1. Professor Martin T Rothman Director Cardiac Research & Development Barts & The London NHS Trust London, England Professor Martin T Rothman Director Cardiac Research & Development Barts & The London NHS Trust London, England PCI or CABG?

2. Professor Martin T Rothman Director Cardiac Research & Development Barts & The London NHS Trust London, England Professor Martin T Rothman Director Cardiac Research & Development Barts & The London NHS Trust London, England PCI or CABG? Silly question… PCI or CABG? Silly question…

3. Professor Martin T Rothman Director Cardiac Research & Development Barts & The London NHS Trust London, England Professor Martin T Rothman Director Cardiac Research & Development Barts & The London NHS Trust London, England PCI or CABG? X X SURGERY

4. 140 LMS patients (Gp I: 47 high risk & Gp II: 93 low risk for CABG) Three vessel disease 47% Occluded RCA 14% Debulking 6% Early death I: 0% & II: 9% TLR (6/12) I: 10.5% & II: 21% Unprotected left main coronary stenting: immediate and medium-term outcomes of 140 elective patients per cent Months Silvestri M et al (personal communication) JACC 2000 (In press) Silvestri M et al (personal communication) JACC 2000 (In press) 1612 98% 89% 72% 66%

5. Inoperable Coronary artery disease How may we manage… Inoperable Coronary artery disease How may we manage…

6. PICVA - Basic Concept Percutaneous In-Situ Coronary Venous Arterialization Selective Coronary Vein Perfuses Myocardium Arterial Supply From Proximal Coronary Artery Single Connection Made Percutaneously Vein Blocked Proximally Bypasses Artery Completely Percutaneous In-Situ Coronary Venous Arterialization Selective Coronary Vein Perfuses Myocardium Arterial Supply From Proximal Coronary Artery Single Connection Made Percutaneously Vein Blocked Proximally Bypasses Artery Completely Transvascular Inc, with permission

7. NOGA Guided TransAccess Two Catheters Used: One Positioned In Target Vessel One Placed In Source Vessel Using NOGA Guidance TransAccess Catheter Pointed Toward Target Catheter Needle Advanced Wire Delivered Into Target Vessel Two Catheters Used: One Positioned In Target Vessel One Placed In Source Vessel Using NOGA Guidance TransAccess Catheter Pointed Toward Target Catheter Needle Advanced Wire Delivered Into Target Vessel Transvascular Inc, with permission

8. New NOGA-Guided PICVA Software “Target” Mode Live Mapper in vein Mapper acts as reference More stable, reproducible Less complicated, faster procedure “Target” Mode Live Mapper in vein Mapper acts as reference More stable, reproducible Less complicated, faster procedure Live Mapper Live TA Transvascular Inc, with permission

9. The Cardiac Valves Can they be replaced percutaneously…. The Cardiac Valves Can they be replaced percutaneously….

10. Percutaneous Valve Technologies Inc. NJ, USA The valve was implanted on April 16th, 2002 by Dr Alain Cribier

15. Abdominal Aortic and Thoracic Aneurysms Can we treat percutaneously… Abdominal Aortic and Thoracic Aneurysms Can we treat percutaneously…

16. Pre-Op Post-Op

18. Stent Graft in Delivery System

19. Part Deployed

21. Mitral regurgitation… Can we treat percutaneously…

22. Mitral ring ‘Cinch’ First Human Use September, 2001 3 Cases Excellent results Reduction in MR noted No complications with access, delivery, deployment (“cinching”) September, 2001 3 Cases Excellent results Reduction in MR noted No complications with access, delivery, deployment (“cinching”)

23. C-Cure™ First Human Use Reduction in MR Jet On LV Angiogram End Diastole Mid Systole End Systole LV LA 4 + MR 2-3 + MR

24. C-Cure™ First Human Use Reduction in Valve Area on 2-D Echo Pre-Cinch 6.80 cm 2 Pre-Cinch 6.80 cm 2 Post-Cinch 5.95 cm 2 Post-Cinch 5.95 cm 2

25. C-Cure™ First Human Use Reduction in MR Area on Color Doppler Pre-Cinch 9.64 cm 2 Pre-Cinch 9.64 cm 2 Post-Cinch 4.04 cm 2 Post-Cinch 4.04 cm 2

26. Professor Martin T Rothman Director Cardiac Research & Development Barts & The London NHS Trust London, England Professor Martin T Rothman Director Cardiac Research & Development Barts & The London NHS Trust London, England PCI or CABG? X X SURGERY !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!!

