ΑΝΤΙΜΕΤΩΠΙΣΗ ΑΣΘΕΝΩΝ ΜΕ ΝΟΣΟ ΣΤΕΛΕΦΟΥΣ

Transcription

1 ΑΝΤΙΜΕΤΩΠΙΣΗ ΑΣΘΕΝΩΝ ΜΕ ΝΟΣΟ ΣΤΕΛΕΦΟΥΣ Δ. ΤΣΙΚΑΔΕΡΗΣ MD,FESC ΘΕΣΣΑΛΟΝΙΚΗ 2012

2 Although LM patients population treated with stenting is usually reported as a single, homogeneous subgroup, LM disease encompasses a wide spectrum of disease states. (Teirstein PS, Circulation 09) Guidelines recommendations should be stratified according to: - Lesion location (Ostial/midshaft Stenting provides better outcomes, driven by lower reintervention rate, than bifurcation stenting) - Extention of CAD

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13 A Meta-analysis Of 3773 Patients Treated With Percutaneous Coronary Intervention Or Surgery For Unprotected Left Main Coronary Artery Disease Hursh Naik; Anthony J. White; James Forrester; Tarun Chakravarty MD; Saibal Kar, MD; Robert E. Weiss; Raj Makkar CEDARS SINAI HEART INSTITUTE, LOS ANGELES, CA J Am Coll Cardiol Intv 2009;2:739-47

14 A Meta-Analysis of 3,773 Patients Treated With Percutaneous Coronary Intervention or Surgery for Unprotected Left Main Coronary Artery Stenosis MORALITY TVR MACCE Conclusions Our analysis reveals no difference in mortality or major adverse cardiovascular or cerebrovascular events, for up to 3 years, between PCI and CABG for the treatment of ULMCA stenosis. However, PCI patients had a significantly higher risk of target vessel revascularization. In selected patients with ULMCA stenosis, PCI is emerging as an acceptable option. J Am Coll Cardiol Intv 2009;2:739 47

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42 Randomized Multicenter Trial Between PCI with Sirolimus-eluting Stent versus CABG for Unprotected Left Main Stenosis E. Boudriot, H. Thiele, C.Liebetrau, T.Walther,T.Pohl, P.Boekstegers, B.Reichart, F.Beier, H.Mudra, B.M.Kemkes, M.Gick, F.J.Neumann, F.W.Mohr, G.Schuler Heart Center Leipzig, Grosshadern LMU University Munich, Neuperlach, Munich, Heart Center Bad Krotzingen Courtesy of E.Boudriot

43 Baseline Characteristics (randomized patients PCI n = 83 CABG n = 84 p value Age (y) Sex (m / f) 59 / / BMI Hypertension (%) Diabetes (%) NIDDM + IDDM Smoking (%) HLP (%) Ejection fraction EuroScore

44 Type of Left Main Stenosis PCI 19% LM ostial CABG 24% 7% 74% shaft distal 8% 68% CX LAD p = 0.72

45 Pre-Procedural Parameters LM and additional stenosis of coronary vessels (%) PCI n = 83 CABG n = 84 p value Isolated left main LM + 1-vessel disease LM + 2-vessel disease LM + 3-vessel disease 9 20

46 1-year Follow up MACE PCI n = 83 CABG n = 84 p value noninferiority! Death 2 (2.4%) 4 (4.8%) -8.2 to 2.9 < MI 2 (2.4%) 3 (3.6%) -6.5 to MI + Death 4 (4.8%) 7 (8.3%) to TVR 10 (12.0%) 4 (4.8%) -0.3 to Cumulative MACE 14 (16.9%) 11 (13.1%) -5.8 to

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48 REGISTRIES DES vs CABG

49 Registries on LM comparing DES (2500) vs Surgery (1773) Lee et al.: 50 DES vs 123 CABG Chieffo et al.: 107 DES vs 142 CABG Sammartin et al.: 96 DES vs 245 CABG Brener et al.: 97 DES vs 190 CABG (matched) Seung et al. (MAIN-COMPARE Registry): 396 DES vs 396 CABG (matched) Chieffo et al. (DELTA Registry): 1754 DES vs 677 CABG No difference in mortality No difference in the composite of Death, MI, CVA Lower revascularization with Surgery

