1. Who needs a PCI in 2008…. Multivessel disease Dr Adrian Banning Consultant Cardiologist John Radcliffe Oxford

2. Dr Adrian Banning - potential conflicts of interest – 07-08 Research funding Boston Scientfic Cordis- J/J Advisory Boards Boston Scientific Elli Lilly Abbott Medtronic Conference expenses Sanofi

3. Who needs a PCI in 2008… Multivessel disease  Can we do it?  Can we do it as well as/better than the surgeons?  What are the issues?  When (in 2008) shouldn’t we do it?

4. Multivessel stenting is off label……. but…….

5. Necessity is the mother of in vention ter

6. 68 yrs old Stable angina Not diabetic Normal LV 3 vessel disease SYNTAX score 15 Can we do it ?

7. 33 x 3.0mm SES to LAD33 x 3.0mm SES to LAD KB to D1KB to D1 Of course we can do it.....

8. 13 x 2.75 mm SES to LCX 13 x 2.5mm SES to PDA Of course we can do it….but should we?

9. Is there an evidence base for stenting in focal multivessel disease?

13. So we can do it – safely?

14. Can we get the same outcome as the surgeons? (sometimes)

15. 67 yrs old 67 yrs old Stable Angina Stable Angina diabetic diabetic Normal LV Normal LV 3 vessel disease 3 vessel disease SYNTAX score 41 SYNTAX score 41 But what about this one?

16. 306 patients with 3 VD treated with PCI ARTS II trial Serruys PW, ACC 2006

17. Multi-vessel Disease & SES: All Patients 12 months follow-up - MACE % Independently adjudicated events p <0.01 p <0.001 Jilaihawi H, Gershlick A, et al, BCS May 2005

18. % Stent thrombosis after MV stenting

22. Syntax the Oxford experience 42 pts (5 th world ) N stentsTotal lenght (mm) Fluoroscopy time (min)Procedural time (min) Contrast (ml) 3 VD3842270475 LM trif3681290385 3VD4681590330 LM-LAD-Circ56827120470 LM-LAD; RCA71361580500 LAD-Circ5801690120 3 VD815828120590 Circ; RCA3601464450 LM-LAD-Circ5761352200 3 VD368953400 3 VD4561960260 3 VD4100943330 3 VD5961258460 3 VD5100946350 LM-LAD2361272200 3 VD71121569750 3 VD61202382460 3 VD5821869500 3 VD51241051400 LM-LAD51001195375 Average4.789.615.4573.7400.25

23. What if Syntax is favourable to stents? What are the issues – at the coal face?

24. Complete revascularisation Complete revascularisation Long stents - Procedural MI Long stents - Procedural MI Calcification – limiting stent expansion Calcification – limiting stent expansion The key issues

25. Issues in MVD (1) Complete revascularisation? The evidence

26. Courage: the main study

30. Length is no longer important or is it?

31. Issues in MVD stenting (2) Long stent - Procedural MI Procedural enzyme elevation in Taxus VI TAXUS (N=219) %(n/N) Control (N=227) %(n/N) P-value In-Hospital Major Adverse Cardiac Events (MACE) MACE, overall 6.8% (15/219) 4.8% (11/227) 0.42 Cardiac Death 0.0% ( 0/219) 0.4% ( 1/227) 1.00 Myocardial Infarction (MI) 6.8% (15/219) 4.0% ( 9/227) 0.21 Q-wave MI 0.9% ( 2/219) 0.9% ( 2/227) 1.00 Non-Q-wave MI 5.9% (13/219) 3.1% ( 7/227) 0.17

32. Background

33. 3 8 13 18 New Hyperenhancement (grams) 258 Troponin rise at 20 hrs (ųg/L) r= 0.78 p<0.001 Correlation of cTnI rise with new myocardial hyperenhancement 0 n = 45

34. New HE-8.5g cTnI 4.8 New HE-8.5g cTnI 4.8µg/L “Adjacent” Hyperenhancement

35. Distal pattern caused by embolisation

36. Circulation 2007;116: 2634-53

38. 234 potentially relevant citations identified and screened for retrieval 15 reports excluded because reviews, incomplete reporting, acute coronary syndromes included, raised baseline TnI included 204 citations excluded by title or abstract examination 15 studies finally included 30 reports retrieved for detailed evaluation What does the new definition of AMI mean in practice? Inclusion criteria: 1) normal baseline Troponin, 2) scheduled procedure for stable or unstable angina 3) post procedure Troponin assessed, 4) complete reporting of procedural outcome and follow up data

39. Troponin level and MACE

40. Troponin level and death

41. Troponin elevation during PCI 100 pts undergoing PCI 100 pts undergoing PCI 28 some elevation of troponin 28 some elevation of troponin 15 diagnosis of MI 15 diagnosis of MI 5 MACE in the next 18 months 5 MACE in the next 18 months

