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

1. Yonathan Hasin
Yaakov Hasin
PCI is a good alternative to CABG
in patients with HF and viable
myocardium
Conflict of interests:
I am an interventional cardiologist

2. Rationale
• Revascularization of viable myocardium may:
– Improve LV function, reverse remodeling
– Improve QOL, improve survival
• Viability diagnosis
– Scar (wall thickness, gadolinium)
– Induced contraction
– Metabolism
– Echo
– PET
– MRI

3. Figure 1 Diagrammatic representation of postulated progressive changes in a patient with hibernating myocardium and ( A ) no
remodeling ( B ), mild to moderate remodeling ( C and D ), and end stage ( E ) of the disorder.WMA , Wal...
Harry R. Phillips , Christopher M. O'Connor , Joseph Rogers
Revascularization for heart failure
American Heart Journal, Volume 153, Issue 4, Supplement, 2007, 65 - 73
Concept of reverse remodeling

4. Cardiac events (cardiac death, myocardial infarction, and hospitalization for heart failure) at 3
-year follow-up for four different patient categories with ischaemic left ventricular dysfunction
according to the presence of substantial viable myocardium (>4 segments) at dobutamine
stress echo and the left ventricular end-systolic volume.
Lauro Cortigiani et al. Eur Heart J Cardiovasc Imaging
2012;13:219-226

5. Results of two meta-analysis on 3088 and 2217 patients with ischaemic cardiomyopathy,
respectively, assessing the effect of revascularization and medical therapy according to the
presence or absence of viability at dobutamine stress echo or nuclear techniques.
Lauro Cortigiani et al. Eur Heart J Cardiovasc Imaging
2012;13:219-226

6. Modes of revascularization
• CABG:
– Technically straight forward,
– Durable
– Evidence based
– Increased risk in heart failure
• PCI:
– Technically challenging (CTO)
– Restenosis
– Paucity of evidence

7. ESC Guidelines Heart failure 2012

8. ESC Guidelines Myocardial
Revascularization 2014

9. ESC Guidelines Heart failure 2012

10. ESC Guidelines Heart failure 2012

11. ESC Guidelines Myocardial
Revascularization 2014

12. Guideline summary
• Conditional revascularization for HF
– Angina
– Proximal anatomy
– Viability/Ischemia
• In Acute heart failure (ACS)
– PCI is preferred over CABG
• In Chronic heart failure
– CABG is preferred over PCI

13. Figure 5 Management algorithm for patients with LV dysfunction and suspected coronary disease.SPECT , Single-photon emission
computed tomography; Echo , echocardiography; CABG , coron...
Harry R. Phillips , Christopher M. O'Connor , Joseph Rogers
Revascularization for heart failure
American Heart Journal, Volume 153, Issue 4, Supplement, 2007, 65 - 73
Flow chart of ischemic
cardiomyopathy

14. Revascularization for chronic HF
Prospective randomized trials
• CABG Vs. Medical: STICH trial
• PCI Vs. Medical: None
• CABG Vs. PCI: None

15. 1212
Randomized
CABG
Randomized
MED only
610602
STICH Revascularization
Hypothesis
•• 99 clinical sites in 22 countries99 clinical sites in 22 countries
•• Enrollment: July 2002 – May 2007Enrollment: July 2002 – May 2007

16. All-Cause Mortality
— As Randomized

17. Death or Cardiovascular
Hospitalization — As Randomized

18. Time-varying Hazard Ratios
— As Randomized

19. LV dysfunctions and comorbidities are
predictors of CABG mortality

20. Post STICH clarifications
• The concept of re-vascularizing viable
myocardium is viable.
• CABG – may be hazardous
• PCI – a possible alternative
- Paucity of evidence

21. PCI can be effective in ischemic
cardiomyopathy
Facilitation of LV functional recovery post PCI by levosimendan
Oct 2012.J Cardiol D… Hasin Y. Int Qarawani
Poria:
No cardiac
surgery

22. P=0.79 P=0.78
LVEF before and after revascularization+ Levosimendan
and after 6 months follow-up
In group A : Improvement in LVEF at discharge (after) relatively to the baseline
( before) (P<.0001) and at 6 months follow up relatively to the discharge (P<0001)
In group B1: Improvement in LVEF at discharge relatively to the baseline (P<0.001); but
there is no significant improvement in LVEF at follow up relatively to the discharge (P=0.485)
In group B2: No improvement in LVEF at discharge relatively to the baseline (P=0.79);
and at follow up relatively to the discharge (P=0.78)
P=0.48
P<0.001P<0.001
P<0.001

23. A,B1 P=0.845
A,B2 P=0.019
B1,B2 P=0.038
Kaplan Meier survival curves
There is no difference in survival between group A (improved LV function post revascularization) and B1
(improved LV function post revascularization and levosimendan (P=0.8475),
The survival of group B2 (no improvement in LV post revascularization and Levosimendan) is significantly reduced
B1
A
B2

24. CABG or PCI for heart failure
Revascularization in patients with heart failure
Tsuyuki, Ross T., et al. "Revascularization in
patients with heart failure."Canadian Medical
Association Journal 175.4 (2006): 361-365.
A retrospective analysis of 2538 patients with Heart failure, ≈ 25% with
EF ≤ 35%, 48.5% PCI

25. Park, Seung-Jung, et al. New England Journal of Medicine 372.13 (2015): 1204-1212.
Trial of Everolimus-Eluting Stents or Bypass
Surgery for Coronary Disease (BEST)

26. Predicting Benefit From Revascularization in Patients With
Ischemic Heart Failure
Orla Buckley, MD; Marcelo Di Carli, MD Circulation.2011; 123: 444-450
Current practice
Case report and contemporary review
“The incorporation of an assessment of ischemia with viability assessment can provide
valuable additional information for patient selection for revascularization.”
“In light of the dilated LV, severe LV dysfunction, and potential surgical morbidity and
mortality, our patient received percutaneous therapy, with successful stenting of the
left anterior descending and right coronary arteries. ”

27. Conclusions
• Revascularization for HF is appropriate provided
significant viable (yet stunned or hibernated)
myocardium
• PCI is preferred for acute HF (ACS)
• CABG in the presence of HF is associated with
increased risk
• Paucity of evidence for PCI in chronic HF
• A RCT comparing CABG VS PCI is needed
• Individual assessment (Patient characteristics, local
expertise) should determine the method of
revascularization in chronic HF