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Cabg is superior to pci in heart failure patients with multivessel disease pro

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Cabg is superior to pci in heart failure patients with multivessel disease pro

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Cabg is superior to pci in heart failure patients with multivessel disease pro

  1. 1. CABG is, today, the best option in most multivessel coronary artery disease patients José L. Pomar, MD, PhD Professor of Surgery Hospital Clinic and University of Barcelona Barcelona, Spain
  2. 2. Vasilii I Kolesov (1904 –1992) Military surgeon in St. Peterburg LITA to marginal branch of LCX on 25 February 1964 Michael E DeBakey (1908-2008) SVG to the LAD on 23 November 1964 Garrett HE et al. JAMA 1973;223:792-4 René G Favaloro (1923-2000) SVG to the RCA on 9 May 1967 J Thorac Cardiovasc Surg 1969;58:178-85
  3. 3. Mason Sones, smoking and serendipity
  4. 4. 1967 Cleveland Clinic
  5. 5. Evidence based myocardial revascularization Head SJ & Davierwala PM et al. Eur Heart J 2014; online
  6. 6. Coronary Artery Bypass Graft Trialist Cooperation Yusuf et al. Lancet 1994;344:563-72 Time from randomization (years) Mortality(%) N = 1325 Medical treatment CABG N = 1324 OR 0.61 [0.48-0.77] P<0.0001 OR 0.83 [0.70-0.98] P=0.03 CABG VS MEDICAL TREATMENT
  7. 7. CABG VS MEDICAL TREATMENT Coronary Artery Bypass Graft Trialist Cooperation (Individual Data from 7 Randomized Trials) Yusuf S et al. Lancet 1994;344:563-72 CABG vs MM 0.00 20.00 40.00 60.00 80.00 100.00 120.00 1VD / 2VD 3VD LM CABG vs MM 0.00 20.00 40.00 60.00 80.00 100.00 120.00 CABG vs MM 0.00 20.00 40.00 60.00 80.00 100.00 120.00P=0.25 P=0.001 P=0.005 Interaction P = 0.02 Meansurvival(months)
  8. 8. CABG VS MEDICAL TREATMENT Network meta-analysis of 100 revascularization trials with 93,553 patients and 262,090 patient-years CABG MM Risk ratio (95% CI) 0.80 (0.70-0.91)Death CABG vs MM MI CABG vs MM Death or MI CABG vs MM Revasc. CABG vs MM SES 0.1 0.3 1 3 Favours CABG Favours MM Windecker S et al. BMJ 2014;348:g3859 0.81 (0.70-0.94) 0.16 (0.13-0.20) 0.79 (0.63-0.99)
  9. 9. RCTs on revascularization Head SJ & Davierwala PM et al. Eur Heart J 2014; online
  10. 10. Hlatky M et al. Lancet 2009;373:1190-97 CABG VS PTCA/BAREMETALSTENTS Pooled analysis of 10 RCTs with 7812 patients (ARTS, BARI, CABRI, EAST, ERACI-II, GABI, MASS-II, RITA, SoS, FMS) PTCA/BMS CABG Mortality(%) 10.0% 8.4%N = 3923 N = 3889 Follow-up (years) HR 0.92 [0.80-1.02] P=0.12 1VD or 2VD 0.91 [0.78-1.06] 3VD 0.91 [0.77-1.09]
  11. 11. RCTs on revascularization Head SJ & Davierwala PM et al. Eur Heart J 2014; online
  12. 12. 2014 ESC/EACTS Guidelines
  13. 13. TAXUS (N=546)CABG (N=549) SYNTAX 3VD cohort All-cause death to 5 years ITT populationCumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates 0 Months Since Allocation CumulativeEventRate(%) 25 50 Before 1 year* 2.9% vs 4.5% P=0.18 1-2 years* 1.2% vs 2.1% P=0.25 2-3 years* 1.7% vs 3.2% P=0.12 3-4 years* 1.7% vs 2.5% P=0.40 4-5 years* 2.4% vs 2.8% P=0.74 0 12 6024 36 48 P=0.006 9.2% 14.6%
  14. 14. 0 Months Since Allocation CumulativeEventRate(%) 25 50 Before 1 year* 2.7% vs 5.2% P=0.04 1-2 years* 0.2% vs 1.2% P=0.12 2-3 years* 0.4% vs 1.0% P=0.45 3-4 years* 0.0% vs 2.3% P=0.001 4-5 years* 0.0% vs 1.3% P=0.03 0 12 6024 36 48 SYNTAX 3VD cohort Myocardial infarction to 5 years P<0.001 3.3% 10.6% TAXUS (N=546)CABG (N=549)
  15. 15. ITT populationCumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates 0 Months Since Allocation CumulativeEventRate(%) 25 50 Before 1 year* 6.6% vs 8.0% P=0.39 1-2 years* 1.8% vs 3.7% P=0.07 2-3 years* 2.5% vs 4.4% P=0.10 3-4 years* 2.1% vs 4.4% P=0.053 4-5 years* 2.4% vs 3.7% P=0.29 0 12 6024 36 48 SYNTAX 3VD cohort Death/Stroke/MI to 5 years P<0.001 14.0% 22.0% TAXUS (N=546)CABG (N=549)
  16. 16. ITT population TAXUS (N=546)CABG (N=549) Cumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates 0 Months Since Allocation CumulativeEventRate(%) 25 50 Before 1 year* 11.5 vs 19.2% P<0.001 1-2 years* 4.4% vs 7.0% P=0.08 2-3 years* 4.6% vs 7.4% P=0.06 3-4 years* 2.8% vs 7.7% P<0.001 4-5 years* 4.5% vs 6.9% P=0.11 0 12 6024 36 48 SYNTAX 3VD cohort MACCE to 5 years P<0.001 24.2% 37.5%
