Multivessel Coronary Artery Disease “IS THE NAIL IN THE COFFIN?” Forrest Glover, M.D. Interventional Cardiologist Jack Steven’s Heart Institute April 25, 2015

What is our goal of therapy? Prevent complications of CAD in effort to prolong life Decrease cardiac morbidity Alleviate symptoms

What are the indications for revascularization? Activity limiting symptoms despite maximal medical therapy Not tolerating medication well or need to increase activity level Anatomy favors survival benefit (significant LMCA disease or multivessel CAD with decreased LVEF)

Will the debate go on forever? Balloon angioplasty vs CABG BARI RITA GABI EAST CABRI

Will the debate go on forever? Bare metal stent vs CABG ERACI - II ARTS SOS Drug eluting stents vs CABG ARTS - II ERACI – III SYNTAX

SYNTAX Trial CABG vs PCI in 3 vessel or LMCA disease 60% patients were 3V CAD 40% LMCA disease Paclitaxel was the DES used

SYNTAX Trial How the score was calculated Amount of segments involved If a CTO was present and if so what type Bifurcation vs trifurcation lesions Ostial lesions Tortuosity Long segment disease Small vessel disease

SYNTAX Trial Composite primary endpoint was higher in PCI vs CABG (17.8% vs 12.4%) Death/MI/Repeat revascularization This was driven by revascularization (13.5% vs 5.9%) Death/Stroke/MI were comparable At 3 and 5 year follow up, primary endpoint remained higher in PCI group (driven by revascularization)

SYNTAX Trial Outcomes were then broken down by disease complexity SS < 23 - no difference in composite endpoint SS 23-32 - endpoint was higher with PCI (37.9% vs 22.6%) SS > 33 - endpoint was higher with PCI (41.9% vs 24.1%)

SYNTAX Trial Criticisms No clinical variables Use of paclitaxel (increased rate of angiographic and clinical restenosis than later generations) Bypass patients were often not on “maximal” medical therapy

SYNTAX II Additional scoring factors Anatomical syntax score Age Creatinine clearance LVEF Presence of unprotected LMCA disease PAD Female sex COPD

PCI preferred 2 vessel CAD especially if LAD is not involved Older patients with significant comorbidities Patients who refuse surgery Patients with low complexity disease that do not have diabetes

PCI or CABG If patients are equally suited Decision should be made by joint team Patients willingness to undergo repeat procedures should be assessed Patients should be aware of slightly higher stroke risk with CABG vs PCI Should not be attempted by low volume operators Assess ability to take DAPT for a long period of time

Case 1 52 year old Woman Diabetic Poor exercise tolerance on stress echo Anterior ischemia

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Case 2 88 year old woman Severe COPD on home oxygen Unable to walk Renal insufficiency

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The Future?