This document discusses PCI (percutaneous coronary intervention) versus CABG (coronary artery bypass grafting) for treating stable coronary artery disease. It provides historical context on the evolution of both procedures and summarizes key randomized controlled trials comparing outcomes of PCI versus CABG. The trials show that CABG provided better long-term outcomes than balloon angioplasty or bare metal stents in multivessel disease. Later trials with drug-eluting stents still found CABG superior for left main or multivessel disease, though the differences were smaller. CABG remains the standard of care for more complex anatomies while PCI is preferred for simpler cases.
There are two basic IVUS catheter designs: mechanical/rotational and solid state. The mechanical catheters (OptiCross IVUS catheter, Boston Scientific, Santa Clara, California; Revolution IVUS catheter, Volcano, Rancho Cordova, California; ViewIT IVUS catheter, Terumo, Tokyo, Japan; and Kodama HD IVUS catheter, ACIST Medical Systems, Eden Prairie, Minnesota) consist of a single transducer element located at the tip of a flexible drive cable housed in a protective sheath and operated by an external motor drive unit. The drive cable rotates the transducer around the circumference (1800rpm) and the transducer sends and receives the ultrasound signals at 1° increment to form the cross-sectional image. The imaging catheters operate at a central frequency of 40 MHz or 60 MHz and are 5F or 6F compatible [Figure 1]A. In the solid-state catheter design (Eagle Eye Catheter, Volcano), no rotating components are present. There are 64 transducer elements mounted circumferentially around the tip of the catheter. The transducer elements are sequentially activated with different time delays to produce an ultrasound beam that sweeps around the vessel circumference. The catheter works at a central frequency of 20 MHz and is 5F compatible
There are two basic IVUS catheter designs: mechanical/rotational and solid state. The mechanical catheters (OptiCross IVUS catheter, Boston Scientific, Santa Clara, California; Revolution IVUS catheter, Volcano, Rancho Cordova, California; ViewIT IVUS catheter, Terumo, Tokyo, Japan; and Kodama HD IVUS catheter, ACIST Medical Systems, Eden Prairie, Minnesota) consist of a single transducer element located at the tip of a flexible drive cable housed in a protective sheath and operated by an external motor drive unit. The drive cable rotates the transducer around the circumference (1800rpm) and the transducer sends and receives the ultrasound signals at 1° increment to form the cross-sectional image. The imaging catheters operate at a central frequency of 40 MHz or 60 MHz and are 5F or 6F compatible [Figure 1]A. In the solid-state catheter design (Eagle Eye Catheter, Volcano), no rotating components are present. There are 64 transducer elements mounted circumferentially around the tip of the catheter. The transducer elements are sequentially activated with different time delays to produce an ultrasound beam that sweeps around the vessel circumference. The catheter works at a central frequency of 20 MHz and is 5F compatible
There are many interventional cardiac procedure those need a trans septal puncture of the interatrial septum. This presentation clearly elaborates everything you need to know about the TSP.
preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.
IVUS may not be clinically warranted in all interventions, and should be seen as an adjunct to angiography. IVUS provides information about vessel morphology, plaque topography, and therapeutic outcomes that is often either equivocal or unavailable in angiographic images.
There are 3 situations in which IVUS has the most clinical utility:
Small vessel stenting: Studies have shown that post-stent restenosis rates are higher in small vessels. This is particularly true for vessels with diameters of 3.0mm or less, wherein small increases in stent diameter have been shown to significantly decrease the rate of restenosis. A study by Moussa et al showed that, as measured by IVUS, the incidence of restenosis has an inverse relationship to the post-procedure in-stent lumen CSA1.
In-Stent restenosis: In these cases, IVUS helps to determine whether the restenosis is due to inadequate stent deployment (underexpansion or incomplete apposition) due to intimal hyperplasia. IVUS will also help you select the proper device size for treatment of the stented area.
