1. Multivessel Coronary Artery Disease
“IS THE NAIL IN THE COFFIN?”
Forrest Glover, M.D.
Interventional Cardiologist
Jack Steven’s Heart Institute
April 25, 2015

3. What is our goal of therapy?
Prevent complications of CAD in effort to prolong life
Decrease cardiac morbidity
Alleviate symptoms

4. What are the indications for revascularization?
Activity limiting symptoms despite maximal medical therapy
Not tolerating medication well or need to increase activity level
Anatomy favors survival benefit (significant LMCA disease or multivessel CAD with decreased LVEF)

5. Will the debate go on forever?
Balloon angioplasty vs CABG
BARI
RITA
GABI
EAST
CABRI

6. Will the debate go on forever?
Bare metal stent vs CABG
ERACI - II
ARTS
SOS
Drug eluting stents vs CABG
ARTS - II
ERACI – III
SYNTAX

7. SYNTAX Trial CABG vs PCI in 3 vessel or LMCA disease
60% patients were 3V CAD
40% LMCA disease
Paclitaxel was the DES used

8. SYNTAX Trial How the score was calculated Amount of segments involved
If a CTO was present and if so what type
Bifurcation vs trifurcation lesions
Ostial lesions
Tortuosity
Long segment disease
Small vessel disease

9. SYNTAX Trial
Composite primary endpoint was higher in PCI vs CABG (17.8% vs 12.4%)
Death/MI/Repeat revascularization
This was driven by revascularization (13.5% vs 5.9%)
Death/Stroke/MI were comparable
At 3 and 5 year follow up, primary endpoint remained higher in PCI group (driven by revascularization)

10. SYNTAX Trial Outcomes were then broken down by disease complexity
SS < 23 - no difference in composite endpoint
SS endpoint was higher with PCI (37.9% vs 22.6%)
SS > 33 - endpoint was higher with PCI (41.9% vs 24.1%)

11. SYNTAX Trial Criticisms No clinical variables
Use of paclitaxel (increased rate of angiographic and clinical restenosis than later generations)
Bypass patients were often not on “maximal” medical therapy

12. SYNTAX II Additional scoring factors Anatomical syntax score Age
Creatinine clearance
LVEF
Presence of unprotected LMCA disease
PAD
Female sex
COPD

13. PCI preferred 2 vessel CAD especially if LAD is not involved
Older patients with significant comorbidities
Patients who refuse surgery
Patients with low complexity disease that do not have diabetes

14. PCI or CABG If patients are equally suited
Decision should be made by joint team
Patients willingness to undergo repeat procedures should be assessed
Patients should be aware of slightly higher stroke risk with CABG vs PCI
Should not be attempted by low volume operators
Assess ability to take DAPT for a long period of time

15. Case 1 52 year old Woman Diabetic
Poor exercise tolerance on stress echo
Anterior ischemia

16. Case 1

18. Case 2 88 year old woman Severe COPD on home oxygen Unable to walk
Renal insufficiency

19. Case 2

20. Case 2

21. Case 2

22. Case 2

23. Case 2

24. Case 2

25. The Future?