42. Troponin elevation during PCI 100 pts undergoing PCI 100 pts undergoing PCI 28 some elevation of troponin 28 some elevation of troponin 15 diagnosis of MI 15 diagnosis of MI 5 MACE in the next 18 months 5 MACE in the next 18 months Look after your side branches! Look after your side branches! Theres not much we can do about embolisation Theres not much we can do about embolisation

43. Issues in MVD (3) Calcification - limiting stent expansion Incomplete expansion remains a major cause of stent thrombosis Incomplete expansion remains a major cause of stent thrombosis Incomplete expansion of DES is a major cause of stenosis and therefore re-stenosis Incomplete expansion of DES is a major cause of stenosis and therefore re-stenosis

45. If all this new technology is so great why don’t UK surgeons use it?

46. Graft occlusion in 2007…. at least stent thrombosis is <1%!

47. Patient with 3 vessel disease Unacceptable Surgery PCI with DES Acceptable What is the patient’s clinical status? Most complex lesion first? -e.g. CTO Stable PCI of culprit lesion Unstable Outcome? Failure Contrast volume? Renal Status? Success Complete revascularization Acceptable Staged procedure What is the periprocedural risk eg. Euroscore? What is the lesion complexity, e.g. Syntax score? Evaluation of other lesions M-C Morice, PCR 2006

48. Multivessel PCI in 2008 If syntax shows equivalence- of course we can do it but to compete effectively with surgical revascularisation we must ensure complete revascularisation optimal stent expansion minimise myocardial injury

49. Multivessel PCI in 2008 If Syntax shows equivalence –remember: 1.complete revascularisation 2.optimal stent expansion 3.minimise myocardial injury This is HARD WORK and not easy for the patient or the interventionalist

50. 24 h post multivessel PCI 24 h post CABG Slide Acknowledgements K Dawkins P Urban L Testa & team at JR

52. Adverse events from CAGs… in contemporary practice

53. Multivessel PCI - Conclusions  For selected patients, MVPCI with BMS is a safe option but remains associated with an increased need for repeat procedures compared to surgery  The use of DES appears to be associated with MACCE rates similar to those of surgery, despite a stent thrombosis rate per patient that is probably higher than for single vessel procedures  The pivotal RCT’s of DES vs CABG are still ongoing  Appropriate patient selection (risk scoring, medication compliance, co-morbidities) and revascularization strategy (single session vs staging, complete vs partial revascularization, etc) continue to play a critical role

54. All patients receiving > 1 SES were enrolled All patients receiving > 1 SES were enrolled Both on- and off-label use were recorded Both on- and off-label use were recorded Clinical FU at one, six and twelve months Clinical FU at one, six and twelve months No mandatory angiographic follow-up No mandatory angiographic follow-up Recruitment completed WW = 15,565 patients from 281 centres in 41 countries Recruitment completed WW = 15,565 patients from 281 centres in 41 countries 1,473 patients (10%) underwent multi-vessel procedures of whom 1,102 had twelve month follow-up (79%) 1,473 patients (10%) underwent multi-vessel procedures of whom 1,102 had twelve month follow-up (79%) Multi-vessel Disease & SES e-CYPHER - Structure/Design Jilaihawi H, Gershlick A, et al, BCS May 2005

56. Multi-vessel Disease & SES: Baseline Characteristics BCS May 2005 MVD ‡ N=1,473 N=1,473 Single Vessel N=11,921 Age (years) 61.6 (SD 11.3) 61.5 (SD 11.3) Male (%) 80.877.4 Diabetes (%) 34.6 28.0 * Prior MI (%) 28.630.2 Prior PCI (%) 23.9 29.8 * Prior CABG (%) 9.310.7 Stable Angina (%) 42.642.3 Unstable Angina (%) 34.032.9 Silent Ischemia / Other indication (%) 10.49.7 2 vessel disease (%) 57.8 27.8 * 3 vessel disease (%) 39.4 20.2 * *p<0.0001 ‡ MVD subset is defined as a patient with at least two CYPHER (ONLY) treated lesions in different vessels at index procedure and Single vessel subset is defined as CYPHER stent only with single vessel treated at index procedure.

57. ARTS II @ 365 days Serruys PW et al Eurointervention 2005; 1: 147-56

58. Radial artery bypass graft vs LIMA and SVG Khot UN et al Circulation 2004;109; 2086-91 310 symptomatic patients 565+511 days after surgery

60. Selection process in RCT’s of treatment for multivessel disease The MAAS trial CABG vs PCI vs medical Rx. Hueb et al JACC 2004;43:1743-51

61. CABG PCI