CABG VS

Multi Vessel PCI

Hasanat Sharif MD FRCS

Chief of Cardiorthoracic Surgery

Aga Khan University Hospital

Multivessel

• Definition

– Cardiologist

– Cardiac Surgeon

Treatment of Coronary Artery Disease

• Medical

• Percutaneous Intervention

• Surgical Revascularization

Treatment of Coronary Artery Disease

• Medical

• Advances in medical treatment

– Anti platelet agents– ACEI/ARB– Statins– Aggressive risk factor modification

Treatment of Coronary Artery Disease

• Primary percutaneous intervention

• Role in evolving acute myocardial infarction

• Culprit vessel addressed

Intervention

• Interventionalist’s procedural bias

• Perception

– Clinician– Referring doctors and – Patient

End Point CABG (%) DES (%) p

MACCE 12.1 17.8 0.0015

Death/MI/CVA 7.7 7.6 0.98

Revascularization 5.9 13.7 <0.0001

Stroke 2.2 0.6 0.003

MI 3.2 4.8 0.11

All Cause death 3.5 4.3 0.37

Syntax Trial

End point CABG (%) PCI (%) p

All-cause death 4.9 6.2 0.24All stroke 2.8 1.4 0.03Stroke before 1 y 2.2 0.6 0.003Stroke after 1 y 0.6 0.7 0.82MI 3.3 5.9 0.01MI before 1 y 3.3 4.8 0.11MI after 1 y 0.1 1.2 0.008All-cause death, stroke, MI

9.6 10.8 0.44

Repeat PCI 8.6 17.4 <0.001MACCE 16.3 23.4 <0.001

Two-year outcomes for SYNTAX

Kappetein AP. European Society of Cardiology 2009 Congress; September 2, 2009: Barcelona, Spain.

Approriateness criteria for coronary revascularization

• Refined and extended guidance beyond that provided by evidence based guidelines

• Expert panel of 17 members

• Year long effort to evaluate available evidence and existing guidelines

Appropriateness Criteria

• Inappropriate 1-3• Uncertain 4-6• Appropriate 7-9

• PCI inappropriate for LM CAD• PCI uncertain for 3 VCAD• PCI appropriate for acute myocardial injury• CABG appropriate for 3VCAD and LM CAD

What happens in actual practice?

• Catheterization laboratory cardiologists in hospitals with PCI capability were more likely to recommend patients for PCI

than

• Hospitals in which only catheterization was performed

Adherence to ACC/AHA guidelines

• Indicated

• CABG 13%

• PCI 59%

• Both 17%

• Recommended

• 53% (34% PCI)

• 94%

• 93% PCI

• 5% CABG

Trials

• Justification– ? Economically/industry driven– ? Extending the boundaries of care

• Randomization• Multi centered• Adequate numbers• Long term follow up• End point - survival

Trials

• Ethics

– Informed patient consent– Critical to provide complete disclosure of

risks/benefits– Survival– Stent thrombosis/graft closure– Risk of re intervention/complications

Trials

• Enrolled only 5-10% of the eligible population

• ? Generalizability of results

• Real life situations

Trials

• Propensity analysis is not perfect

• Euroscore over predicts procedural risk

• Cost analysis and impact on healthcare budget

Observational data

• Consistently show a survival advantage for CABG over PCI

• STS database

• Northern New England database

• Duke

• New York

AKU Data

Fifty month data Jan 2006-March 2010

• Total CABG n=2041

• Left main n= 406 (19.9%)

• 1 VCAD n= 69 (3.4%)

• 2 VCAD n= 257 (12.6%)

• 3 VCAD n= 1715 (84%)

AKU Data

• Mean age 58 years (+/-11)

• Males 82%

• LVEF 48% (+/-14)

• IMA usage 90%

• CVA n = 8 (0.4%)

• Mortality n = 32 (1.6%)

Cost Considerations

• CABG package 225K

• One bare metal stent 285K– Additional stent 32K

• One DES 395K– Additional stent 139K

Triple vessel and left main coronary stenosis

• CABG first choice for majority of patients

• Consider PCI for patients with co morbidities that preclude CABG

• Advances – PCI technology and – Surgical techniques/ peri operative care

• Extending the boundaries of cardiovascular care

Treatment of coronary artery disease

• Multidisciplinary team approach– Cardiologist– Interventionalist– Cardiac Surgeon

• Separate diagnosis from treatment!

• Treatment option given on cath table

• Scare tactics

Thank You