Bài giảng A decade of left main intervention: PCI vs CABG where are we now

A Decade of Left Main Intervention :
PCI vs CABG
Where are we now ?
Gim-Hooi Choo
Cardiac Vascular Sentral KL (CVSKL)

12th. July, 2019


Disclosure
• No conflicts pertaining to this
lecture

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Sypnosis
• Left Main Stem Revascularisation: The Story A
Decade Earlier
• After EXCEL and NOBLE in 2016 :
More Clarity or Confusion?
• Current Position of LMCA Revascularisation


Left Main : Why the Fuss ?

• 1 inch length
• 5 % of coronary intervention
• Supplies 75% of myocardial perfusion (if Right dominance)
• Major Bifurcation
• Associated with Multi-vessel disease

Andreas Gruentzig’s Log Book :
1st. Successful LMCA PCI :
3rd. PCI case [Nov 24th. 1977]

“Third PCI patient ever treated. Forty-three year old man with severe angina pectoris since
September, 1977. First angiogram (November 11) revealed severe stenosis of the main
L.C.A. . .”
Note: The patient expired suddenly about 4 months after this procedure.
Gruntzig A. Lancet 1978;1:263.


CABG was the ONLY option !

Yusuf S et al. Lancet 1994; 344: 563-70


For 30 years, Surgeons RULED !
Left Main is a No Entry Zone for Interventionalists !


LMCA Interventionalists are
called COWBOY Doctors


MAIN COMPARE, 5 Year
Propensity Match Patients (n=542)
DES vs CABG

Park DW, et al. JACC 2010;56:117-24


Pre-2016 RCTs

Limitations :
First Generation of DES ; Low rate of IVUS/OCT use
Non inferiority trial
Relative small sample size
SYNTAX – LM : a subgroup
Large Non-Inferiority margin (6-7%)
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SYNTAX: Left Main Subgroup
De novo disease (n=1800)

Serruys PW et al. NEJM 2009;360:961-72


[Death /MI /Stroke /Repeat Revascularization]

ITT population

Cumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates

Mohr FW et al. Lancet 2013;381:629–38

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SYNTAX : Left Main Disease
5 year Outcomes [n=705]

Mohr FW et al. Lancet 2013;381:629–38


MACCE to 5 Years by SYNTAX Score Tercile
Low to Intermediate Scores (0-32)

Serruys PW et al. Lancet 2013;381:629–38

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MACCE to 5 Years by SYNTAX Score Tercile
High Scores ≥ 33

Serruys PW et al. Lancet 2013;381:629–38


PCI vs. CABG for Left Main Disease
Meta-analysis of 4 RCTs, 1,611 Patients
1 Year MACCE

Capodanno et al, JACC 2011;58:1426-32
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PCI vs. CABG for Left Main Disease

Meta-analysis of 4 RCTs.
1 year MACCE

Fixed effects estimate

Capodanno et al, JACC 2011;58:1426-32


PCI vs. CABG for Left Main Disease
Meta-analysis of 4 RCTs.
1 year mortality

Capodanno et al, JACC 2011;58:1426-32

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PCI vs. CABG for Left Main Disease
Meta-analysis of 4 RCTs.
1 year MI

Fixed effects estimate

Capodanno et al, JACC 2011;58:1426-32


PCI vs. CABG for Left Main Disease
Meta-analysis of 4 RCTs.
1 year TVR

Fixed effects estimate

Capodanno et al, JACC 2011;58:1426-32

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PCI vs. CABG for Left Main Disease
Meta-analysis of 4 RCTs.
1 year stroke

Fixed effects estimate

Capodanno et al, JACC 2011;58:1426-32


Guideline Recommendations for
Left Main Revascularisation

Levine G, et al. J Am Coll Cardiol. 2011;58:44-122; Windecker S, et al. Eur Heart J. 2014;35:2541-619


Temporal Trends of LM Revascularization
(IRIS LM Registry n=5,883), 2017
Medical Tx
CABG

PCI

Temporal Trends in Unprotected Left Main PCI
in the US (NCDR)
3,342,162 Patients 33,128 PCI

Valle et al, JAMA Cardiol. 2019;4:100-109


Before 2016
N=201

N=105

N=600

N=705