S Ten Tse and Sensibility! The evidence for surgery in triple vessel coronary artery disease and Left main stem disease Joseph Zacharias 28th July 2006

The evidence for Coronary artery surgery. Surgery Vs medical therapy Surgery Vs POBA Surgery Vs Bare Metal Stents Surgery Vs Drug Eluting Stents Evidence Vs Philosophy 28th July 2006

Surgery Vs Medical therapy VA Study (1972-74) Mortality 5.6% European study (1973-76) Mortality 3.6% CASS study (1975-79) Mortality 1.4% Predominantly male patients. Predominantly single or double vessel disease Predominantly Good LV function. Age criteria < 65 yrs. 28th July 2006

Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. - The CABG group had significantly lower mortality than the medical treatment group at 5 years (10.2 vs 15.8%) -10 years (26.4 vs 30.5%) -The risk reduction was greater in patients with left main artery disease than in those with disease in three vessels or one or two vessels Lancet. 1994 Aug 27;344(8922):563-70. 28th July 2006

Comparison of surgical and medical group survival in patients with left main coronary artery disease. Long-term CASS experience. 1484 patients with LMCD in the Coronary Artery Surgery Study (CASS) Registry Median survival in the surgical group was 13.3 years (12.8 to 13.8 years, 95% confidence limits) compared with only 6.6 years (5.4 to 7.9 years) in the medical group The 15-year cumulative survival estimates were 37% for the 1153 patients in the surgical group compared with 27% for the 331 patients in the medical group. a disproportionate increase in the late surgical group mortality. Circulation. 1995 May 1;91(9):2325-34. 28th July 2006

Surgery Vs POBA RITA 88-91 2.5 yrs 3.6 3.1 4.0 37 78/59 ERACI-1 88-90 Death Revasc Angina CABG/ PCI CABG/PCI CABG/PCI RITA 88-91 2.5 yrs 3.6 3.1 4.0 37 78/59 ERACI-1 88-90 3 yrs 4.7 9.5 6.3 96/95 GABI 86-91 1 yr 5.1 0.5 43 71/74 EAST 85-86 6.2 7.1 14 63 88/80 CABRI 88-92 2.7 3.9 3.5 36 75/67 MASS 2 yrs 2.9 5.7 0.0 30 73/64 BARI 5 yrs 10.7 13.7 8.0 54 NA 28th July 2006

A meta-analysis of randomized controlled trials comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty: one- to eight-year outcomes. A meta-analysis of 13 randomized trials on 7,964 patients comparing PTCA with CABG. 1.9% absolute survival advantage favoring CABG over PTCA for all trials at five years (p < 0.02) subgroup analysis of multivessel disease, CABG provided significant survival advantage at both five and eight years. CABG is associated with a lower five-year mortality, less angina, and fewer revascularization procedures J Am Coll Cardiol. 2003 Apr 16;41(8):1293-304. 2003 Apr 16;41(8):1293-304. 2003 Apr 16;41(8):1293-304 28th July 2006

Surgery Vs Bare metal stents Death % Revasc % Angina free CABG/ PCI CABG/PCI CABG/PCI ARTS 97-98 1 yr 2.8 2.5 3.8 21 89.5 78.9 SoS 96-99 2 yrs 2 5 6.0 79% 66% AWESOME 95-00 5 yrs 27 22 5.0 12 60% 56% 28th July 2006

One-year outcomes of CABG versus PCI with multiple stenting for multisystem disease: a meta-analysis of individual patient data from randomized clinical trials. Arterial Revascularization Therapies Study, Stent or Surgery Trial, Argentine Randomized Trial of Percutaneous Transluminal Coronary Angioplasty Versus Coronary Artery Bypass Surgery in Multivessel Disease 2, Medicine, Angioplasty, or Surgery Study 2 PCI with multiple stenting (N = 1518) versus CABG surgery (N = 1533) Repeat revascularization procedures occurred more frequently in patients allocated to PCI with multiple stenting compared with CABG 18% vs 4.4% freedom from angina was slightly lower after PCI than after CABG 77% vs 82% J Thorac Cardiovasc Surg. 2005 Aug;130(2):512-9 28th July 2006

