Phẫu thuật bắc cầu nối cho tốn thương nhiều thân mạch vành khi nào và tại sao

PCI versus CABG: ASCERT Registry Weintraub, et al... Impact of diabetes Impact of age Meta-Analysis of 10 randomized CABG vs... 1800 patients with 3 vessel CAD randomized to PCI with Pac

PCI for multi-vessel CAD

when & how?

Dinh Duc Huy, MD, FSCAI Tam Duc Heart Hospital

2 Very

different

ways to treat

1 disease

Gersh and Frye

New Engl J Med

2005;352:2235

PCI versus CABG: ASCERT Registry

Weintraub, et al New Engl J Med 2012;366:1457-76

189,000 stable patients =65 years old treated with either PCI or CABG

Impact of diabetes Impact of age

Meta-Analysis of 10 randomized CABG vs PCI

trials- 7000 patients

Hlatky, et al Lancet 2009;373:1190-97

1800 patients with 3 vessel CAD randomized to PCI with Paclitaxel DES or CABG

SYNTAX study- 5 year outcomes

Mohr, et al Lancet 2013;381:629-38

Stroke

MACCE

Impact of Syntax Score

Serruys, et al N Engl J Med 2009;360:961-72

Farkouh, et al N Engl J Med 2012;367:2375-84

Freedom trial- long term outcomes

1900 diabetics enrolled from 140 centers with mostly 1st generation DES

Backgrounds- Most trials comparing PCI with CABG have not made

use of 2nd -generation drug-eluting stents

The primary end point = composite of death, MI, or TVR at 2 years after randomization

Park S J N Engl J Med 2015;372:1204-12

BEST study- main results

Park S J N Engl J Med 2015;372:1204-12

• 27 centers in East Asia

• 880 patients

• 438 in PCI group

• 442 in CABG group

• MACEs was higher

among those who had

undergone PCI with the

use of Everolimus-DES

than among those who

had undergone CABG

Long-term

clinical outcomes end

points

Park S J N Engl J Med 2015;

372:1204-12

Subgroup analysis- Impact of Diabetes, Syntax score, EuroSCORE

Park S J N Engl J Med 2015;372:1204-12

Bangalore S N Engl J Med 2015;372:1213-22

Same data from New York State registry-

Everolimus-eluting stent or bypass surgery for multi vessel coronary disease?

PCI CABG HR (95%CI) P value

Complete versus Incomplete Revascularization

from New York Registry

PCI CABG HR (95%CI) P value

Complete versus Incomplete Revascularization

from BEST study

2nd message:

Complete Revascularization is important practical issue

PCI for multi-vessel CAD

FAME Study: Angio-guided verus FFR-guided PCI

1005 patients with 2-3 vessel CAD randomized to Angio or FFR-guided PCI

Fearon W New Engl J Med 2009;360:213-24

FFR- guided PCI versus CABG- FAME 3 study

Is FFR-guided PCI with the 2nd -generation Resolute DES non-inferior to CABG

in patients with multi vessel CAD?

3rd message:

Ischemic-guided (by FFR) PCI may lead to better outcomes

PCI for multi-vessel CAD

ESC Guidelines 2014 Elective PCI for 3 Vessel Disease

CABG PCI

Recommendation

According to extent of CAD Class Level Class Level

3 VD with SYNTAX score 23-32 I A III B

3 VD with SYNTAX score > 32 I A III B

Thank you for your attention!