1. C.H.T Dr.Salarifar 1 Tehran Heart Center Tehran University of Medical Sciences PCI VS CABG M. SALARIFAR, MD

2. C.H.T Dr.Salarifar 2 PCI VS CABG From 1987 to 2003 326% increase in PCI Now more than 90% stenting

3. C.H.T Dr.Salarifar 3 Factors in patient selection 1.The need for mechanical revascularization as opposed to medical treatment & risk factor modification. 2.The likelihood of success ( vessel size, calcification, tortuosity, side branches ) 3.The risk and potential consequences of acute failure of PCI ( Coronary anatomy % viable myocardium, LV function. PCI VS CABG

4. C.H.T Dr.Salarifar 4 4.The likelihood of restenosis ( diabetes, prior restenosis, small vessel, long lesion, Total occlusion, SVG disease). 5. The need for complete revascularization based on the extent of CAD, severity of ischemia, LV function. 6. The presence of comorbid conditions 7. Patient preference PCI VS CABG

5. C.H.T Dr.Salarifar 5 Ideal cases of PCI  Significant symptoms despite intensive medical therapy  Low risk for complications  Technical success rate  No history of CHF  EF > 40% PCI VS CABG

6. C.H.T Dr.Salarifar 6 Patients with increased risk for PCI Advanced age Female gender Unstable angina CHF LM equivalent disease Multivessel disease DM Renal failure PCI VS CABG

7. C.H.T Dr.Salarifar 7 Current expectations for PCI  Procedural success at least 90%  Mortality < 1%  Q ware MI < 1.5%  Emergency by pass surgery 1 – 2 % PCI VS CABG

8. C.H.T Dr.Salarifar 8 PCI and Medical therapy RCT comparing PCI with medical therapy are few in number and < 5000 patients, enrolled patients with SVD and prior stenting and enhanced adjunctive pharmaco therapy. * Results : Better control of angina Functional capacity Quality of life PCI VS CABG

9. C.H.T Dr.Salarifar 9 No RCT to date has demonsrated a reduction in death or MI with PCI compared with medical thraphy for patient with chronic stable angina PCI VS CABG

10. C.H.T Dr.Salarifar 10  RITA – 2 showel excess of death and MI  62% Patients multivessed disease  COURAGE TRIAL : 2287 patients PCI did not reduce the risk of death or MI over a medium 4.6 years follow up.  TIMe Trial : similar results in elderly patients. PCI and Medical therapy PCI VS CABG

11. C.H.T Dr.Salarifar 11 Most patients with chronic stable angina and class I – II symptoms Medical treatment. PCI for patients with severe symptoms despite medical therapy or patients with high risk criteria on Noninvasive tests. PCI and Medical therapy Conclusion PCI VS CABG

12. C.H.T Dr.Salarifar 12 PCI in LV dysfunction In hospital & long term mortality was higher in LV dysfunction. EF ≤ 40% 11 % 1 Year Mortality EF 41 – 49% 4.5 % 1 Year Mortality EF ≥ 50% 1.9 % 1 Year Mortality PCI VS CABG

13. C.H.T Dr.Salarifar 13 CABG  Garrett, Dennis, DeBakey : Bailoat CABG in 1964  Fovoloro : late 1960 s  Kolessov : use of IMA 1967  Green : 1970  % 26 in CABG since 1997  In 2004 : 20% off – PUMP CABG  Minimally Invasive  Hybrid procedure PCI VS CABG

14. C.H.T Dr.Salarifar 14 Surgical outcomes CABG  Patient population of CABG Higher risk ( older, 3VD, History of Revascularization, LV dysfunction Diabetes, Peripheral vascular disease )  Out comes with CABG Remain stable or improved PCI VS CABG

15. C.H.T Dr.Salarifar 15 Operative Mortality Mortaliy of 503, 478 CABG - only in the s td data base 1997 – 1999: 3.05 % 2005 : 2. 2 % CABG PCI VS CABG

16. C.H.T Dr.Salarifar 16 In THC data base :

17. C.H.T Dr.Salarifar 17 CABG Complications Mojor morbidity ( death, stroke, Renal failure sternal infection : 13.4% in 30 days MI : 3.9% Respiratory complications Bleeding : 2-6 % reparation for bleeding Wound infection Post operative HTN Cerebrovascular complication Stroke 2.6% PCI VS CABG

18. C.H.T Dr.Salarifar 18 CABG Complications AF : One of the most frequent complications of CABG up to 40% Risk of stroke Use of beta blockers reoluces post operative AF Brady arrhythmia : 0.8% need for permanent pacemaker Renal dysfunction PCI VS CABG

19. C.H.T Dr.Salarifar 19 Return to Employment 80% who were employed prior to CABG Return to work Patient undergoing CABG return to work 6 W later than PCI But long term employment is similar. PCI VS CABG

20. C.H.T Dr.Salarifar 20 SVG Patency Early occlusion : 8 – 12 % 1 year occlusion : 15 – 30 % occlusion 1 – 6 y occlusion : 2% Annually 6 – 10 occlusion : 4% Annually At 10 y :50% SVG occlusion and 20 -40% significant stenosis in Remaining PCI VS CABG

21. C.H.T Dr.Salarifar 21 Arterial graft patency IMA graft patency rate 95% 1 y 88% 5 y, 83% 10 y. PCI VS CABG

22. C.H.T Dr.Salarifar 22 Indications for Revascularization CABG :  Significant left main disease : Regardless of the severity of symptoms or LV dysfunction  Patients with 3 VD that Includes LAD proximal lesion & LV dysfunction  Patients with 2 VD with LAD proximal lesion & LV dysfunction or high risk non invasive tests PCI VS CABG

