Le# Main Interven-on: When Is It Appropriate. Femi Philip, MD Assistant Professor Of Medicine UC Davis

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1 Le# Main Interven-on: When Is It Appropriate Femi Philip, MD Assistant Professor Of Medicine UC Davis

2 Nil Disclosures

3 Outline What is the LMCA? Should we revascularize severe LMCA disease? What revascularizacon strategy? What are the guideline recommendacons? Conclusion

4 LMCA

5 LMCA Defined as a stenosis of 50 % LM equivalent: oscal LAD and LCX involvement IVUS measurement MLA < 6.0 mm 2

6 LMCA: Heterogeneity in the SYNTAX Study LM + 3 V n=258 (37%) LM n=91 (13%) LM + 1 V n=138 (20%) LM + 2 V n=218 (31%) Morice MC et al CirculaCon 2010; 121:2645

7 LMCA: Plaque distribucon 58 LAD/D1 bifurcacons compared with 81 LMCA bifurcacons 1/1,1,1 MV (1/1) 1/0,1,1 MV (1/0) 1/0,1,0 MV (1/0) 0/1,1,1 MV (0/1) 0/0,1,0 MV (0/0) 0/0,1,1 MV (0/0) 0/1,0,1 MV (0/1) MB (1) SB (1) MB (1) SB (1) MB (1) SB (0) MB (1) SB (1) MB (1) SB (0) MB (1) SB (1) MB (0) SB (1) LMCA (n=81) 60(74%) 10 (12%) 8 (10%) 3 (4%) 0 (0%) 0 (0%) 0 (0%) LAD/D1 (n=58) 42 (72%) 5 (9%) 5 (9%) 0 (0%) 3 (5%) 2 (3%) 1 (2%) >90% of LMCA bifurcacons had plaque extending from LMCA into the LAD, with 78% extension into the LCX (and LCX had less plaque and calcium) Yakushiji EurointervenCon 2013

8 LM PCI Subset of SYNTAX Study Aorto-ostial n=79 (22%) Mid-shaft n=49 (15%) Syntax score could range from Distal * n=229 (64%) Morice MC et al CirculaCon 2010; 121:2645.

9 LMCA: Vessel Involvement According SYNTAX score 100%# 90%# 80%# 70%# 60%# 50%# 40%# 30%# 20%# 10%# 0%# 5# 18# 25# 71# 42# 67# 35# 27# 8# 2# Low#Syntax# Intermediate#Syntax# High#Syntax# LM#+#3VD# LM#+#2VD# LM#+#1VD# LM#isolated# Morice MC et al CirculaCon 2010; 121:2645.

10 LMCA: Conical Shape by FD- OCT Fujino et al, JACC CV Intv 2013

11 LMCA: Atheroma Parameter LMCA Epicardial P Value Baseline Plaque Atheroma Volume 30.7 ± ± 9.0 <0.001 Avg EEM (mm 2 ) 21.4 ± ± 4.0 <0.001 Avg lumen area (mm 2 ) 14.9 ± ± 2.6 <0.001 Change PAV ± ± 0.1 <0.001 Avg EEM (mm 2 ) ± ± 0.1 <0.001 Avg lumen area (mm 2 ) ± ±0.1 < pts with LMCA of 5 mm and serial IVUS in 7 trials of anc- atherosclerocc therapies Puri et al, JACC CV Intv 2013

12 Should we revascularize LMCA disease?

13 Network Meta- Analysis of LMCA RevascularizaCon 12 studies (4 RCT s, 4 observaconal matched studies and 4 cohort studies) comparing CABG with PCI ( n=4574) 7 studies (2 RCT s and 5 observaconal studies) comparing CABG with MT ( n=3224) Biol JA. CirculaCon. 2013;127:

