Bài giảng A decade of left main intervention: PCI vs CABG where are we now

The lecture presents the content LMCA interventionalists are called cowboy doctors; mai primary endpoint landmark analysisn compare 5 year; syntax left main subgroup; guideline recommendations for left main revascularisation; temporal trends of LM revascularization...

A Decade of Left Main Intervention : PCI vs CABG Where are we now ? Gim-Hooi Choo Cardiac Vascular Sentral KL (CVSKL) 12th July, 2019 Disclosure • No conflicts pertaining to this lecture hinhanhykhoa.com Sypnosis • Left Main Stem Revascularisation: The Story A Decade Earlier • After EXCEL and NOBLE in 2016 : More Clarity or Confusion? • Current Position of LMCA Revascularisation Left Main : Why the Fuss ? • inch length • % of coronary intervention • Supplies 75% of myocardial perfusion (if Right dominance) • Major Bifurcation • Associated with Multi-vessel disease Andreas Gruentzig’s Log Book : 1st Successful LMCA PCI : 3rd PCI case [Nov 24th 1977] “Third PCI patient ever treated Forty-three year old man with severe angina pectoris since September, 1977 First angiogram (November 11) revealed severe stenosis of the main L.C.A .” Note: The patient expired suddenly about months after this procedure Gruntzig A Lancet 1978;1:263 CABG was the ONLY option ! Yusuf S et al Lancet 1994; 344: 563-70 For 30 years, Surgeons RULED ! Left Main is a No Entry Zone for Interventionalists ! LMCA Interventionalists are called COWBOY Doctors MAIN COMPARE, Year Propensity Match Patients (n=542) DES vs CABG Park DW, et al JACC 2010;56:117-24 Pre-2016 RCTs Limitations : First Generation of DES ; Low rate of IVUS/OCT use Non inferiority trial Relative small sample size SYNTAX – LM : a subgroup Large Non-Inferiority margin (6-7%) hinhanhykhoa.com Results Total repeat revascularization HR 1·50 (1·04–2·17); p=0·03 16·2% 10·4% Makikallio T et al Lancet 2016;388:2743–52 Results : Stroke HR 2·25 (0·92–5·48); p=0·07 4·9% 1·7% Makikallio T et al Lancet 2016;388:2743–52 Results SYNTAX score subgroups K-M estimates 4.9% 1.9% HR 1·88 (1·23–2·89); p=0·0031 HR 1·16 (0·76–1·78); p=0·48 HR 1·41 (0·62–3·20); p=0·41 SYNTAX score assessed by independent corelab (CERC) Updated Meta-analysis PCI vs CABG at years RCTs, n=4,686 pts, Boudriot, LE MANS, PRECOMBAT, SYNTAX, NOBLE, EXCEL Palmerini T et al Am Heart J 2017;190:54-63 LM Revascularisation : Are only these Endpoints Important? CABG or PCI revascularisation Two Very Different Procedures… Different Cosmesis & Recovery Potential EXCEL: Major Adverse Events Within 30 Days (Periprocedural Events) Peri-procedural MAE, any - Death* - Stroke* - Myocardial infarction* - Ischemia-driven revascularization* - TIMI major/minor bleeding - Transfusion ≥2 units - Major arrhythmia** - Surgery/radiologic procedure - Renal failure† - Sternal wound dehiscence - Infection requiring antibiotics - Prolonged intubation (>48 hours) - Post-pericardiotomy syndrome PCI (n=948) CABG (n=957) RR [95%CI] P-value 8.1% 23.0% 0.35 [0.28, 0.45]