100% SYNTAX SCORE 21 SYNTAX SCORE 52 Patient 1 Patient 2 CD % CD A % CD 100% ESC 2009 Two-year Outcomes of the SYNTAX Trial Kappetein Slide 13

14 Patients, % Patients, % 2 Year Outcomes in 3VD and LM Subgroups CABG TAXUS 40 P=0.11 P<0.001 P< P=0.48 P=0.01 P= ,8 22, ,1 8,2 7,5 17,4 14, ,8 10,2 10,4 17,3 19,3 0 0 Death/CVA/MI Revasc MACCE 3 Vessel Disease n=1095 Time-to Event; Log-rank P value ESC 2009 Two-year Outcomes of the SYNTAX Trial Kappetein Slide 14 Death/CVA/MI Revasc MACCE Left Main Disease n=705 ITT population

15 LM 3V SYNTAX 0-22 SYNTAX SYNTAX > 33 Lancet 2013; 381:

16 Patients with SCAD and LM

17 Patients with SCAD and three-vessel disease

18 Pros and Cons of SYNTAX score II Capodanno TCT 2013, October, 28, 2013 Slide 18 The SYNTAX Score II Follows The Principle That Combining Clinical And Angiographic Variables Achieves Superior Prognostic Accuracy vs The SYNTAX Score Global Risk Classification Capodanno AHJ 2010 Capodanno JACC Intv 2011 Serruys JACC Intv 2012 Clinical SYNTAX Score Garg Circ Interv 2010 Capodanno JACC Intv 2011 Girasis EHJ 2011 You CCI 2013 Park Circ J 2013 NERS Score Chen JACC Intv 2010 Logistic Clinical SYNTAX Score Farooq EHJ 2012 Capodanno CCI 2013 Development studies SYNTAX Score II Farooq Lancet 2013 Validation studies Ferrarotto Hospital University of Catania

19 SYNTAX Score

20 SYNTAX Score II

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22 European Heart Journal (2014) 35,

23 When should we indisputably perform CABG? Extensive and Complex Coronary Artery Disease Diabetic patients

24 FREEDOM NEJM 2012; 367:

25 FREEDOM FU 5 years Death/MI/Stroke Death NEJM 2012; 367:

26 FREEDOM FU 5 years MI Repeat Revascul. 13,9 % 12,6 % 6 % 4,8 % NEJM 2012; 367:

27 Interactive CardioVascular and Thoracic Surgery 19 (2014)

28 Percutaneous coronary intervention versus coronary artery bypass grafting three trials at 5 years Interactive CardioVascular and Thoracic Surgery 19 (2014)

29 Percutaneous coronary intervention versus coronary artery bypass grafting three trials at 5 years Interactive CardioVascular and Thoracic Surgery 19 (2014)

30 European Heart Journal (2014) 35,

31 When should we indisputably perform CABG? Extensive and Complex Coronary Artery Disease Diabetic patients Poor Left Ventricular Function

32 We identified 3,584 patients with 3-vessel and/or left main disease of 15,939 patients undergoing first myocardial revascularization enrolled in the CREDO-Kyoto PCI/CABG Registry Cohort-2. Of them, 2,676 patients had preserved LV systolic function, defined as an LV ejection fraction (LVEF) of >50% and 908 had impaired LV systolic function (LVEF 50%). CARDIAC DEATH Am J Cardiol 2014;114:988e996

33 European Heart Journal (2014) 35,

34 When should we indisputably perform CABG? Extensive and Complex Coronary Artery Disease Diabetic patients Poor Left Ventricular Function Significant Valvular Disease

35 European Heart Journal (2014) 35,

36 When should we indisputably perform CABG? Extensive and Complex Coronary Artery Disease Diabetic patients Poor Left Ventricular Function Significant Valvular Disease When PCI is impossible

37 Reasons for inclusion in the CABG registry: Too complex coronary anatomy to undergo PCI (70.9%), Chronic total occlusion untreatable with PCI (22.0%), Unable to take antiplatelet medication (0.9%), Refusal to undergo PCI (0.5%), or other reasons (5.7%). J Am Coll Cardiol Intv 2012;5:618 25

38 J Am Coll Cardiol Intv 2012;5:618 25

39 CONCLUSIONS When should we indisputably perform CABG? Extensive and Complex Coronary Artery Disease Diabetic patients Poor Left Ventricular Function Significant Valvular Disease When PCI is impossible Common sens: Restenosis, difficult FU, Patient Choice

40 CABG Arm (12-month MACCE, %) MACCE at 12-months by Site French Subset TAXUS 5 Arm 10 (12-month MACCE, 30 %) 35 Size of circle adjusted for number of patients