Difficult to assess lesions: At times, images of a lesion and the adjacent reference segment are often hazy. IVUS should be used to identify whether the angiographic appearance is due to dissection, thrombus, residual plaque, or is benign.
There are many interventional cardiac procedure those need a trans septal puncture of the interatrial septum. This presentation clearly elaborates everything you need to know about the TSP.
preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.
IVUS may not be clinically warranted in all interventions, and should be seen as an adjunct to angiography. IVUS provides information about vessel morphology, plaque topography, and therapeutic outcomes that is often either equivocal or unavailable in angiographic images.
There are 3 situations in which IVUS has the most clinical utility:
Small vessel stenting: Studies have shown that post-stent restenosis rates are higher in small vessels. This is particularly true for vessels with diameters of 3.0mm or less, wherein small increases in stent diameter have been shown to significantly decrease the rate of restenosis. A study by Moussa et al showed that, as measured by IVUS, the incidence of restenosis has an inverse relationship to the post-procedure in-stent lumen CSA1.
In-Stent restenosis: In these cases, IVUS helps to determine whether the restenosis is due to inadequate stent deployment (underexpansion or incomplete apposition) due to intimal hyperplasia. IVUS will also help you select the proper device size for treatment of the stented area.
Difficult to assess lesions: At times, images of a lesion and the adjacent reference segment are often hazy. IVUS should be used to identify whether the angiographic appearance is due to dissection, thrombus, residual plaque, or is benign.
Catheter Based Intervention and Surgical Management of Peripheral Arterial Oc...Omar Haqqani
Dr. Omar P. Haqqani, MD discusses the details of catheter based blood vessel intervention, focussed on management of peripheral arterial disease (PAD).
RECENT ADVANCES IN THE MANAGEMENT OF REFRACTORY HEART FAILUREApollo Hospitals
Heart failure is a pathophysiological state in which structural or functional cardiac disorder impairs the ability of the heart to function as a pump to support the physiological circulation. The medical therapy remains the
mainstay of treatment in these patients. The medical therapy can improve the quality of life and the longevity in
these patients, but this becomes insufficient in refractory heart failure. The heart failure is considered refractory when patients continued to be symptomatic despite optimal dose of medications, characterized by advanced structural heart disease. These patients will need frequent hospitalizations and the overall prognosis is very poor.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
The hemodynamic and autonomic determinants of elevated blood pressure in obes...
Pci vs cabg
1. PCI vs CABG IN CSAPCI vs CABG IN CSA
DR VINIT KUMAR
2. CSACSA
Stable coronary artery disease is generallyStable coronary artery disease is generally
characterized by episodes of reversiblecharacterized by episodes of reversible
myocardial demand/supply mismatch,myocardial demand/supply mismatch,
related to ischaemia or hypoxia, which arerelated to ischaemia or hypoxia, which are
usually inducible by exercise, emotion orusually inducible by exercise, emotion or
other stress and reproducible—but, whichother stress and reproducible—but, which
may also be occurring spontaneously.may also be occurring spontaneously.