Propensity analysis of long-term survival after surgical or percutaneous revascularization in patients with multivessel coronary artery disease and high-risk features. Cleveland clinic Registry 6033 consecutive patients who underwent revascularization in the late 1990s. PCI was performed in 872 patients; 5161 underwent CABG. The 1- and 5-year unadjusted mortality rates were 5% and 16% for PCI and 4% and 14% for CABG In patients with multivessel coronary artery disease and many high-risk characteristics, CABG was associated with better survival than PCI after adjustment for risk profile. Circulation. 2004 May 18;109(19):2290-5. 28th July 2006

Long-term outcomes of coronary-artery bypass grafting versus stent implantation. New York's cardiac registries 37,212 patients with multivessel disease who underwent CABG 22,102 patients with multivessel disease who underwent PCI January 1, 1997, to December 31, 2000. Risk-adjusted survival rates were significantly higher among patients who underwent CABG than among those who received a stent in all of the anatomical subgroups studied. Rates of revascularization at 3 years: 7.8 percent vs. 0.3 percent for subsequent CABG 27.3 percent vs. 4.6 percent for subsequent PCI. For patients with two or more diseased coronary arteries, CABG is associated with higher adjusted rates of long-term survival than stenting. N Engl J Med. 2005 May 26;352(21):2174-83 28th July 2006

Coronary artery stenting and non cardiac surgery: a prospective outcome study. Dept of Anaesthesia and Intensive care , university of Graz, Austria. 103 pts. after coronary stents within 1 yr Antiplatelet drugs not or briefly interrupted. 44.7% complication rate post non cardiac surgery 4.9% mortality The risk was 2.11 fold greater within 35 days of stenting compared with >90 days. BJA,Volume 96 (6) 686-693. 28th July 2006

“We estimate that only 10-15% of candidates for bypass surgery have lesions suitable for this procedure.” A Gruentzig & U Sigwart 1976. 28th July 2006

Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease. Cedars-Sinai Medical Center, University of California, Los Angeles School of Medicine, California, USA. 123 patients underwent CABG, and 50 patients underwent PCI with DES for ULMCA disease The 30-day major adverse cardiac and cerebrovascular event (MACCE) rate for CABG and PCI was 17% and 2% MACCE-free survival at six months and one year was 83% and 75% in the CABG group versus 89% and 83% in the PCI group J Am Coll Cardiol. 2006 Feb 21;47(4):864-70 28th July 2006

Percutaneous treatment with drug-eluting stent implantation versus bypass surgery for unprotected left main stenosis: a single-center experience. Interventional Cardiology, San Raffaele Scientific Institute, Milan, Italy Two hundred forty-nine patients with LMCA stenosis were treated with PCI and DES implantation (n=107) or coronary artery bypass grafting (CABG) (n=142) At 1 year, there was no statistical difference in the occurrence of death in PCI versus CABG No difference was detected in the occurrence of major adverse cardiac and cerebrovascular event Circulation. 2006 May 30;113(21):2542-7 28th July 2006

Indications of coronary angioplasty and stenting in 2003: what is left to surgery? “In high volume experienced centers, CABG indications would be reduced in the future to the technical pitfalls of stenting (complex or tortuous anatomy, chronic occlusions) or to the adverse additional cost of this device. We expect randomised studies of CABG versus stented angioplasty using drug eluting stents to confirm these preliminary data.” J Cardiovasc Surg (Torino). 2003 Jun;44(3):307-12. 28th July 2006

Insights from the SYNTAX run-in phase. Synergy between PCI with TAXUS drug-eluting stent and Cardiac Surgery randomized trial comparing PCI with drug-eluting stent versus CABG for three-vessel and left main disease Coronary artery bypass grafting was the most frequently performed procedure (N=8895, 74%) PCI for left main and/or three-vessel disease was performed: USA: 18%. Europe: 29% Percutaneous coronary intervention is performed frequently without supporting data from the literature. Eur J Cardiothorac Surg. 2006 Apr;29(4):486-91 28th July 2006

Market Forces FAD or Disruptive Technology? 28th July 2006

Perceived Risk = Hazard x Outrage* * Steven d Levitt ; Freakonomics, HarperCollins 2005 28th July 2006

Conclusion The gap is narrowing between CABG & PCI The long term results with CABG remain unmatched The widespread use of DES will be dictated more by economics than evidence Coexistence of PCI and CABG with increasing hybrid procedures 28th July 2006