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Giuseppe Biondi Zoccai University of Turin, Turin, Italy METCARDIO, Turin, Italy gbiondizoccai@gmail.com

LEFT MAIN/MULTIVESSEL DISEASE: WHEN PERCUTANEOUS CORONARY INTERVENTION, WHEN SURGERY?. Giuseppe Biondi Zoccai University of Turin, Turin, Italy METCARDIO, Turin, Italy gbiondizoccai@gmail.com. Educational Fellowship in PCI for Young Interventionalists -

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Giuseppe Biondi Zoccai University of Turin, Turin, Italy METCARDIO, Turin, Italy gbiondizoccai@gmail.com

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  1. LEFT MAIN/MULTIVESSEL DISEASE: WHEN PERCUTANEOUS CORONARY INTERVENTION, WHEN SURGERY? Giuseppe Biondi Zoccai University of Turin, Turin, Italy METCARDIO, Turin, Italy gbiondizoccai@gmail.com Educational Fellowship in PCI for Young Interventionalists - Certified Training Course (EAPCI, SCAI, GISE) - Bologna, 25/9/2008 – 14:30-17:30 (15’)

  2. LEARNING GOALS • Should I bother with left main (LM)/ multivessel disease (MVD)? • Who is the winner between PCI and CABG in LM/MVD? • When is surgery appropriate for LM/MVD? • When is PCI appropriate for LM/MVD?

  3. LEARNING GOALS • Should I bother with left main (LM)/ multivessel disease (MVD)? • Who is the winner between PCI and CABG in LM/MVD? • When is surgery appropriate for LM/MVD? • When is PCI appropriate for LM/MVD?

  4. PREVALENCE AND PROGNOSIS OF LM/MVD DISEASE • Out of 1000 ptsundergoingcoronaryangio: • 30-80 willhaveunprotected LM, • 20-60 protected LM, • a total of 300-700 willhave MVD • Unprotected LM has, historically, a 36% 5-year mortality rate withmedicalRxonly, whichisreducedto 12% after CABG (p=0.004) • Correspondingfiguresfor 3VD are 18% vs 10% (p<0.001), and for 2VD are 12% vs 10% (p=0.45) • Whenever LV functionisabnormal, 5-year mortalitywithmedicalRxonlyis 25%, whichisreducedto 14% after CABG (p=0.02) Chaitman et al, Circulation 1981;64:360-367; Yusuf et al, Lancet 1994;344:563-570; Melidonis et al, Angiology 1999;50:997-1006

  5. LEARNING GOALS • Should I bother with left main (LM)/ multivessel disease (MVD)? • Who is the winner between PCI and CABG in LM/MVD? • When is surgery appropriate for LM/MVD? • When is PCI appropriate for LM/MVD?

  6. WHO’S THE WINNER BETWEEN PCI AND SURGERY IN LM-MVD?

  7. ARE THEY ENEMIES OR FRIENDS?

  8. LET’S LOOK AT THE PAST…

  9. META-ANALYSIS OF RCTS OF CABG VS PCI: 5-YEAR-SURVIVAL WITH POBA VS BMS Bravata et al, Ann Intern Med 2007;147:703-716

  10. META-ANALYSIS OF RCTS OF CABG VS PCI: 5-YEAR-SURVIVAL WITH POBA VS BMS Bravata et al, Ann Intern Med 2007;147:703-716

  11. META-ANALYSIS OF RCTS OF CABG VS PCI: 5-YEAR-SURVIVAL IN DIABETICS Bravata et al, Ann Intern Med 2007;147:703-716

  12. HOWEVER, PCI WITH BMS WAS INFERIOR TO CABG FOR THE RISK OF REPEAT PCI/CABG Biondi-Zoccai et al, Ital Heart J 2003;4:271-280

  13. WHAT ABOUT THE PRESENT…

  14. RISK OF MACE AT MID-TERM FOLLOW-UP FOLLOWING PCI WITH DES FOR ULM Biondi-Zoccai et al, Am Heart J 2008;155:274-283

  15. IMPACT OF LESION LOCATION AND PATIENT RISK FEATURES ON OUTCOMES OF ULM PCI Biondi-Zoccai et al, Am Heart J 2008;155:274-283

  16. SYNTAX REGISTRIES PCI REGISTRY (N=192) CABG REGISTRY (N=644) Mohr et al, ESC 2008

  17. SYNTAX TRIAL: 12-MONTH RESULTS % P=0.0015 P<0.001 P=0.37 P=0.11 P=0.003 P=0.89 Serruys et al, ESC 2008

  18. SYNTAX TRIAL: 12-MONTH MACES Serruys et al, ESC 2008

  19. SYNTAX TRIAL: DM VS NON-DM Serruys et al, ESC 2008

  20. LEARNING GOALS • Should I bother with left main (LM)/ multivessel disease (MVD)? • Who is the winner between PCI and CABG in LM/MVD? • When is surgery appropriate for LM/MVD? • When is PCI appropriate for LM/MVD?