14 How should we revascularize LMCA disease?

15 CCABG it is! HELP! What should I do? PCI it is! We can do it from the wrist

16 LMCA: RCT PCI vs. CABG Trial Pa-ent profile F/P Groups Mortality No. (%) P- value TVR No, (%) P- value MACCE No, (%) P- value LE MANS >50% LM with or without MVCAD 1 CABG (n- 53) DES/BMS (n=52) 4 (7.5) 1 (1.9) (9.4) 15 (28.8) (24.5) 16 (30.8) 0.29 PRECOMBAT >50% LM stable angina or NSTEMI 2 CABG (n- 300) Sirolimus (n=300) 10 (3.4) 7 (2.4) (4.2) 26 (9.0) (12.2) 14 (13.9) 0.12 Boudriot >50% LM with or without MVCAD 1 CABG (n=101) Sirolimus (n=100) 5 (5.0) 2 (2.0) (5.9) 14 (14) (13.9) 19 (19.0) 0.19 SYNTAX >50% LM with 1,2, or 3 vessel disease 1 CABG (n=348) Paclitaxel (n=357) (13.7) 56 (15.8) 0.44

17 MACCE up to 5 years by low/ intermediate SYNTAX score (0-32) CABG PCI P value Cumulative Event Rate (%) Death 15.1% 7.9% 0.02 CVA 3.9% 1.4% 0.11 MI 3.8% 6.1% 0.33 Death, CVA or MI 19.8% 14.8% 0.16 Revasc. 18.6% 22.6% 0.36 Months Since Allocation Morice MC. Circulation 2014; 129:2388

18 MACCE up to 5 years by high SYNTAX score (>33) CABG PCI P value Death 14.1% 20.9% 0.11 CVA 4.9% 1.6% 0.13 MI 6.1% 11.7% 0.13 Death, CVA or MI 22.1% 26.1% 0.40 Revasc. 11.6% 34.1% <0.001 Morice MC. CirculaCon 2014; 129:2388.

19 LMCA: PCI vs. CABG Trials NOBLE EXCEL N, sites 1200, 26 EU sites 1900, 126 sites DES Biomatrix (BES) Xience (EES) LM LocaCon OsCal, shar or bifurcacon OsCal, shar or bifurcacon LM Severity Angio DS > 50% or FFR < 0.80 Other anatomic criteria < 3 addiconal non- complex lesions Angio DS > 70% or 50%- 70% + either FFR < 0.80 or IVUS MLA < 6.0 mm2 or non- invasive evidence of extensive ischemia Syntax < 32 Primary endpoint Death, CVA, MI or revasc D, CVA or MI Timing of primary EP 2 years 3 years Follow- up 5 years 5 years

20 Making Sense of the Guidelines ACCF/AHA Guidelines SIHD ( 2014 update) PCI (2011) CABG (2011) UAP/NSTEMI (2012 update) STEMI (2013, no LMCA) ESC Guidelines RevascularizaCon Guidelines (2014) SCAD (2013)

21 Heart Team Approach to RevascularizaCon I IIa IIb III A Heart Team approach to revascularizacon is recommended in pacents with unprotected ler main or complex CAD. I IIa IIb III CalculaCon of the STS and SYNTAX scores is reasonable in pacents with unprotected ler main and complex CAD.

22 ESC Guidelines on SCAD 2013 Left main coronary artery with relevant stenosis a ±1 vessel disease +2 or 3 vessel disease Ostium/mid shaft Distal bifurcation Syntax score 32 Syntax score 33 High surgical risk b Heart Team Discussion Low surgical risk b PCI Montalescot G, et al Eur Heart J 2013 CABG

23 2014 ESC/EACTS Guidelines on Myocardial RevascularizaCon Recommendations according to extent of CAD CABG PCI Class a Level b Class a Level b One or two-vessel disease without proximal LAD stenosis. IIb C I C One-vessel disease with proximal LAD stenosis. I A I A 1 Two-vessel disease with proximal LAD stenosis. I B I C Left main disease with a SYNTAX score 22. I B I B Left main disease with a SYNTAX score I B IIa B Left main disease with a SYNTAX score >32. I B III B Three-vessel disease with a SYNTAX score 22. I A I B Three-vessel disease with a SYNTAX score I A III B Three-vessel disease with a SYNTAX score >32. I A III B