4. Evolution of CABG
1818
Heberden coins
the term “angina
pectoris”
1950
Vineburg
reroutes IMA
into heart
muscle
1953
Gibbon performs
1st
successful
open heart
surgery using a
cardio-pulmonary
bypass machine
1957/8
Bailey/Longmire
report successful
coronary
revascularization
on a beating heart
1962
Sabiston
attempts to
suture an SVG
into coronary
circulation
1968
Favaloro 1st
surgeon to
perform bypass
surgery (SVG)
1999
Diegler et al
publish OPCAB
technique
1958
Sones discovers
the diagnostic
coronary
angiogram
1996
Greenspun et al
and Benetti et al
publish MIDCAB
technique
2000
Falk et al publish
TECAB technique
2003
Shrivastava
et al publish
ThoraCAB
technique
1876
Hammer
diagnoses the
first cardiac
infarct in a living
human
1910
Carrell presents
a paper
describing
coronary artery
bypass
2005
Updated
ACC/AHA/SCAI
guidelines:
CABG remains
the standard of
care for
3VD/LM
disease
5. Evolution of PCI
1844
Bernard coins the
term “cardiac
catheterization”
1929
Forssmann
peforms the 1st
human cardiac
catheterization
1958
Sones discovers
the diagnostic
coronary
angiogram
1962
Ricketts and
Abrams use the
percutaneous
approach in
coronary arteries
1964
Dotter
introduces
transluminal
angioplasty
1977
Gruentzig
peforms the 1st
PTCA
1967
Judkins perfects
the transfemoral
approach
1986
Sigwart and Puel
implant the 1st
coronary stent
1994
1st
coronary stent
approved by the
FDA 2003
FDA approval of
1st
DES
2006
FDA panel on
the safety of
DES
Today
Increasing
real-world use
of PCI in LM
and 3VD
2002
CE Mark on 1st
DES
6. CABGCABG PCIPCI
+
Angina reliefAngina relief
+
Reduced reinterventionReduced reintervention
+
Complex anatomyComplex anatomy
+
CompleteComplete
revascularizationrevascularization
+
Mortality benefit in selectedMortality benefit in selected
patient groupspatient groups
Potential high costsPotential high costs
InvasiveInvasive
+
Initially cost effectiveInitially cost effective
+
Fast recoveryFast recovery
+
Reduced acuteReduced acute
complicationscomplications
+
Least invasiveLeast invasive
Increased restenosisIncreased restenosis
Repeat revascularizationRepeat revascularization
CABG is standard of care in patients
with left main & multivessel disease
Historical Pros & Cons
7. Why is CABG better than PCI?Why is CABG better than PCI?
PCI treats an isolatedPCI treats an isolated
lesion in the proximallesion in the proximal
vessel.vessel.
CABG bypasses theCABG bypasses the
proximal 2/3 of theproximal 2/3 of the
vessel, where thevessel, where the
current lesioncurrent lesion andand
future threateningfuture threatening
lesionslesions occuroccur..
This advantage ofThis advantage of
CABG will persist,CABG will persist,
even if Stenteven if Stent
restenosis is ZERO.restenosis is ZERO.
Gersh and Frye NEJM , May
2005
8. CABGCABG
PCIPCI
Evolution of Revascularization
+
Improved techniqueImproved technique
+
Improved stentImproved stent
designdesign
+
DESDES
+
Improved guidewiresImproved guidewires
+
Off pump techniqueOff pump technique
+
Less invasive approachLess invasive approach
+
Increased arterialIncreased arterial
revascularizationrevascularization
+
Optimal perioperativeOptimal perioperative
carecare
?
How does modern
CABG compare to PCI
in high-risk patients
eligible for both
techniques ?
Randomized Trial
10. Eras of Comparative CABG
Trials
Drug Eluting Stents
DES vs CABG (randomized)
Plain Balloon Angioplasty
POBA vs CABG
Bare Metal Stents
BMS vs CABG
Drug Eluting Stents
DES vs CABG
13. PCI Vs CABG in MVD POBA eraPCI Vs CABG in MVD POBA era
Observational studiesObservational studies
Randomised controlled trialsRandomised controlled trials
14. OBSERVATIONAL STUDIES.OBSERVATIONAL STUDIES.
CABG ass. with less mortality in long runCABG ass. with less mortality in long run
recurrent events, including angina pectoris and the needrecurrent events, including angina pectoris and the need
for repeat revascularization procedures, were morefor repeat revascularization procedures, were more
frequent in the PTCA than the CABG group,frequent in the PTCA than the CABG group,
largely as a consequence of incompletelargely as a consequence of incomplete
revascularization and restenosis.revascularization and restenosis.
