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Welcome to the 6 th European Bifurcation Club 22-23 October 2010 - BUDAPEST

Welcome to the 6 th European Bifurcation Club 22-23 October 2010 - BUDAPEST. Summary of Left Main Stem publications since last EBC Alaide Chieffo, MD San Raffaele Scientific Institute Milan, Italy . No conflict to declare. CONFLICT OF INTEREST t.

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Welcome to the 6 th European Bifurcation Club 22-23 October 2010 - BUDAPEST

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  1. Welcome to the 6th European Bifurcation Club 22-23 October 2010 - BUDAPEST Summary of Left Main Stem publications since last EBC Alaide Chieffo, MD San Raffaele Scientific Institute Milan, Italy

  2. No conflict to declare CONFLICT OF INTERESTt

  3. Hierarchical End Point at 5 Years: Milan Experience Chieffo et al JACC Cardiovasc Interv 2010; 3(6):595-601

  4. MACCE (including repeated revascularization) at 5 years PCI better CABG better 38% in DES vs 32% in CABG Adjusted OR 1.57; 95% CI0.82 to 3.05; P=0.18 Chieffo et al JACC Cardiovasc Interv 2010; 3(6):595-601

  5. CVE+Death+MI at 5 years PCI better CABG better 11.2% in DES vs 20.4% in CABG Adjusted OR= 0.43, 95% CI 0.17- 0.97; P=0.04 Chieffo et al JACC Cardiovasc Interv 2010; 3(6):595-601

  6. STENT THROMBOSIS vs. SYMMPTOMATIC GRAFT OCCLUSIONS CABG PCI Chieffo et al JACC Cardiovasc Interv 2010; 3(6):595-601

  7. Wave 1 (BMS) BMS (n=318) and CABG (n=448) Wave 2 (DES) DES (n=784) and CABG (n=690) 2006 2008 3 year 2010 5 year Clinical follow-up every 12 months Death, Composite of Death/MI/Stoke, TVR MAIN COMPARE registry Total 2240 Stent (N=1102) CABG (N=1138) From January 2000 through June 2006 Park et al. NEJM 2008;358:1781–92.

  8. Unadjusted K-M Stenting CABG Death in the Overall Patients 96.6 94.1 91.5 95.2 90.0 88.2 91.9 89.5 87.7 86.4 Log-Rank P=0.06 No. at Risk Stenting 1102 1063 1032 994 804 517 CABG 1138 1083 1042 997 879 684 Park et al. JACC 2010;56:117-24

  9. Death, Q-wave MI, or Stroke 96.0 93.5 91.0 89.5 93.5 87.8 90.5 88.3 86.6 85.3 Log-Rank P=0.03 Stenting CABG No. at Risk Stenting 1102 1050 1020 983 795 511 CABG 1138 1049 1011 969 854 662 Unadjusted K-M Park et al. JACC 2010;56:117-24

  10. TVR 98.5 97.4 96.8 96.5 96.0 90.8 88.7 86.9 85.8 84.0 Log-Rank P<0.001 Stenting CABG No. at Risk Stenting 1102 967 919 868 694 437 CABG 1138 1066 1015 964 847 654 Unadjusted K-M Park et al. JACC 2010;56:117-24

  11. 96.1 92.8 96.1 91.3 92.6 89.2 90.2 87.3 89.1 86.7 Stenting P=0.91 CABG 5-Year: Death (Overall : 542 matched pairs) 4.6% 8.7% 13.3% 9.8% 2.9% 12.7% No. at Risk Stenting 542 519 499 486 388 241 CABG 542 521 499 478 421 320 Park et al. JACC 2010;56:117-24

  12. 5-Year: Death, Q-MI, or Stroke 95.5 92.2 94.8 90.7 91.6 88.4 86.3 89.1 88.5 86.5 Stenting P=0.94 CABG (Overall 542 matched pairs) 4.2% 9.3% 13.5% 2.8% 13.7% 10.9% No. at Risk Stenting 542 512 492 479 383 239 CABG 542 506 487 467 411 311

  13. 5-Year: TVR 98.1 96.9 96.3 96.1 95.8 90.6 87.5 85.9 83.9 81.9 Stenting P<0.001 CABG (Overall : 542 matched pairs) 0.5% 4.2% 3.7% 4.0% 18.1% 14.1% No. at Risk Stenting 542 472 438 421 328 198 CABG 542 511 484 460 403 305

