Αγγειοπλαστική στη νόσο στελέχους. Αποτελούν τα DES τη λύση;

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1 Αγγειοπλαστική στη νόσο στελέχους. Αποτελούν τα DES τη λύση; Γεώργιος Λάτσιος, MD, PhD, EAPCI Επιμελητής, Α Πανεπιστημιακή Καρδιολογική Κλινική Ιπποκράτειο Νοσοκομείο Αθηνών

2 Left Main Coronary Artery Disease 1st description by J. Herrick in 1912 Aorto-ostial lesion Disease processes other than atherosclerosis Iatrogenic dissections Predisposition for radiation induced lesions Conduit for % of the myocardial blood supply Gives rise to a major bifurcation or even trifurcation

3 Left Main - Anatomic Characteristics Reig J, Petit M. Clin Anat 2004;17:6 13 Average Length 10.8±5.5 mm 62% of cases 2 side branches Length (mm) Average Diameter 4.9±0.8 mm No. of side branches Average Angle 86.7 ±28.8 N=100 autopsy cases Diameter (mm) Angle LAD/LCX

4 Coronary Arteriographic Findings In TACTICS-TIMI <50% 1 vs CAD 2vs CAD 3vs CAD Left Main Cannon CP et al. N Engl J Med 2001;344:

5 Coronary Artery Disease in Patients With LM Morice et al. Circulation 2010;121: % % % % % Isolated LM LM +1vessel LM +2vessels LM +3vessels

6 Benefit of Revascularization in Left Main Disease VA Cooperative Study Takaro Circulation 1982 CASS Registry Caracciolo Circulation 1995

7 ESC Guidelines on Myocardial Revascularization Wijns W et al. Eur Heart J 2010

8 First attempts Balloon angioplasty for left main coronary artery disease pre post during Case #4, November 11, 1977

9 Case #4, November 11, 1977

10 Left Main PCI today

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12 DES decrease restenosis

13 Persistence of Neointimal Growth Up to 1 Year Following Left Main PCI Valgimigli M et al. J Am Coll Cardiol 2006;47: mm Late Loss P< % Diameter Stenosis P< Months 12 Months 0 6 Months 2 Years

14 7.1% Ostium+Bifurc >60% of left main disease involves the distal bifurcation LM 54.1% Bifurcation only Morice et al. Circulation 2010;121: % Ostium only 15.4% Shaft only

15 LMdistal bifurcation lesion with common need for 2 stent techniques

16 Clinical Outcomes According to Lesion Localization in LM Toyofuku M et al. Circulation 2009;120: Cardiac Death Target Lesion Revascularization

17 Clinical Outcomes According to Treatment Strategy in LM Toyofuku M et al. Circulation 2009; 120 Cardiac Death Target Lesion Revascularization 1 Stent 2 Stents 1 Stent 2 Stents

18 Patiens with DES develop less downstream stenoses compared with BMS Krasuski R et al, Am Heart J 2011;162:764-77

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20 GISE-SICI registry 1453 pts with UPLMCA PCI Tamburino C et al, European Heart Journal (2009) 30,

21 DES vs historical BMS control in UPLM Gao RL et al, Am Heart J 2008; 155:

22 Korean multi-center registry pts registry of ULM PCI Kim YH et al. Circulation 2009; 120

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24 Stents versus CABG for LM MAIN-COMPARE registry Seung KB et al. N Engl J Med 2008 % 15 Death, MI, stroke HR=1.10 P= Stent CABG

25 Stents versus CABG for LM (TLR) MAIN-COMPARE registry Seung KB et al. N Engl J Med 2008 BMS vs CABG DES vs CABG HR=10.7 P<0.001 HR=6.0 P<0.001

26 Unprotected Left Main Lesions DES vs BMS % TLR % MACE Drug-Eluting Stent Bare Metal Stent

27 Meta-analysis of DES vs BMS in UPLM 10,342 patients DES are associated with favorable outcomes for mortality, MI, TVR/TLR, and MACE as compared to BMS Pandya S at al,jacc Cardiovasc Interv June ; 3(6):

28 ESC Guidelines on Myocardial Revascularization Wijns W et al. Eur Heart J 2010

29 One Year Clinical Outcomes in Patients With Left Main CAD in the SYNTAX Trial Morice MC et al. Circulation % P=0.29 P=0.01 P=0.02 P= Death, CVA, MI CVA Repeat Revasc MACCE CABG PCI

30 MACCE to 3 Years by SYNTAX Score Tercile in Patients With Left Main CAD Low Scores (0-22) Intermediate Scores (23-32) High Score 33