15. Impact of Coronary BypassImpact of Coronary Bypass
Surgery on SurvivalSurgery on Survival
Coronary Artery Surgery Study (CASS)
16. PCI vs CABG Trial ResultsPCI vs CABG Trial Results
SummarySummary
Significant
decrease of
revascularization
expected with DES
17. BARIBARI
1829 pts. of multivessel CAD1829 pts. of multivessel CAD
Primary endpoint was allcause mortality at 5yrsPrimary endpoint was allcause mortality at 5yrs
Separate analysis of diabetic pts.Separate analysis of diabetic pts.
RESULTRESULT
No significant differences overallNo significant differences overall
the composite end point of cardiac mortality or MIthe composite end point of cardiac mortality or MI
cardiac mortality in nondiabetic patients regardless ofcardiac mortality in nondiabetic patients regardless of
symptoms,symptoms,
LV function,LV function,
number of diseased vessels, ornumber of diseased vessels, or
stenotic pLAD artery.stenotic pLAD artery.
23. BMS Vs CABG IN SVD (p-LAD)BMS Vs CABG IN SVD (p-LAD)
MASSMASS (Medicine, Angioplasty or Surgery Study, 1995) &(Medicine, Angioplasty or Surgery Study, 1995) &
Lausanne TrialLausanne Trial, 1994 (LIMA to LAD), 1994 (LIMA to LAD)
–– No difference in overall survival in both studiesNo difference in overall survival in both studies
–– In Lausanne Trial, more CABG pts were free from lateIn Lausanne Trial, more CABG pts were free from late
events such as angina at 2.5 yearsevents such as angina at 2.5 years
The RITA, subset of 45% had SVD.The RITA, subset of 45% had SVD.
Over 2 to 3 years, the rates of mortality, MI andOver 2 to 3 years, the rates of mortality, MI and
improvement in symptoms were similarimprovement in symptoms were similar
Frequent reintervention in patients treated with PTCA.Frequent reintervention in patients treated with PTCA.
24. Comparison of BMS With MinimallyComparison of BMS With Minimally
Invasive Bypass Surgery for LADInvasive Bypass Surgery for LAD
25. PCI Vs CABG in MVD - BMS eraPCI Vs CABG in MVD - BMS era
Observational studiesObservational studies
Randomised controlled trialsRandomised controlled trials
26. Northern New England DatabaseNorthern New England Database
1994-2001 N=14,4931994-2001 N=14,493
Circulation 2005;112[suppl I]:I-371-I-376.
27. New York State 1997-2000New York State 1997-2000
3-Vessel Disease N=23,0223-Vessel Disease N=23,022
Adjusted Survival
N Engl J Med 2005;352:2174-83.
28. Stenting vs Surgery for MVD Patients:Stenting vs Surgery for MVD Patients:
New York State Registry (3-yr survival %)New York State Registry (3-yr survival %)
Stent CABGStent CABG
2V No LAD 91.4 93.52V No LAD 91.4 93.5
2V non prox LAD 90.9 93.02V non prox LAD 90.9 93.0
3V non prox LAD 84.6 89.33V non prox LAD 84.6 89.3
3V prox LAD 84.5 89.33V prox LAD 84.5 89.3
( HR for 3V CABG 0.64 )( HR for 3V CABG 0.64 )
Hannan EL, NEJM, 2005
29. Absolute Survival Advantage
CABG vs BMS
• A significant survival advantage for CABG has been
demonstrated, and appears to increase with longer F.U.
Patients Source 1 year 3 years 5 Years 7 years
14,493 NNE 1.7% 3.1% 4.6% 6.3%
23,022 NY State 2.8% 4.9%
1,722 Duke 1.6% 6.8% 9.4% 6.6%
39,237 Overall 2.3% 4.3% 5.1% 6.3%
Survival Advantage of CABG vs BMS for 3 Vessel Disease
Peter K. Smith, MD Duke University
30. Death , MI , CVA and one – year mortality were similar .Death , MI , CVA and one – year mortality were similar .
In PCI group DM was the main factor for poor out comeIn PCI group DM was the main factor for poor out come
PCI was associated with a greater need for RepeatPCI was associated with a greater need for Repeat
Revascularization .Revascularization .
