1. www.metcardio.org 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’) LEFT MAIN/MULTIVESSEL DISEASE: WHEN PERCUTANEOUS CORONARY INTERVENTION, WHEN SURGERY? LEFT MAIN/MULTIVESSEL DISEASE: WHEN PERCUTANEOUS CORONARY INTERVENTION, WHEN SURGERY?

2. www.metcardio.org 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. www.metcardio.org 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. www.metcardio.org PREVALENCE AND PROGNOSIS OF LM/MVD DISEASE Chaitman et al, Circulation 1981;64:360-367; Yusuf et al, Lancet 1994;344:563-570; Melidonis et al, Angiology 1999;50:997-1006 Out of 1000 pts undergoing coronary angio: 30-80 will have unprotected LM, 20-60 protected LM, a total of 300-700 will have MVD Unprotected LM has, historically, a 36% 5-year mortality rate with medical Rx only, which is reduced to 12% after CABG (p=0.004) Corresponding figures for 3VD are 18% vs 10% (p<0.001), and for 2VD are 12% vs 10% (p=0.45) Whenever LV function is abnormal, 5-year mortality with medical Rx only is 25%, which is reduced to 14% after CABG (p=0.02)

5. www.metcardio.org 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. www.metcardio.org WHO’S THE WINNER BETWEEN PCI AND SURGERY IN LM-MVD?

7. www.metcardio.org ARE THEY ENEMIES OR FRIENDS?

8. www.metcardio.org LET’S LOOK AT THE PAST…

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

12. www.metcardio.org 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. www.metcardio.org WHAT ABOUT THE PRESENT…

14. www.metcardio.org 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. www.metcardio.org 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. www.metcardio.org SYNTAX REGISTRIES Mohr et al, ESC 2008 PCI REGISTRY (N=192) CABG REGISTRY (N=644)

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

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

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

20. www.metcardio.org 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. www.metcardio.org ESC 2005 GUIDELINES Silber et al, Eur Heart J 2005;26:804-847

22. www.metcardio.org ESC 2005 GUIDELINES Silber et al, Eur Heart J 2005;26:804-847 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

23. www.metcardio.org 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. www.metcardio.org WHAT ABOUT ITALIAN INTERVENTIONISTS? Sheiban et al, Int J Cardiol 2008 – in press Results of run-in survey for the RITMO Study on the management of unprotected left main disease in Italy (data limited to 2006) RESPONDERSNON-RESPONDERS Number of centers 45195 Total coronary angiographies 61,370198,906 Coronary angiographies per center 1363±8661036±630 Total PTCA 31,69992,392 PTCA per center 704±479499±308 Total multivessel PTCA 7,87019,947 Multivessel PTCA per center 183±163109±106 Total PTCA with stenting 28,96185,732 PTCA with stenting per center 673±428465±288 Total PTCA with drug-eluting stenting 18,35746,498 PTCA with drug-eluting stenting per center 426±350261±200 ULM diagnosed at angiography per center, of total angio 5.0% (1.9-15.8)- ULM treated with CABG per center, out of total ULM at angio 50.0% (9.3-99.1)- ULM treated with PTCA per center, out of total ULM at angio 20.0% (0-80.8)-

25. www.metcardio.org 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. www.metcardio.org CAN WE CAN DO WHATEVER THE SURGEON DOES?

27. www.metcardio.org CAN YOU DO IT? 85-year-old with non-STEMI and true trifurcational unprotected LM disease, high surgical risk and LVEF 45% 85-year-old ♂ with non-STEMI and true trifurcational unprotected LM disease, high surgical risk and LVEF 45%

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

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

30. www.metcardio.org ESC 2005 GUIDELINES Silber et al, Eur Heart J 2005;26:804-847 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

31. www.metcardio.org 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 (?!) but provided patient and referring colleagues are consenting!

32. www.metcardio.org 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 but still provided patient and referring colleagues are consenting!

33. www.metcardio.org TAKE HOME MESSAGES

34. www.metcardio.org 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 CABG favored, but PCI reasonable ULM or 3VD without unfavorable features Risk-benefit balance supports PCI, but CABG should still be considered and discussed with patient and family Protected LM/2VD with any of these “favorable” features : Ostial LAD is ok Lack of diffuse disease No true bifurcations No CTO Ongoing STEACS

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

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

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

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