对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术课件

PercutaneousorSurgicalRevascularizationforMultivesselCoronaryArteryDisease?VergheseMathew,MD,FACCConsultant,DivisionofCardiovascularDiseasesandDepartmentofRadiologyProfessorofMedicine,MayoClinicCollegeofMedicinePercutaneousorSurgicalRevas1RevascularizationStrategiesHowdowedecide?Anatomy Clinical Patient presentationpreferenceRiskvs.BenefitRevascularizationStrategiesHo2InvasiveTherapiesLowRiskPatientHighRiskPatientSomeacuteriskLesslong-termriskreductionGreateracuteriskGreaterlong-termriskreductionInvasiveTherapiesLowRiskPat312-YearSurvivalinPatientswithCAD >50 35-49 <35 EmondMetal:Circ90:2645,199423,467Medically-TreatedPatientsinCASSRegistryLVEFCP1203018-212-YearSurvivalinPatientsw412-YearSurvivalinPatientswithCAD NoCAD 1vessel 2vessel 3vesselEmondMetal:Circ90:2645,199423,467Medically-TreatedPatientsinCASSRegistryCP1203018-112-YearSurvivalinPatientsw5ClinicalPresentationAgeAcuteischemicsyndromeversuschronicstableanginaPriorcardiachistory(MI,CABG,intervention)Co-morbidconditions(diabetes,cerebrovasculardisease,renaldisease,lungdisease)FunctionalimpairmentIschemicburdenClinicalPresentationAge6ExtensionofSurvivalwithCABGvsMedicalTherapyAfter10YearsCP1203018-14Extensionofsurvival(mo)YusufSetal:

Lancet344:563,1994OverallVesseldisease1/2vessels3vesselsLeftmainLVfunctionNormal

AbnormalExercisetestNormal

AbnormalAnginaClass0,I,IIClassIII,IVLowModerateHighLowModerateHighVAriskscoreStepwise

riskscoreExtensionofSurvivalwithCAB7CABGvsStentingforMVDMeta-AnalysisofARTS,ERACI-II,MASS-IIandSOSCirc118,2008DaysEvent-FreeSurvivalAnalysis

ofDeath

1,518 1,472 1,456 1,440 1,406 1,347

1,533 1,479 1,457 1,439 1,412 1,349Overallsurvival(%)P=0.78DaysRepeatRevascularization

1,518 1,204 772 740 707 665

1,533 1,428 927 911 882 855P<0.0001Overallsurvival(%)DaysDeath,StrokeorMI

1,518 1,381 913 896 872 846

1,533 1,377 908 891 868 845Overallsurvival(%)P=0.64DaysMajorAdverseCardiacandCerebrovascularEvents

1,518 1,153 729 691 657 616

1,533 1,332 867 846 812 785P<0.0001Overallsurvival(%)PCI91.5%CABG91.8%PCI71.0%CABG92.1%PCI83.3%CABG83.1%PCI60.8%CABG77.0%CABGvsStentingforMVDMeta-IncreasedLikelihoodofRestenosisLesion/PatientSubsetsSmallvesselsBifurcationsOstialCTOBaremetalISRSVGAMI(thrombus)DiabetesmellitusIncreasedLikelihoodofResten9Hazardratio95%CICP1045415-3SIRIUS–ClinicalRestenosis(TLR)at1Year Sirolimus ControlOverall 4.9 20.0Male 5.2 20.5Female 4.1 19.0Diabetes 8.4 26.4Nodiabetes 3.7 17.6LAD 6.0 23.0Non-LAD 4.1 18.0Smallvessel(<2.75) 6.6 22.3Largevessel 3.1 18.2Shortlesion 4.0 18.6Longlesion(>13.5) 6.0 21.9Overlap 5.7 23.2Nooverlap 4.5 18.6P0.00010.00010.00020.00020.00010.00010.00010.00010.00010.00010.00010.00010.0001Events

prevented/

1,000pt152153149180138170140157151146158175141OddsratioHazardratio95%CICP1045415-310CABGvsDrug-ElutingStentsinMultivesselCoronaryDisease