N Engl J Med 344:1117, 2001N Engl J Med 344:1117, 2001
Arterial RevascularizationArterial Revascularization
Therapies Study (ARTS) 1205 ptsTherapies Study (ARTS) 1205 pts
32. The ‘Stent or Surgery’ TrialThe ‘Stent or Surgery’ Trial
Longer Term Follow UpLonger Term Follow Up
Well matched between randomised groupsWell matched between randomised groups
488- PCI, 500- CABG.488- PCI, 500- CABG.
•• Mean age - 61 years Males - 79%Mean age - 61 years Males - 79%
•• LV EF (by 2D echo) - 57%LV EF (by 2D echo) - 57%
•• Diabetes - Insulin Tx 3%, Other Tx 12%Diabetes - Insulin Tx 3%, Other Tx 12%
•• 2 vessel disease - 57% 3VD - 42%2 vessel disease - 57% 3VD - 42%
At a median follow-up of 6 years, a continuing survivalAt a median follow-up of 6 years, a continuing survival
advantage was observed for patients managed withadvantage was observed for patients managed with
CABG, which is not consistent with results from otherCABG, which is not consistent with results from other
stent-versus-CABG studies.stent-versus-CABG studies.
33.
34. Mortality by subgroups at aMortality by subgroups at a
median follow-up of 6 yearsmedian follow-up of 6 years
35. A meta-analysis of 10 RCT comparingA meta-analysis of 10 RCT comparing
CABG and PTCA: 1 to 8 yr outcomesCABG and PTCA: 1 to 8 yr outcomes
The early studies (patient entry fromThe early studies (patient entry from
1987 to 1993) used balloon angioplasty as the PCI1987 to 1993) used balloon angioplasty as the PCI
technique, and the later studies (patient entry from 1994technique, and the later studies (patient entry from 1994
to 2002) used stents (BMS) as the PCI techniqueto 2002) used stents (BMS) as the PCI technique
Most RCTs comparing CABG and PCI have beenMost RCTs comparing CABG and PCI have been
conducted in populations with double-vessel disease,conducted in populations with double-vessel disease,
good LV function.good LV function.
38. CABG vs. PCI Multivessel DiseaseCABG vs. PCI Multivessel Disease
Restenosis and the need for repeat revascularizationRestenosis and the need for repeat revascularization
has been the main difference between PCI and CABG inhas been the main difference between PCI and CABG in
the majority of patients undergoing revascularization forthe majority of patients undergoing revascularization for
chronic multivessel CAD.chronic multivessel CAD.
Some predicted that DES would eliminate the soleSome predicted that DES would eliminate the sole
remaining gap between PCI and CABG.remaining gap between PCI and CABG.
This prediction may have overstated and oversimplifiedThis prediction may have overstated and oversimplified
reality.reality.
40. DES Vs CABGDES Vs CABG
ARTS-II TrialARTS-II Trial
FREEDOMFREEDOM
•• SYNTAXSYNTAX
•• CARDia (UK & Ireland)CARDia (UK & Ireland)
41.