23. C.H.T Dr.Salarifar 23 Indications for Revascularization PCI :  In patients with SVD the aim of procedure is relief of symptoms or objective evidence of sever ischemia  In patients with angina who are not high risk, medical treatment, PCI & CABG are similar. PCI VS CABG

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28. C.H.T Dr.Salarifar 28 PCI or CABG witch strategy ? SVD : PCI 2VD Multivessel disease : PCI as initial strategy especially in patients with good LV function, suitable anatomy and patient preference. CABG : Severe LAD proximal lesion, DM LV dysfunction, LM lesion, Diffuse disease. Advanced age and comorbidity : PCI is better Younger patient < 50 y : PCI is initial strategy CASS Registry : Impaired survivial in young patients PCI VS CABG

29. C.H.T Dr.Salarifar 29 PCI VS CABG Observational studies: Recent studies after stenting 60/000 patients with multivessel disease treated with stenting or CABG in the newyork state Registry (1997 – 2000 ) : Higher survival with CABG after adjustment for medical comorbidities. PCI VS CABG

30. C.H.T Dr.Salarifar 30 PCI VS CABG Randomized trials : ARTS trial ; Death, MI, CVA and one – year mortality were similar. CK – MB more than twice in CABG and was a predictor of poor outcome. In PCI groupe DM was the main factor for poor out come PCI was associated with a greater need for Repeat Revascularization. TVR was Higher in stenting groupe. PCI VS CABG

31. C.H.T Dr.Salarifar 31 BARI Diabetic patients with CABG had better survival at two years. PCI VS CABG

32. C.H.T Dr.Salarifar 32 PCI VS CABG Recent Publications NENGLJMED 358 : 4 January 2008 * DES VS. CABG in multivessel disease Newyork state Registry ( oct 2003 – Dec 2004 ) More than 17000 patients ( 9963 DES, 7437 CABG ) CABG was associated with lower mortality, MI and repeat revascularization

33. C.H.T Dr.Salarifar 33 The – MAIN – COMPARE Registry PCI VS CABG Stenting VS. CAGB for LM 1102 stenting & 1138 CABG in Korea 2000 -2006 No significant difference in Death, MI, stroke Higher Rate of TVR in stenting

34. C.H.T Dr.Salarifar 34 ACC/AHA Guidelines for Revascularization with PCI and CABG in Patients with Stable Angina Indication EvidenceClass 1. CABG for patients with significant left main coronary disease A 2. CABG for patients with triple-vessel disease. The survival benefit is A greater in patients with abnormal LV function (ejection fraction <0.50) 3. CABG for patients with double-vessel disease with significant A proximal LADCAD and either abnormal LV function (ejection fraction <50%) or demonstrable ischemia on noninvasive testing 4. PCI for patients with double- or triple-vessel disease with significant B proximal LAD CAD, who have anatomy suitable for catheter-based therapy and normal LV function and who do not have treated diabetes 5. PCI or CABG for patients with single- or double-vessel CAD without B significant proximal LAD CAD but with a large area of viable myocardium and high-risk criteria on noninvasive testing I (indicated)

35. C.H.T Dr.Salarifar 35 Indication EvidenceClass 6. CABG for patients with single- or double-vessel CAD without C significant proximal LAD CAD who have survived sudden cardiac death or sustained ventricular tachycardia 7. In patients with prior PCI, CABG or PCI for recurrent stenosis C associated with a large area of viable myocardium or high-risk criteria on noninvasive testing 8. PCI or CABG for patients who have not been successfully treated B by medical therapy and can undergo revascularization with acceptable risk I (indicated)

36. C.H.T Dr.Salarifar 36 1.Repeat CABG for patients with multiple saphenous C vein graft stenoses, especially when there is significant stenosis of a graft supplying the LAD; it may be appropriate to use PCI for focal saphenous vein graft lesions or multiple stenoses in poor candidates for reoperative surgery 2. Use of PCI or CABG for patients with single- or double- B vessel CAD without significant proximal LAD disease but with a moderate area of viable myocardium and demonstrable ischemia on noninvasive testing 3. Use of PCI or CABG for patients with single-vessel B disease with significant proximal LAD disease IIa (good supportive evidence) Indication Evidence* Class

37. C.H.T Dr.Salarifar 37 1.Compared with CABG, PCI for patients with double- B or triple-vessel disease with significant proximal LAD CAD,who have anatomy suitable for catheter-based therapy and who have treated diabetes or abnormal LV function 2. Use of PCI for patients with significant left main C coronary disease who are not candidates for CABG 3. PCI for patients with single- or double-vessel CAD C without significant proximal LAD CAD who have survived sudden cardiac death or sustained ventricular tachycardia IIb (weak supportive evidence) Indication Evidence* Class

38. C.H.T Dr.Salarifar 38 1. Use of PCI or CABG for patients with single- or C double-vessel CAD without significant proximal LAD CAD, who have mild symptoms that are unlikely due to myocardial ischemia, or who have not received and adequate trial of medical therapy and a. have only a small area of viable myocardium Or b. have no demonstrable ischemia on noninvasive testing 2. Use of PCI or CABG for patients with borderline C coronary stenoses (50-60% diameter in locations other than the left main coronary artery) and no demonstrable ischemia on noninvasive testing 3. Use of PCI or CABG for patients with insignificant C coronary stenosis (<50% diameter) 4. Use of PCI in patients with significant left main B coronary artery disease who are candidates for CABG III (not indicated) Indication Evidence* Class

39. C.H.T Dr.Salarifar 39 حیرت اندر حیرت است ای یار من این نه کار توست و نه هم کار من

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