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1、Percutaneous or Surgical Revascularization for Multivessel Coronary Artery Disease?Verghese Mathew,MD,FACCConsultant,Division of Cardiovascular Diseases and Consultant,Division of Cardiovascular Diseases and Department of RadiologyDepartment of RadiologyProfessor of Medicine,Mayo Clinic College of M
2、edicineProfessor of Medicine,Mayo Clinic College of Medicine第一页，共三十八页。Revascularization StrategiesHow do we decide?AnatomyClinicalPatientpresentation preferenceRisk vs.Benefit第二页，共三十八页。Invasive TherapiesLow Risk PatientLow Risk PatientHigh Risk PatientHigh Risk PatientSome acute Some acute riskriskL
3、ess long-term risk Less long-term risk reductionreductionGreater acute Greater acute riskriskGreater long-term Greater long-term risk reductionrisk reduction第三页，共三十八页。12-Year Survival in Patients with CAD5035-4935Emond M et al:Circ 90:2645,199423,467 Medically-Treated Patients in CASS Registry23,467
4、 Medically-Treated Patients in CASS RegistryLVEFCP1203018-2第四页，共三十八页。12-Year Survival in Patients with CADNo CAD1 vessel2 vessel3 vesselEmond M et al:Circ 90:2645,199423,467 Medically-Treated Patients in CASS Registry23,467 Medically-Treated Patients in CASS RegistryCP1203018-1第五页，共三十八页。Clinical Pre
5、sentationAgeAcute ischemic syndrome versus chronic stable anginaPrior cardiac history(MI,CABG,intervention)Co-morbid conditions(diabetes,cerebrovascular disease,renal disease,lung disease)Functional impairmentIschemic burden第六页，共三十八页。Extension of Survival with CABG vs Medical Extension of Survival w
6、ith CABG vs Medical Therapy After 10 YearsTherapy After 10 YearsCP1203018-14Extension of survival(mo)Extension of survival(mo)Yusuf S et al:Yusuf S et al:Lancet 344:563,1994Lancet 344:563,1994OverallOverallVessel diseaseVessel disease1/2 vessels1/2 vessels3 vessels3 vesselsLeft mainLeft mainLV funct
7、ionLV functionNormalNormalAbnormalAbnormalExercise testExercise testNormalNormalAbnormalAbnormalAnginaAnginaClass 0,I,IIClass 0,I,IIClass III,IVClass III,IVLowLowModerateModerateHighHighLowLowModerateModerateHighHighVA risk scoreVA risk scoreStepwiseStepwise risk score risk score第七页，共三十八页。3011246-8C
8、ABG vs Stenting for MVD Meta-Analysis of ARTS,ERACI-CABG vs Stenting for MVD Meta-Analysis of ARTS,ERACI-II,MASS-II and SOSII,MASS-II and SOSCirc 118,2008Circ 118,2008DaysEvent-Free Survival Analysis of Death1,5181,5181,4721,4721,4561,4561,4401,4401,4061,4061,3471,3471,5331,5331,4791,4791,4571,4571,
9、4391,4391,4121,4121,3491,349 Overall Overall survival(%)survival(%)P=0.78P=0.78DaysRepeat Revascularization1,5181,5181,2041,2047727727407407077076656651,5331,5331,4281,428927927911911882882855855P0.0001P0.0001 Overall Overall survival(%)survival(%)DaysDeath,Stroke or MI1,5181,5181,3811,3819139138968
10、968728728468461,5331,5331,3771,377908908891891868868845845 Overall survival Overall survival(%)(%)P=0.64P=0.64DaysMajor Adverse Cardiac and Cerebrovascular Events1,5181,5181,1531,1537297296916916576576166161,5331,5331,3321,332867867846846812812785785P0.0001P0.0001 Overall survival Overall survival(%
11、)(%)PCI 91.5%PCI 91.5%CABG 91.8%CABG 91.8%PCI 71.0%PCI 71.0%CABG 92.1%CABG 92.1%PCI 83.3%PCI 83.3%CABG 83.1%CABG 83.1%PCI 60.8%PCI 60.8%CABG 77.0%CABG 77.0%第八页，共三十八页。Increased Likelihood of Restenosis Lesion/Patient SubsetsSmall vesselsSmall vesselsBifurcationsBifurcationsOstialOstialCTOCTOBare meta
