左主病变治疗

Left Main Disease: DES or CABG ?,Chen Yundai MD,Director of Department of Cardiology,Capital University of Medical Science Affiliated Beijing Anzhen Hospital, China,Background,Left main coronary stenosis is an infrequent disease (3-7% of CA) but remains associated with poor prognosticCABGPCID.E.S.,Cardiac Surgeon said:,Interventional Cardiologist said:,CABG in LM Disease,LMCA is now the indication for surgery in 20-25% of CABG casesLM disease is an independent predictor for mortality and morbidity post CABGOperative mortality is 3-4% for LMCAOPB-CABG may offer a mortality benifit,U.S. Penetration of DES,28% (2003),75% (2004),Cypher as of 4/03 and Taxus as of 3/04,2003,2004,Gap of MACEs between CABG and BMS,One year survival is comparableRestenosis,DES vs CABG?,PCI vs. CABGRepeat Revascularization,CABG=DES,ARTS II: multi-vessel,ARTS-I and II: 1 year adverse event rate (MACE),LM Stenting: Impact of D.E.S.,LM Stenting: Impact of D.E.S.,MACE: 2-25%,LM Stenting: Impact of D.E.S.,TLR: 0-19%,LM Stenting: Impact of D.E.S.,Restenosis: 0-19% Distal: 0-19% non distal: 0,ULMCA Stenting: Remaining Issues,Technical difficulty of distal LM stentingRestenosis Stent thrombosis Risk of mortality ASA-Plavix+,So, we can know that in the “real world”, DES in LMCA lesion, But, More efficacy data in specific lesion subsets such as LM diseases (esp.distal bifurcation lesion) should be .,Syntax Trial Design,CABG only populationPCI only populationPatient/physician preference,amenable for 1 interventional treatment,Patients with de novo 3-vessel-disease and/or left main disease,screening,TAXUS,CABG,vs,Registries,amenable for both treatments options,Multi-center randomized controlled trial,Diabetes Mellitus w/ 2-3 VD,Randomized ArmN=2400 (1:1),amenable for one treatment approach,amenable for both treatments options,DES,CABG,vs,Two Registry ArmsN=2000,CABGAll captured and followed,PCIAll captured and followed,follow-up: 30d, 6m, 1-5 yrs Goal: to define the most appropriate treatment for diabetic patients through randomized trial methods,Consensus exists that only one treatment option (CABG vs PCI) is appropriateGoal: to compare outcomes with randomized group,FREEDOM Trial Design,Surgeon and interventionalist,CASE:CABG VS DES?,Female,62yrsCABG(2000.4):SVG-RCA-LAD, for the reason that severe calcification of left IMA and aortic arteryUnstable angina pectoris for 4 months and admission in 2004.9,Angiographic results (2004.09),DISSCUSSION 1,Re-CABG or PCI?If in the era of DES, you should select PCI or CABG at first for this patient?,GC: Cordis 6F JL4.0GW: Cordis Stablizer supersoftBalloon: SORIN Hypro 2.015mm,Another GW: Cordis Stablizer supersoft Stent: Cordis Cypher select 3.018mm,Stent: MUSTANG Firebird 3.523mm,Final result,DISSCUSSION 2,PCI/CABG?Lesion characteristics: calcification, tortuousIncomplete revascularization for this patients.,LM-PCI：ACC/AHA/ESC guildline,ACC/AHA Guidelines for LM-PCI should be from IIB to IB!Because In the real world, with global DES use, the TLR event-free survival of LM is now 95% !,One day, ,Drug-Eluting Stent Eu