50 Study CABG, n Chieffo 142 LIMA % PCI, n DES, % BMS, % NA Method of comparison Matched by Euroscore 4.3 vs 4.4 ns (PCI vs CABG) Years Palmerini Sanmartin Unmatched PCI group had a significantly higher Parsonett score. Matched buy Euroscore >6 (no significant difference) Buszman LE MANS Brener Randomized Matched by Euroscore >6 (no significant difference) Seung MAIN- COMPARE White whenever possible Propensity matched Propensity matched Wu NY State Makikallio Serruys SYNTAX NA NA Propensity matched Unmatched PCI group with a significantly higher Euroscore (7.7 vs 5.2) NA Randomized Total

51 CABG PCI Summary 95% CI n n OR Year Year Year No Difference In Mortality Up To 3 Years

52 CABG n PCI n Summary OR 95% CI Year Year Year No Difference In Death, MI and Stroke Up To 3 Years

53 CABG n PCI n Summary OR 95% CI Year Year Year Increased TVR Up To 3 years

54 STENT THROMBOSIS DELFT Registry (Meliga et al, JACC 2008) 3 years rate of definite/propable ST : 1.7% 2 events after 30 days Chiefo et al, (EHJ 2008) 731 pts 0.5% definite ST 1 late, no VLST ISAR-LEFT MAIN (JACC 2009) Sirolimus vs Paclitaxel 2 years: 0.5% definite ST SYNTAX 1 year ST : 2.7% 1 year graft occlusion: 3.7% (p=0.49) Reassuring and consistent evidence to support DES in UPLM disease

55 Unprotected Left Main Stenting Left main is not just left main -- Geoffrey Hartzler 1986

56 A Meta-analysis of ULM Stenting with DES Biondi Zoccai et al Am Heart J Feb;155(2):274-83

57 Ostial/midshaft LM lesions Valgimigli et al. Palmerini et al. 7% 20% Chieffo et al: 147 patients with non bifurcation lesions from 5 centers In Hospital Follow-up (886±308 days) Cardiac Death, n (%) 0 4 (2.7) Cardiac Death in 87 low risk pts, n (%) 0 0 Total Death, n (%) 1 (0.7) 5 (3.4) Q wavemi, n (%) 0 0 Non Q wave MI, n (%) 5 (3.4) 0 TLR, n (%) 1 (0.7) 1 (0.7) MACE (CD, MI, TLR), n (%) 6 (4.0) 11 (7.4)

58 The technique IVUS Optimal stent deployment High pressure inflation Avoidance of malaposition bigger balloon inflation Kissing balloon

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60 Before After IVUS guidance during DES Left Main PCI associated with reduction in mortality; HR=0.43; CI, (SJ Park; MAIN-COMPARE Registry)

61 DES 3.5x16mm LAD and Cx>>FKB

62 FKB with NCB LAD: NCB 4.0x15mm at 18 atm Cx: NCB 3.5x12mm at 18 atm NCB 4.0x20mm at 20 atm

63 Case report - UPLMS ΓΤΝΑΙΚΑ 69 ΥΡΟΝΩΝ ΥΝΑ Δ ΣΔΥΝΗΣΟ ΝΔΦΡΟ 2005 ΑΚΥΑΡΩΓΗ ΓΙΑΒΗΣΗ 1992 ΓΑΓΓΡΑΙΝΑ ΓΑΚΣΤΛΩΝ ΑΡ. ΠΟΓΙΟΤ ΤΠΔΡΣΑΗ ΣΗΘΑΓΥΗ

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66 ΕΚΣΙΜΗΗ ΣΗ ΣΕΦΑΝΙΟΓΡΑΦΙΑ ΣΟΜΙΑΚΗ ΒΛΑΒΗ ΠΔΡΙΠΩΜΔΝΗ ΔΠΑΒΔΣΩΗ ΠΡΟΘΙΟΤ ΚΑΣΙΟΝΣΟ ΜΔ ΣΟΜΙΑΚΗ ΒΛΑΒΗ

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68 IVUS ΣΕΛΕΥΟΤ ΠΡΟΘΙΟΤ ΚΑΣΙΟΝΣΟ ΠΔΡΙΦΔΡΔΙΑ ΣΔΛΔΥΟΤ - ΠΡΟΘΙΟ ΚΑΣΙΩΝ ΣΟΜΙΑΚΗ ΒΛΑΒΗ ΜΔ MLA 3.2 MM 2 ΚΑΙ ΑΒΔΣΙΟ SYNTAX SCORE 23