  17. 17. SYNTAX 3VD Cohort Multivariate cox regression: PCI vs CABG HR (95% CI) MACCE Death/stroke/MI Death 0.5 1 2 5 HR 1.66 (1.32-2.09) HR 1.81 (1.33-2.46) HR 1.81 (1.24-2.67) Favours PCI Favours CABG
  18. 18. SYNTAX 3VD cohort SYNTAX score terciles Death Myocardial infarction Stroke Repeat Revasc. TAXUS (N=546)CABG (N=549)
  19. 19. SYNTAX 3VD cohort SYNTAX score terciles Head SJ & Davierwala PM et al. Eur Heart J 2014; online TAXUS (N=546)CABG (N=549) Death/stroke/MIMACCE CABG PCI
  20. 20. SYNTAX 3VD cohort Completeness revascularization Incomplete revasc. Complete revasc.P = 0.010 P = 0.17 MACCE(%) Head SJ & Davierwala PM et al. Eur Heart J 2014; online
  21. 21. Completness revascularization PCI N=63,945 CABG N=25,938 Incomplete revasc. Complete revasc. 75% 44%56% 25% SXS <23 SXS 23-32 SXS >32 Patients (%) 0 10 20 30 40 50 60 70 Complete Resid SXS 0-4 Resid SXS 4-8 Resid SXS >8 Farooq V et al. Circulation 2013;128:141-51 Garcia S et al. JACC 2013;62:1421-31
  22. 22. SYNTAX PCI cohort Residual SYNTAX score Resid SXS 0-4 Resid SXS 4-8 Resid SXS >8 Hazardratio(95%CI) 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 MACCE DeathDeath/stroke/MI Farooq V et al. Circulation 2013;128:141-51
  23. 23. SYNTAX 3VD Cohort Diabetic patients 0.3 1 3 10 Hazard Ratio (95% CI) MACCE: Diabetes No diabetes Death/stroke/MI: Diabetes No diabetes All-cause death: Diabetes No diabetes Interaction P=0.095 P=0.44 P=0.37 Head SJ & Davierwala PM et al. Eur Heart J 2014; online Favours CABG
  24. 24. FREEDOM Trial Similar results as SYNTAX Death/Stroke/MI(%) Follow-up (years) Death/(%) Follow-up (years) 26.6% 18.7% P=0.005 16.3% 10.9% P=0.049 SYNTAX 3VD: 24.9% vs 13.2% P = 0.021 SYNTAX 3VD: 20.2% vs 10.1% P = 0.027
  25. 25. SYNTAX II Score Risk score predicting 4-year mortality 84.2% Favours CABG 15.8% Favours PCI
  26. 26. Annual Cumulative SYNTAX Trial Economics Cohen DJ & Osnabrugge RL, et al. Circulation 2014; online Δ cost = $10,036 Δ cost = $5619
  27. 27. -$20 000 -$10 000 $0 $10 000 $20 000 -2 -1 0 1 2 $50,000 per QALY 84.7% below ∆ Cost = $5081 ∆ QALY = 0.307 ICER = $16,537/QALY ∆ QALYs (CABG-PCI) ∆Long-termcost (CABG-PCI)  Cost  QALY  Cost  QALY  Cost  QALY  Cost  QALY SYNTAX Cost-effectiveness ∆ Cost = $3350 ∆ QALY = 0.68 ICER = $4,905/QALY $50,000 per QALY 94.3% below 3VD cohort
  28. 28. Multivessel disease (MVD) CABG Diabetics with MVD FREEDOM Left main disease SYNTAX Decision- making and assessing riskHeart Team
  29. 29. PCI/CABG ratios worldwide Country PCI/CABG CABG : PCI (per 100,000 of population) Mexico New Zealand Canada United Kingdom Ireland Australia Denmark Portugal Luxembourg Finland Netherlands Norway Sweden Belgium OECD Czech Republic Iceland Switzerland Poland Germany Hungary United States Italy France Spain 200 100 0 100 200 300 400 500 600 0.67 ??? 1.40 1.87 2.03 2.15 2.19 2.24 2.33 2.34 2.37 2.41 3.09 3.20 3.21 3.29 3.36 3.56 3.67 3.80 4.18 4.30 5.17 5.26 5.98 8.63 Head SJ et al. Eur Heart J 2013;94:1954-60
  30. 30. Evidence based myocardial revascularization CABG is clearly superior to Medical Management SYNTAX trial shows superior survival with CABG over first- generation, paclitaxel-eluting stents for 3VD Guidelines favours CABG for complex MV disease Differences between PCI and CABG appear particularly with higher degree of incomplete revascularization
  31. 31. Evidence based myocardial revascularization Surgery, since the beggining showed better results when patients had an LV dysfunction PCI is an alternative to CABG for low SYNTAX score, but still more repeat revascularizations are required CABG is economically attractive
  32. 32. Conclusions to take home 1 • In 2015, CABG turned 50 years old…Many, many patients benefited. 2 • SYNTAX trial and others show superior survival with CABG over first- generation stents for 3VD 3 • Differences between PCI and CABG appear particularly with higher degree of incomplete revascularization 6 • CAD patients with poor LV function or HF are better treated by surgery, but Heart Team assessment is, in 2015, mandatory 4 • CABG is superior to PCI in diabetic patients, irrespective of insulin dependence 5 • PCI provides similar outcomes as CABG 3VD patients with low or intermediate SYNTAX scores
  33. 33. Thanks to Dr. Stuart Head for some few slides and apologies on behalf of Dr. David Taggart

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