12、l ISRBare metal ISRSVGSVGAMI(thrombus)AMI(thrombus)Diabetes mellitusDiabetes mellitus第九页，共三十八页。Hazard ratio 95%CIHazard ratio 95%CIHazard ratio 95%CICP1045415-3SIRIUS Clinical Restenosis(TLR)at 1 YearSIRIUS Clinical Restenosis(TLR)at 1 YearSirolimusSirolimusSirolimusControlControlControlOverallOvera
13、llOverall4.94.94.920.020.020.0MaleMaleMale5.25.25.220.520.520.5FemaleFemaleFemale4.14.14.119.019.019.0DiabetesDiabetesDiabetes8.48.48.426.426.426.4No diabetesNo diabetesNo diabetes3.73.73.717.617.617.6LADLADLAD6.06.06.023.023.023.0Non-LADNon-LADNon-LAD4.14.14.118.018.018.0Small vessel(2.75)Small ves
14、sel(2.75)Small vessel(13.5)Long lesion(13.5)Long lesion(13.5)6.06.06.021.921.921.9OverlapOverlapOverlap5.75.75.723.223.223.2No overlapNo overlapNo overlap4.54.54.518.618.618.6P PP0.00010.00010.00010.00010.00010.00010.00020.00020.00020.00020.00020.00020.00010.00010.00010.00010.00010.00010.00010.00010
15、.00010.00010.00010.00010.00010.00010.00010.00010.00010.00010.00010.00010.00010.00010.00010.00010.00010.00010.0001EventsEventsEventsprevented/prevented/prevented/1,000 pt1,000 pt1,000 pt1521521521531531531491491491801801801381381381701701701401401401571571571511511511461461461581581581751751751411411
16、41Odds ratioOdds ratioOdds ratio第十页，共三十八页。CABG vs Drug-Eluting Stents in Multivessel Coronary CABG vs Drug-Eluting Stents in Multivessel Coronary DiseaseDiseaseA Meta-Analysis on 24,268 PatientsA Meta-Analysis on 24,268 PatientsBenedetto et al:EJCTS 6958,2009Benedetto et al:EJCTS 6958,2009Favors DES
17、-PCIFavors DES-PCIFavors CABGFavors CABG0.010.1110100HR and 95%CIHR and 95%CIStudy nameStudy nameParkParkHannanHannanBriguoriBriguoriYang JHYang JHLeeLeeYang ZKYang ZKJavaidJavaidVaraniVaraniTarantiniTarantini第十一页，共三十八页。Left Main DiseaseLeft Main Disease(isolated,+1,+2 or+3 vessels)(isolated,+1,+2 o
18、r+3 vessels)3 Vessel Disease3 Vessel Disease(revasc all 3 vascular territories)(revasc all 3 vascular territories)SYNTAX Eligible PatientsDe novo diseaseDe novo diseaseLimited Exclusion CriteriaLimited Exclusion Criteria Previous interventions Previous interventions Acute MI with CPK2x Acute MI with
19、 CPK2x Concomitant cardiac surgery Concomitant cardiac surgery第十二页，共三十八页。SYNTAX Inclusion Criteria3-vessel disease and/or left main disease Total occlusion without time limitationPrevious stroke 1 month Renal and respiratory insufficiencyDecreased pump functionMyocardial ischemia(unstable-silent-sta
20、ble)Patients with comorbidityReal world patient populationReal world patient population第十三页，共三十八页。PCIPCIn=198n=198TAXUSTAXUS*n=903n=903 CABGCABGn=897n=897vsvsvsvsCABGCABGn=1077n=1077no f/uno f/un=428n=4285yr f/u5yr f/un=649n=649Two Registry ArmsTwo Registry ArmsN=1275N=1275Randomized ArmsRandomized
21、ArmsN=1800N=1800Heart Team(surgeon&interventionalist)Heart Team(surgeon&interventionalist)Amenable for only one Amenable for only one treatment approachtreatment approachAmenable for bothAmenable for bothtreatment optionstreatment optionsStratification:Stratification:LM and DiabetesLM and DiabetesLM
22、LM33.7%33.7%3VD3VD66.3%66.3%LMLM34.6%34.6%3VD3VD65.4%65.4%23 US Sites23 US Sites62 EU Sites62 EU Sites+SYNTAX Trial Design*TAXUS Express第十四页，共三十八页。3011246-15Cumulative Cumulative rate(%)rate(%)SYNTAX:OutcomesSYNTAX:OutcomesNEJM 360(10),2009NEJM 360(10),2009Cumulative Cumulative rate(%)rate(%)Death f
