Controversies in Cardiovascular Medicine -Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention

Skipper : Stoll Debate

Eric R. Skipper, MD, FACSChief, Adult Cardiovascular Surgery

Surgical Director of Cardiac Transplantationand Mechanical Circulatory Support

“KISS” Principle – Keep It Simple for Skipper

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CABG vsPCILow Risk MVD

• 15+ RCT’s – most were from the pre-stent era5 using stents < 5% of pt’s screened were enrolledAll had LVEF’s over 50% Incidence of 3 vessel CAD << 50%Excluded high-risk pt’s

» DM» Low EF» 3VD or left main disease

Conclude that both groups have similar outcomes• Caution re: generalizing these results to all CAD pt’s

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CABG vsPCI in Low Risk MVD

Trial # Scr % Ran

% 3VD

ProxLAD

EF >50

% DM

AWESOME 454 - 45 - - -ERACI-II 450 2 56 - - 17ARTS 1205 5 32 - 100 19SOS 988 5 38 45 100 14MASSII 408 2 41 - -

SUMMARY 3505 3.5 42.4 - - 17

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CABG vsPCILow Risk MVD

• 15+ RCT’s – most were from the pre-stent era5 using stents < 5% of pt’s screened were enrolledAll had LVEF’s over 50% Incidence of 3 vessel CAD << 50%Excluded high-risk pt’s

» DM» Low EF» 3VD or left main disease

Conclude that both groups have similar outcomes• Caution re: generalizing these results to all CAD pt’s

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CABG vsPCILow Risk MVD

• Appropriate conclusions:Both are reasonable options in single or double

vessel CAD with normal LVEFCABG may offer a slight long-term mortality benefit

over balloon angioplasty which is nullified with use of stents

Repeat procedures are significantly greater in pt’s initially treated with stents (~ 4x)

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CABG vsPCIHigh Risk Multivessel

• Brener et al – Circ 2004; 109: 2290-2295Propensity analysis6033 pt’sMVD and high risk features (DM or low LVEF)PCI 2.3 x higher mortality at 5 years

• Niles et al – JACC 2001; 37: 1008-10152766 risk matched diabetic pt’sPCI 1.5-3.9 x higher mortality at 5 years

• Pell et al – Diabet Med 2004; 21: 790-792PCI 2.6 x higher mortality at 2 years w DM

• New York Registry – NEJM 2005; 352: 2174-218337212 CABG and 22102 PCI pt’s w > 2 VDAfter 3 years, CABG significantly reduced mortality

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CABG vsPCIHigh Risk Multivessel

CABG vs PCI trial – using DES•SYNTAX - Synergy between PCI w TAXUS and CABG

Presented at European Society of Cardiology Congress 2008 – Munich

62 sitesAll-comers design

» Exclusions – prior PCI, acute MI w CKMB > 2x, or concomitant cardiac surgery

Avg stent implantation per pt + 4.6PCI carried a higher MACCE rate at 12 months

(PCI:CABG 18%:12:%; p = 0.0015)PCI was inferior in pt’s w DM, isolated 3 VD, LM +

2 or 3 VD

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CABG vsPCIHigh Risk Multivessel

• Conclusion: CABG remains the first-line therapy in pt’s with

high-risk MVDDMLV dysfunction

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CABG vsPCI in Left Main Disease

• LM stenosissignificant if > 50% diameterOccurs as an isolated lesion in 6-9% of pt’s40-90% occur in the distal LM segment and extend

into the proximal LAD or LCX branchesConcomitant MVD occurs in 70-80% of pt’s

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CABG vsPCI in Left Main Disease

• LEMANS trial – JACC 2008; 51: 538-545Unprotected Left Main Stenting vs CABG52 PCI vs 53 CABG pt’s60% distal LM stenoses3 VD – 60% PCI vs 75% CABGCABG more short-term complicationsPCI and CABG similar MACE rate at 1 year

Problem: only 75% of CABG pt’s received LIMA grafts thus questioning the “quality” of the surgery as LIMA useage is >98% in most contemporary cardiac surgery practices

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CABG vsPCI in Left Main Disease

• SYNTAX trial outcomes analysisOverall 12 month MACE favors CABG (PCI:CABG

15.8%:13.7%) Isolated LM dz and LM dz + single vessel CAD

favor PCI (7.1%:8.5%)CABG is favored with

» LM dz + 2 VD (19.8%:14.4%) » LM dz + 3 VD (19.4%:15.4%) » 3 VD alone (19.2%:11.5%)

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CABG vsPCI in Left Main Disease

• Conclusion: PCI with DES can be a future alternative to CABG

in pt’s with: » isolated, unprotected LM dz, or» LM dz + 1 VD

Catastrophic consequences of LM PCI, including stent restenosis, acute and late thrombosis must be a part of the informed consent discussion

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Cost Effectiveness CABG vsPCI

• Hill et al - Health Technology Assessment 2004; 8: 1242-1245

1720 pt’s allocated to PCI, CABG or both followed for 7 yearsConclusion using a conventional quality-

adjusted life year of $60,000» Medical therapy and CABG were cost-effective» PCI was not» The additional benefit of stenting over best

medical therapy was “to small to justify the additional cost”

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Cost Effectiveness CABG vsPCI

• Griffin et al – Br Med J 2007; 334: 624-627UK Health Technology Asssessment Group

warning that widespread use of DES might » reduce the gain in quality, and » possibly the duration of life arising for CABG in

the long term

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Conclusions

• “Multivessel disease” must be accurately defined as 2VD or 3VD.

• CABG remains an excellent and in many instances superior long-term form of revascularization in select groups of 2VD, and most groups with 3VD.

• Collaboration with a multidisciplinary team approach is going to be a key driver for the future success of these patients as we move into a Value Driven, Quality and Outcomes Oriented Healthcare Model.

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Selection is Key

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Not the Best Model…..

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Thank you

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