27. UK Cardiac Surgical Register British Cardiovascular Intervention Society UK Cardiac Surgical Register British Cardiovascular Intervention Society CABG (isolated) & Percutaneous interventions

28. UK Cardiac Surgical Register British Cardiovascular Intervention Society UK Cardiac Surgical Register British Cardiovascular Intervention Society

31. Guidance on Coronary Artery Stents in the Treatment of Ischaemic Heart Disease (May 11 th 2000) patients with angina or who have had a heart attack, who will be having balloon angioplasty/PCI should now normally receive a coronary artery stent if a patient is suitable for both a PCI and a coronary artery bypass graft (CABG), then it may be considered preferable for these patients to undergo a PCI with a coronary artery stent, instead of a CABG

32. CABG PCI Diffuse MVD SVD Complex MVD LMS MVD + Complex LMS + MVD CTO

33. CABG PCI Diffuse MVD SVD Complex MVD LMS MVD + Complex LMS + MVD CTO

34. Single v Multi-vessel disease CABG & PCI 95.4% 82.5% UK Cardiac Surgical Register British Cardiovascular Intervention Society UK Cardiac Surgical Register British Cardiovascular Intervention Society

35. 95.4% 82.5% UK Cardiac Surgical Register British Cardiovascular Intervention Society UK Cardiac Surgical Register British Cardiovascular Intervention Society 80% Single v Multi-vessel disease CABG & PCI !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Martin T Rothman BCIS 2002

36. !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Martin T Rothman BCIS 2002

37. Guidance on Coronary Artery Stents in the Treatment of Ischaemic Heart Disease (May 11 th 2000) patients with angina or who have had a heart attack, who will be having balloon angioplasty/PCI should now normally receive a coronary artery stent if a patient is suitable for both a PCI and a coronary artery bypass graft (CABG), then it may be considered preferable for these patients to undergo a PCI with a coronary artery stent, instead of a CABG

38. !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Martin T Rothman BCIS 2002

39. !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Martin T Rothman BCIS 2002

40. !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Martin T Rothman BCIS 2002

41. * * NSF !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Martin T Rothman BCIS 2002

42. * BLT * * NSF (BLT = Barts and the London) !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Martin T Rothman BCIS 2002

43. !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Martin T Rothman BCIS 2002

44. !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Martin T Rothman BCIS 2002

45. !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! !! HEALTH WARNING !! Some of the numbers and all of the opinions that follow are mine!! Martin T Rothman BCIS 2002

46. PCI or CABG ? – my view PCI will increase PCI will take CABG cases Because of Drug Eluting Stents Because of improving skill and equipment CABG will decrease The CABG we ask for will be more complex But the surgeons will be less experienced We need to participate in the development of PCI, not be lead by NSF – BCIS lead activity Centres need to develop strategy for increasing volume Less operators doing more More operators doing less Both…. BCIS lead activity We need to address AMI – BCIS lead activity We must hope for an improved thrombolytic strategy that evolves quickly! PCI will increase PCI will take CABG cases Because of Drug Eluting Stents Because of improving skill and equipment CABG will decrease The CABG we ask for will be more complex But the surgeons will be less experienced We need to participate in the development of PCI, not be lead by NSF – BCIS lead activity Centres need to develop strategy for increasing volume Less operators doing more More operators doing less Both…. BCIS lead activity We need to address AMI – BCIS lead activity We must hope for an improved thrombolytic strategy that evolves quickly!