April 4, 2019

The SYNTAX Trials:The take home message for the surgical team

Scott R. Martin, MD FACC FSACIDirector, Interventional CardiologyStamford HealthcareAssistant Clinical ProfessorValegos College of Physicians & SurgeonsColumbia University

Disclosure Statement of Financial Interest

❖ None pertinent to this presentation

PCI for Left Main and Triple Vessel CAD

❖ Since the beginning of the PCI experience, there has been a push to treat complex disease and replace bypass surgery

PCI for Left Main and Triple Vessel CAD

❖ Since the beginning of the PCI experience, there has been a push to treat complex disease and replace bypass surgery

❖ In early experience, PCI was limited by poor imaging, primitive equipment, high rate of acute closure

❖ With advancements in equipment and technique (stents, DES), marked improvement in short-term outcomes

PCI for Left Main and Triple Vessel CAD

❖ Advantages of PCI over CABG:

❖ Recovery

❖ Decrease in early complications (stroke, renal failure)

❖ Acceleration of native disease with CABG, particularly with saphenous vein grafts

POD #1: CABG vs PCI

PCI for Left Main and Triple Vessel CAD

❖ Advantages of PCI over CABG:

❖ Recovery

❖ Decrease in early complications (stroke, renal failure)

❖ Acceleration of native disease with CABG, particularly with saphenous vein grafts

PCI for Left Main and Triple Vessel CAD

❖ Advantages of PCI over CABG:

❖ Recovery

❖ Decrease in early complications (stroke, renal failure)

❖ Acceleration of native disease with CABG, particularly with saphenous vein grafts

So why not PCI for all?

So why not PCI for all?

❖ Multiple trials over the years have shown marked increase in need for repeat revascularization with multi-vessel PCI with bare-metal stents

❖ ARTS 1, MASS 2, ERACI-II, AWESOME

❖ Long-term trials also show late mortality benefit of bypass surgery

❖ SOS

So why not PCI for all?

❖ SYNTAX trial designed to compare contemporary (2005-2007) treatment with DES vs CABG in multi-vessel or left main coronary disease

SYNTAX Trial

SYNTAX Trial

So why not PCI for all?

SYNTAX Trial

❖ Pre-specified subgroups of left main disease and triple-vessel disease

SYNTAX Trial

❖ Clear interaction between extent of disease and incremental benefit of CABG over PCI

SYNTAX Trial

So why not PCI for all?

❖ Even with DES there is clearly a reduction in repeat procedures with CABG

❖ Still a long-term decrease in mortality with CABG

❖ Incremental benefit increases with triple-vessel disease, complexity, diabetes

❖ PCI with equivalent outcomes to CABG in less complex left main disease

SYNTAX II Study

❖ Major technical and procedural advances in PCI since SYNTAX trial that influence outcomes

❖ Physiology based revascularization decision using iFR/FFR

❖ Second generation DES (thin strut, biodegradable polymer, everolimus eluting Synergy DES)

❖ IVUS guided optimization of stent deployment

❖ Contemporary CTO revascularization technique

❖ Improved guideline directed medical therapy

SYNTAX II Study

❖ Multi-center, prospective, single-arm, open label trial of patients with de novo triple-vessel CAD

❖ Compared to predefined comparator groups in the CABG and PCI arms of the original SYNTAX trial

❖ Primary endpoint of composite MACCE at two years

SYNTAX II Study

❖ Compared to SYNTAX I, contemporary state-of-the-art PCI in SYNTAX II led to significantly fewer lesions treated with PCI, and significantly higher success rates in CTO revascularization

❖ At one year, outcomes in intermediate SYNTAX score patients were similar to those observed in low SYNTAX score patients

❖ One-year outcomes were significantly improved compared to the SYNTAX I PCI-arm, and comparable to the SYNTAX I CABG-arm

Where are we now?

❖ When is CABG favored?

❖ High anatomic complexity / SYNTAX score

❖ Unable to achieve complete revascularization with PCI

❖ Diabetics

❖ Technically difficult PCI (tortuosity, calcification)

❖ Unable to tolerate dual-antiplatelet therapy

❖ Recurrent in-stent restenosis

Where are we now?

❖ When is PCI favored?

❖ Isolated left main coronary disease

❖ Frailty

❖ Oxygen dependent

❖ Porcelain aorta

❖ Poor surgical targets

Where are we now?

❖ What to expect going forward

❖ Expectation for optimal PCI / CABG

❖ IVUS or OCT guided / multiple arterial grafts

❖ Less complex left main disease patients will be treated with stents

❖ SYNTAX III

❖ CTA guided decision making