1. PCI For MVD: Complete vs Partial Revascularization --Partial More Realistic in Most Patients Yuejin Yang MD, PhD, FACC Cardiovascular Institute and Fu-Wai Hopital, CAMS & PUMC CIT 2010, Mar.31-April.3,2010, Beijing, China

2. Indications for Revascularization Myocardial ischemia due to chronic severe coronary mechanical blockages (stable AP) Acute myocardial ischemia due to acute coronary severe mechanical stenosis (UA or NSTEMI) AMI due to acute coronary thrombotic total blockages (STEMI) The evidence of myocardial ischemia or infarction The evidence of coronary mechanical severe stenosis even obstructions except for non- mechanical one

3. Why Revascularization? Solve the coronary mechanical blockages –Bypass a new conduit (CABG) –Open and scarfolding the blockage lesions (PCI: stenting) Not for the non-mechanical obstructions Not for thrombotic stenosis except for total obstructions (STEMI) Medications for the non-mechanical and less severe coronary obstructions –Anti-spasm –Anti-platelet and anti-coagulation –Stablizing the vulnerable plaque

4. Why Complete Revarscularization CABG era –Once bypass surgery, complete Revars. –No routine dual-antiplatelet therapy –No statins –No medications for stabilizing even preventing from progression of the atherosclerotic plaque lesions

5. Why Partial Revarscularization DES period –Routine dual anti-platelet regimen –Routing statins –Medical treatment can stabilize or prevent from lesion progression –Borderline lesions(50%-70%): no need for stenting without evidence of myocardial ischemia

6. PCI: Complete Revascularization? No need in some pts with MVD –No improving long term outcomes –Just prevent myocardial ischemia and relieve ischemic symptoms –In pts without symptoms and ischemic evidence –In disdal coronary lesions –In senior persons –In small vessels –In 1-V CTO lesion with abundant collateral circulations

7. PCI: Complete Revascularization? Technically impossible in some Pts –3-V diffused disease –Diffused lesions –Small vessel CTOs –Distal severe stenosis even CTOs –Non-dominant RCA stenosis –High risk lesions (severe calcifications ) –In very old, weak and high risk pts –In AMI pts with another coronary CTOs

8. PCI: Complete Revascularization? No more benefits even harmful for the pts –More stents –Much more costs –Over treatment –High risks for stent thrombosis –High risks for stent restenosis and revascularizations –Not criterion of PCI –No faithfulness between Drs and Pts –Waste limited medical sources

9. PCI: Partial Revascularization More realistic in most pts with MVD Stenting the ischemia related vessel Ischemic symptoms alleviated even no more PCI only for IRA in Pts with STEMI can save life PCI only for proximal severe stenosis can improving quality of life and outcomes Cost much less Save the huge amount of medical sources and social expenses Affordable for more pts and families

10. Mr. Wang MX M 46yrs 698802 09-9-18 Baseline CAA: LM: OK LAD: unremarkable Mid-LCX: CTO, but small Mid-RCA: 100% occluded (2 stents deployed) 3 days later STEMI occurred CAA: mid-RCA stent totally occluded Cases 1: No need PCI for Samll LCX CTO

11. Baseline CAA (09-18-09)

12. RCA: 2 DES deployed

13. LM-Bif. with Severe Calcification: Technically Impossible for complete revas. 杜贵荣 F 80 Yrs ACS LM bifurcation with severe calcification lesion CABG strong suggested and contraindicated IABP inserted Kissing stenting performed Sequential high pressure and final kissing High pressure pre- and post-dilatation(20 atm) IVUS checked

14. Baseline CAA+LVG

15. IABP+TFI+Balloon Predilatation

16. Kissing Stenting with High Pressure Deployment and Post-dilatation

17. Final Optimal Results

18. Triple-VD with Diffused Lesions: Technically Impossible for Complete Revas. 陈立忠 M 55yrs 682710 3-VD: 均弥漫病变 LAD 弥漫病变最重 90% （做） LCX 弥漫病变最重 90% （做） Nondominant RCA 弥漫病变最重 90% （未做）

19. Baseline CAA

20. LAD Stenting

21. Dominant LCX Stenting

22. Cases 3 Mr. Yang XP M 62 yrs 456039 09-8-26 STEMI (IPW)×4 hrs 2001 Mid-LCX BMS×1 2004 follow-up CAA: normal 2006 Ischemic symptom-driven Second BMS (driver) in Prox-LCX Statin discontinued for 2 yrs due to side effects Severe chest pain for 4 hrs STEMI: No More Benefit of Complete Revascularization

23. Baseline CAA: LCX(IRA) definite ST occlusion

24. OCT Exam first, then Ballooning was done

25. Conclusions PCI of complete revascularization in multi- vessel disease is not needed, technically impossible, no benefit and even harmful to the patients. On the other hand, partial revascularization of PCI is cost effective, technically feasible, and also can improve quality of life and outcomes Partial revascularization in PCI is more realistic in most patients with multi-vessel disease It can save huge amount of money even though revascularization rate might be 10% higher in partial vs complete revascularization.

26. Welcome Attend China Heart Conference (IHF2010) ： 2nd international TR Coronary Therapeutics (TRCT) Chaired by Yue-Jin Yang MD. PhD. FACC Co-Chaired by Dr. Saito Dr. kiemeneiji NCC, 2010/08/13-15, Beijing, China

27. Thank you very much !