AMeta-Analysison24,268PatientsBenedettoetal:EJCTS6958,2009FavorsDES-PCIFavorsCABG 0.01 0.1 1 10 100HRand95%CIStudynameParkHannanBriguoriYangJHLeeYangZKJavaidVaraniTarantiniCABGvsDrug-ElutingStentsin11LeftMainDisease(isolated,+1,+2or+3vessels)3VesselDisease(revascall3vascularterritories)SYNTAXEligiblePatientsDenovodiseaseLimitedExclusionCriteriaPreviousinterventionsAcuteMIwithCPK>2xConcomitantcardiacsurgeryLeftMainDisease3VesselDise12SYNTAXInclusionCriteria3-vesseldiseaseand/orleftmaindiseaseTotalocclusionwithouttimelimitationPreviousstroke>1monthRenalandrespiratoryinsufficiencyDecreasedpumpfunctionMyocardialischemia(unstable-silent-stable)PatientswithcomorbidityRealworldpatientpopulationSYNTAXInclusionCriteria3-ves13PCIn=198TAXUS*n=903

CABGn=897vsCABGn=1077nof/un=4285yrf/un=649TwoRegistryArmsN=1275RandomizedArmsN=1800HeartTeam(surgeon&interventionalist)AmenableforonlyonetreatmentapproachAmenableforbothtreatmentoptionsStratification:

LMandDiabetesLM33.7%3VD66.3%LM34.6%3VD65.4%23USSites62EUSites+SYNTAXTrialDesign*TAXUSExpressPCITAXUS*CABGvsCABGnof/u5yrf14Cumulative

rate(%)SYNTAX:OutcomesNEJM360(10),2009Cumulativerate(%)DeathfromAnyCauseDeathfromAnyCause,

Stroke,orMIRepeatRevascularizationMajorAdverseCardiacorCerebrovascularEventMonthssincerandomizationCumulative

rate(%)Cumulative

rate(%)MonthssincerandomizationP=0.37P=0.993.5P<0.001P=0.002MonthssincerandomizationMonthssincerandomizationPCICABG4.4PCI7.77.6CABGPCICABG13.55.917.812.4PCICABGCumulative

rate(%)SYNTAX:OuSYNTAXCABG/PCIRegistriesSYNTAXappendix:NEJM,2009ReasonsforCABGComplexanatomy 70.9%Untreatablechronic 22.0%

totalocclusionUnabletotake 0.9%

anti-plateletmedicationsPatientrefusedPCI 0.5%Other 5.7%ReasonsforPCIComorbidity 70.7%Nograftmaterial 9.1%PatientrefusedCABG 5.6%Smallorpoorquality 1.5%

ofdistalvesselOther 13.1%n=644n=192SYNTAXCABG/PCIRegistriesSYNTSYNTAXScoreNumber&locationoflesionsTortuosityThrombusBifurcationTotalOcclusionDiffuseLeftMainDominanceSYNTAXScoreCalcificationEuroInterv2005;1:219-227SYNTAXScoreNumber&location17OutcomesStratifiedbySYNTAXScoreNEJM360:970,2009CumulativerateofmajoradversecardiacorcerebrovasculareventsP=0.71CumulativerateofmajoradversecardiacorcerebrovasculareventsP=0.10MonthssincerandomizationMonthssincerandomizationCumulativerateofmajoradversecardiacorcerebrovasculareventsP<0.001MonthssincerandomizationLowSYNTAXScore(0-22)IntermediateSYNTAXScore(22-32)HighSYNTAXScore(>33)14.713.6CABGPCI16.712.0CABGPCI23.410.9PCICABGOutcomesStratifiedbySYNTAX18对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术课件19对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术课件20对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术课件21对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术课件22对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术课件23对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术课件24对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术课件25对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术课件26ProceduralDifferencesBetween

SYNTAXCABGRandomizedvsRegistry CABGRCT CABGregistryVariable n=897 n=644Completerevasc(%) 63.2(550/870) 74.7(481/644)Graftrevascularization(%) Atleast1arterialgraft 97.3(831/854) 96.7(623/644) ArterialgrafttoLAD 95.6(816/854) 94.7(610/644) DoubleLIMA/RIMA 27.6(236/854) 16.1(104/644) Completearterial 18.9(161/854) 11.2(72/644)

revascularization Venousgraftsonly 2.6(22/854) 3.3(21/644)ProceduralDifferencesBetweenCardiac-RelatedMedicationsGivenaftertheStudyProcedure*

