1. In Diabetics with Ischemic Heart Disease CABG revascularization is always superior? Dr. Paolo Ferrazzi

2. DN, male, 65 yr NIDDM, HT BMI 28 3 vessel disease What is the best OPTION? CLINICAL SCENARIO

3. Background Major developments in CABG – off-pump technique, less invasive approach, increased arterial revascularization and optimal perioperative care Major developments in PCI – improved technique, stent design, guide wires, anti-platelet therapy, and drug- eluting stents Important to reassess the respective values of the two revascularization

4. 7812 patients Median FU 6 years 65%: 1 or 2 VD; all normal LV 1233 with DM HR for CABG vs PCI in DM 0.70; p= 0.01 Survival benefit of CABG increases with time Lancet 2009; 373: 1190–97

9. p=0,38 p=0,078 p<0,001

11. FREEDOM TRIAL:PATIENTS WITH DIABETES New England J. of Medicine, December 20, 2012; Vol. 367 No. 25

12. Survival benefit with two IMA grafts?

13. Bergamo experience 2012 Diabetic and non Diabetic Patients Patients n.139 LIMA (%)99% BIMA (%)43% A RAD (%)32% Perioperative mortality0.92

14. Bergamo experience Surgical options in diabetes LIMA Pedicled + RIMA skeletonized in situ LIMA + RIMA skeletonized in situ LIMA in situ + RIMA (Y grafted)

16. Actuarial survival unmatched diabetic pts Actuarial survival propensity score–matched diabetic pts Actuarial survival unmatched diabetic pts <65yr Actuarial survival unmatched diabetic pts ≥65yr p<0.001 P=0.006 P=0.014 Compared with SIMA grafting, BIMA grafting in propensity score–matched patients provides diabetics with enhanced survival without any increase in perioperative morbidity or mortality

18. Conclusions CABG seems to have better long-term results in complex multivessel diabetic patients Two mammary seems to be better than one Adding radial artery to revascularization strategy could further improve results The optimum revascularization strategy for each individual patient will depend on a careful consideration of the risks and benefits of each procedure in conjunction with the baseline risk profile

19. PCI CABG

21. SYNTAX Trial: top 15 Enrollers

22. P=0.001 P<0.001