1. CABG VS Multi Vessel PCI Hasanat Sharif MD FRCS Chief of Cardiorthoracic Surgery Aga Khan University Hospital

2. Multivessel Definition –Cardiologist –Cardiac Surgeon

3. Treatment of Coronary Artery Disease Medical Percutaneous Intervention Surgical Revascularization

4. Treatment of Coronary Artery Disease Medical Advances in medical treatment –Anti platelet agents –ACEI/ARB –Statins –Aggressive risk factor modification

6. Treatment of Coronary Artery Disease Primary percutaneous intervention Role in evolving acute myocardial infarction Culprit vessel addressed

7. Intervention Interventionalist’s procedural bias Perception –Clinician –Referring doctors and –Patient

10. End PointCABG (%)DES (%) p MACCE12.117.80.0015 Death/MI/CVA7.77.60.98 Revascularization5.913.7<0.0001 Stroke2.20.60.003 MI3.24.80.11 All Cause death3.54.30.37 Syntax Trial

11. End pointCABG (%)PCI (%)p All-cause death4.96.20.24 All stroke2.81.40.03 Stroke before 1 y2.20.60.003 Stroke after 1 y0.60.70.82 MI3.35.90.01 MI before 1 y3.34.80.11 MI after 1 y0.11.20.008 All-cause death, stroke, MI 9.610.80.44 Repeat PCI8.617.4<0.001 MACCE16.323.4<0.001 Two-year outcomes for SYNTAX Kappetein AP. European Society of Cardiology 2009 Congress; September 2, 2009: Barcelona, Spain.

14. Approriateness criteria for coronary revascularization Refined and extended guidance beyond that provided by evidence based guidelines Expert panel of 17 members Year long effort to evaluate available evidence and existing guidelines

15. Appropriateness Criteria Inappropriate 1-3 Uncertain 4-6 Appropriate 7-9 PCI inappropriate for LM CAD PCI uncertain for 3 VCAD PCI appropriate for acute myocardial injury CABG appropriate for 3VCAD and LM CAD

17. What happens in actual practice? Catheterization laboratory cardiologists in hospitals with PCI capability were more likely to recommend patients for PCI than Hospitals in which only catheterization was performed

18. Adherence to ACC/AHA guidelines Indicated CABG 13% PCI 59% Both 17% Recommended 53% (34% PCI) 94% 93% PCI 5% CABG

21. Trials Justification –? Economically/industry driven –? Extending the boundaries of care Randomization Multi centered Adequate numbers Long term follow up End point - survival

22. Trials Ethics –Informed patient consent –Critical to provide complete disclosure of risks/benefits –Survival –Stent thrombosis/graft closure –Risk of re intervention/complications

23. Trials Enrolled only 5-10% of the eligible population ? Generalizability of results Real life situations

24. Trials Propensity analysis is not perfect Euroscore over predicts procedural risk Cost analysis and impact on healthcare budget

25. Observational data Consistently show a survival advantage for CABG over PCI STS database Northern New England database Duke New York

27. AKU Data Fifty month data Jan 2006-March 2010 Total CABG n=2041 Left main n= 406 (19.9%) 1 VCADn= 69 (3.4%) 2 VCADn= 257(12.6%) 3 VCADn= 1715(84%)

28. AKU Data Mean age 58 years(+/-11) Males 82% LVEF 48% (+/-14) IMA usage 90% CVA n = 8 (0.4%) Mortalityn = 32(1.6%)

29. Cost Considerations CABG package 225K One bare metal stent 285K –Additional stent 32K One DES395K –Additional stent139K

30. Triple vessel and left main coronary stenosis CABG first choice for majority of patients Consider PCI for patients with co morbidities that preclude CABG Advances –PCI technology and –Surgical techniques/ peri operative care Extending the boundaries of cardiovascular care

31. Treatment of coronary artery disease Multidisciplinary team approach –Cardiologist –Interventionalist –Cardiac Surgeon Separate diagnosis from treatment! Treatment option given on cath table Scare tactics

32. Thank You