  14. 10 Year- Outcome BMS vs CABG Park et al J Am Coll Cardiol 2010 56: 1366-1375

  15. 10 Year- Outcome BMS vs CABG Park et al J Am Coll Cardiol 2010 56: 1366-1375

  16. 5 Year Outcome DES vs CABG Park et al J Am Coll Cardiol 2010 56: 1366-1375

  17. 5 Year Outcome DES vs CABG Park et al J Am Coll Cardiol 2010 56: 1366-1375

  18. The Global Risk Classification (GRC) 100 96.1% 94.6% 90 78.1% Cardiac death free survival (%) P = 0.004* 80 SYNTAX score < 19 19-27 > 27 70 LOW MIDDLE 60 0-2 L L I HIGH SYNTAX score 12 24 0 Time (months) 3-6 L L I EuroSCORE 98.4% 100 > 6 I I H 90 84.0% Cardiac death free survival (%) 80 P < 0.001* 70 LOW 68.6% MIDDLE 60 HIGH GRC 12 24 * log rank test; n = 255 LM patients undergoing PCI 0 Time (months) Capodanno et al, Am Heart J 2010:159:103-9

  19. Patients in SYNTAXLeft Main (LM) Subset RCT: Enrolled N=705 CABG n=348 PCI n=357 RCT: 1 Year Follow-up N=691 (98.0%) CABG n=336 PCI n=355 RCT: 2 Year Follow-up N=683 (96.9%) CABG n=331 PCI n=352 RCT: 3 Year Follow-up N=674 (95.6%) CABG n=325 PCI n=349

  20. Patient CharacteristicsLM Subset Core laboratory reported unless *Site-reported Morice et al Circulation 2010; 121 (24): 2645-53

  21. Summary of 1-Year Results LM Subset 40 40 40 40 20 20 20 20 Cumulative Event Rate (%) Cumulative Event Rate (%) Cumulative Event Rate (%) Cumulative Event Rate (%) PCI(N=903) CABG(N=897) 0 0 0 0 0 0 0 6 6 6 12 12 12 0 6 12 Months Since Allocation Months Since Allocation Months Since Allocation Months Since Allocation Death/CVA/MI Stroke P=0.009* P=0.29* 9.1% 7.0% 2.7% 0.3% Event rate ± 1.5 SE, *Fisher exact test ITT population Event rate ± 1.5 SE, *Fisher exact test ITT population Repeat Revasc. MACCE P=0.02* P=0.44* 15.8% 13.6% 12.0% 6.7% *Any revascularization (PCI or CABG); ITT population Event rate ± 1.5 SE, *Fisher exact test Event rate ± 1.5 SE, *Fisher exact test ITT population Morice et al Circulation 2010; 121 (24): 2645-53

  22. MACCE to 12 Months by SYNTAX Score TertileLow Scores (0-22) LM Subset CABG(N=103) TAXUS(N=118) 40 Mean baseline SYNTAX Score CABG 15.5 ± 4.3 TAXUS 15.7 ± 4.4 20 Cumulative Event Rate (%) 0 0 6 12 Months Since Allocation P=0.19* 13.0% 7.7% Event rate ± 1.5 SE, *Fisher exact test Calculated by core laboratory; ITT population

  23. CABG(N=92) TAXUS(N=195) 40 Mean baseline SYNTAX Score CABG 27.2 ± 3.0 TAXUS 27.0 ± 2.7 20 Cumulative Event Rate (%) 0 0 6 12 Months Since Allocation MACCE to 12 Months by SYNTAX Score TertileIntermediate Scores (23-32) LM Subset P=0.54* 15.5% 12.6% Event rate ± 1.5 SE, *Fisher exact test Calculated by core laboratory; ITT population

  24. MACCE to 12 Months by SYNTAX Score TertileHigh Scores (33) Left Main Subset CABG(N=150) TAXUS(N=135) 40 Mean baseline SYNTAX Score CABG 42.1 ± 7.6 TAXUS 43.8 ± 9.1 20 Cumulative Event Rate (%) 0 0 6 12 Months Since Allocation P=0.008* 25.3% 12.9% Event rate ± 1.5 SE, *Fisher exact test Calculated by core laboratory; ITT population

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