Phẫu thuật bắc cầu nối cho tốn thương nhiều thân mạch vành khi nào và tại sao

PCI for multi-vessel CAD when & how? Dinh Duc Huy, MD, FSCAI Tam Duc Heart Hospital Very different ways to treat disease Gersh and Frye New Engl J Med 2005;352:2235 PCI versus CABG: ASCERT Registry 189,000 stable patients =65 years old treated with either PCI or CABG Weintraub, et al New Engl J Med 2012;366:1457-76 Meta-Analysis of 10 randomized CABG vs PCI trials- 7000 patients Impact of diabetes Impact of age Hlatky, et al Lancet 2009;373:1190-97 SYNTAX study- year outcomes 1800 patients with vessel CAD randomized to PCI with Paclitaxel DES or CABG Mortality MI MACCE Stroke Mohr, et al Lancet 2013;381:629-38 Impact of Syntax Score Serruys, et al N Engl J Med 2009;360:961-72 Freedom trial- long term outcomes 1900 diabetics enrolled from 140 centers with mostly 1st generation DES Farkouh, et al N Engl J Med 2012;367:2375-84 Backgrounds- Most trials comparing PCI with CABG have not made use of 2nd -generation drug-eluting stents The primary end point = composite of death, MI, or TVR at years after randomization Park S J N Engl J Med 2015;372:1204-12 BEST studymain results • 27 centers in East Asia • 880 patients • 438 in PCI group • 442 in CABG group • MACEs was higher among those who had undergone PCI with the use of Everolimus-DES than among those who had undergone CABG Park S J N Engl J Med 2015;372:1204-12 Longterm clinical outcomes end points Park S J N Engl J Med 2015; 372:1204-12 Subgroup analysis- Impact of Diabetes, Syntax score, EuroSCORE Park S J N Engl J Med 2015;372:1204-12 PCI for multi-vessel CAD 1st message: PCI is good in patients with young age, less complex CAD (low Syntax score), and non-diabetic Same data from New York State registryEverolimus-eluting stent or bypass surgery for multi vessel coronary disease? Bangalore S N Engl J Med 2015;372:1213-22 Complete versus Incomplete Revascularization from New York Registry PCI CABG HR (95%CI) P value Complete Revascularization N=1911 N=1911 Death at year 2.54% 2.5% 1.08 (0.82-1.42) 0.58 Myocardial infarction 1.43% 1.37% 1.02 (0.71-1.47) 0.93 Stroke 0.42% 0.84% 0.43 (0.24-0.75) 0.003 Revascularization 5.46% 3.4% 1.55 (1.26-1.9)