23、rom Any CauseDeath from Any Cause,Stroke,or MIRepeat RevascularizationMajor Adverse Cardiac or Cerebrovascular EventMonths since randomizationCumulativeCumulativerate (%)rate (%)Cumulative Cumulative rate(%)rate(%)Months since randomizationP=0.37P=0.37P=0.99P=0.993.53.5P0.001P0.001P=0.002P=0.002Mont
24、hs since randomizationMonths since randomizationPCIPCICABGCABG4.44.4PCIPCI7.77.77.67.6CABGCABGPCIPCICABGCABG13.513.55.95.917.817.812.412.4PCIPCICABGCABG第十五页，共三十八页。3011719-16SYNTAX CABG/PCI RegistriesSYNTAX CABG/PCI RegistriesSYNTAX appendix:NEJM,2009SYNTAX appendix:NEJM,2009Reasons for CABGReasons f
25、or CABGComplex anatomyComplex anatomy70.9%70.9%Untreatable chronicUntreatable chronic22.0%22.0%total occlusiontotal occlusionUnable to takeUnable to take 0.9%0.9%anti-platelet medicationsanti-platelet medicationsPatient refused PCIPatient refused PCI 0.5%0.5%OtherOther 5.7%5.7%Reasons for PCIReasons
26、 for PCIComorbidityComorbidity70.7%70.7%No graft materialNo graft material 9.1%9.1%Patient refused CABGPatient refused CABG 5.6%5.6%Small or poor qualitySmall or poor quality 1.5%1.5%of distal vesselof distal vesselOtherOther13.1%13.1%n=644n=644n=192n=192第十六页，共三十八页。SYNTAX ScoreNumber&Number&location
27、 of location of lesionslesionsTortuosityTortuosityThrombusThrombusBifurcationBifurcationTotal OcclusionTotal OcclusionDiffuseDiffuseLeft MainLeft MainDominanceDominanceSYNTAXSYNTAXScoreScoreCalcificationCalcificationEuroInterv 2005;1:219-227第十七页，共三十八页。Outcomes Stratified by SYNTAX ScoreOutcomes Stra
28、tified by SYNTAX ScoreNEJM 360:970,2009NEJM 360:970,2009Cumulative rate of major adverse Cumulative rate of major adverse cardiac or cerebrovascular cardiac or cerebrovascular eventseventsP=0.71P=0.71Cumulative rate of major Cumulative rate of major adverse cardiac or adverse cardiac or cerebrovascu
29、lar eventscerebrovascular eventsP=0.10P=0.10Months since randomizationMonths since randomizationMonths since randomizationMonths since randomizationCumulative rate of major Cumulative rate of major adverse cardiac or adverse cardiac or cerebrovascular eventscerebrovascular eventsP0.001P 33)33)14.714
30、.713.613.6CABGCABGPCIPCI16.716.712.012.0CABGCABGPCIPCI23.423.410.910.9PCIPCICABGCABG第十八页，共三十八页。第十九页，共三十八页。第二十页，共三十八页。第二十一页，共三十八页。第二十二页，共三十八页。第二十三页，共三十八页。第二十四页，共三十八页。第二十五页，共三十八页。第二十六页，共三十八页。3011719-27Procedural Differences Between SYNTAX CABG Randomized vs RegistryCABG RCTCABG RCTCABG registryCABG re
31、gistryVariableVariablen=897n=897n=644n=644Complete revasc(%)Complete revasc(%)63.2(550/870)63.2(550/870)74.7(481/644)74.7(481/644)Graft revascularization(%)Graft revascularization(%)At least 1 arterial graftAt least 1 arterial graft97.3(831/854)97.3(831/854)96.7(623/644)96.7(623/644)Arterial graft t
32、o LADArterial graft to LAD95.6(816/854)95.6(816/854)94.7(610/644)94.7(610/644)Double LIMA/RIMADouble LIMA/RIMA27.6(236/854)27.6(236/854)16.1(104/644)16.1(104/644)Complete arterialComplete arterial18.9(161/854)18.9(161/854)11.2(72/644)11.2(72/644)revascularizationrevascularizationVenous grafts onlyVe
33、nous grafts only2.6(22/854)2.6(22/854)3.3(21/644)3.3(21/644)第二十七页，共三十八页。Cardiac-Related Medications Given after the Study Procedure*Medication Medication PCI PCI CABG CABG p p Value Value percent percent Any Any 98.998.998.698.60.620.62Aspirin Aspirin At discharge At discharge 96.396.388.588.50.001
34、0.001 6 mo after randomization 6 mo after randomization 93.293.282.782.70.001 0.001 Thienopyridine Thienopyridine At discharge At discharge 96.896.819.519.50.001 0.001 6 mo after randomization 6 mo after randomization 91.391.316.116.10.001 0.001 Any antiplatelet drug Any antiplatelet drug At dischar
