PCI vs. CABG: Review of the evidence and suggestions Giuseppe Biondi Zoccai Division of Cardiology, University of Turin, Turin, Italy Meta-analysis and Evidence-based medicine Training in Cardiology (METCARDIO), Ospedaletti, Italy 2 nd Fellows’ Meeting, 2-3 October 2009, Bubbio – 2 October 2009, 15:00-15:30

DISCLOSURE I am a consultant invasive and non- invasive cardiologist who completed fellowship in 2005 I am giving a lecture at a Fellows’ Course

LEARNING GOALS Who was the winner between PCI and CABG in the past? Who is the winner between PCI and CABG now? When is surgery more appropriate than PCI? When is PCI more appropriate than surgery?

LEARNING GOALS Who was the winner between PCI and CABG in the past? Who is the winner between PCI and CABG now? When is surgery more appropriate than PCI? When is PCI more appropriate than surgery?

WHO WAS WINNER BETWEEN PCI AND SURGERY?

ARE THEY ENEMIES OR FRIENDS?

LET’S LOOK AT THE PAST…

META-ANALYSIS OF RCTS OF CABG VS. PCI: 5-YEAR-SURVIVAL WITH MVD VS. SVD Bravata et al, Ann Intern Med 2007

META-ANALYSIS OF RCTS OF CABG VS. PCI: 5-YEAR-SURVIVAL WITH POBA VS. BMS Bravata et al, Ann Intern Med 2007

HOWEVER, PCI WITH BMS WAS INFERIOR TO CABG FOR THE RISK OF REPEAT PCI/CABG Biondi-Zoccai et al, Ital Heart J 2003

FURTHER STRATIFICATION FOR DIABETES Hlatky et al, Lancet 2009

Hlatky et al, Lancet 2009 INCLUDING BARI EXCLUDING BARI FURTHER STRATIFICATION FOR DIABETES

LEARNING GOALS Who was the winner between PCI and CABG in the past? Who is the winner between PCI and CABG now? When is surgery more appropriate than PCI? When is PCI more appropriate than surgery?

WHAT ABOUT THE PRESENT…

RISK OF MACE AT MID-TERM FOLLOW-UP FOLLOWING PCI WITH DES FOR ULM Biondi-Zoccai et al, Am Heart J 2008

IMPACT OF LESION LOCATION AND PATIENT RISK FEATURES ON OUTCOMES OF ULM PCI Biondi-Zoccai et al, Am Heart J 2008

THE SYNTAX TRIAL Serruys et al, New Engl J Med 2009

THE SYNTAX 1 YEAR Serruys et al, New Engl J Med 2009

THE SYNTAX 2 YEARS

THE SYNTAX 2 YEARS

THE SYNTAX 2 YEARS

SYNTAX 1 YEAR PCI REGISTRY (N=192) CABG REGISTRY (N=644)

CORONARY ARTERY DISEASE IN DIABETICS BARI 2D, New Engl J Med 2009

CORONARY ARTERY DISEASE IN DIABETICS BARI 2D, New Engl J Med 2009

BARI 2D, New Engl J Med 2009 Med Rx = Revasc

BARI 2D, New Engl J Med 2009 Med Rx = PCI Med Rx = PCI Med Rx < CABG Med Rx = CABG

LEARNING GOALS Who was the winner between PCI and CABG in the past? Who is the winner between PCI and CABG now? When is surgery more appropriate than PCI? When is PCI more appropriate than surgery?

ESC 2005 GUIDELINES Silber et al, Eur Heart J 2005

ESC 2005 GUIDELINES Silber et al, Eur Heart J 2005 THUS CABG IS RECOMMENDED INSTEAD OF PCI IN MOST CASES OF CAD IN DIABETICS, IN MOST CASES OF MVD, AND ALL BUT A FEW CASES OF ULM …however, the guidelines are based mainly on differences in repeat revascularization rate

MY SURGICAL MUST DOs Concomitant compelling indication to cardiothoracic surgery (eg severe MR) Absolute contraindications to antiplatelet therapy Previous failed PCI attempts (especially LAD) Multivessel CTO or CTO involving proximal-mid LAD Very high SYNTAX score

LEARNING GOALS Who was the winner between PCI and CABG in the past? Who is the winner between PCI and CABG now? When is surgery more appropriate than PCI? When is PCI more appropriate than surgery?

CAN WE CAN DO WHATEVER THE SURGEON DOES?

