Σηεθανιαία νόζορ ζηελέσοςρ. Εσγεμία Παππά Καρδιολόγος Διεσθύμηρια Ε.Σ.Υ. Καρδιολογική Κλιμική Γεμικού Νοζοκομείοσ Ιωαμμίμωμ «Γ.

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1 Σηεθανιαία νόζορ ζηελέσοςρ Εσγεμία Παππά Καρδιολόγος Διεσθύμηρια Ε.Σ.Υ. Καρδιολογική Κλιμική Γεμικού Νοζοκομείοσ Ιωαμμίμωμ «Γ. Χαηζηκώζηα»

2 Gruntzing 1978 Lancet 5 ππώηοι αζθενείρ PTCA 2 από αςηούρ PTCA ULMCA! 43y ζηηθάγση πποζπάθειαρ 11/1977 Αιθνίδιορ θάναηορ ζε δςο μήνερ!

3 ULMA CABG: (ClassI) Μελέηερ CABG vs PCI δεν ζςμπεπιέλαβαν αζθενείρ με ULMCA Δξέλιξη PCI: Δπεμβαηικέρ ηεσνικέρ Υλικά και θάπμακα

4 CABG vs PCI for ULMCA

5 5-Year Results from the MAIN COMPARE Registry DW Park et al J. Am. Coll. Cardiol. 2010; 56;

6 5-Year Results from the MAIN COMPARE Registry DW Park et al J. Am. Coll. Cardiol. 2010; 56;

7 5-Year Outcomes Following Percutaneous Coronary Intervention With Drug-Eluting Stent Implantation Versus Coronary Artery Bypass Graft for Unprotected Left Main Coronary Artery Lesions Chieffo A, et al. J Am Coll Cardiol Intv. 2010; 3: The Milan Experience patients

8 5-Year Outcomes Following Percutaneous Coronary Intervention With Drug-Eluting Stent Implantation Versus Coronary Artery Bypass Graft for Unprotected Left Main Coronary Artery Lesions DES N=107 CABG N=142 Unadjusted Odds Ratio (95% CI) Adjusted Odds Ratio (95% CI) MACCE 38.3% 32.4% 1.41 ( ; P=0.26) 1.57 ( ; P=0.18) TVR 28% 8.4% 4.19 ( ; P=0.0001) 4.41 ( ; P=0.0004) Chieffo A, et al. J Am Coll Cardiol Intv. 2010; 3:

9 Long Term Outcomes After Stenting Versus Coronary Artery By Pass Grafting for Unprotected Left Main Coronary Artery Disease: 10-Year Results of Bare-Metal Stent and 5-Year Result of Drug-eluting Stent from the ASAN-MAIN Registry DW Park et al J. Am. Coll. Cardiol. 2010;56;

10 Χωπίρ ζημανηικέρ διαθοπέρ ζε θάναηο Θάναηο, QWMI, ΑΕΕ BMS/ DES TVR ζημανηικά αςξημένη ζε PCI vs CABG DW Park et al J. Am. Coll. Cardiol. 2010;56;

11 The Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery: The SYNTAX Study The 4-year Outcomes of the SYNTAX Trial in the Subset of Patients With Left Main Disease Presented by Dr Marie Claude Morice, Transcatheter Cardiovascular Therapeutics Scientific Sessions, San Francisco, USA November 7 th 2011

12 Cumulative Event Rate (%) SYNTAX Study All-Cause Death/CVA/MI to 4 Years Left Main Subset CABG (n=348) TAXUS (n=357) 50 Before 1 year * 9.2% vs 7.0% P= years * 2.8% vs 3.2% P= years * 2.6% vs 3.0% P= years * 3.7% vs 4.9% P=0.45 P= % 17.1% Months Since Allocation Cumulative KM Event Rate ± 1.5 SE; log-rank P value; * Binary rates ITT population

13 Cumulative Event Rate (%) SYNTAX Study Repeat Revascularization to 4 Years Left Main Subset CABG (n=348) TAXUS (n=357) 50 Before 1 year * 6.5% vs 11.8% P= years * 5.0% vs 8.2% P= years * 2.6% vs 3.9% P= years * 3.0% vs 4.0% P=0.50 P= % 14.6% Months Since Allocation Cumulative KM Event Rate ± 1.5 SE; log-rank P value; * Binary rates ITT population

