LEFT MAIN PERCUTANEOUS CORONARY INTERVENTION. A/Prof Koh Tian Hai Medical Director National Heart Centre, Singapore

Transcription

1 LEFT MAIN PERCUTANEOUS CORONARY INTERVENTION A/Prof Koh Tian Hai Medical Director National Heart Centre, Singapore

2 Disclosures Advisory Panel, Asian Medical Board Medtronics, Abbott Vascular. Speaker-honoraria, Medtronics, Boston Scientific

3 The First LM PTCA A Gruentzig SH Rahimtoola. JACCIntv 2008; 1: 108

4 SYNTAX TRIAL: LM Subset MC Morice. CIRC2010; 121:

5 SYNTAX-LM Subset: 1 year Outcomes MC Morice. CIRC2010; 121:

6 SYNTAX-LM 1 yr MACCE by SYNTAX Score Tertiles MC Morice. CIRC2010; 121:

7 SYNTAX Trial- Outcomes at 4 years PW Serruys: TCT 8Nov2011

8 PW Serruys: TCT 8Nov2011

9 PW Serruys: TCT 8Nov2011

10 PW Serruys: TCT 8Nov2011

11 4 yr MACCE according to SYNTAX Score PW Serruys: TCT 8Nov2011

12 PW Serruys: TCT 8Nov2011

13 Ostial / Shaft LM

14 ESC-EACTS Guidelines on Myocardial Revascularisation IIa B IIb B LM: Ostium or Shaft- Isolated or 1 Vessel Disease LM: Distal Bifurcation- Isolated or 1 Vessel Disease LM: with 2 or 3 Vessel Disease & Syntax < 32 III B LM: with 2 or 3 Vessel Disease & Syntax >33 W Wijns et al EHJ2010; 31:

15 AHA-ACCF-SCAI Guidelines Unprotected Left Main >50%, Stable IHD COR LOE Modified from GN Levine et al. JACC2011; 58:

16 Ostial/midshaft vs Bifurcations UPLM Freedom from MACE at 2yr 19 centre Italian study 1111 patients UPLM Treated with DES T Palmerini et al. EHJ2009; 30:

17 What kind of stenting techniques for Distal LM Bifurcations?

18 Bifurcations: one vs two stents 2 yr Freedom from MACE T Palmerini et al. EHJ2009; 30:

19 Technical Issues Consider IVUS for assessment & stent optimisation Debulking if calcified Single stent cross over as default strategy Proximal optimisation of stent (POT) Double stent techniques T stent if bifurcation angle is >60 degrees Minicrush/Culotte if < 60% Final kissing balloon

20 IVUS in UPLM: AHA-ACCF-SCAI guidelines GN Levine et al. JACC2011; 58:

21 IVUS in UPLM Assessment & Stenting MLA < 6mm2 for intervention threshold Correlated with FFR <0.75 (Jasti et al.) Clinical Outcome in Registry of Med vs PCI Kang et al. showed MLA<4.8mm2 correlated with FFR<0.8 MLD of <2.8 mm Correlated with FFR of <0.75 R Puri et al. JACCIntv2012; 5:

22 Post Intervention IVUS Optimisation Parameters LM-MLA: > 8.5mm2 Single Stent Strategy into LAD Ostium of LCX-MLA: >4mm2 Dual Stent Strategy Each Daughter Ostium > 5.5mm2 Pullback from each daughter branch to assess true lumen size of distal LM and ostium of daughter branches R Puri et al. JACCIntv2012; 5:

23 IVUS studies in UPLM R Puri et al. JACCIntv2012; 5:

24 FFR in UPLM: AHA-ACCF-SCAI Guidelines GN Levine et al. JACC2011; 58:

25 Meta-analysis of DES vs CABG in UPLM in 5674 patients across 18 studies Mortality At 1 yr Death/MI/ Stroke TVR MACCE MP Barros de Oliviera Sa et al. EJCTS2012; 19apr online

26 What can we summarise from recent metaanalyses of UPLM with DES vs CABG H Naik et al. JACCIntv 2009 SB Pandya et al. JACCIntv 2010 G Ferrante et al. EuroIntv 2011 D Cappadonno et al.jacc 2011 C Cao et al. JTCVS 2012 MP Barros de Olivierra Sa et al. EJCTS 2012 JS Jang et al. Am J Cardiol 2012

27 What can we summarise from recent meta-analyses of UPLM with DES vs CABG Trend towards lower mortality benefit at 1 yr with PCI No difference in combined Death/MI/Stroke Trend towards increased MACCE with PCI Increased repeat revascularisation with PCI Lower Stroke risk with PCI

28 Arguments from Surgeons Randomised PCI-CABG UPLM trials recruit a minority of patients that were evaluated. Randomised patients generally have less extensive disease eg SYNTAX score <32. Longer term studies needed, as CABG has an early hazard. None of the randomised studies powered for individual endpoints.

29 Long term outcomes with PCI using DES

30 ASAN MV Revascularisation Registry 5 year outcomes DES vs CABG 3042 pt registry Single Centre Prospective 1st Gen SES/PES Median 5.6 yr follow-up 5yr cumulative def/prob Stent Thrombosis = 2.6% Unadjusted for differences In baseline variables DWPark et al.jacc2011;57:

31 ASAN MV Revasc Registry: 5 year outcomes DES vs CABG, after multivariable adjustments Outcome DES events CABG events Unadjusted HR p MVariable adjusted p Overall Cohort 1547 pts 1495 pts Death Death/MI/ storke Repeat Revascularisa tion < <0.001 DWPark et al.jacc2011;57:

32 EXCEL TRIAL 165 international sites Final data for primary EP is Dec Patients UPLM Heart Team Consensus YES NO 1300 PCI-Xience Prime 1300 CABG 1000 pci-cabg REGISTRY

33 Key Differences between EXCEL & SYNTAX D Capodanno & C Tamburino. IJCard2012; 156: 1-3

34 Conclusions PCI of Ostial and Shaft UPLM have good outcomes. PCI can also be performed in Distal LM and 1 vessel disease. More complex/extensive disease (Syntax score >33) do better with CABG. Follow-up at 4-5 years show that results/safety are maintained.

35 Conclusions II IVUS and FFR will help to improve diagnostic precision and outcomes. The initial default strategy should be provisional T stenting for distal bifurcations. EXCEL trial results are awaited, to provide definitive proof of benefit with a PCI approach.

36 Thank You

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38 What EXCEL hopefully will tell us. PCI is non-inferior to CABG in lower risk UPLM patients in hard endpoints of Death/MI/stroke;?Superiority. Clarify the Role of IVUS & FFR. What we will not know: UPLM with Syntax Score >33, since not recruited into study.

39 Eligibility for EXCEL based upon Syntax Trial D Capodanno & C Tamburino. IJCard2012; 156: 1-3

40 Arguments from Surgeons Progression of disease not prevented in nonstented segments. PCI has lower complete revascularisation rates vs CABG.

41 Studies Underpowered for Individual Endpts MP Barros de Oliviera Sa et al. EJCTS2012; 19apr online

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