In Diabetics with Ischemic Heart Disease CABG revascularization is always superior?

Dr. Paolo Ferrazzi

DN, male, 65 yrNIDDM, HTBMI 283 vessel disease

What is the best OPTION?

CLINICAL SCENARIO

Background

• Major developments in CABG – off-pump technique, less invasive approach,

increased arterial revascularization and optimal perioperative care

• Major developments in PCI– improved technique, stent design, guide

wires, anti-platelet therapy, and drug-eluting stents

• Important to reassess the respective values of the two revascularization

• 7812 patients• Median FU 6 years• 65%: 1 or 2 VD; all normal LV• 1233 with DM

• HR for CABG vs PCI in DM 0.70; p= 0.01

• Survival benefit of CABG increases with time

Lancet 2009; 373: 1190–97

Scores ≤ 22 (n=136) Scores 23-32 (n=156)

Scores ≥ 33 (n=157)0

10

20

30

40

50

60

33.728.6

25.5

42.5 41.5

56.7

5y MACCE in DM (% pts)

CABG PES

p=0,38 p=0,078p<0,001

FREEDOM TRIAL:PATIENTS WITH DIABETES

New England J. of Medicine, December 20, 2012; Vol. 367 No. 25

Survival benefit with two IMA grafts?

Bergamo experience 2012Diabetic and non Diabetic Patients

Patients n. 139

LIMA (%) 99%

BIMA (%) 43%

A RAD (%) 32%

Perioperative mortality 0.92

Bergamo experienceSurgical options in diabetes

LIMA Pedicled + RIMA skeletonized in situ

LIMA + RIMA skeletonized in situ

LIMA in situ + RIMA (Y grafted)

Actuarial survival unmatched diabetic pts

Actuarial survival propensity score–matched diabetic pts

Actuarial survival unmatched diabetic pts <65yr

Actuarial survival unmatched diabetic pts ≥65yr

p<0.001

p<0.001

P=0.006

P=0.014

Compared with SIMA grafting, BIMA grafting in propensity score–matched patients provides diabetics with enhanced survival without any increase in perioperative morbidity or mortality

Conclusions• CABG seems to have better long-term results in

complex multivessel diabetic patients• Two mammary seems to be better than one• Adding radial artery to revascularization strategy

could further improve results

The optimum revascularization strategy for each individual patient will depend on a careful

consideration of the risks and benefits of each procedure in conjunction with the baseline risk profile

PCI

CABG

SYNTAX Trial: top 15 Enrollers

P=0.001P<0.001