CAN YOU DO IT? 85-year-old with non-STEMI, true trifurcational unprotected LM, concomitant MVD, high surgical risk and LVEF 45% 85-year-old ♂ with non-STEMI, true trifurcational unprotected LM, concomitant MVD, high surgical risk and LVEF 45%

ACTUALLY, IT CAN BE DONE, BUT SHOULD I DO IT? BEFORE PCI AFTER PCI WITH 4 STENTS Sheiban et al, Catheter Cardiovasc Interv 2009

ESC 2005 GUIDELINES Silber et al, Eur Heart J 2005

ESC 2005 GUIDELINES Silber et al, Eur Heart J 2005 THE ROLE OF PCI APPARENTLY LIMITED IN MOST CASES OF CAD IN DIABETICS, IN MOST CASES OF MVD, AND ALL BUT A FEW CASES OF ULM …however, the guidelines are based mainly on differences in repeat revascularization rates

MY PCI MUST DOs Previous CABG (especially if LIMA already there) Prohibitive surgical risk (with compelling indication) FFR unmasks MVD as just SVD Ongoing STEACS with culprit lesion amenable to primary PCI Patients refuses CABG (?!) but provided patient and referring colleagues are consenting!

MY EQUIPOISE Non-bifurcational ULM with high surgical risk Multivessel but focal disease with only A-B2 lesions, or non-challenging C lesions Good LV function Very young or very old Depending also on need for and likelihood of completeness of revascularization but still provided patient and referring colleagues are consenting!

TAKE HOME MESSAGES

MY PRACTICAL FLOWCHART

MY PRACTICAL FLOWCHART ULM or 3VD with any of the following unfavorable features: True bifurcational disease of ULM 1 or > clinically relevant CTO LV dysfunction (LVEF<40%) Inexperienced operator (<1000 PCI) Diabetes mellitus Other surgical indications CABG as first choice! Attempt PCI if: CABG contraindicated Patient/family and cardiac surgeon agree on PCI

MY PRACTICAL FLOWCHART ULM or 3VD with any of the following unfavorable features: True bifurcational disease of ULM 1 or > clinically relevant CTO LV dysfunction (LVEF<40%) Inexperienced operator (<1000 PCI) Diabetes mellitus Other surgical indications CABG as first choice! Attempt PCI if: CABG contraindicated Patient/family and cardiac surgeon agree on PCI CABG favored, but PCI reasonable ULM or MVD without any of above unfavorable features

MY PRACTICAL FLOWCHART ULM or 3VD with any of the following unfavorable features: True bifurcational disease of ULM 1 or > clinically relevant CTO LV dysfunction (LVEF<40%) Inexperienced operator (<1000 PCI) Diabetes mellitus Other surgical indications CABG as first choice! Attempt PCI if: CABG contraindicated Patient/family and cardiac surgeon agree on PCI CABG favored, but PCI reasonable ULM or MVD without any of above unfavorable features Risk-benefit balance fine for PCI, but CABG can still be appropriate and thus should be discussed with patient and family Protected LM or 2VD with any of these “favorable” features : Ostial LAD ok Lack of diffuse disease No true bifurcations No CTO No diabetes Ongoing STEACS

MY PRACTICAL FLOWCHART ULM or 3VD with any of the following unfavorable features: True bifurcational disease of ULM 1 or > clinically relevant CTO LV dysfunction (LVEF<40%) Inexperienced operator (<1000 PCI) Diabetes mellitus Other surgical indications CABG as first choice! Attempt PCI if: CABG contraindicated Patient/family and cardiac surgeon agree on PCI CABG favored, but PCI reasonable ULM or MVD without any of above unfavorable features Risk-benefit balance fine for PCI, but CABG can still be appropriate and thus should be discussed with patient and family Protected LM or 2VD with any of these “favorable” features : Ostial LAD ok Lack of diffuse disease No true bifurcations No CTO No diabetes Ongoing STEACS PCI recommended (CABG should be considered only for proximal LAD) 1VD without other surgical indications

A. 1 ST STEP IN CRISIS MANAGEMENT IS PREVENTING IT: FOLLOW GUIDELINES UNLESS YOU ARE JUSTIFIED…

B. COLLABORATIVE DECISON-MAKING IN ALL BUT CLEAR-CUT CASES: INVOLVE OTHER INTERVENTIONAL COLLEAGUES, NON-INVASIVE CARDIOLOGISTS, AND SURGEONS

C. NEVER FORCE TOO MUCH… EITHER INDICATIONS, DEVICES, TECHNIQUES, OR ANCILLARY THERAPY (E.G. ANTI-THROMBOTIC RX)

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