MedicationPCICABGpValue

percentAny98.998.60.62AspirinAtdischarge96.388.5<0.0016moafterrandomization93.282.7<0.001ThienopyridineAtdischarge96.819.5<0.0016moafterrandomization91.316.1<0.001AnyantiplateletdrugAtdischarge9723.7<0.0016moafterrandomization91.418.4<0.001Warfarinderivative2.67.1<0.001Statin86.774.5<0.001Beta-blocker81.378.60.17ACEinhibitor55.144.6<0.001AngiotensinII–receptorantagonist13.37<0.001*Percentagesarefromtheintention-to-treatanalysis.ACEdenotesangiotensin-convertingenzyme,CABGcoronary-arterybypassgrafting,andPCIpercutaneouscoronaryintervention.SerruysPetal.NEnglJMed2009;10.1056/NEJMoa0804626Cardiac-RelatedMedicationsGi28ProceduralDifferencesBetweenSYNTAXPCIRandomizedCohortandthePCIRegistry PCIRCT PCIregistryVariable n=903 n=192Completerevasc(%) 56.7(508/896) 36.5(70/192)Lesions,no.(mean±SD) 4.4±1.8 4.5±1.8Stentsimplanted 4.6±2.3 3.1±1.8

(mean±SD)Totallengthimplanted, 86.1±47.9 58.5±41.2

mean±SD(mm)Range(mm) 8.0-324.0 8.0-252.0Longstenting 33.2(291/877) 12.2(23/188)

(>100mm)(%)ProceduralDifferencesBetweenSYNTAX

StentThrombosisandSymptomaticGraftOcclusionCP1294833-1StentThrombosisSymptomaticGraftOcclusionIncidence MortalityTFeldmanEuroPCR2009SYNTAX

StentThrombosisandSy30PercutaneousorSurgicalRevascularizationforMultivesselCoronaryArteryDisease?Spectrumofrisk(anatomic,clinical)inpatientswithstablemultivesselCADPatientswithmoreextensive,diffuseCAD(higherSYNTAXscore)farebetterwithCABGthanPCIduetorepeatrevascularizationratesLowerSYNTAXscorepatientsdowellwithPCITherearesomepatientstoohighriskforCABGPercutaneousorSurgicalRevas31LimitationsofPCITLRremainshigherwithPCIthanCABGLongsegmentsofstentsPost-dilation,IVUSDualantiplatelettherapyStentthrombosisPCIstillhasasignificantacutefailurerateinspecificlesionsubsets:CTOBifurcationSVGSeverecalcification/tortuosityLimitationsofPCITLRremains32LimitationsofCABGLong-termgraftattrition;totalarterialrevascularizationstilluncommonNativevesselprogressionCABGnotcurativePCIfrequentlyutilizedforsymptomreliefinpost-CABGLimitationsofCABGLong-termg33SelectionofRevascularizationModality-WhatShouldWeEmphasizeMovingForward?CarefulassessmentofanatomicandclinicalriskMeticulousstentdeploymenttechniquesProlongeddualantiplatelettherapyforDESBioabsorbablestentsDevice/equipmentdevelopmenttocontendwithlesionsubsetsinwhichPCIfailsOptimizeadjuvantmedicaltherapy(antiplatelet,statin,ACE-I)particularlyinpostCABGpatientsTotalarterialrevascularizationSelectionofRevascularization34ExploreTheBestOfBothWorlds?

Hybridapproachestominimizemorbidity,recovery,painandmaximizedurabilityRoboticIMAtoLADPCIwithDEStonon-LADdiseaseExploreTheBestOfBothWorld35对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术课件36对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术课件37PercutaneousorSurgicalRevascularizationforMultivesselCoronaryArteryDisease?VergheseMathew,MD,FACCConsultant,DivisionofCardiovascularDiseasesandDepartmentofRadiologyProfessorofMedicine,MayoClinicCollegeofMedicinePercutaneousorSurgicalRevas38RevascularizationStrategiesHowdowedecide?Anatomy Clinical Patient presentationpreferenceRiskvs.BenefitRevascularizationStrategiesHo39InvasiveTherapiesLowRiskPatientHighRiskPatientSomeacuteriskLesslong-termriskreductionGreateracuteriskGreaterlong-termriskreductionInvasiveTherapiesLowRiskPat4012-YearSurvivalinPatientswithCAD >50 35-49 <35 EmondMetal:Circ90:2645,199423,467Medically-TreatedPatientsinCASSRegistryLVEFCP1203018-212-YearSurvivalinPatientsw4112-YearSurvivalinPatientswithCAD NoCAD 1vessel 2vessel 3vesselEmondMetal:Circ90:2645,199423,467Medically-TreatedPatientsinCASSRegistryCP1203018-112-YearSurvivalinPatientsw42ClinicalPresentationAgeAcuteischemicsyndromeversuschronicstableanginaPriorcardiachistory(MI,CABG,intervention)Co-morbidconditions(diabetes,cerebrovasculardisease,renaldisease,lungdisease)FunctionalimpairmentIschemicburdenClinicalPresentationAge43ExtensionofSurvivalwithCABGvsMedicalTherapyAfter10YearsCP1203018-14Extensionofsurvival(mo)YusufSetal:

