CABG VS Multi Vessel PCI

1. CABG VSMulti Vessel PCI Hasanat Sharif MD FRCS Chief of Cardiorthoracic Surgery Aga Khan University Hospital

2. Multivessel • Definition • Cardiologist • Cardiac Surgeon

3. Treatment of Coronary Artery Disease • Medical • Percutaneous Intervention • Surgical Revascularization

4. Treatment of Coronary Artery Disease • Medical • Advances in medical treatment • Anti platelet agents • ACEI/ARB • Statins • Aggressive risk factor modification

6. Treatment of Coronary Artery Disease • Primary percutaneous intervention • Role in evolving acute myocardial infarction • Culprit vessel addressed

7. Intervention • Interventionalist’s procedural bias • Perception • Clinician • Referring doctors and • Patient

10. Syntax Trial

11. Two-year outcomes for SYNTAX Kappetein AP. European Society of Cardiology 2009 Congress; September 2, 2009: Barcelona, Spain.

14. Approriateness criteria for coronary revascularization • Refined and extended guidance beyond that provided by evidence based guidelines • Expert panel of 17 members • Year long effort to evaluate available evidence and existing guidelines

15. Appropriateness Criteria • Inappropriate 1-3 • Uncertain 4-6 • Appropriate 7-9 • PCI inappropriate for LM CAD • PCI uncertain for 3 VCAD • PCI appropriate for acute myocardial injury • CABG appropriate for 3VCAD and LM CAD

17. What happens in actual practice? • Catheterization laboratory cardiologists in hospitals with PCI capability were more likely to recommend patients for PCI than • Hospitals in which only catheterization was performed

18. Indicated CABG 13% PCI 59% Both 17% Recommended 53% (34% PCI) 94% 93% PCI 5% CABG Adherence to ACC/AHA guidelines

21. Trials • Justification • ? Economically/industry driven • ? Extending the boundaries of care • Randomization • Multi centered • Adequate numbers • Long term follow up • End point - survival

22. Trials • Ethics • Informed patient consent • Critical to provide complete disclosure of risks/benefits • Survival • Stent thrombosis/graft closure • Risk of re intervention/complications

23. Trials • Enrolled only 5-10% of the eligible population • ? Generalizability of results • Real life situations

24. Trials • Propensity analysis is not perfect • Euroscore over predicts procedural risk • Cost analysis and impact on healthcare budget

25. Observational data • Consistently show a survival advantage for CABG over PCI • STS database • Northern New England database • Duke • New York

27. AKU Data Fifty month data Jan 2006-March 2010 • Total CABG n=2041 • Left main n= 406 (19.9%) • 1 VCAD n= 69 (3.4%) • 2 VCAD n= 257 (12.6%) • 3 VCAD n= 1715 (84%)

28. AKU Data • Mean age 58 years (+/-11) • Males 82% • LVEF 48% (+/-14) • IMA usage 90% • CVA n = 8 (0.4%) • Mortality n = 32 (1.6%)

29. Cost Considerations • CABG package 225K • One bare metal stent 285K • Additional stent 32K • One DES 395K • Additional stent 139K

30. Triple vessel and left main coronary stenosis • CABG first choice for majority of patients • Consider PCI for patients with co morbidities that preclude CABG • Advances • PCI technology and • Surgical techniques/ peri operative care • Extending the boundaries of cardiovascular care

31. Treatment of coronary artery disease • Multidisciplinary team approach • Cardiologist • Interventionalist • Cardiac Surgeon • Separate diagnosis from treatment! • Treatment option given on cath table • Scare tactics

32. Thank You