1. Multi-vessel disease and intracoronay physiology Combat MI 2009 Kees-joost Botman MD, PhD Catharina hospital Eindhoven Heart Institute The Netherlands Kees-joost Botman MD, PhD Catharina hospital Eindhoven Heart Institute The Netherlands

2. PCI vs CABG in multivessel disease: THE TAILORED APPROACH For years, cardiologists and cardiac surgeons have disputed about the optimum treatment of MVD : “ Is CABG the treatment of choice ?” “ Is PCI the treatment of choice ?” BUT......not all patients are the same !! background considerations (1):

3. PCI vs CABG in multivessel disease CABG and STENTING are equally effective treatments to prevent death and AMI, but excess repeated revascularization and more angina in STENT group IN MULTIVESSEL DISEASE: The decision for revascularization of a particular lesion was based upon angiography ( stenosis > 50%) ARTS – Study:

4. PCI vs CABG in multivessel disease CABG and STENTING are equally effective treatments to prevent death and AMI, but excess repeated revascularization and more angina in STENT group IN MULTIVESSEL DISEASE: The decision for revascularization of a particular lesion was based upon angiography ( stenosis > 50%) SYNTAX – Study:

5. PCI vs CABG in multivessel disease: THE TAILORED APPROACH In patients with similar degree of anatomic disease, the most important predictor of outcome is the presence and extent of inducible ischemia (Beller,Circulation 2000 ): 12000 patients with MVD, similar severity of angiographic abnormalities: MIBI negative  0.6 % per year mortality / AMI MIBI positive  7.2% per year mortality / AMI background considerations (2)

6. PCI vs CABG in multivessel disease: THE TAILORED APPROACH Revascularization is warranted for functionally significant stenoses only (DEFER study, Circulation, june 2001) background considerations (3) AND :

7. The DEFER Study: Adverse Events Death, AMI, CABG and (re)PTCA

8. The DEFER Study: Event-free Survival

9. PCI vs CABG in multivessel disease THE TAILORED APPROACH THEREFORE: Simply treating all patients with multivessel disease in the same way ( either CABG or PCI ) makes little sense and is a rather crude approach TAILORED APPROACH Split up the multivessel population in two groups depending on the functional extent of disease, by assessing the functional significance of the individual stenoses

10. OPTIMUM TREATMENT OF MULTIVESSEL DISEASE: THE TAILORED APPROACH In many patients with multivessel disease, non-invasive testing can not indicate which of several stenoses are culprit, but..... Fractional Flow Reserve (FFR), calculated from coronary pressure measurement, is an easy and accurate index to indicate specifically which lesions are culprit and which are not background considerations (4)

11. 24 def/spuit + draad Introduction

12. Hartspier Aorta Krans slagader 100 0 P a =100 Q normaal 100 Perfusiedruk 100 mmHg Maximale hyperaemie Q sten /Q norm = P d / P a = 0.70 (70%) 100 0 P a =100 Q stenose ΔP 30 mmHg P d =70 Perfusiedruk 70 mmHg

13. 1000 X  0.014 inch

16. OPTIMUM TREATMENT OF MULTIVESSEL DISEASE: THE TAILORED APPROACH 150 patients with multivessel disease, ARTS and SYNTAX like characteristics (410 stenoses) Coronary Pressure measurement in all stenoses If FFR < 0.75  stenosis considered as “culprit” If FFR > 0.75  stenosis “non - culprit” If 3 culprit lesions or 2 culprit lesions including LMCA : CABG If 1 or 2 culprit lesion (not incl LMCA) : PCI Botman CJ et.al, JACC 2001

17. OPTIMUM TREATMENT OF MULTIVESSEL DISEASE: THE TAILORED APPROACH In this way, the population with multivessel disease was split up in two groups, not distinguishable by the degree of angiographic abnormalities, but with different degree of functional disease.