35、ge At discharge 979723.723.70.001 0.001 6 mo after randomization 6 mo after randomization 91.491.418.418.40.001 0.001 Warfarin derivative Warfarin derivative 2.6 2.6 7.1 7.10.001 0.001 Statin Statin 86.786.774.574.50.001 0.001 Beta-blocker Beta-blocker 81.381.378.678.60.170.17ACE inhibitor ACE inhib
36、itor 55.155.144.644.60.001 0.001 Angiotensin IIreceptor antagonist Angiotensin IIreceptor antagonist 13.313.37 70.001 100 mm)(%)(100 mm)(%)第二十九页，共三十八页。SYNTAXStent Thrombosis and Symptomatic Graft OcclusionStent Thrombosis and Symptomatic Graft OcclusionCP1294833-1Stent ThrombosisStent ThrombosisSymp
37、tomaticSymptomaticGraft OcclusionGraft OcclusionIncidenceIncidenceMortalityMortalityT Feldman EuroPCR 2009T Feldman EuroPCR 2009第三十页，共三十八页。Percutaneous or Surgical Revascularization for Multivessel Coronary Artery Disease?Spectrum of risk(anatomic,clinical)in patients Spectrum of risk(anatomic,clini
38、cal)in patients with stable multivessel CADwith stable multivessel CADPatients with more extensive,diffuse CAD Patients with more extensive,diffuse CAD(higher SYNTAX score)fare better with CABG(higher SYNTAX score)fare better with CABG than PCI due to repeat revascularization than PCI due to repeat
39、revascularization ratesratesLower SYNTAX score patients do well with PCILower SYNTAX score patients do well with PCIThere are some patients too high risk for CABGThere are some patients too high risk for CABG第三十一页，共三十八页。Limitations of PCITLR remains higher with PCI than CABGTLR remains higher with P
40、CI than CABGLong segments of stentsLong segments of stentsPost-dilation,IVUSPost-dilation,IVUSDual antiplatelet therapyDual antiplatelet therapyStent thrombosisStent thrombosisPCI still has a significant acute failure rate in PCI still has a significant acute failure rate in specific lesion subsets:
41、specific lesion subsets:CTOCTOBifurcationBifurcationSVGSVGSevere calcification/tortuositySevere calcification/tortuosity第三十二页，共三十八页。Limitations of CABGLong-term graft attrition;total arterial revascularization still uncommonNative vessel progressionCABG not curativePCI frequently utilized for sympto
42、m relief in post-CABG第三十三页，共三十八页。Selection of Revascularization Modality-What Should We Emphasize Moving Forward?Careful assessment of anatomic and clinical riskCareful assessment of anatomic and clinical riskMeticulous stent deployment techniques Meticulous stent deployment techniques Prolonged dua
43、l antiplatelet therapy for DESProlonged dual antiplatelet therapy for DESBioabsorbable stentsBioabsorbable stentsDevice/equipment development to contend with Device/equipment development to contend with lesion subsets in which PCI failslesion subsets in which PCI failsOptimize adjuvant medical thera
44、py(antiplatelet,statin,Optimize adjuvant medical therapy(antiplatelet,statin,ACE-I)particularly in post CABG patients ACE-I)particularly in post CABG patients Total arterial revascularizationTotal arterial revascularization第三十四页，共三十八页。Explore The Best Of Both Worlds?Hybrid approaches to minimize mor
45、bidity,recovery,pain and maximize durabilityRobotic IMA to LADPCI with DES to non-LAD disease第三十五页，共三十八页。第三十六页，共三十八页。第三十七页，共三十八页。内容(nirng)总结Percutaneous or Surgical Revascularization for Multivessel Coronary Artery Disease。0.010.1110100。Complete revasc(%)63.2(550/870)74.7(481/644)。Double LIMA/RIMA27.6(236/854)16.1(104/644)第三十八页，共三十八页。