42. ARTS-II TrialARTS-II Trial
Arterial Revascularization Therapies Part II: a non-Arterial Revascularization Therapies Part II: a non-
randomized comparison of contemporary PCI andrandomized comparison of contemporary PCI and
coronary artery bypass grafting (CABG) in patients withcoronary artery bypass grafting (CABG) in patients with
multi-vessel coronary artery lesionsmulti-vessel coronary artery lesions
43. Registry n = 607 MV revasc by DESRegistry n = 607 MV revasc by DES
More diabetes than ARTS 1 (26% v 18%)More diabetes than ARTS 1 (26% v 18%)
More 3 VD (54% v 28%)More 3 VD (54% v 28%)
More stents (3.7 [73mm] v 2.8 [48mm])More stents (3.7 [73mm] v 2.8 [48mm])
6 month freedom from MACCE6 month freedom from MACCE
ARTS 2 - 93.6 %ARTS 2 - 93.6 %
ARTS 1: PCI - 84.7% CABG - 94.5%ARTS 1: PCI - 84.7% CABG - 94.5%
ARTS 2ARTS 2
44. Differences between ARTS I andDifferences between ARTS I and
ARTS IIARTS II
Drug eluting stentsDrug eluting stents
ClopidogrelClopidogrel
IIb/IIIaIIb/IIIa
More aggressive lipid lowering, ?BP control andMore aggressive lipid lowering, ?BP control and
diabetes managementdiabetes management
Improved techniqueImproved technique
All could contribute to improved outcomesAll could contribute to improved outcomes
45. ARTS II – Study designARTS II – Study design
Primary endpoint: effectiveness of coronary stent
implantation using the CYPHER® Sirolimus-eluting stent with
that of surgery as observed in ARTS I measured as MACCE
free survival at 1 year.
51. FREEDOM DesignFREEDOM Design
To evaluate whether PCI with drug eluting stenting isTo evaluate whether PCI with drug eluting stenting is
more or less effective than CABG in diabetic patientsmore or less effective than CABG in diabetic patients
with multivessel disease.with multivessel disease.
52. Treated Diabetes MellitusTreated Diabetes Mellitus
Angiographically confirmed multivessel CAD andAngiographically confirmed multivessel CAD and
amenable to either PCI or CABGamenable to either PCI or CABG
Indication for revascularizationIndication for revascularization
Primary End-point-Primary End-point- MI, stroke, death.MI, stroke, death.
56. SYNTAX Trial (SYNergy between PCISYNTAX Trial (SYNergy between PCI
with TAXUS and Cardiac Surgery)with TAXUS and Cardiac Surgery)
DES vs CABG in patients with 3 vessel or left mainDES vs CABG in patients with 3 vessel or left main
diseasedisease
•• 104 sites over 3 months104 sites over 3 months
•• Primary outcome- 12mo MACCEPrimary outcome- 12mo MACCE
•• Exclusions- prior CABG or PCI, AMI at presentation, valveExclusions- prior CABG or PCI, AMI at presentation, valve
disease requiring Surgerydisease requiring Surgery
74% treated with CABG74% treated with CABG
57. 71% enrolled (N=3,075)
All Pts with de novo 3VD and/or
LM disease (N=4,337)
Treatment preference (9.4%)
Referring MD or pts. refused
informed consent (7.0%)
Inclusion/exclusion (4.7%)
Withdrew before consent (4.3%)
Other (1.8%)
Medical treatment (1.2%)
23 US Sites62 EU Sites +
SYNTAX Trial Design
*
TAXUSTM
Express2TM
Stent System
58. SYNTAX Primary Endpoint
Randomized TrialRandomized Trial
The Primary Clinical Endpoint is the 12 Month Major
Cardiovascular or Cerebrovascular Event Rate (MACCE *)
MACCE is defined as:
• All cause Death
• Cerebrovascular Event (Stroke)
• Documented Myocardial Infarction
• Any Repeat Revascularization (PCI and/or CABG)
Patients were treated with the intention of achieving
complete revascularization of all vessels at least 1.5 mm in
diameter with stenosis of 50% or more.