24 2014 ACC/AHA SIHD Guidelines: UPLM RevascularizaCon for Survival Class Of Recommendation LOE CABG I B PCI IIa For SIHD when low risk of PCI complications and high likelihood of good long-term outcome (e.g., SYNTAX score of 22, ostial or trunk left main CAD), and a signficantly increased CABG risk (e.g., STS-predicted risk of operative mortality 5%) IIb For SIHD when low to intermediate risk of PCI complications and intermediate to high likelihood of good long-term outcome (e.g., SYNTAX score of <33, bifurcation left main CAD) and increased CABG risk (e.g., moderate-severe COPD, disability from prior stroke, prior cardiac surgery, STS-predicted operative mortality >2%) III: Harm For SIHD in patients (versus performing CABG) with unfavorable anatomy for PCI and who are good candidates for CABG B B B

25 AUC and MulC- vessel RevascularizaCon Must have CCS > 2 or Int/high risk non- invasive CABG Two-vessel CAD with proximal LAD stenosis A A Three-vessel CAD with low CAD burden (i.e., three focal stenosis, low SYNTAX score) A PCI A Three-vessel CAD with intermediate to high CAD burden (i.e., multiple diffuse lesions, presence of CTO, or high SYNTAX score) A U Isolated left main stenosis A U Left main stenosis and additional CAD with low CAD burden (i.e., one to two vessel additional involvement, low SYNTAX score) Left main stenosis and additional CAD with intermediate to high CAD burden (i.e., three vessel involvement, presence of CTO, or high SYNTAX score) A A U I

26 rgoing myocardial revascularization ESC/EACTS Guidelines on In patients with NSTE-ACS, an lactic acidosis in patients receiving iodinated rally stated that administration of metformin efore angiography or PCI, and resumed 48 dequate renal function. The plasma half-life rs; however, there is no convincing evidence ation. Checking Chronic renal HF function w/ef 35 after angiogtformin and witholding the drug when renal ight be an acceptable alternative to automatic CABG is recommended for in. In patients with with significant renal LM failure, stenosis metformin and LM equivalent with proximal I pped before the procedure. Accepted indiduced arteries. lactic acidosis are arterial ph,7.35, stenosis of both LAD and LCx CABG Myocardial is recommended revascularization for should /L (45 mg/dl), and detectable plasma metforuratecan viable recognition bemyocardium. predictably ofachieved. metformin-associated be considered in the presence of IIa pt initiation PCI CABG may with of be haemodialysis surgical considered ventricular if anatomy are important is suitable, in the presence of viable overy. IIb Recommendations Class a Level b myocardium, and surgery is not indicated. ave raised concern over the use of sulphoated with primary PCI for acute myocardial C B C if it can be performed within recommended time limits. early invasive strategy is Myocardial RevascularizaCon recommended over noninvasive management. In stable patients with multivessel CAD and/or evidence of ischaemia, revascularization is indicated in order to reduce cardiac Scenarios where CABG is Preferred over LM PCI Diabetes adverse events. In patients with stable multivessel CAD and an acceptable surgical risk, CABG is recommended over PCI. I A I B 93 I A 106, In patients with stable multivessel CAD and SYNTAX score 22, PCI should be IIa B 34 considered as alternative to CABG. New-generation DES are recommended *LMCA I A 35 overis BMS. excluded from DM- Bilateral specific mammary recommendacons artery in ACC/ IIa B grafting should be AHA considered. guidelines In patients on metformin, renal function should be carefully I C monitored for 2 to 3 days after

27 What about LMCA in ACS?

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31 LMCA RevascularizaCon in ACS I IIa IIb III PCI to improve survival is reasonable in patients with UA/ NSTEMI when an unprotected left main coronary artery is the culprit lesion and the patient is not a candidate for CABG. I IIa IIb III PCI to improve survival is reasonable in patients with acute STEMI when an unprotected left main coronary artery is the culprit lesion, distal coronary flow is less than TIMI grade 3, and PCI can be performed more rapidly and safely than CABG.

32 Conclusion LMCA disease is the only lesion subset for which revascularizacon is unequivocally accepted as improving survival over medical therapy Heart Team approach CABG in the high SYNTAX score and/or DM pacent PCI is becoming more accepted as a primary treatment modality for LMCA disease Especially in pacents at higher surgical risk Especially with low- intermediate SYNTAX score

33 Thank you QuesCons?