31 PRECOMBAT - PCI vs CABG for LM Disease Park S et al. N Engl J Med 2011 EP: Death from Any Cause, MI, Stroke, 2 Years Death from Any Cause, MI, or 2 Years

32 Drug-Eluting Stents in Unprotected Left Main Lesions % 20 Overall Mortality at 1 Year Elective Only Elective and ACS N=102 N=85 N=50 N=107 N=63 N=50 N=95 N=101 N=358 Total JACC 2005 Circ 2005 JACC 2006 Circ 2006 AJC 2008 JACC 2006 Circ 2005 CCI 2006 JACC 2008 N=1011

33 DES in Non-bifurcation Lesions of Unprotected Left Main 147 patients undergoing PCI with DES: Mean follow-up 886 days Chieffo A et al. Circulation 2007;116: Ischemic Endpoints Revascularization Death MI MACE 0 Restenosis TLR TVR

34 Durability of Revascularization With DES in Unprotected Left Main Disease Seung KB et al. N Engl J Med 2008;358 Meliga E et al. J Am Coll Cardiol 2008;51: TVR During Long-Term Follow-up DES: DELFT N=358 DES: MAIN-COMPARE N= Year 10.0% 3 Years 14.2% 1 Year 6.2% 3 Years 9.3%

35 Randomized Comparison of PES and SES in Left Main PCI - ISAR LEFT MAIN Mehilli J et al. J Am Coll Cardiol % P=0.64 P=0.59 P=0.51 P=0.47 P= % 21.3% 20.6% 15% 10% 10.4% 8.7% 9.2% 10.7% 5% 5.4% 4.6% 2.1% 1.5% 0% Death MI Stroke TLR Death/MI/TLR PES (N=302) SES (N=305)

36 Stent Thrombosis Following DES Implantation in Unprotected Left Main Chieffo A al. Eur Heart J consecutive patients treated with SES/PES in unprotected LMCA Mean follow-up: 30±14 months early (0-30 days) late (1-12 months) very late (>12 months) Definite ST % Probable ST Definite or probable % 0.9% Stent Thrombosis (%)

37 EXCEL: Study Design 4000 pts with left main disease SYNTAX score 32 Consensus agreement by HEART TEAM Yes (N=3100) R No (N=1500) PCI and CABG registries PCI (Xience Prime) (N=1550) CABG (N=1550) Clinical follow-up: 30 days, 6 months, yearly through 5 years

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39 PCI of un-protected LM with DES Feasible In-hospital morbidity and mortality is similar or better with DES than CABG PCI using DES has improved outcomes compared with BMS. However, TVR following 1st generation DES implantation remain higher compared with CABG Ostial and shaft LM lesions: DES competitive Distal bi-trifurcation: DES inferior to CABG

40 LM PCI is the therapy of choice in selected patients No surgical candidate STEMI Iatrogenic LM dissection

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42 ΧΡΟΝΙΑΙΑ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ: Νόσος κύριου στελέχους η χειρουργική αντιµετώπιση είναι µονόδροµος Γ. ΛΑΤΣΙΟΣ Καρδιολογικό Τµήµα, Νοσοκοµείο «Ι οκράτειο»

43 Σε ασθενείς µε οξύ στεφανιαίο σύνδροµο, αγγειογραφικά σηµαντική νόσος στο κύριο στέλεχος της αριστεράς στεφανιαίας αρτηρίας εµφανίζεται σε ποσοστό: 1. 10% 2. 20% 3. 30% 4. 40%

44 Προστατευµένο» στέλεχος σηµαίνει: 1. Ο ασθενής έχει υ οβληθεί σε PCI στον LAD, µε καλώς διατηρούµενο α οτέλεσµα. 2. Ο ασθενής έχει υ οβληθεί σε PCI στο στέλεχος, µε καλώς διατηρούµενο α οτέλεσµα. 3. Ο ασθενής έχει υ οβληθεί σε CABG, µε βατό το µόσχευµα στον LAD. 4. Ο ασθενής έχει ενδαορτική αντλία.

45 Έκβαση της αγγειοπλαστικής µε DES στο στέλεχος εξαρτάται από όλα, εκτός: 1. Θέση της βλάβης στο αγγείο (στόµιο vs σώµα vs διχασµός) 2. Αριθµός συνολικών συνυ αρχόντων ασχόντων αγγείων 3. Χρήση ενδαορτικής αντλίας 4. Παρουσία οξέος στεφανίαου συνδρόµου vs σταθερής στηθάγχης

46 Η αγγειοπλαστική στο στέλεχος απαιτεί οπωσδήποτε: 1. 1 stent 2. 2 stents 3. IVUS (ενδο-στεφανιαίο υ ερηχογράφηµα) 4. IABP (ενδο-αορτικη αντλία)