Revascularization Strategy: Syntax Score and Beyond Ahsan Achtchi, DO, FACC

Disclosures & Conflict of Interest No relevant financial relationships with any commercial interests. No honorarium.

Case #1 76 M peripheral vascular disease, type 2 diabetes mellitus, obstructive sleep apnea, morbid obesity, COPD, former smoker, HTN, HL CCS III unstable angina

Revascularization? DM2 Multiple comorbidities Left main disease Normal LVEF

CABG vs PCI

Evolution of revascularization PCI Improving technology Better delivery and optimization techniques More efficacious drugs Staging Need for repeat revascularization Restenosis CABG Off pump techniques Robotic, hybrid techniques Higher likelihood of complete revascularization Typically single procedure Cost

In the past… CABG favored: Diabetic patients with MVD, particularly LM or proximal LAD Diminished LVEF Composite outcomes mostly driven by repeat revascularization and ACS BARI – CABG superior in diabetic patients, no significant difference in nondiabetics – late 1980s (POBA) BARI-2D – high risk diabetic patients did better with CABG, lower risk favored for OMT and provisional revasc First generation DES

http://www.bari2d.org/public/home.html

http://www.bari2d.org/public/home.html

http://www.bari2d.org/public/home.html

Difference driven by need for revascularization and MI - First generation stents and POBA (mixed bag) http://www.bari2d.org/public/home.html

Courage Trial

Limitations Excluded left main or equivalent Excluded EF less than 30% Excluded CCS IV angina Only ¼ of patients had > CCS II angina (75% CCS II or less) Taxus stents Real world adherence to intensive medical therapy

Syntax Trial 1800 patients 3V disease or left main 1:1 CABG or PCI Very low enrollment of LVEF <40% Outcomes Death Revascularization, MI, cerebrovascular events

Syntax Score Dominance Number of lesions Aorto ostial lesions Tortuosity Bifurcation, trifurcation disease Heavy calcification Length >20 mm CTO Thrombus Diffuse disease

More recent trials BEST trial NOBLE trial, EXCEL trial Everolimus eluting stents comparable to CABG in MVD CABG superior at 2 years in terms of MACCE Driven by revascularization NOBLE trial, EXCEL trial Syntax <32 Everolimus eluting stent noninferior to CABG

Case #1 76 M peripheral vascular disease, type 2 diabetes mellitus, obstructive sleep apnea, morbid obesity, COPD, former smoker, HTN, HL CCS III unstable angina

Clinical Implications PCI is a reasonable alternative to CABG in low syntax score patients CABG preferred in high syntax score Intermediate score? Other considerations STS score Patient preference Other Excludes patients with ACS and previous revascularization

CABG vs PCI

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