18. OPTIMUM TREATMENT OF MULTIVESSEL DISEASE: THE TAILORED APPROACH 150 patients 410 stenoses: FFR measured in 360 stenoses total occlusion in 21 vessels:  culprit by definition not able to measure: 7 stenoses not “recognized” : 22 stenoses 259 culprit 101 not culprit

19. OPTIMUM TREATMENT OF MULTIVESSEL DISEASE: THE TAILORED APPROACH Based upon these measurements, 87 patients qualified for CABG and 63 patients qualified for PCI Risk factors and angiographic characteristics were completely similar in both groups 2 vessels: n=38 1 vessel: n=25

20. Patient Characteristics 1 RISK FACTORS CABG GROUP = 87 PTS PCI GROUP = 63 PTS Smoking41.1%49.2% Family history47.1%54.0% Hyperchol.72.4%63.5% Hypertension28.7%28.6% Diabetes24.1%23.8%

21. CHARACTERISTICS 2 Angina Class (CCS) total no.of pts = 150 ClassNo.% I00 % II3020% III6040 % IV6040 %

22. CHARACTERISTICS 3 No.of vessels involved per patient total no.of pts = 150 QtyNo.% 100 % 26946 % 38154 %

23. Angiographic characteristics of the culprit and non-culprit lesions FFR < 0.75FFR > 0.75 REFERENCE DIAMETER 2.97 +/- 0.633.11 +/- 0.77 STENOSIS PERCENTAGE 54.1 +/- 19.753.6 +/- 21.3 M.L.D.1.41 +/- 0.511.49 +/- 0.62

24. Male, 50-year-old Angina class 2-3 Positive ET

25. Intermediate branch, hyperemia  pull-back

26. LAD, hyperemia

27. After stenting LAD

28. LAD, after stenting

29. Adverse events at hospital discharge CABG GROUP (N = 87)PCI GROUP (N = 63) No.%No% (re) CABG11.2 %00 % (re) PCI00 %11.6 % Infarction11.2 %11.6 % Death11.2 %00 % Total events33.5%23.2%

30. Adverse events at 2 years CABG GROUP (N = 87)PCI GROUP (N = 63) No.% % (re) CABG33.4 %34.8 % (re) PCI78.1 %711.2 % Infarction44.6 %23.2 % Death22.3 %00 % Total events1618.4%1219.1%

31. Angina class (CCS) 1 year follow-up CABG GROUP (N = 87)PCI GROUP (N = 63) CLASS N% N% I788 %545486 % II101012 %914 % III00 %0 IV00 %0

32. Angina class (CCS) at 2-year follow-up CABG GROUP (N = 87)PCI GROUP (N = 63) CLASSN%N% I7384 %5282 % II1113 %1016 % III33 %12 % IV00 %0

33. Optimum Revascularization Strategy for Multivessel Disease : THE TAILORED APPROACH Ww3139 Serruys, NEJM 2001; Botman, ESC 2002

34. SYNTAX Subgroup MACCE Rates at 12 Months CABGTAXUS* Patients (%) All LM N=705 LM+1VD N=138 LM Isolated N=91 LM+2VD N=218 LM+3VD N=258 Comparisons for the LM and 3VD subgroups are observational only and hypothesis generating 3VD ( w/o LM) N=1095 * TAXUS TM Express 2TM Stent System Source: See Glossary

35. OPTIMUM TREATMENT OF MULTIVESSEL DISEASE : CONCLUSIONS: 1.In multivessel disease, coronary pressure measurement is an excellent tool to identify the culprit lesion(s) by FFR < 0.75 2. In this way, patients with otherwise similar characteristics can be stratified in 2 groups, according to the functional extent of disease (“number of culprit lesions”): PCI group: one or 2 culprit lesions; CABG group: 3 or more culprit lesions) 3.PCI and CABG used in this way provide an equally effective treatment, both in terms of adverse events, repeated revascularization, and quality of life