  21. ESC 2005 GUIDELINES Silber et al, Eur Heart J 2005;26:804-847

  22. ESC 2005 GUIDELINES THUS CABG IS RECOMMENDED INSTEAD OF PCI IN MOST CASES OF CAD IN DIABETICS, IN MOST CASES OF MVD, AND ALL BUT A FEW CASES OF ULM …however, the guidelines are based mainly on differences in repeat revascularization rate Silber et al, Eur Heart J 2005;26:804-847

  23. MY SURGICAL MUST DOs • Concomitant compelling indication to cardiothoracic surgery (eg MR) • Absolute contraindications to antiplatelet therapy • Previous failed PCI attempts (especially LAD) • Multivessel CTO or CTO involving proximal-mid LAD • Very high SYNTAX score (?!)

  24. WHAT ABOUT ITALIAN INTERVENTIONISTS? Results of run-in survey for the RITMO Study on the management of unprotected left main disease in Italy (data limited to 2006) Sheiban et al, Int J Cardiol 2008 – in press

  25. LEARNING GOALS • Should I bother with left main (LM)/ multivessel disease (MVD)? • Who is the winner between PCI and CABG in LM/MVD? • When is surgery appropriate for LM/MVD? • When is PCI appropriate for LM/MVD?

  26. CAN WE CAN DO WHATEVER THE SURGEON DOES?

  27. CAN YOU DO IT? 85-year-old ♂withnon-STEMI and truetrifurcationalunprotected LM disease, high surgicalrisk and LVEF 45%

  28. ACTUALLY, IT CAN BE DONE,BUT SHOULD I DO IT? AFTER PCI WITH 4 STENTS BEFORE PCI Sheiban et al, Catheter Cardiovasc Interv 2008 – in press

  29. ESC 2005 GUIDELINES Silber et al, Eur Heart J 2005;26:804-847

  30. ESC 2005 GUIDELINES THUS THE ROLE OF PCI IS LIMITED IN MOST CASES OF CAD IN DIABETICS, IN MOST CASES OF MVD, AND ALL BUT A FEW CASES OF ULM …however, the guidelines are based mainly on differences in repeat revascularization rates Silber et al, Eur Heart J 2005;26:804-847

  31. MY PCI MUST DOs • Previous CABG (especially if redo already performed and/or LIMA already there) • Prohibitive surgical risk (with compelling indication) • FFR unmasks MVD as just SVD • Ongoing STEACS with culprit lesion amenable to primary PCI • Patients refuses CABG (?!) butprovidedpatient and referringcolleagues are consenting!

  32. MY EQUIPOISE • Non-bifurcational ULM with high surgical risk • Multivessel but focal disease with only A-B2 lesions, or non-challenging C lesions • Good LV function • Very young or very old • Depending also on need for and likelihood of completeness of revascularization butstillprovidedpatient and referringcolleagues are consenting!

  33. TAKE HOME MESSAGES

  34. MY PRACTICAL FLOWCHART • ULM or 3VD with any of the • following unfavorable features: • True bifurcational disease of ULM • 1 or > clinically relevant CTO • LV dysfunction (LVEF<40%) • Inexperienced operator (<1000 PCI) • Other surgical indications • CABG as first choice! • Attempt PCI only if: • CABG contraindicated and • Patient/family and cardiac surgeon • agree on PCI ULM or 3VD without unfavorable features CABG favored, but PCI reasonable • Protected LM/2VD with any of • these “favorable” features : • Ostial LAD is ok • Lack of diffuse disease • No true bifurcations • No CTO • Ongoing STEACS Risk-benefit balance supports PCI, but CABG should still be considered and discussed with patient and family

  35. A. 1ST STEP IN CRISIS MANAGEMENT IS PREVENTING THE CRISIS: FOLLOW GUIDELINES UNLESS YOU ARE JUSTIFIED …

  36. B. COLLABORATIVE DECISON-MAKING IN ALL BUT CLEAR-CUT CASES: INVOLVE OTHER INTERVENTIONAL COLLEAGUES, NON-INVASIVE CARDIOLOGISTS, AND SURGEONS

  37. C. NEVER FORCE TOO MUCH…EITHER INDICATIONS, DEVICES, TECHNIQUES, OR ANCILLARY THERAPY (EG ANTI-THROMBOTIC RX)

  38. For further slides on these topics please feel free to visit the metcardio.org website:http://www.metcardio.org/slides.html

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