14 Cumulative Event Rate (%) SYNTAX Study CVA to 4 Years Left Main Subset CABG (n=348) TAXUS (n=357) 50 Before 1 year * 2.7% vs 0.3% P= years * 0.9% vs 0.6% P= years * 0.3% vs 0.3% P= years * 0.3% vs 0.3% P=1.00 P= % 1.5% Months Since Allocation Cumulative KM Event Rate ± 1.5 SE; log-rank P value; * Binary rates ITT population

15 Cumulative Event Rate (%) SYNTAX Study MACCE to 4 Years Left Main Subset CABG (n=348) TAXUS (n=357) 50 Before 1 year * 13.7% vs 15.8% P= years * 7.5% vs 10.3% P= years * 5.2% vs 5.7% P= years * 6.4% vs 8.3% P=0.35 P= % % Months Since Allocation Cumulative KM Event Rate ± 1.5 SE; log-rank P value; * Binary rates ITT population

16 Patients (%) SYNTAX Trial ULMCA Subset Symptomatic Graft Occlusion & Stent Thrombosis to 3 Years CABG (n=348) TAXUS (n=357) P= n=12 n=14 CABG TAXUS Serruys PW. Transcatheter Cardiovascular Therapeutics 2010

17 Έκβαζη ανάλογα με Syntax score Low Syntax score (0-22) Παπόμοια MACCE (CABG/PCI p=0,33) Intermediate score (23-32) Παπόμοια MACCE (CABG/PCI p=0,9) High score Σημανηικά αςξημένα MACCE ζηην ομάδα PCI (p=0.003)

18 Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease PRECOMBAT trial Park et al NEJM 2011; 364:

19 PRECOMBAT Study Enrolled Patients (N=1454) Randomized Cohort N=600 CABG registry N=335 PCI registry N=475 Medication registry N=44 Assigned CABG N=300 Treated CABG N=248 Treated PCI N=51 Treated medical N=1 1-year follow-up N=296 2-year follow-up N=266 Assigned PCI N=300 Treated CABG N=24 Treated PCI N=276 Treated medical N=0 1-year follow-up N=298 2-year F/U N=270 1-year follow-up CABG registry N=310 PCI registry N=457 Medication registry N=41 2-year follow-up CABG registry N=259 PCI registry N=289 Medication registry N=39

20 Cumulative Incidence, % PRECOMBAT Study Death, MI or Stroke PCI CABG 10 p=0.66 p= No. at Risk PCI CABG Days Since Randomization Park et al NEJM 2011; 364:

21 PRECOMBAT Study Park et al NEJM 2011; 364:

22 PRECOMBAT Study Park et al NEJM 2011; 364:

23 Randomized Comparison of Percutaneous Coronary Intervention with Sirolimus-Eluting Stents versus Coronary Artery Bypass Grafting in Unprotected Left Main Stem Stenosis Boudriot et al J Am Coll Cardiol 2011;57:538 45

24 Study Flow Chart 430 Patients with Unprotected Left Main Disease 201 Eligible 100 Assigned to PCI 101 Assigned to CABG 3 Converted to CABG 5 No Angiographic Follow-up 20 No Angiographic Follow-up 229 Non-Eligible 22 Infarction < 48 Hours 11 Cardiogenic Shock 8 Chronic Total Occlusion 65 Lesion Length > 30 mm 6 Non-CABG Suitable 14 Prior Cardiac Surgery 36 Age > 80 Years 21 Malignancy 27 Combined Cardiac Surgery 19 Dominant Left Circumflex 179 CABG 40 PCI 10 Conservative 0 Lost to Follow-up 1 Lost to Follow-up 100 Included in Primary Analysis 100 Included in Secondary Analysis 100 Included in Primary Analysis 100 Included in Secondary Analysis Boudriot et al J Am Coll Cardiol 2011;57:538 45

25 MACE 12 Months 30 PCI CABG p value for non-inferiority p < p = p = 0.35 p = Death MI TVR MACE Boudriot et al J Am Coll Cardiol 2011;57:538 45

26 PCI vs. CABG Surgery in Left Main Coronary Artery Disease Meta-analysis included 1,611 patients, 809 randomized to PCI and 802 to surgery Capodanno D. et al. J Am Coll Cardiol. 2011;58:

