Lésions du tronc commun: Reste t il une place pour la chirugie? Pierre Deharo, CHU TIMONE, Marseille

Lésions du tronc commun: Reste t il une place pour la chirugie? Pierre Deharo, CHU TIMONE, Marseille

Disclosure Statement of Financial Interest I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company : Speaker's name: Pierre, Deharo, MARSEILLE I do not have any potential conflict of interest

Guidelines: indications ESC guidelines, Eur Heart J 2014

Methods of revascularisation ESC guidelines, Eur Heart J 2014

LMS: evidence 5-y PRECOMBAT + SYNTAX LMS analyse Subgroup of negative study! Cavalcante, JACC 2016

SYNTAX calculator = a very complicated tool!

New evidence for LMS: What is the source of dilemna? EXCEL STUDY Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease. PCI non inferior to CABG Stone G et al. N Engl J Med Dec. 2016 NOBLE STUDY Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. PCI NOT non inferior to CABG and CABG superior to PCI Mäkikallio T et al. Lancet Dec. 2016

EXCEL Study PCI non inferior to CABG for LM disease LM and SYNTAX<32 Xience stent, 28% BIMA CABG vs PCI, n= 1905 PEP= Death, MI, stroke Stone et al, NEJM 2016

NOBLE Study PCI not non-inferior to CABG for LM disease (HR>1.35) Left Main Biomatrix stent (>90%) CABG vs PCI, n= 1201, 8% BIMA PEP= Death, non procedural MI, stroke + Revasc Mäkikallio et al, Lancet 2016

Why different results? EXCEL study NOBLE study PEP without repeat revasc. PEP: All MI PEP with repeat revasc. PEP: Only non procedural MI 3 years FU 5 years FU Positive Study Non Inferiority of PCI Negative study No Non inferiority of PCI Superiority of CABG Stone et al, NEJM 2016 Mäkikallio et al, Lancet 2016

How study design impacts study results! EXCEL study: PEP NOBLE study: PEP CABG PCI CABG PCI Difference in KM curves Earlier (MI Definition / Early Hazard) Faster (Repeat Revasc. In PEP) Larger (Longer follow-up) Stone et al, NEJM 2016 Mäkikallio et al, Lancet 2016

EXCEL NOBLE All cause death Higher Higher CV death Equal Equal Periprocedural MI Lower* Lower Non Periprocedural MI Higher Higher* Revasc Higher* Higher* Stroke Lower Higher ST/SGO Lower* Lower PCI as reference * p<0,05 Stone, NEJM 2016 Makikallio, Lancet 2016

EXCEL NOBLE AF Lower* Lower* Transfusion Lower* Lower* Anemia Lower* Lower* PCI as reference * p<0,05 Stone, NEJM 2016 Makikallio, Lancet 2016

Revascularization strategy ESC guidelines, Eur Heart J 2014

Revascularization strategy STS Age SCA vs. SCAD Diabetes Compliance DAPT SYNTAX Ostial vs. Bifurcation Downstream bed CTO Previous failure All arterial Delays Imaging

Revascularization strategy SYNTAX Ostial vs. Bifurcation Downstream bed CTO Previous failure STS Age SCA vs. SCAD Diabetes Compliance DAPT CABG PCI - Hybride Final tailored decision All arterial Delays Imaging

One patient is one patient... 63 yo Current smoker EF 50% No comorbidity egfr 80 = RIMA to LCX + LIMA to LAD 86 yo COPD PAD Frail EF 30% egfr 40 = PCI to LMS/LAD 1 DES

Remaining questions in 2018

SYNTAX score 2016 Stone, NEJM 2016 Makikallio, Lancet 2016

Score SYNTAXII

Constant devices improvement Last generation stents in LMS - diabetes Systematic use of intracoronary imaging in LMS procedures Less invasive PCI (6 Fr radial) Complete revascularisation (CTOs)

Conclusions LMS PCI: validated alternative except for complex anatomy Is there still a place for CABG: YES!... But if well done: all arterial

Graft patency Tranbaugh et al, Annals of thoracic surgery 2017

Conclusions Heart Team Expert centers Patient-based decision instead of SYNTAX based Need for optimization of PCI outcomes (OCT/IVUS, newer DES, bifurcations techniques, CTOs)