Triple vessels & LM disease When to PCI, When to CABG

Ts.Bs.Nguyễn Thượng Nghĩa

PGĐ TT Tim mạch – TK TMCT

BV Chợ Rẫy

PROGRESS OF ATHEROSLEROSIS PLAQUE

Stary HC et al. Circulation 1995;92:1355-1374.

Revascularisation vs medical treatment in patients with stable coronary artery disease: network meta-analysis 100 RCTs, N= 93553 pts, 1980-2013

BMJ 2014;348:g3859

Revascularisation vs medical treatment in patients with stable coronary artery disease: network meta-analysis 100 RCTs, N= 93553 pts, 1980-2013

BMJ 2014;348:g3859

FAME2: PCI Guided by Fractional Flow Reserve vs OMT

Xaplanteris P. et al. N Engl J Med 2018; 379:250-259

MACE: Death, MI , Urgent Revascularization Urgent Revascularization

N= 1222 (888) , T: 5 years

Meta-analysis: PCI Guided by Fractional Flow Reserve vs OMT

Zimmermann FM. et al.European Heart Journal (2019) 40, 180–186

MACE: Death, MI

Meta-Analysis of 3 RCTs

DANAMI 3-PRIMULTI

Compare-Acute

FAME 2

N= 2400 , T: 35 months

Objectives of treatment of triple vessel /LM coronary artery disease

1. Cải thiện triệu chứng & Chất lượng cuộc sống Tiêu chí “mềm”

2. Cải thiện tiên lượng Tiêu chí “cứng”: Tử vong, NMCT, Đau ngực tái phát, nhập viện

Indication of myocardial revascularization (CABG/PCI)

• Nhom phân tâng nguy cơ cao khi lam nghiêm phap găng sưc, test chân đoan hinh anh.

• Tôn thương ĐMV năng, nguy cơ cao ( Thân chung, 3 nhanh, LAD, LCx, RCA đoan gân, SYNTAX cao)

• Điêu tri nôi khoa tôi ưu không cai thiên triêu chưng

CÂN BẰNG GIỮA NGUY CƠ & LỢI ÍCH TÁI THÔNG ĐỘNG MẠCH VÀNH BẰNG CABG VS PCI

Khuyến cáo Rx tái thông ĐMV trên Bệnh ĐMV 3 nhánh/Thân chung

Patel MR et al. J Am Coll Cardiol. 2017; 69:2012-41

SYNTAX SCORES

Serruys P. et al, N Engl J Med 2009;360:961-71

SYNTAX SCORE Calculator Mild: 0-22, Moderate:23-32; Severe:≥33

Revascularization with CABG or PCI ? SYNTAX trial , N = 1800 pts

All cause Death Rate : CABG 11,9% vs PCI 13,9% (p=0,10) Cardiac Death Rate: CABG 9,0% vs PCI 9,0%

Chang-Wook Nam et al, JACC, Volume 58, Issue 12, September 2011

Meta-analysis: CABG vs PCI 11 RCTs, 11 518 pts SIHD with LMCA/ Multivessel diseases

Head SJ. Et al. Lancet 2018;391:939–948

In Diabetes Patients

1-year Mortality

5-year Mortality

Fan Zhang et al., Diabetes research and clinical practice 97(2):178-84 · April 2012

In Diabetes Patients 1-year Mortaility repeat revascularization

Fan Zhang et al., Diabetes research and clinical practice 97(2):178-84 · April 2012

Meta-analysis : CABG vs PCI in Diabetes Patients 11 RCTs, 11 518 pts SIHD with LMCA/ Multivessel

diseases

Head SJ. Et al. Lancet 2018;391:939–948

CABG PCI

Class LOE Class LOE

Recommendations according to extent of CAD & T2DM

European Heart Journal (2019) 40, 87–165

Tái thông Thân chung ĐM vành trái CABG hoặc PCI ?

PCI vs. CABG for Left Main Disease Meta-analysis of 4 RCTs - N=1,611 Pts Demographics

Capodanno et al, JACC 2011;58:1426-32

PCI vs. CABG for Left Main Disease Meta-analysis of 4 RCTs - N=1,611 Pts Mortality to 1 year

Capodanno et al, JACC 2011;58:1426-32

PCI vs. CABG for Left Main Disease Meta-analysis of 4 RCTs - N=1,611 Pts 1-year MI

Capodanno et al, JACC 2011;58:1426-32

PCI vs. CABG for Left Main Disease Meta-analysis of 4 RCTs - N=1,611 Pts 1-year Stroke

Capodanno et al, JACC 2011;58:1426-32 Palmerini T et al. JACC 2012;60:798-805

6

PCI vs. CABG for Left Main Disease Meta-analysis of 4 RCTs - N=1,611 Pts MACCE 1 year

Capodanno et al, JACC 2011;58:1426-32

PCI vs. CABG for Left Main Disease Meta-analysis of 4 RCTs - N=1,611 Pts Revascularization 1 year

Capodanno et al, JACC 2011;58:1426-32

PCI vs. CABG for Left Main Disease SYNTAX Trial MACCE to 5 years

Mohr FW et al. Lancet 2013;381:629–38

PCI vs. CABG for Left Main Disease SYNTAX Trial, SYNTAX Scores ≤ 32 MACCE to 5 years

Serruys PW et al. Lancet 2013;381:629–38 Mohr FW et al. Lancet 2013;381:629–38

PCI vs. CABG for Left Main Disease SYNTAX Trial, SYNTAX Scores ≥ 33 MACCE to 5 years

Serruys PW et al. Lancet 2013;381:629–38 Mohr FW et al. Lancet 2013;381:629–38

French Left Main Taxus (FLM Taxus) and the LEft MAin Xience (LEMAX) Registries

N=344 pts

Moynagh A et al. EuroIntervention 2013;9:452-62

LM PCI vs CABG

Death

Trial

OR (95%CI) DES

Events, %

Favors DES

1 5

Favors CABG

Boudriot et al.