63. Cerebrovascular Events to 12 Months
0.6%
2.2%
0 6 12
10
20
0
Months Since Allocation
CumulativeEventRate(%)
P=0.003¥
Event Rate ± 1.5 SE
ITT population
¥
Fisher Exact Test
TAXUS* (N=903)CABG (N=897)
*
TAXUS®
Express®
Stent System
64. MACCE events in SYNTAX ScoreMACCE events in SYNTAX Score
CategoryCategory
low SYNTAX scores (0 to 22)
intermediate SYNTAX scores (23 to 32)
SYNTAX scores
Low- 0 to 22
Intermediate- 23 to 32
High ≥33
65. Medically Treated Diabetes and Non-Diabetic
All-Cause Death/CVA/MI and MACCE at 12 MonthsAll-Cause Death/CVA/MI and MACCE at 12 Months
ITT population
Diabetes (Medical Treatment)
N=452
Non-Diabetic
N=1348
TAXUS*CABG
Death/CVA/MI MACCE Death/CVA/MI MACCE
P=0.96 P=0.0025 P=0.08P=0.97
*
TAXUS®
Express®
Stent System
66. SYNTAX ConclusionsSYNTAX Conclusions
The primary endpoint (12-months MACCE) inThe primary endpoint (12-months MACCE) in
this noninferiority trial for PCI was not met.this noninferiority trial for PCI was not met.
Overall MACCE higher in the PCI group (17.8%Overall MACCE higher in the PCI group (17.8%
vs 12.1%) due to an excess of redovs 12.1%) due to an excess of redo
revascularization in the PCI vs CABG (13.7% vsrevascularization in the PCI vs CABG (13.7% vs
5.9%),5.9%),
Comparable safety outcomes (death, CVA, MI,)Comparable safety outcomes (death, CVA, MI,)
in CABG and PCI patients at 12 months.in CABG and PCI patients at 12 months.
Rates of symptomatic graft occlusion and stentRates of symptomatic graft occlusion and stent
thrombosis were similar.thrombosis were similar.
Significantly higher rate of CVA in the CABGSignificantly higher rate of CVA in the CABG
groupgroup
The SYNTAX score will help stratify patients forThe SYNTAX score will help stratify patients for
the appropriate revascularization optionthe appropriate revascularization option
67. • TheThe largest benefit from CABG seemslargest benefit from CABG seems
to be in patients with diabetes mellitus.to be in patients with diabetes mellitus.
• The results of this trial also suggest thatThe results of this trial also suggest that
patients with LM only, LM + 1-VD, andpatients with LM only, LM + 1-VD, and
nondiabetics may do as well with bothnondiabetics may do as well with both
CABG and PCICABG and PCI, although the trial was not, although the trial was not
powered to study these differencespowered to study these differences
individually.individually.
68. PCI vs CABG: Gap NarrowingPCI vs CABG: Gap Narrowing
BARI/CABRI: Difference between PCI andBARI/CABRI: Difference between PCI and
CABG ~ 34%CABG ~ 34%
ARTS: Reduced to ~ 14%ARTS: Reduced to ~ 14%
SYNTAX: More complex patients ~ 5.5%SYNTAX: More complex patients ~ 5.5%
differencedifference
SYNTAX score:SYNTAX score:
Score < 22, no difference PCI vs CABGScore < 22, no difference PCI vs CABG
Score 22 - 33, slight advantage for CABGScore 22 - 33, slight advantage for CABG
Score > 33, surgical candidateScore > 33, surgical candidate
SYNTAX, Serruys P, et al. ESC 2008.
69. Limitations of SYNTAXLimitations of SYNTAX
Follow-up period was only 12 months;Follow-up period was only 12 months;
Most of the patients (> 78%) were men,Most of the patients (> 78%) were men,
Patients who underwent CABG were less likelyPatients who underwent CABG were less likely
to receive optimal medical therapy(DAPT), whichto receive optimal medical therapy(DAPT), which
may have contributed to their increased risk formay have contributed to their increased risk for
stroke.stroke.
Time to procedure longer for CABGTime to procedure longer for CABG
89. 18 years of age or older,18 years of age or older,
angiographically confirmed multivesselangiographically confirmed multivessel
CAD with stenosis of more than 70% ofCAD with stenosis of more than 70% of
the vessel diameter in major epicardialthe vessel diameter in major epicardial
vessels in the territories of at least twovessels in the territories of at least two
coronary arteries, and werecoronary arteries, and were
considered by the physicians andconsidered by the physicians and
surgeons, a suitable candidates for eithersurgeons, a suitable candidates for either
PCI or CABGPCI or CABG
90.
