1 / 40

Tehran Heart Center Tehran University of Medical Sciences

PCI VS CABG. M . SALARIFAR , MD. Tehran Heart Center Tehran University of Medical Sciences. PCI VS CABG. From 1987 to 2003 326% increase in PCI Now more than 90% stenting. PCI VS CABG. Factors in patient selection.

caraf
Download Presentation

Tehran Heart Center Tehran University of Medical Sciences

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. PCI VS CABG M . SALARIFAR , MD Tehran Heart Center Tehran University of Medical Sciences Dr.Salarifar

  2. PCI VS CABG • From 1987 to 2003 326% increase in PCI • Now more than 90% stenting Dr.Salarifar

  3. PCI VS CABG Factors in patient selection • The need for mechanical revascularization as opposed to medical treatment & risk factor modification . • The likelihood of success ( vessel size , calcification , tortuosity , side branches ) • The risk and potential consequences of acute failure of PCI ( Coronary anatomy % viable myocardium , LV function . Dr.Salarifar

  4. PCI VS CABG 4.The likelihood of restenosis ( diabetes , prior restenosis , small vessel , long lesion , Total occlusion , SVG disease) . 5. The need for complete revascularization basedon the extent of CAD , severity of ischemia , LV function . 6. The presence of comorbid conditions 7. Patient preference Dr.Salarifar

  5. PCI VS CABG Ideal cases of PCI • Significant symptoms despite intensive medical therapy • Low risk for complications • Technical success rate • No history of CHF • EF > 40% Dr.Salarifar

  6. PCI VS CABG Patients with increased risk for PCI • Advanced age • Female gender • Unstable angina • CHF • LM equivalent disease • Multivessel disease • DM • Renal failure Dr.Salarifar

  7. PCI VS CABG Current expectations for PCI • Procedural success at least 90% • Mortality < 1% • Q ware MI < 1.5% • Emergency by pass surgery 1 – 2 % Dr.Salarifar

  8. PCI VS CABG PCI and Medical therapy • RCT comparing PCI with medical therapy are few in numberand < 5000 patients , enrolled patients with SVD and priorstenting and enhanced adjunctive pharmaco therapy. • * Results : • Better control of angina • Functional capacity • Quality of life Dr.Salarifar

  9. PCI VS CABG • No RCT to date has demonsrated a reduction in death or MI with PCI compared with medical thraphy for patient with chronic stable angina Dr.Salarifar

  10. PCI VS CABG PCI and Medical therapy • RITA – 2 showel excess of death and MI • 62% Patients multivessed disease • COURAGE TRIAL : • 2287 patients • PCI did not reduce the risk of death or MI over a medium 4.6 years follow up . • TIMe Trial : similar results in elderly patients . Dr.Salarifar

  11. PCI VS CABG PCI and Medical therapy Conclusion • Most patients with chronic stable angina and class I – II symptoms Medical treatment . • PCI for patients with severe symptoms despite medical therapy or patients with high risk criteria on Noninvasive tests . Dr.Salarifar

  12. PCI VS CABG PCI in LV dysfunction In hospital & long term mortality was higher in LV dysfunction . EF ≤ 40% 11 % 1 Year Mortality EF 41 – 49% 4.5 % 1 Year Mortality EF ≥ 50% 1.9 % 1 Year Mortality Dr.Salarifar

  13. PCI VS CABG CABG • Garrett , Dennis , DeBakey : Bailoat CABG in 1964 • Fovoloro : late 1960 s • Kolessov : use of IMA 1967 • Green : 1970 • % 26 in CABG since 1997 • In 2004 : 20% off – PUMP CABG • Minimally Invasive • Hybrid procedure Dr.Salarifar

  14. PCI VS CABG CABG Surgical outcomes • Patient population of CABG Higher risk ( older , 3VD , History of Revascularization , LV dysfunction Diabetes , Peripheral vascular disease ) • Out comes with CABG Remain stable or improved Dr.Salarifar

  15. PCI VS CABG CABG Operative Mortality Mortaliy of 503 , 478 CABG - only in the s td data base 1997 – 1999: 3.05 % 2005 : 2 . 2 % Dr.Salarifar