PRECOMBAT

0.39 (0.07, 2.07) 0.72 (0.38, 1.38)

2/ 100 17/ 300

5/101

23/300

2.60

14.59

0.90 (0.58, 1.39)

1.10

(0.67, 1.78)

1.38

(0.96, 1.99)

45/ 357

36/

592

71/

948

48/348 33/592 53/957

26.67 22.85 33.29

Overall (I-squared = 58.1%, p=0.61)

SYNTAX NOBLE EXCEL

1.03 (0.78, 1.35)

171/ 2297

162/ 2298

MI

CABG Weight Trial

OR (95%CI) DES

Events,

CABG

%

Weight

Favors DES

1 5

Favors CABG

Boudriot et al.

PRECOMBAT

1.01 (0.20, 5.13) 1.20 (0.36, 3.99)

3/ 100 6/ 300

3/101

5/300

7.97

12.50

28/ 357

29/

592 72/ 948

16/348 24.43 10/592 21.82 77/957 33.28

Overall (I-squared 100.00 = 23.7%, p=0.08)

SYNTAX NOBLE EXCEL

1.46 (0.88, 2.45)

138/ 2297

111/ 2298

100.00

1.77 (0.94, 3.33)

3.00

(1.45, 1.39) 0.94 (0.67, 1.31)

Nerlekar et al, Circ Cardiovasc Interv. 2016;9:e004729

Revascularization of LMCA CABG or PCI ? Contemporary Meta-Analysis (5 RCTs, N= 3887 pts)

LM PCI vs CABG Contemporary Meta-Analysis

Nerlekar et al, Circ Cardiovasc Interv. 2016;9:e004729

Stroke

Trial

OR (95%CI) DES

Events, %

Favors DES

1 5

Favors CABG

PRECOMBAT 1.00 (0.14, 7.15)

2/ 300

2/300 12.06

p=0.53)

SYNTAX NOBLE EXCEL

Overall (I-squared

= 62.5%,

0.34 (0.12, 0.95)

2.32

(0.95, 5.68)

0.77

(0.43, 1.39) 0.88 (0.39, 1.97)

5/ 357

16/

592

20/

948 43/ 2197

14/348 7/592 26/957

49/

2197

25.14 27.99 34.81 100.00

Boudriot et al.

CABG Weight Trial

OR (95%CI) DES

Events,

2.58 (0.95, 7.01)

14/ 100

6/101

CABG

%

Weight

3.62

1

38/ 300

90/

357

71/

592 114/ 948

21/300 11.59

49/348 24.43 47/592 24.11 67/957 36.24

Overall (I-squared = 0.0%, p=<0.001)

Favors DES

PRECOMBAT

SYNTAX NOBLE EXCEL

1.85 (1.53, 2.23)

5

Favors CABG

327/ 2297

190/ 2298

100.00

1.93 (1.10, 3.37)

2.06

(1.40, 3.02)

1.58

(1.07, 2.33) 1.82 (1.32, 2.49)

Repeat revascularization

Revascularization of LMCA CABG or PCI ? Contemporary Meta-Analysis (5 RCTs, N=3887 pts)

Revascularization of LMCA CABG or PCI ? Contemporary Meta-Analysis (11 RCTs, N= 4478 pts )

Head SJ, et al. Lancet 2018;391:939-48

CABG PCI

Class LOE Class LOE

Recommendations according to extent of CAD & T2DM

European Heart Journal (2019) 40, 87–165

N= 280 IABP KHÔNG IABP CHUNG

EUROSCORE II 8,55 ± 4,02% 2,02 ± 1,2% 7,67 ± 3,9%

QUAN SÁT 42,6%

(20/47) 5,6%

(13/233) 11,8%

(33/280)

NGHIÊN CỨU ĐÁNH GIÁ HIỆU QUẢ IABP/ CABG

Khoa Hồi sức- phẫu thuật tim, bệnh viện Chợ rẫy từ 1/2015 đến 12/2016

Tỉ lệ tử vong dự tính theo Euroscore II và Thực tế quan sát

(Luận văn Cao học Ng Cong Cưu – Pham Tho Tuan Anh – ĐH Y Duoc TPHCM 2017)

Kết luận • Đa sô BN SIHD nên được điêu tri nội khoa tối ưu (GDMT) trươc khi điêu tri tai

tươi mau vơi CABG/PCI

• Mục tiêu tái tươi máu bệnh thân chung & bệnh mạch vành nhiêu nhánh Cải thiện triệu chứng và Cải thiện tiên lượng là chủ yếu

• Chọn lựa CABG & PCI trên tái thông ĐMV sẽ “cá thể hóa” dựa trên:

1. Giải phẫu, chức năng ĐMV cũng như tiên lượng bằng SYNTAX Scores, 2. Nguy cơ phẫu thuật bằng STS Scores (Ia), EUROSCORE II (IIb) 3. Tái thông hoàn toàn hoặc không hoàn toàn 4. Bệnh kèm theo đặc biệt bệnh đai tháo đường 5. Lựa chọn của bệnh nhân

How to choose PCI or CABG on Patients with LMCA/Multivessel coronary heart disease

European Heart Journal (2019) 40, 87–165