Management of Patients with Stable CAD Left Main PCI vs. CABG: Real World Marco Roffi, MD, FESC University Hospital Geneva, Switzerland
SYNTAX-LMT The SYNTAX trial included a pre-specified subgroup of 705 patients with predominant distal LM disease, who were randomly assigned to CABG or PCI using early generation drug eluting stent (paclitaxel-eluting stent). At 5 years of follow-up, the primary end point was the composite of major adverse cardiovascular and cerebrovascular events (MACCE), which included all-cause death, cerebrovascular accident/stroke, MI, and repeat revascularizations Morice MC et al Circulation. 2014;129:2388-2394
Morice MC et al Circulation. 2014;129:2388-2394
SYNTAX-LMT At 5 years follow-up CABG PCI CABG PCI P=NS P<0.001 26.7% 36.9% 31.0% 15.5% P=0.03 14.6% 12.8% 4.3% 1.5% 4.8% 8.2% Death Stroke MI Repeat Revascularization MACCE n:705 MACCE: All-cause death, cerebrovascular accident/stroke, MI, and repeat revascularizations
MACCE 31.5% SYNTAX-LMT CABG PCI P=NS 32.3% 32.7% 30.4% Low SYNTAX Score Mohr FW Lancet 2013; 381: 629 38 Intermediate SYNTAX Score low 22, intermediate 23 32, and high 33
SYNTAX SCORE 33 MACCE CABG CABG PCI 34.1% PCI P=0.11 P=0.003 20.9% 14.1% 29.7% 11.6% 46.5% P<0.001 P=0.13 4.9% 1.6% Mortality Repeat revascularization Stroke Morice MC et al Circulation. 2014;129:2388-2394 MACCE: All-cause death, cerebrovascular accident/stroke, MI, and repeat revascularizations
PRECOMBAT The PRECOMBAT trial randomized 600 patients with LM disease and a mean SYNTAX score of 25 to CABG or PCI using early generation DES (sirolimus-eluting stent). At 5 years of follow-up, the primary endpoint was death, MI, stroke, or target vessel repeat revascularization Ahn JM Am Coll Cardiol 2015 May 26;65(20):2198-206
14.3% PRECOMBAT CABG The incidence of stroke was similar for PCI (0.7%) and 17.5% CABG (0.7%) in contrast to the findings in SYNTAX n:600 PCI P=NS 9.6% 8.4% Primary Endpoint PE: Death, MI, stroke, or target vessel repeat revascularization Death, MI or Stroke Ahn JM Am Coll Cardiol 2015 May 26;65(20):2198-206
Ahn JM Am Coll Cardiol 2015 May 26;65(20):2198-206
Pooled analysis of SYNTAX and PRECOMBAT At 5 years of follow-up 15.1% P=NS 14.0% CABG PCI 19.5% P<0.001 10.8% Death, MI and Stroke Repeat revascularization Cavalcante R et al J Am Coll Cardiol. 2016 Sep 6;68(10):999-1009
EXCEL The EXCEL trial compared CABG with PCI using new generation DES (everolimus-eluting stent) among 1905 patients with significant LM disease on coronary angiography with evidence of invasive or non invasive ischaemia treated between 2010 and 2014. Although complex LM disease defined as a SYNTAX score > 32 constituted an exclusion criterion, the distribution of SYNTAX score tertiles according to the Core laboratory evaluation were 36%, 40% and 24% for low ( 22), intermediate (23 32) and high ( 33) SYNTAX scores, respectively. At 3 years of follow-up, the primary endpoint was death, stroke or MI Stone GW N Engl J Med 2016 Dec 8;375(23):2223-2235
N=1905 P=NS EXCEL CABG PCI From 3015.4% days to 3 years 14.7% At 3 years of follow-up 11.5% P=0.02 P<0.001 Primary endpoint: 12.9% death, stroke or MI 7.9% P=0.03 6.0% P=0.07 3.8% 4.3% 2.7% 7.6% Death, stroke and MI Peri-procedural Primary Endpoint Spontaneous MI MI Repeat Revascularization Stone GW N Engl J Med 2016 Dec 8;375(23):2223-2235
Stone GW N Engl J Med 2016 Dec 8;375(23):2223-2235
NOBLE The NOBLE trial compared CABG with PCI using new generation DES (biolimus-eluting stent*) among 1201 patients with significant LM disease (mean SYNTAX score of 23) treated between 2008 and 2015. At a median follow-up of 3.1 years, the primary endpoint was death, non-procedural MI, stroke and repeat revascularization. Mäkikallio T et al Lancet 2016; 388: 2743 52
NOBLE No significant differences in the incidence of all-cause CABG PCI and cardiac death At a median follow-up of 3.1 years CABG 28.0% PCI P=0.03 P=0.004 n:1201 18.0% P=0.004 10.0% 15.0% 6.0% 2.0% Primary Endpoint Non procedural MI Death, non-procedural Repeat MI, stroke and repeat revascularization Mäkikallio T et al Lancet 2016; 388: 2743 52
Mäkikallio T et al Lancet 2016; 388: 2743 52
Meta analysis SYNTAX (LMCA Cohort) PRECOMBAT EXCEL NOBLE Primary Endpoint: Composite of allcause death, myocardial infarction, or stroke Giacoppo D et al. JAMA Cardiol. 2017;2(10):1079-1088
Meta analysis All-cause death, myocardial infarction, or stroke at long-term follow-up Giacoppo D et al. JAMA Cardiol. 2017;2(10):1079-1088
Impact of Operator Experience/Volume on Outcomes After LMT PCI Pts treated by experienced operators had more complex/extensive CAD Adjusted risks for cardiac death lower for pts treated by experienced operators Unprotected LM PCI at a single institution Experienced/high-volume 30-day HR 0.22 (95% LM CI: operator: 0.09 to >15 0.59), LM p PCI/y = 0.003 for >3 consecutive years 1948 patients treated in 8 y = 243 pts/y! 3-year HR: 0.49 (95% CI: 0.29 to 0.84); Xu B et p = al. 0.009 J Am Coll Cardiol Intv 2016;9:2086 93
IVUS Guidance for LMT PCI: Pooled Analysis of Patient-Level Data 4 registries, N=1,670, analysis on N=505 (30.2%) with PCI under IVUS guidance and matched with N=505 without IVUS guidance de la Torre Hernandez JM et al. J Am Coll Cardiol Intv 2014;7:244 54
IVUS Guidance for LMT PCI: Pooled Analysis of Patient-Level Data Pooled analysis suggests an association of IVUS guidance with better outcomes in LMT PCI de la Torre Hernandez JM et al. J Am Coll Cardiol Intv 2014;7:244 54
IRIS-MAIN registry A total of 3,504 consecutive patients with LMCAD treated with CABG (n = 1,301) or PCI with DES (n = 2,203) Matched cohorts (N=2x950) Lee PH et al. Am Heart J 2017;193:76-83
ESC 2014 Recommendations in patients with SCAD, LMT disease, suitable anatomy for both procedures and low predicted surgical mortality Windecker at al. Eur Heart J. 2014;35:2541-619