Lancet344:563,1994OverallVesseldisease1/2vessels3vesselsLeftmainLVfunctionNormal

AbnormalExercisetestNormal

AbnormalAnginaClass0,I,IIClassIII,IVLowModerateHighLowModerateHighVAriskscoreStepwise

riskscoreExtensionofSurvivalwithCAB44CABGvsStentingforMVDMeta-AnalysisofARTS,ERACI-II,MASS-IIandSOSCirc118,2008DaysEvent-FreeSurvivalAnalysis

ofDeath

1,518 1,472 1,456 1,440 1,406 1,347

1,533 1,479 1,457 1,439 1,412 1,349Overallsurvival(%)P=0.78DaysRepeatRevascularization

1,518 1,204 772 740 707 665

1,533 1,428 927 911 882 855P<0.0001Overallsurvival(%)DaysDeath,StrokeorMI

1,518 1,381 913 896 872 846

1,533 1,377 908 891 868 845Overallsurvival(%)P=0.64DaysMajorAdverseCardiacandCerebrovascularEvents

1,518 1,153 729 691 657 616

1,533 1,332 867 846 812 785P<0.0001Overallsurvival(%)PCI91.5%CABG91.8%PCI71.0%CABG92.1%PCI83.3%CABG83.1%PCI60.8%CABG77.0%CABGvsStentingforMVDMeta-IncreasedLikelihoodofRestenosisLesion/PatientSubsetsSmallvesselsBifurcationsOstialCTOBaremetalISRSVGAMI(thrombus)DiabetesmellitusIncreasedLikelihoodofResten46Hazardratio95%CICP1045415-3SIRIUS–ClinicalRestenosis(TLR)at1Year Sirolimus ControlOverall 4.9 20.0Male 5.2 20.5Female 4.1 19.0Diabetes 8.4 26.4Nodiabetes 3.7 17.6LAD 6.0 23.0Non-LAD 4.1 18.0Smallvessel(<2.75) 6.6 22.3Largevessel 3.1 18.2Shortlesion 4.0 18.6Longlesion(>13.5) 6.0 21.9Overlap 5.7 23.2Nooverlap 4.5 18.6P0.00010.00010.00020.00020.00010.00010.00010.00010.00010.00010.00010.00010.0001Events

prevented/

1,000pt152153149180138170140157151146158175141OddsratioHazardratio95%CICP1045415-347CABGvsDrug-ElutingStentsinMultivesselCoronaryDisease

AMeta-Analysison24,268PatientsBenedettoetal:EJCTS6958,2009FavorsDES-PCIFavorsCABG 0.01 0.1 1 10 100HRand95%CIStudynameParkHannanBriguoriYangJHLeeYangZKJavaidVaraniTarantiniCABGvsDrug-ElutingStentsin48LeftMainDisease(isolated,+1,+2or+3vessels)3VesselDisease(revascall3vascularterritories)SYNTAXEligiblePatientsDenovodiseaseLimitedExclusionCriteriaPreviousinterventionsAcuteMIwithCPK>2xConcomitantcardiacsurgeryLeftMainDisease3VesselDise49SYNTAXInclusionCriteria3-vesseldiseaseand/orleftmaindiseaseTotalocclusionwithouttimelimitationPreviousstroke>1monthRenalandrespiratoryinsufficiencyDecreasedpumpfunctionMyocardialischemia(unstable-silent-stable)PatientswithcomorbidityRealworldpatientpopulationSYNTAXInclusionCriteria3-ves50PCIn=198TAXUS*n=903

CABGn=897vsCABGn=1077nof/un=4285yrf/un=649TwoRegistryArmsN=1275RandomizedArmsN=1800HeartTeam(surgeon&interventionalist)AmenableforonlyonetreatmentapproachAmenableforbothtreatmentoptionsStratification:

LMandDiabetesLM33.7%3VD66.3%LM34.6%3VD65.4%23USSites62EUSites+SYNTAXTrialDesign*TAXUSExpressPCITAXUS*CABGvsCABGnof/u5yrf51Cumulative

rate(%)SYNTAX:OutcomesNEJM360(10),2009Cumulativerate(%)DeathfromAnyCauseDeathfromAnyCause,

Stroke,orMIRepeatRevascularizationMajorAdverseCardiacorCerebrovascularEventMonthssincerandomizationCumulative

rate(%)Cumulative

rate(%)MonthssincerandomizationP=0.37P=0.993.5P<0.001P=0.002MonthssincerandomizationMonthssincerandomizationPCICABG4.4PCI7.77.6CABGPCICABG13.55.917.812.4PCICABGCumulative

rate(%)SYNTAX:OuSYNTAXCABG/PCIRegistriesSYNTAXappendix:NEJM,2009ReasonsforCABGComplexanatomy 70.9%Untreatablechronic 22.0%

totalocclusionUnabletotake 0.9%

anti-plateletmedicationsPatientrefusedPCI 0.5%Other 5.7%ReasonsforPCIComorbidity 70.7%Nograftmaterial 9.1%PatientrefusedCABG 5.6%Smallorpoorquality 1.5%

ofdistalvesselOther 13.1%n=644n=192SYNTAXCABG/PCIRegistriesSYNTSYNTAXScoreNumber&locationoflesionsTortuosityThrombusBifurcationTotalOcclusionDiffuseLeftMainDominanceSYNTAXScoreCalcificationEuroInterv2005;1:219-227SYNTAXScoreNumber&location54OutcomesStratifiedbySYNTAXScoreNEJM360:970,2009CumulativerateofmajoradversecardiacorcerebrovasculareventsP=0.71CumulativerateofmajoradversecardiacorcerebrovasculareventsP=0.10MonthssincerandomizationMonthssincerandomizationCumulativerateofmajoradversecardiacorcerebrovasculareventsP<0.001MonthssincerandomizationLowSYNTAXScore(0-22)IntermediateSYNTAXScore(22-32)HighSYNTAXScore(>33)14.713.6CABGPCI16.712.0CABGPCI23.410.9PCICABGOutcomesStratifiedbySYNTAX55对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术课件56对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术课件57对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术课件58对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术课件59对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术课件60对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术课件61对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术课件62对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术课件63ProceduralDifferencesBetween

SYNTAXCABGRandomizedvsRegistry CABGRCT CABGregistryVariable n=897 n=644Completerevasc(%) 63.2(550/870) 74.7(481/644)Graftrevascularization(%) Atleast1arterialgraft 97.3(831/854) 96.7(623/644) ArterialgrafttoLAD 95.6(816/854) 94.7(610/644) DoubleLIMA/RIMA 27.6(236/854) 16.1(104/644) Completearterial 18.9(161/854) 11.2(72/644)

revascularization Venousgraftsonly 2.6(22/854) 3.3(21/644)ProceduralDifferencesBetweenCardiac-RelatedMedicationsGivenaftertheStudyProcedure*

MedicationPCICABGpValue

percentAny98.998.60.62AspirinAtdischarge96.388.5<0.0016moafterrandomization93.282.7<0.001ThienopyridineAtdischarge96.819.5<0.0016moafterrandomization91.316.1<0.001AnyantiplateletdrugAtdischarge9723.7<0.0016moafterrandomization91.418.4<0.001Warfarinderivative2.67.1<0.001Statin86.774.5<0.001Beta-blocker81.378.60.17ACEinhibitor55.144.6<0.001AngiotensinII–receptorantagonist13.37<0.001*Percentagesarefromtheintention-to-treatanalysis.ACEdenotesangiotensin-convertingenzyme,CABGcoronary-arterybypassgrafting,andPCIpercutaneouscoronaryintervention.SerruysPetal.NEnglJMed2009;10.1056/NEJMoa0804626Cardiac-RelatedMedicationsGi65ProceduralDifferencesBetweenSYNTAXPCIRandomizedCohortandthePCIRegistry PCIRCT PCIregistryVariable n=903 n=192Completerevasc(%) 56.7(508/896) 36.5(70/192)Lesions,no.(mean±SD) 4.4±1.8 4.5±1.8Stentsimplanted 4.6±2.3 3.1±1.8

(mean±SD)Totallengthimplanted, 86.1±47.9 58.5±41.2

mean