91. CONCLUSIONS
CABG does not hold any advantage overCABG does not hold any advantage over
multivessel PCI in preventing death or MImultivessel PCI in preventing death or MI
No advantage of CABG except for theNo advantage of CABG except for the
decrease in repeat revascularisationdecrease in repeat revascularisation
proceduresprocedures
PCI comparable to CABG even inPCI comparable to CABG even in
diabetics in terms of death ,MI, and strokediabetics in terms of death ,MI, and stroke
92. PCI or CABG which strategy ?
SVD : PCI
2VD
Multivessel disease : PCI as initial strategy especially in
patients with good LV function , suitable anatomy and patient
preference .
CABG : Severe LAD proximal lesion , DM LV dysfunction ,
LM lesion , Diffuse disease .
Advanced age and comorbidity : PCI is better
Younger patient < 50 y : PCI is initial strategy
93. Factors in patient selection
1. The need for mechanical revascularization as opposed to
medical treatment & risk factor modification .
2. The likelihood of success ( vessel size , calcification ,
tortuosity , side branches )
3. The risk and potential consequences of acute failure of
PCI ( Coronary anatomy % viable myocardium , LV
function .
94. 4.The likelihood of restenosis ( diabetes , prior restenosis ,
small vessel , long lesion , Total occlusion , SVG
disease) .
5. The need for complete revascularization based on the
extent of CAD , severity of ischemia ,
LV function .
6. The presence of comorbid conditions
7. Patient preference
95.
96.
97.
98.
99.
100.
101. 2013 ESC guidelines on the management of2013 ESC guidelines on the management of
stable coronary artery diseasestable coronary artery disease
The 5-year cardiac mortality rate for the total population of 1829 patients was 4.9% for CABG vs 8% for PTCA (RR=1.55; P=.022). The 5-year cardiac mortality or MI rate was 17.5% for CABG vs 20.2.% for PTCA (P=NS).
In the 1476 nondiabetic patients, the 5-year cardiac mortality rate was 4.2% for CABG vs 4.6% for PTCA (P=NS). The 5-year cardiac mortality or MI rate was 13.2% for CABG vs 12.6% for PTCA (P=NS).
Treatment comparison of 5-year cardiac mortality rates for all patients (left) and for patients without diabetes drug therapy at baseline (right) stratified by subgroup. The RRs for cardiac mortality (PTCA:CABG) with 95% CIs are shown in the filled squares and horizontal lines. The overall treatment effect is shown in the large square at the top of the plot. Estimates of RR are expressed in logarithmic scale, are based on Cox regression analyses, and may differ from the simple ratio of 5-year cardiac mortality rates. QMI indicates Q-wave MI; LAD, left anterior descending coronary artery. *, **, and *** denote significant subgroup-by-treatment interactions at the .05, .01, and .005 levels, respectively.
Internal mammary artery use
was also consistently high: SoS 97%, ART 93% (reported
arterial conduits),16 MASS II 92%, and ERACI II 89%.
P for interaction test with a proportional hazards model
A- All trial, B- MVD.
The SYNTAX primary clinical endpoint is the 12 Month major Cardiovascular or Cerebrovascular event rate (MACCE *)
MACCE is defined as:
All cause Death
Cerebrovascular Event (Stroke)
Documented Myocardial Infarction
Any Repeat Revascularization (PCI and/or CABG)
All events were CEC Adjudicated
Cerebrovascular Events to 12 months was 0.6 for TAXUS patients and 2.2 for CABG patients (p=0.003)
The composite of all cause death, cerebrovascular events and myocardial infarction in the medically treated diabetics at 12 months was similar between CABG and TAXUS patients.