27 LEMANS SYNTAX LM Boudriot RECOMBAT

28 Νέες κατεσθύνσεις και ορίζοντες ULM PCI με δεύτερης γενιάς DES

29 Unprotected left main stenting with a Second Generation Drug-Eluting Stent: One Year Outcomes of the Left Main Xience V LEMAX Pilot Study Salvatella N. et al Eurointervention (6):

30 LeMax Pilot Design Salvatella N et al Eurointervention (6):

31 LeMaX Pilot Study Results No late stent thrombosis Salvatella N et al Eurointervention 2011; 7(6):

32 Evaluation of Xience Prime versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization EXCEL trial

33 EXCEL: Study Design 3600 pts with left main disease SYNTAX score 32 Consensus agreement by heart team Yes (N=2600) PCI (Xience Prime) R (N=1300) Primary endpoint: Death, MI, or Stroke at 3 years No (N=1000) PCI and CABG registries (limited in-hosp data) CABG (N=1300)

34 Δπεμβαηικέρ ηεσνικέρ-ζηπαηηγικέρ Δνηόπιζη ζηένωζηρ Σηόμιο-ζώμα Καλύηεπα αποηελέζμαηα Άμεζη έκβαζη-επιπλοκέρ Μακποππόθεζμη έκβαζη Βλάβη δισαζμού(>60%) Πποζέγγιζη με δςο stents σειπόηεπα αποηελέζμαηα 40% bifurcation LM 2 stents Crush, culotte, V- or T- stenting?

35 Bifurcation dedicated stents

36 IVUS Καηανομή πλάκαρ Σςμμεηοσή δισαζμού Αζβέζηωζη Μέγεθορ stent Stent-wall apposition Βεληιωμένη επιβίωζη Αποηελέζμαηα θεηικά ανεξάπηηηα από ηη σπήζη IVUS

37 IABP-Aιμοδςναμική ςποζηήπιξη Μείωζη επιπλοκών Αιμοδςναμικήρ αζηάθειαρ Όσι καλύηεπη κλινική έκβαζη

38 Ανηιαιμοπεηαλιακή αγωγή και θπόμβωζη stents ULM stent thrombosis ζπάνια Γιακοπή θειονοπςπιδινών μέζα ζε 6 μήνερ ππογνωζηικόρ δείκηηρ θπόμβωζηρ Γιπλή ανηιαιμοπεηαλιακή αγωγή μεηά ηο έηορ μη ζημανηική μείωζη ζε MACCE και ST H βέληιζηη διάπκεια διπλήρ ανηιαιμοπεηαλιακήρ αγωγήρ δεν έσει καθοπιζηεί

39 Follow up Παπακολούθηζη με αγγειογπαθία? Γεν ζςνιζηάηαι Αναίμακηορ έλεγσορ ζε 6 και 12 μήνερ μεηά ανά έηορ Δπαναζηένωζη μεηά ULMPCI PCI or CABG? Σε πεπίπηωζη νέαρ PCI αγγειογπαθικόρ έλεγσορ ζε 4-6 μήνερ

40 Risk score system? Σςνδςαζμόρ SYNTAX/EUROSCORE Global Risk Classification Βεληίωζη ππόγνωζηρ καπδιακήρ θνηηόηηηαρ NERS score Μεηαβληηέρ Κλινικέρ Αγγειογπαθικέρ Σσεηικέρ με επέμβαζη Βεληίωζη ππόγνωζηρ MACCE και ST Capodanno D, et al. Am Heart J 2010;159:103-9 Chen SL, et al. J Am Coll Cardiol Intv 2010;3:

41 ESC/EACTS 2010 Guidelines on Myocardial Revascularization CABG PCI Left Main (isolated or 1VD, ostium/shaft) IA IIa B Left Main (isolated or 1VD, distal bifurcation) IA IIb B Left Main + 2VD or 3VD and SYNTAX score <32 IA IIb B Left Main + 2VD or 3VD and SYNTAX score 33 IA IIIB Wijns W et al. Eur Heart 2010 Oct;31(20):

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47 5-Year Results from the MAIN COMPARE Registry DW Park et al J. Am. Coll. Cardiol. 2010; 56;

48 5-Year Results from the MAIN COMPARE Registry DW Park et al J. Am. Coll. Cardiol. 2010; 56;

49 5-Year Results from the MAIN COMPARE Registry DW Park et al J. Am. Coll. Cardiol. 2010; 56;