COMMENT DEFINIR UN PLURITRONCULAIRE. Didier Carrié CHU Toulouse Rangueil

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1 COMMENT DEFINIR UN PLURITRONCULAIRE VISION ANGIOGRAHIQUE DU PLURITRONCULAIRE Didier Carrié CHU Toulouse Rangueil Congrès GRCI 03 Décembre 2010 Pôle Cardiovasculaire et Métabolique

2 Avec quel œil je regarde un pluritronculaire? Vision angiographique pure Evaluation fonctionnelle Scores cliniques Pôle Cardiovasculaire et Métabolique

3 SYNTAX Trial Design 62 EU Sites + 23 US Sites Heart Team (surgeon & interventionalist) Amenable for both treatment options Total enrollment N=3075 Stratification: Stratification: LM LM and and Diabetes Diabetes Amenable for only one treatment approach Randomized Arms n=1800 Randomized Arms CABG n=1800 TAXUS * N=897 n=897 N=903 n=903 3VD 66.3% LM 33.7% 3VD 65.4% LM 34.6% Two Registry Arms CABG PCI 2500 N=1077 n=1077 N=198 n= w/ f/u 5yr f/u n=649 Two Registry Arms no f/u n=428 all captured w/ follow up * TAXUS TM Express 2TM Stent System

4 Local Heart team (surgeon & interventional cardiologist) will assess each patient in regards to: Dominance Patient s operative risk (EuroSCORE & Parsonnet score) Coronary lesion complexity (Newly developed SYNTAX score) The goal of the SYNTAX score is provide a tool to assist physicians in their 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: BARI classification of coronary segments 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:

5 Reduction in Vessel Diameter The SYNTAX Score considers only significant or occlusive lesions Multiplication factor based on level of stenosis Specific % stenosis is not used Total Occlusion x 5 Significant lesion 50-99% x 2 100% 50% 99% EuroInterv 2005;1:

6 Lesion Location Points added based on dominance x location of lesion: Points EuroInterv 2005;1:

7 Total Occlusions EuroInterv 2005;1:

8 Bifurcations Points added based on type of bifurcation: Prebranch Postbranch Parent vessel only Bifurcation Ostial Prebranch Ostial Ostial Postbranch Angulation <70º <70º EuroInterv 2005;1:

9 Additional Lesion Characteristics Points added based on other adverse lesion characteristics: EuroInterv 2005;1:

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11 70 60 Inter-observer Differences in SYNTAX Score Calculation Score Kappa=0.45 Measurement Measurement 1

12 Clinical Case: "Mr. D." 46 year-old male Stable angina class II Dyslipidemia, Family History of CAD, BMI 35 No co-morbidities, Good LVEF 60% LM + 3 VD 100% RCA1, 70-80% 1st marginal branch, 70-80% mid LAD, 70% Distal LM EuroScore 2 Syntax score 55

13 Left coronary artery dominance 100% Proximal RCA

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21 Linear Increase in MACCE by Number of Stents in the SYNTAX Trial 12m MACCE in TAXUS Arm 1.5 Stents Typical Real World Average 1 stent 5.6% 4.6 Stents SYNTAX Average 17.8% Avg. in pts with 5-8+ stents in SYNTAX 19.6% 12m MACCE Probability 12m MACCE Rate Number of Stents Implanted

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24 MACCE to 3 Years by SYNTAX Score Tercile Low Scores (0-22) CABG (N=171) TAXUS (N=181) CABG PCI P value 40 3VD Death 6.8% 7.3% 0.86 Cumulative Event Rate (%) P= % 22.2% CVA 3.2% 1.2% 0.20 MI 4.9% 5.1% 0.93 Death, CVA or MI 12.3% 11.2% Revasc. 11.6% 18.8% 0.06 Months Since Allocation Pôle Cardiovasculaire et Métabolique

25 MACCE to 3 Years by SYNTAX Score Tercile Low Scores (0-22) 40 CABG (N=104) TAXUS (N=118) Left Main CABG PCI P value Death 6.0% 2.6% 0.21 Cumulative Event Rate (%) P= % 18.0% CVA 4.1% 0.9% 0.12 MI 2.0% 4.3% 0.36 Death, CVA or MI 11.0% 6.9% Months Since Allocation 36 Revasc. 13.4% 15.4% 0.69 Cumulative KM Event Rate ± 1.5 SE; log-rank P value TCT 2010 Three-year Outcomes of the SYNTAX Trial: Left Main Subgroup Serruys Slide 25 Site-reported Data; ITT population

26 MACCE to 3 Years by SYNTAX Score Tercile Intermediate Scores (23-32) 40 CABG (N=92) TAXUS (N=103) Left Main CABG PCI P value Death 12.4% 4.9% 0.06 Cumulative Event Rate (%) P= % 23.4% CVA 2.3% 1.0% 0.46 MI 3.3% 5.0% 0.63 Death, CVA or MI 15.6% 10.8% Months Since Allocation 36 Revasc. 14.0% 15.9% 0.75 Cumulative KM Event Rate ± 1.5 SE; log-rank P value TCT 2010 Three-year Outcomes of the SYNTAX Trial: Left Main Subgroup Serruys Slide 26 Site-reported Data; ITT population

27 MACCE to 3 Years by SYNTAX Score Tercile Intermediate Scores (23-32) CABG (N=208) TAXUS (N=207) CABG PCI P value 40 3VD Death 5.7% 10.3% 0.09 Cumulative Event Rate (%) P= % 16.8% CVA 3.6% 2.5% 0.53 MI 3.1% 8.9% 0.01 Death, CVA or MI 11.3% 16.1% Revasc. 8.4% 18.2% Months Since Allocation Pôle Cardiovasculaire et Métabolique

28 MACCE to 3 Years by SYNTAX Score Tercile High Scores ( 33) CABG (N=166) TAXUS (N=155) CABG PCI P value 40 3VD Death 4.5% 11.1% 0.03 Cumulative Event Rate (%) P= % 17.9% CVA 1.9% 4.3% 0.28 MI 1.9% 7.2% 0.02 Death, CVA or MI 8.3% 17.7% Revasc. 10.5% 21.5% Months Since Allocation Pôle Cardiovasculaire et Métabolique

29 MACCE to 3 Years by SYNTAX Score Tercile Left Main SYNTAX Score 33 Cumulative Event Rate (%) CABG (N=149) TAXUS (N=135) Left Main P= % 21.2% Months Since Allocation CABG PCI P value Death 7.6% 13.4% 0.10 CVA 4.9% 1.6% 0.13 MI 6.1% 10.9% 0.18 Death, CVA or MI 15.7% 20.1% 0.34 Revasc. 9.2% 27.7% <0.001 Cumulative KM Event Rate ± 1.5 SE; log-rank P value TCT 2010 Three-year Outcomes of the SYNTAX Trial: Left Main Subgroup Serruys Slide 29 Site-reported Data; ITT population

30 Guidelines EHJ 2010 Pôle Cardiovasculaire et Métabolique

31 Tonino et al JACC 2010 Pôle Cardiovasculaire et Métabolique

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33 FAME à 2 ans Pjils Jacc 2010 Pôle Cardiovasculaire et Métabolique

34 21/02/11 Pôle Cardiovasculaire et Métabolique

35 Follow up Fajadet et al EuroIntervention 2008

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37 Capodanno Am Heart J 2010

38 Summary The SYNTAX score is a good predictor of MACCE Increasing SYNTAX scores (and lesion complexity) are related to increased adverse outcomes in PCI, whereas outcomes of CABG are independent of SYNTAX score Anatomical definition of MVD? Or implication of comorbidity and functional approach