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Surgery: Still the best treatment for
multivessel disease

1. Current Trends

2. Results of Coronary Bypass Surgery

3. Results of Percutaneous Revascularization

TRENDS IN PCI vs.CABG

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400 PCI
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200 CABG
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2000 2001 2002 2003 2004
YEAR

1995 to 2004 Radford. Circulation 2006.114:1229-1231 Copyright ©2006 American Heart Association . M. Coronary revascularization procedures in New York State. J.

. Eur J Cardiothorac Surg 2006.29:486-491 Copyright ©2006 Elsevier Science B. et al. . Procedures by region or country for three-vessel disease Kappetein.V. P. A.

29:486-491 Copyright ©2006 Elsevier Science B.. Eur J Cardiothorac Surg 2006. et al. Procedure by region or country for left main disease Kappetein A. .V. P.

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Transcatheter Cardiovascular Therapeutics Conf Washington DC 2002 Speaking on the results of the trials evaluating DES. Marty Leon sends a message to the cardiothoracic surgeons of the world to “ Get a new day job” . Dr.

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Coronary Artery Bypass Surgery .

6% 3.6% 1. surgical revascularization VA Study ECSS CASS No pts. 686 768 780 Time Period 1972-1974 1973-1976 1975-1979 CAD >50% > 1 >50% > 2 >70% > 1 LV Function LVEF < 50 LVEF >50 LVEF >50 in 55% in 100% in 74% Op Mort 5. Original multicenter randomized controlled trials: medical therapy vs.4% .

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3% 17.5% .4% 19.5% LVEF < 35% 10.6% 23.3% 9.0% 10.2% 2.6% 26.7 62.7% 8. RISK FACTORS FOR CORONARY BYPASS SURGERY Ann Thor Surgery 2000.4 Age > 70 15.2% 20.8% Diabetes 18.5% failure PVD 11.7% Chronic renal 2.0% 25.8 63.7% Recent MI 7.2% 22. 70:84-90 1990 .1995 1996-1998 Age 60.1992 1993 .1% Urgent Op 26.2% 41.9% 34.4% 20.

EF < 40% : 33% 2. Previous Stent 30% New Risk Factors Diffuse coronary artery disease: est. Age >80 : 10% 4.50% Morbid Obesity (BMI >40) Full Metal Jacket . Diabetes : 26% 3. 30 . Risk Factors for Isolated CABG 2007 (NSUH) 1.

Diffuse coronary artery disease in 87 year old with dementia and chronic renal failure .

Full Metal Jacket .

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. Comparative patencies of different in situ and free arterial conduits at 5 years Hayward P.84:795-799 Copyright ©2007 The Society of Thoracic Surgeons . A. et al. Ann Thorac Surg 2007.R.

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Cleveland Clinic.0% 82.6% <0.0% <0.05 2 VD 79.10 year survival CABG NEJM 1986: 314: 1-6 SVG IMA(LAD) p value 1 VD 88.0001 .0001 3 VD 71.5% 90.0 % 93.4% 0.

D.V.14:554-571 Copyright ©1998 European Association for Cardio-Thoracic Surgery. . Eur J Cardiothorac Surg 1998. (A) Twenty-year event-free survival after left internal thoracic artery grafting for single vessel anterior descending disease compared with age and gender matched US population Loop F. Published by Elsevier B.. All rights reserved.

117:855-872 Copyright ©1999 The American Association for Thoracic Surgery .. et al. W. Single Mammary Artery Grafting Lytle B. Bilateral vs. J Thorac Cardiovasc Surg 1999.

Ann Thorac Surg 2007. et al. S..83:1008-1015 . Adjusted cumulative event curves during 20 years in patients who received internal mammary artery grafts to multiple systems (solid line) versus a single system (dashed line) Rankin J.

Proximal LAD stenosis with impaired ventricular function .Anatomically equivalent LMCAD with 70% proximal left anterior descending coronary artery and left circumflex artery .LMCAD 50% . particularly in the setting of impaired left ventricular ejection fraction .Triple-vessel CAD. ACC/AHA Guidelines CABG 2004 Class I: .

1979 Number 2 Nonoperative dilatation of coronary-artery stenosis: percutaneous transluminal coronary angioplasty AR Gruentzig. A Senning. Volume 301:61-68 July 12. . and WE Siegenthaler “ We estimate that only about 10 to 15 per cent of candidates for bypass surgery have lesions suitable for this procedure.

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Acute MI 2. Stenting is highly effective 1. Cardiogenic shock 4. Stenting in multivessel disease??? . Unstable coronary syndromes 3.

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37% of patients have a Troponin elevation 28% have MRI defined mean loss of 6 gm of LV muscle (5% LV mass) 10% of patients have a significant MI with each PCI .

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114:662-669 Copyright ©2006 American Heart Association . Circulation 2006. I.Frequency of angiographically determined side branch impairment and closed microvasculature after stenting (TMPG 0 to 1) according to the magnetic resonance-defined pattern of delayed hyperenhancement (HE) Porto. et al.