  16. In THC data base : Dr.Salarifar

  17. CABG Complications PCI VS CABG • Mojor morbidity ( death , stroke , Renal failure sternal infection : 13.4% in 30 days MI : 3.9% • Respiratory complications • Bleeding : 2-6 % reparation for bleeding • Wound infection • Post operative HTN • Cerebrovascular complication • Stroke 2.6% Dr.Salarifar

  18. PCI VS CABG CABG Complications • AF : One of the most frequent complications of CABG up to 40% Risk of stroke Use of beta blockers reoluces post operative AF • Brady arrhythmia : 0.8% need for permanent pacemaker • Renal dysfunction Dr.Salarifar

  19. PCI VS CABG Return to Employment • 80% who were employed prior to CABG Return to work • Patient undergoing CABG return to work 6 W later than PCI • But long term employment is similar . Dr.Salarifar

  20. PCI VS CABG SVG Patency Early occlusion : 8 – 12 % 1 year occlusion : 15 – 30 % occlusion 1 – 6 y occlusion : 2% Annually 6 – 10 occlusion : 4% Annually At 10 y :50% SVG occlusion and 20 -40% significant stenosis in Remaining Dr.Salarifar

  21. PCI VS CABG Arterial graft patency IMA graft patency rate 95% 1 y 88% 5 y , 83% 10 y . Dr.Salarifar

  22. PCI VS CABG Indications for Revascularization CABG : • Significant left main disease : Regardless of the severity of symptoms or LV dysfunction • Patients with 3 VD that Includes LAD proximal lesion & LV dysfunction • Patients with 2 VD with LAD proximal lesion & LV dysfunction or high risk non invasive tests Dr.Salarifar

  23. PCI VS CABG Indications for Revascularization PCI : • In patients with SVD the aim of procedure is relief of symptoms or objective evidence of sever ischemia • In patients with angina who are not high risk , medical treatment , PCI & CABG are similar . Dr.Salarifar

  24. Dr.Salarifar

  25. Dr.Salarifar

  26. Dr.Salarifar

  27. Dr.Salarifar

  28. PCI VS CABG PCI or CABG witch 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 CASS Registry : Impaired survivial in young patients Dr.Salarifar

  29. PCI VS CABG PCI VS CABG Observational studies: • Recent studies after stenting 60/000 patients with multivessel disease treated with stenting or CABG in the newyork state Registry (1997 – 2000 ) : Higher survival with CABG after adjustment for medical comorbidities . Dr.Salarifar

  30. PCI VS CABG PCI VS CABG Randomized trials : ARTS trial ; • Death , MI , CVA and one – year mortality were similar . • CK – MB more than twice in CABG and was a predictor of poor outcome . • In PCI groupe DM was the main factor for poor out come • PCI was associated with a greater need for Repeat Revascularization . • TVR was Higher in stenting groupe . Dr.Salarifar

  31. PCI VS CABG BARI • Diabetic patients with CABG had better survival at twoyears . Dr.Salarifar

  32. PCI VS CABG Recent Publications • NENGLJMED 358 : 4 January 2008 * DES VS . CABG in multivessel disease • Newyork state Registry ( oct 2003 – Dec 2004 ) • More than 17000 patients ( 9963 DES , 7437 CABG ) • CABG was associated with lower mortality , MI and repeat revascularization Dr.Salarifar

  33. PCI VS CABG The – MAIN – COMPARE Registry • Stenting VS . CAGB for LM • 1102 stenting & 1138 CABG in Korea 2000 -2006 • No significant difference in Death , MI , stroke • Higher Rate of TVR in stenting Dr.Salarifar

  34. ACC/AHA Guidelines for Revascularization with PCI and CABG in Patients with Stable Angina Dr.Salarifar

  35. Dr.Salarifar

  36. Dr.Salarifar

  37. Dr.Salarifar

  38. Dr.Salarifar

  39. حیرت اندر حیرت است ای یار من این نه کار توست و نه هم کار من Dr.Salarifar

  40. Dr.Salarifar

More Related