69 Rotablation LAD cutting balloon Cx Minicrush with DES Kissing balloon Very high final pressure inflation

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76 ΤΜΠΕΡΑΜΑΣΑ ΔΝΓΟΣΔΦΑΝΑΙΑΙΟ ΤΠΔΡΗΥΟ ΒΟΗΘΑ ΣΗΝ ΔΚΣΙΜΗΗ ΣΗ ΒΛΑΒΗ ΣΗΝ ΔΠΙΛΟΓΗ ΣΡΑΣΗΓΙΚΗ ΚΑΙ ΣΗΝ ΔΚΣΙΜΗΗ ΣΟΤ ΣΔΛΙΚΟΤ ΑΠΟΣΔΛΔΜΑΣΟ ΠΔΡΙΣΡΟΦΙΚΗ ΑΘΗΡΔΚΣΟΜΗ ΔΦΙΚΣΗ Δ ΑΠΡΟΣΑΣΔΤΣΟ ΣΔΛΔΥΟ

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78 More Patients with Left Main Stem Disease should undergo PCI! Elderly Patients (>80 y) Comorbidities Syntax Score <32 Ostial midshaft LMS disease Single DES Stent Strategy STEMI ACS?

79 Unprotected left main revascularization in patients with acute coronary syndromes Gilles Montalescot (GRACE Investigators) EHJ 2009 Unprotected left main coronary disease in ACS is associated with high mortality, especially in patients with STEMI and/or haemodynamic or arrhythmic instability PCI is now the most common revascularization strategy and preferred in higher risk patients CABG is often delayed and performed in lower risk patients, leading to good 6-month survival The two approaches therefore appear complementary Coronary artery bypass graft revascularization was associated with a five-fold increase in stroke

80 Does evidence support Left Main PCI as a Class IIa Recommendation? Ten trials in a meta-analysis, including two randomized trials, provide the evidence base to make PCI a class IIa recommendation for about 50% of patients with LM disease (level of evidence = B) However, PCI should be a class IIb or III recommendation for patients with left main disease and high SYNTAX scores (i.e. >33) Larger, randomized trials that will improve the level of evidence, and further refine patient selection for left main stenting are underway. SCRIPPS CLINIC

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83 Duke Database CABG for Left Main Disease N=1374 Mortality(%) N= Roxana Mehran tctmd 2006

84 Ostial/midshaft LM lesions Valgimigli et al. Palmerini et al. 7% 20% Chieffo et al: 147 patients with non bifurcation lesions from 5 centers In Hospital Follow-up (886±308 days) Cardiac Death, n (%) 0 4 (2.7) Cardiac Death in 87 low risk pts, n (%) 0 0 Total Death, n (%) 1 (0.7) 5 (3.4) Q wavemi, n (%) 0 0 Non Q wave MI, n (%) 5 (3.4) 0 TLR, n (%) 1 (0.7) 1 (0.7) MACE (CD, MI, TLR), n (%) 6 (4.0) 11 (7.4)

85 FAILS (Failure in Left Main Study) registry of DES restenosis JACC 2009 restenosis occurred in 70 of 718 patients (9.7%) 59 were treated percutaneously 7 patients underwent bypass surgery 4 were treated medically MACE: 50% medical 25.4% PCI 14.3% CABG Definite, probable, and possible ST occurred in 0 (0%), 1 (1.4%), and 1 (1.4%) patient, respectively

86 POD #1 after UPLM revascularization: CABG POD #1 after UPLM revascularization: PCI

87 1 single center randomized study comparing LM stenting vs Surgery: The LE MANS study 105 patients with unprotected left main artery disease: 52 treated with PCI and 53 with CABG Patients with acute MI, comorbidities, EuroScore 8, recent CVA, renal dysfunction were excluded Survival MACCE-free Survival pci cabg pci cabg Although this is a prospective randomized study, it is too small and has important drawbacks to support a guidelines change!

88 The LE MANS study DES, rather than BMS, were placed in the 35 % of patients At one year, the primary end point of a significant increase in LVEF occurred only in the PCI group (3.3 versus 0.5 percent) secondary end points of survival and MACCE were comparable in both groups

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