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Professor Martin T Rothman Director Cardiac Research & Development Barts & The London NHS Trust London, England

PCI or CABG?. Professor Martin T Rothman Director Cardiac Research & Development Barts & The London NHS Trust London, England. PCI or CABG? Silly question…. Professor Martin T Rothman Director Cardiac Research & Development Barts & The London NHS Trust London, England. SURGERY. X.

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Professor Martin T Rothman Director Cardiac Research & Development Barts & The London NHS Trust London, England

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  1. PCI or CABG? Professor Martin T Rothman Director Cardiac Research & Development Barts & The London NHS Trust London, England

  2. PCI or CABG? Silly question… Professor Martin T Rothman Director Cardiac Research & Development Barts & The London NHS Trust London, England

  3. SURGERY X PCI or CABG? Professor Martin T Rothman Director Cardiac Research & Development Barts & The London NHS Trust London, England

  4. Unprotected left main coronary stenting: immediate and medium-term outcomes of 140 elective patients per cent • 140 LMS patients (Gp I: 47 high risk & Gp II: 93 low risk for CABG) • Three vessel disease 47% • Occluded RCA 14% • Debulking 6% • Early death I: 0% & II: 9% • TLR (6/12) I: 10.5% & II: 21% 98% 89% 72% 66% 1 6 12 Months Silvestri M et al (personal communication) JACC 2000 (In press)

  5. Inoperable Coronary artery disease How may we manage…

  6. PICVA - Basic Concept Percutaneous In-Situ Coronary Venous Arterialization • Selective Coronary Vein Perfuses Myocardium • Arterial Supply From Proximal Coronary Artery • Single Connection Made Percutaneously • Vein Blocked Proximally • Bypasses Artery Completely Transvascular Inc, with permission

  7. NOGA Guided TransAccess • Two Catheters Used: • One Positioned In Target Vessel • One Placed In Source Vessel • Using NOGA Guidance • TransAccess Catheter Pointed Toward Target Catheter • Needle Advanced • Wire Delivered Into Target Vessel Transvascular Inc, with permission

  8. New NOGA-Guided PICVA Software Live Mapper • “Target” Mode • Live Mapper in vein • Mapper acts as reference • More stable, reproducible • Less complicated, faster procedure Live TA Transvascular Inc, with permission

  9. The Cardiac Valves Can they be replaced percutaneously….

  10. Percutaneous Valve Technologies Inc. NJ, USAThe valve was implanted on April 16th, 2002 by Dr Alain Cribier

  11. Percutaneous Valve Technologies Inc. NJ, USAThe valve was implanted on April 16th, 2002 by Dr Alain Cribier

  12. Percutaneous Valve Technologies Inc. NJ, USAThe valve was implanted on April 16th, 2002 by Dr Alain Cribier

  13. Percutaneous Valve Technologies Inc. NJ, USAThe valve was implanted on April 16th, 2002 by Dr Alain Cribier

  14. Percutaneous Valve Technologies Inc. NJ, USAThe valve was implanted on April 16th, 2002 by Dr Alain Cribier

  15. Abdominal Aortic and Thoracic Aneurysms Can we treat percutaneously…

  16. Pre-Op Post-Op

  17. Stent Graft in Delivery System

  18. Part Deployed

  19. Part Deployed

  20. Mitral regurgitation… Can we treat percutaneously…

  21. Mitral ring ‘Cinch’First Human Use • September, 2001 • 3 Cases • Excellent results • Reduction in MR noted • No complications with access, delivery, deployment (“cinching”)

  22. C-Cure™ First Human UseReduction in MR Jet On LV Angiogram 4+MR LA LV End Diastole Mid Systole End Systole 2-3+MR

  23. C-Cure™ First Human UseReduction in Valve Area on 2-D Echo Pre-Cinch 6.80 cm2 Post-Cinch 5.95 cm2

  24. C-Cure™ First Human UseReduction in MR Area on Color Doppler Pre-Cinch 9.64 cm2 Post-Cinch 4.04 cm2

  25. SURGERY X PCI or CABG? !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Professor Martin T Rothman Director Cardiac Research & Development Barts & The London NHS Trust London, England

  26. CABG (isolated) & Percutaneous interventions UK Cardiac Surgical Register British Cardiovascular Intervention Society

  27. CABG (isolated) & Percutaneous interventions UK Cardiac Surgical Register British Cardiovascular Intervention Society

  28. Guidance on Coronary Artery Stents in the Treatment of Ischaemic Heart Disease (May 11th 2000) • patients with angina or who have had a heart attack, who will be having balloon angioplasty/PCI should now normally receive a coronary artery stent • if a patient is suitable for both a PCI and a coronary artery bypass graft (CABG), then it may be considered preferable for these patients to undergo a PCI with a coronary artery stent, instead of a CABG

  29. CABG Diffuse MVD LMS + MVD MVD + Complex LMS MVD Complex CTO SVD PCI

  30. CABG Diffuse MVD LMS + MVD MVD + Complex LMS MVD Complex CTO SVD PCI

  31. Single v Multi-vessel diseaseCABG & PCI 95.4% 82.5% UK Cardiac Surgical Register British Cardiovascular Intervention Society

  32. Single v Multi-vessel diseaseCABG & PCI 95.4% 82.5% 80% UK Cardiac Surgical Register British Cardiovascular Intervention Society !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Martin T Rothman BCIS 2002

  33. !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Martin T Rothman BCIS 2002

  34. Guidance on Coronary Artery Stents in the Treatment of Ischaemic Heart Disease (May 11th 2000) • patients with angina or who have had a heart attack, who will be having balloon angioplasty/PCI should now normally receive a coronary artery stent • if a patient is suitable for both a PCI and a coronary artery bypass graft (CABG), then it may be considered preferable for these patients to undergo a PCI with a coronary artery stent, instead of a CABG

  35. !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Martin T Rothman BCIS 2002

  36. !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Martin T Rothman BCIS 2002

  37. !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Martin T Rothman BCIS 2002

  38. * NSF !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Martin T Rothman BCIS 2002

  39. *BLT * NSF (BLT = Barts and the London) !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Martin T Rothman BCIS 2002

  40. !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Martin T Rothman BCIS 2002

  41. !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Martin T Rothman BCIS 2002

  42. !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Martin T Rothman BCIS 2002

  43. PCI or CABG ? – my view • PCI will increase • PCI will take CABG cases • Because of Drug Eluting Stents • Because of improving skill and equipment • CABG will decrease • The CABG we ask for will be more complex • But the surgeons will be less experienced • We need to participate in the development of PCI, not be lead by NSF – BCIS lead activity • Centres need to develop strategy for increasing volume • Less operators doing more • More operators doing less • Both…. BCIS lead activity • We need to address AMI – BCIS lead activity • We must hope for an improved thrombolytic strategy that evolves quickly!

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