PCI Therapy of CAD (Personal Perspectives) Prof. Yean Leng LIM AM, Monash University, Australia
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1 冠心病介入治療之我見 PCI Therapy of CAD (Personal Perspectives) Prof. Yean Leng LIM AM, Monash University, Australia
2 Coronary Revascularization by PCI alone Current Coronary Revascularization Complete (Index/Staged) vs Incomplete Revascularization Complete Coronary Revascularization for Complex Lesions Equivalence of Western CABG & Eastern PCI Complete CR
3 50 yrs of CAD Therapy A Upward Spiral 1977 PTCA acabg OMT: Optimal Medical Therapy SubOMT: Suboptimal Med. Therapy PCI: Percutaneous Coronary Intervention (PTCA: Balloon PCI; Funct: Functional FFR-guided) CABG: Coronary Artery Bypass Graft Surgery (v:venous; a:arterial, mi: minimal invasive) BMS: Bare-Metal Stent DES: Drug-Eluting Stent
4 Beneficial Role of Coronary Revascularization
5 Coronary Revascularization by PCI alone Current indications for Coronary Revascularization Complete (Index/Staged) vs Incomplete Revascularization Complete Coronary Revascularization for Complex Lesions Equivalence of Western CABG & Eastern PCI Complete CR
6 Long-term Outcome of Incomplete Revascularization After PCI SCAAR: 23,342 patients with multivessel disease undergoing PCI (65% had incomplete revascularization) ) in Sweden, Incomplete revascularization tied to higher rates of death, MI, or repeat revascularization (33.4% vs 15.3%) and individual components Elevated risks of composite endpoint, death, and composite of death/mi remained after propensity-score adjustment Greater risk of death, MI, or repeat revascularization was consistent regardless of type of presentation Conclusion: Incomplete vs complete revascularization after PCI is associated with poorer 1-year outcomes. Hambraeus K, et al. J Am Coll Cardiol Intv. 2016;9:
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8 Incomplete Revascularization SYNTAX Revascularization Index (SRI=bSS-rSS/bSS) Concl: 1 yr adverse clinical outcomes were inversely proportional to SRI (SRI < 80% had best prognostic accuracy) Genereux P et al Eurointervention 2014
9 PCI Revascularization for CAD My Current Practice Treat only Culprit lesion at Index PCI In MVD pts, after Rx of Culprit lesion, treat nonculprit lesions according to Sx or evidence of ischemia (preferably by non-invasive rather than invasive FFR) Staged PCI ischemic non-culprit lesions to achieve complete revascularization CR or at least to SRI < 80%
10 1 stent to 3 Vessel Disease (NOT 3 stents to 1VD) Pre-PCI Post-PCI FFR DES3.0x15 to LAD
11 3yr later : 3 stents to treat 1 RCA lesion! Symptomatic, repeat angio. showed patent LAD stent. Progression of RCA lesion found & PCI performed without prior FFR using 2 overlapping stents (3.0x 18 & 3.0x15), and a third proximal stent (3.0x8) to teat Amplatz guide dissection. Real-Life (Self) evidence to support CR by Staged PCI!
12 Coronary Revascularization by PCI alone Current indications for Coronary Revascularization Complete (Index/Staged) vs Incomplete Revascularization Complete Coronary Revascularization for Complex Lesions Equivalence of Western CABG & Eastern PCI Complete CR
13 High Risk PCI Revascularization Complex PCI Lesions: Left Main Disease & Large Bifurcation Chronic Total Occlusions (CTOs) Diffuse Long Lesions N.B. Risk of CABG constant and dependent on comorbidities of patients not lesion complexities
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15 PCI versus CABG: Complex Disease (West) Long-term outcomes after Coronary Revascularization
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21 CTO PCI Success Rate in the West
22 CTO PCI Success Rate in the East
23 Diabetic MVD - Calcified Diffuse Long Lesions
24 複雜介入手術 是我到東方學壞了還是西方人沒有學好? 多年來中國介入醫生到西方學習介入手術, 現在該是西方介入醫生到東方學習複雜介入手術了!
25 Coronary Revascularization by PCI alone Current indications for Coronary Revascularization Complete (Index/Staged) vs Incomplete Revascularization Complete Coronary Revascularization for Complex Lesions Equivalence of Western CABG & Eastern PCI Complete CR
26 東西方冠心病診療 Current Status of CAD Therapy in East and West 東方 ( 中國 ) 冠心病診療 葯物治療不完善 血運重建 ( 複雜病變 ) 介入手術為主 康復 : 中西結合前景 : 證明複雜介入完全血運重建不亞於繞道手術? 西方 ( 澳洲 ) 冠心病診療 葯物治療不完善 血運重建 ( 複雜病變 ) 繞道外科手術為主 康復 : 西式前景 : 強化完全介入血運重建技術?
27 Non-equivalent procedures with equivalent Outcome in Patients with Complex Diseases? 西方 東方
28 China s PCI Challenge 2016 Non-inferiority Trial of Eastern PCI vs Western CABG Hypothesis: Eastern Staged CR PCI is non-inferior to Western CABG CR for complex CAD Inclusion: Complex CAD pts (by SS/FSS>33) Therapy: Best-practice Functional PCI in selected PCI centers in the East vs Inclusion: Complex CAD pts (by SS/FSS>33) Therapy: Best-practice CABG in selected centers in the West Primary End-point: In-hospital, 30d & annual all-cause mortality & MACCE for 5 yr
29 Synergy of East/West Coronary Revasc 東西方 各取其長 ; 和諧共進 Work in the Hexagon to achieve Equivalence *Working at the same Level
30 Conclusion : Complex lesions (SYNTAX>33) are the remaining indication for CABG surgery Sequential staged PCI to achieve adequate ( > 80%) complete CR that is superior to Incomplete CR Complete CR of complex lesions (SYNTAX >33) by PCI is technically feasible and practiced routinely in the East Evidence of non-inferiority of Eastern PCI CR compared to Western CABG is eagerly awaited ( 加油 )!
31 謝謝 Thank You
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