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CABG - summitMD.com

Percutaneous Therapy for

Left Main & Multivessel CAD:

SYNTAX

Ted Feldman, M.D., FSCAI, FACC

Angioplasty Summit

April 25-27 th th 2007

Seoul, Korea


Ted Feldman MD, FACC, FSCAI

Disclosure Information

The following relationships exist:

Grant support: Abbott, Atritech, BSC, Cardiac Dimensions, Cordis, Evalve,

EV3, St Jude, .

Consultant: BSC, Cardiac Dimensions, Cordis, Edwards,Myocor

Speaker: Boston Scientific

Off label use of products and investigational devices

will be discussed in this presentation


The LANCET

FEBRUARY 4, 1978

Letters to the

Editor

TRANSLUMINAL

DILATATION OF

CORONARY ARTERY

STENOSIS


CABG is better…


NEJM 2005;352:2174-2183

2183


Hazard Ratio for Death following CABG vs. PCI

CABG Better

PCI Better

2-VD (No LAD)

2-VD (Non-Prox LAD)

2-VD (Prox LAD)

3-VD (All)

3-VD (Prox LAD)

0 0.5 1.0 1.5 2.0

Adjusted Hazard Ratio [95% CI]

NEJM 2005;352:2174-2183

2183


Long-term survival in 11,661 patients with

multivessel CAD in the era of stenting (1995-98):

A report from the Alberta Provincial Project for Outcome Assessment

in Coronary Heart Disease (APPROACH) Investigators

CABG

PCI

CABG

PCI

MED


PCI is better…


Superior Treatment Modality CABG PCI No difference

Clinical Parameters

Trial

Mortality & MI

Angina Relief

Repeat

Revascularization

Angiographic

Endpoints

Cost

Assessment

GABI

PCI

PCI

CABG

No difference

n/a

EAST

No difference

CABG

CABG

CABG

PCI

RITA

No difference

CABG

CABG

n/a

n/a

ERACI

CABRI

BARI

MASS-2

No difference

No difference

No difference

CABG (MI)

CABG

CABG

n/a

n/a

Significant CABG

decrease CABG of

revascularization

expected CABGwith

CABG DES

n/a

n/a

n/a

n/a

PCI

n/a

n/a

No difference

AWESOME

No difference

No difference

CABG

n/a

n/a

ERACI-2

PCI

n/a

CABG

CABG

No difference

SoS

CABG

(Mortality)

CABG

CABG

n/a

n/a

ARTS

No difference

n/a

CABG

n/a

PCI


ARTS II - Procedural Characteristics

Lesions, #

Stented les. / anast. seg., #

Stents, #

ARTS II

N=607 pts

N=2160 les.

3.6

3.2

3.7

ARTS I (CABG)

N=605 pts

N=1638 les.

2.8

2.8

-

ARTS I (PCI)

N=600 pts

N=1606 les.

2.8

2.5

2.8

Max. inflation pressure, atm

16.4

-

14.6

Total stent length, mm

72

-

48

(range)

12-253

-

8-165

GP IIb/IIIa inhibitor use, %

32

-

-

Use of arterial conduit, %

Duration of procedure, mins 85

193

99

Hospital stay, days

since procedure

-

3.4

Figures in Orange indicate statistical difference (95% CI) between ARTS II and ARTS I groups

93

9.6

-

3.9


ARTS II - MACCE up to 3 years

Event free Survival (%)

100

95

90

85

80

75

70

65

60

- ARTS II

- ARTS I CABG

- ARTS I PCI

P (log rank) = 0.22 between

ARTS II and ARTS I-CABG

P (log rank)


The old vein graft…


Graft Patency

LIMA, SVG and Radial artery grafts

p


March 27, 2007


PCI is just as good…


Evolution of Revascularization

+ Improved

technique

+ Improved stent

design

+ DES

- Restenosis

- Repeat

revascularization

?

P C I C A B G

+ Off pump

technique

+ Less invasive

approach

+ Increased arterial

revascularization

+ Optimal

perioperative

monitoring

- High costs

- Invasive

Over the last decade, the standard of care for both CABG and

PCI has continuously improved, leveling the playing field.


Inclusions Exclusions

• Stable/unstable angina

• De novo 3VD

• Left Main

• Left Main equivalent

• Left main with 1,2,3 vessel

disease

• Age < 21 Years

• Previous CABG or PCI

• Acute Myocardial Infarction

(CK > 2 x ULN)

• Concomitant cardiac Surgery

• Participation in other trial

• Uncertainty Adherence to

protocol

• Pregnancy


Patient Flow

screening

registration

Patients with de novo 3-vesseldisease

and /or left main disease

Physician Team

(surgeon and interventionalist)

TAXUS

amenable for both

treatments options

Multi-center randomized

controlled trial

Randomization

vs

CABG

amenable for ≤1

interventional treatment

Registries

• define CABG only

population

• define PCI only

population

• define

patients/physicians

refusing randomization


Calcification

Lesion

location

Left Main

Thrombus

SYNTAX

score

3 Vessel

Bifurcation

Total

Occlusion

Tortuosity

Goal: SYNTAX score to provide guidance on optimal revascularization strategies for

patients with high risk lesions


BARI

ARTS 1&2/ Syntax


SYNTAX Score

• Occlusion

• Ostial location

• Tortuosity

• Length >20mm

• Heavy calcification

• Thrombus

• Diffuse disease

Raw SYNTAX Score

MACE (1 yr )

Weighted SYNTAX Score

EuroInterv 2005;1:219-227

227


Overall enrollment – Apr 18

1800

1600

1400

1200

1000

800

600

Randomized

3V Disease Only

Left Main Disease

Enrolling Centers

total registry

1796

1276

1090

706

400

200

0

84

One patient to go 4/24/2007…………


73

48

15

12.1

SYNTAX

ARTS II

ARTS I

TAXI

140

120

100

80

60

40

20

0

18

15.7

21.5

DES Trial Comparison

Lesion Length

26.1 27.5 28.7

23

25

21.5

14.3

13.1

17.14

E-SIRIUS

Reality-Cypher

Reality-Taxus

TAXUS V

CORPAL

ISAR Desire

ISAR DM

REALITY

SIRTAX

TAXUS4

SIRIUS

TAXUS2

RAVEL

Lesion Length mm


Left Main Stenosis

STENT ME !!

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