EPIC STUDY: Periprocedural myonecrosis and subsequent mortality Circ. Aug 2005 112: 906-915 .

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Contrasting Mechanisms of Obstruction of Bare- Metal Stents and Drug-Eluting Stents Shuchman M. N Engl J Med 2006.355:1949-1952 .

2005: In a large cohort of pts (2229) reported. Timeline for Action regarding Stent Thrombosis 1. 9 month rate of 1.3%. July 2003: FDA issues initial warning of increased risk of stent thrombosis 2. October 2003: Official warning letter sent after 290 reports of stent thrombosis 3. significantly higher than that reported in the randomized trials Mortality 45% 4. December 2006: FDA convenes special panel to make recommendations regarding stent thrombosis .

FDA Circulatory System Devices Advisory Panel Dec 2006 1) increase in stent thrombosis with DES at one year (mortality 50-80%) 2) increase in adverse events when DES used off label 3) data for off label use is limited 4) longer duration of Plavix treatment may be beneficial (d/c Plavix rate 7.3%) .

BASKET Trial .

Late stent thrombosis and related clinical events

Pfisterer, M. et al. J Am Coll Cardiol 2006;48:2584-2591

Copyright ©2006 American College of Cardiology Foundation. Restrictions may apply.

What is the evidence for PCI/Stenting in
Multi-vessel disease?

Randomized Trials

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O. Ph.. M. Thomas J. Ryan.D. Edward Bennett... Hannan. M.D. M. Rose. Robert H... M.D. Ph.D..D. Jeffrey P. Gold..012 Stent Pts N Engl J Med Volume 352. M. M. Jones. 37.. Wayne Isom. M. 2005 . M.Long-Term Outcomes of Coronary-Artery Bypass Grafting versus Stent Implantation Edward L. and Eric A.D. Michael J.21:2174-2183 May 26. Culliford.D. Gary Walford.D. Alfred T.D.212 CABG Pts 22.D. Racz.

Hannan E. et al : NEJM 2005. 352: 2174-2183 .

NY State Data: Hannan et al. .

Percentage of Patients Undergoing a Second Revascularization Procedure within Three Years Hannan E et al.352:2174-2183 . N Engl J Med 2005.

3 . 6033 risk matched patients PCI increased 5 year mortality x 2.

Ann Thorac Surg 2006.81:1949-1957 Copyright ©2006 The Society of Thoracic Surgeons .. Relative excess mortality at 3 years with initial stenting versus initial coronary artery bypass graft surgery (CABG) Guyton R. A.

Northern New England Registry Long term survival in patients with multivessel disease after CABG or PCI Circ. 2005 112: I-371-I- 376 .

Era 1:1986-1990. Era 2: 1991-1995.Duke Registry: 18.000 pts. Era 3:1996-2000/ 33% survival advantage at 5 years in TVD Ann Thor Surg 2006 82: 1420-1429 .

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N Engl J Med 2008.358:331-341 .Adjusted Curves for Long-Term Survival and Survival Free from Myocardial Infarction According to the Number of Diseased Vessels Hannan E et al.

Rates of Revascularization within 18 Months after Initial Procedure Hannan E et al. N Engl J Med 2008.358:331-341 .

Drug eluting stents .1%. Stenting vs.8% 2) In large observational databases (the real world) significant survival advantage with CABG as early as three years 3) Survival benefit increases with time 4) Highly significant event free survival in the surgical group-reduction of seven fold at three years 5) Survival benefit at 18 months with CABG vs. CABG 1. Surgery in multivessel disease 1) Early mortality PCI 1.

Why is PCI replacing CABG for the treatment of multivessel disease against all available evidence? .

the patient will always choose the non-surgical treatment . 1. When given the choice of “equivalent” therapies.

” . “It is likely that most people undergoing coronary angiography are not told the entire story when a decision is made about undergoing a percutaneous intervention.

Cardiologist is the gate keeper- conflict of interest (self-referral) .2.

“Never hold discussions with the monkey when the organ grinder is in the room” Sir Winston Churchill (1874-1965) .

3. Disingenuous presentation and inappropriate application of randomized controlled trials .

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A multibillion dollar industry vs.4. evidence based medicine? .

Future Trends for the Treatment of Coronary Artery Disease .

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2008 Angioplasty’s Golden Era May Be Fading By Steve Sternberg. D. Inflating the balloon clears the blockage and restores blood flow. March 26. . USA TODAY By Andrew Councill for USA TODAY Kenneth Kent performs a "routine" angioplasty at Washington Hospital Center in Washington.C. Angioplasty involves guiding a tiny balloon to a blocked artery supplying the heart.

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Number of active thoracic surgeons. L.85:8-24 Copyright ©2008 The Society of Thoracic Surgeons . 1990 to 2004 Grover F. Ann Thorac Surg 2008..

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