Multivessel Coronary Artery Disease: Bypass Surgery. Bruce Lytle, MD
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1 Multivessel Coronary Artery Disease: Bypass Surgery Bruce Lytle, MD
2 Coronary Artery Bypass Surgery Prolongs Survival Angiographic Subgroups MR (%) LMT stenosis (> 50%) 68% 3V CAD (> 50%) 42% 1/2V CAD and proximal LAD (> 50%) 32% no proximal LAD -5%
3 Coronary Artery Bypass Surgery Prolongs Survival The more severe the coronary disease, symptoms, and LV dysfunction, the greater the survival benefit of surgery over medical therapy.
4 Coronary Artery Bypass Surgery Improves Quality of Life Independent of Severity of CAD Angina Increase in exercise capacity Decrease in antianginal medications
5 Randomized Studies versus Mostly low risk patients Mostly normal LV function Mostly 2 vessel CAD Insufficient numbers of patients with extensive CAD
6 Cumulative Event Rate (%) MACCE to 4 Years 3VD Subset 50 Before 1 year * 11.5% vs 19.2% P 1-2 years * 4.4% vs 7.0% P= years * 4.6% vs 7.4% P= years * 2.8% vs 7.7% P P TAXUS (N=546) 33.7% % (N=549) Months Since Allocation Cumulative KM Event Rate ± 1.5 SE; log-rank P value; * Binary rates ITT population
7 Cumulative Event Rate (%) All-Cause Death to 4 Years 3VD Subset 50 Before 1 year * 2.9% vs 4.5% P= years * 1.2% vs 2.1% P= years * 1.7% vs 3.2% P= years * 1.7% vs 2.5% P=0.40 P= TAXUS (N=546) 11.9% Months Since Allocation (N=549) 7.3% Cumulative KM Event Rate ± 1.5 SE; log-rank P value; * Binary rates ITT population
8 Cumulative Event Rate (%) Repeat Revascularization to 4 Years 3VD Subset 50 Before 1 year * 5.5% vs 14.6% P 1-2 years * 2.8% vs 3.9% P= years * 2.5% vs 3.0% P= years * 0.6% vs 4.4% P P 25 TAXUS (N=546) 22.8% 10.2% Months Since Allocation (N=549) Cumulative KM Event Rate ± 1.5 SE; log-rank P value; * Binary rates ITT population
9 Cumulative Event Rate (%) Myocardial Infarction to 4 Years 3VD Subset 50 Before 1 year * 2.7% vs 5.2% P= years * 0.2% vs 1.2% P= years * 0.4% vs 1.0% P= years * 0.0% vs 2.3% P=0.001 P 25 (N=549) TAXUS (N=546) 9.0% 0 3.3% Months Since Allocation Cumulative KM Event Rate ± 1.5 SE; log-rank P value; * Binary rates ITT population
10 Cumulative Event Rate (%) CVA to 4 Years 3VD Subset 50 Before 1 year * 1.9% vs 0.7% P= years * 0.4% vs 0.8% P= years * 0.6% vs 0.8% P= years * 0.4% vs 0.2% P=0.62 P= (N=549) TAXUS (N=546) 3.4% 2.8% Months Since Allocation Cumulative KM Event Rate ± 1.5 SE; log-rank P value; * Binary rates ITT population
11 Cumulative Event Rate (%) MACCE to 4 Years by SYNTAX Score Tercile Intermediate Scores (23-32) 3-vessel Disease P value 50 P= TAXUS (N=207) 33.3% Death 12.4% 18.6% CVA 3.6% 2.5% MI 3.1% 10.5% % (N=208) Months Since Allocation Death, CVA or MI 12.4% 18.6% 0.09 Revasc. 8.3% 21.0% Cumulative KM Event Rate ± 1.5 SE; log-rank P value Site-reported Data; ITT population
12 Cumulative Event Rate (%) MACCE to 4 Years by SYNTAX Score Tercile High Scores ( 33) 50 3-vessel Disease P= % TAXUS (N=155) P value Death 6.5% 14.5% 0.02 CVA 2.6% 5.1% % (N=166) Months Since Allocation MI 1.9% 7.9% 0.01 Death, CVA or MI 11.0% 22.3% Revasc. 11.2% 26.7% Cumulative KM Event Rate ± 1.5 SE; log-rank P value Site-reported Data; ITT population
13 ASCERT Trial 2/3 V CAD: ,793 Total
14 Proportion Surviving IPW Adjusted Survival 1.0 Age >75 Age < RR =.77 at 4 years 0.6 RR =.78 at 4 years ,000 1, ,000 1,500 Days from Index Procedure
15 Proportion Surviving IPW Adjusted Survival 1.0 Men Women RR =.81 RR = ,000 1, ,000 1,500 Days from Index Procedure
16 Proportion Surviving IPW Adjusted Survival 1.0 No Diabetes Diabetes: No Insulin Diabetes: Insulin RR =.81 RR =.78 RR = ,000 1, ,000 1, ,000 1,500 Days from Index Procedure
17 Proportion Surviving IPW Adjusted Survival 1.0 EF<30 EF EV> RR =.70 RR =.70 RR = ,000 1, ,000 1, ,000 1,500 Days from Index Procedure
18 Proportion Surviving IPW Adjusted Survival 1.0 GFR<30 GFR GFR> RR = ,000 1,500 RR =.79 RR = ,000 1, ,000 1,500 Days from Index Procedure
19 Emilia-Romagna Registries July 2002 Dec 2008 (REAL) 6246 (RERIC) Surgery 5504 Excluded STEMI, Previous Revasc All had either LMCA, Two other vessels or both
20 Cumulative rate of Death (%) and DES only in Propensity Score Matched Sample Death DES Months
21 Hazard Ratio of Death at Five-years Subgroups No. deaths/total no. (%) Hazard ratio (95% CI) P valve Overall Age <55 yr >55 yr Sex Female Male No. vessles diseased 1 with LMCA 2. Without LMCA 2. With LMCA 3. Wihtout LMCA 3. With LMCA LEVF >36% <35% Previous MI No Yes CHF No Yes Diabetes No Yes CVD No Yes CRF No Yes COPD No Yes Malignancy No Yes 587/2702 (20.3) 90/967 (9.3) 470/1,776 (36.5) 142/614 (23.1) 410/2.128 (19.3) 21/65 (32.3) 101/671 (15.1) 80/269 (29.7) 272/1407 (19.3) 70/154 (45.5) 501/2583 (19.4) 73/154 (45.5) 330/1,891 (17.5) 252/611 (31.1) 347/2.204 (15.7) 215/523 (41.1) 352/1,998 (17.8) 219/730 (30.0) 445/2,392 (15.7) 105/364 (28.8) 483/2,581 (15.7) 75/139 (54.0) 457/2,508 (15.2) 86/222 (35.7) 511/2,636 (10.4) 45/108 (42.8) 422/2,762 (15.3) 69/967 (7.1) 361/1776 (20.3) 109\614 (17.8) 314/2,128 (14.8) 17/65 (26.2) 99/671 (14.8) 51/269 (19.0) 198/1407 (14.1) 36/154 (23.4) 376/2,583 (14.6) 43/142 (30.3) 228/1,891 (12.1) 163/811 (22.6) 267/2,204 (12.1) 144/523 (27.5) 272/1,998 (13.6) 151/730 (20.7) 355/2,392 (13.9) 88/364 (24.2) 355/2,581 ( /130 (37.4) 34/2,506 (13.6) 70/222 (31.5) 1.55 ( ) 1.52 ( ) 1.56 ( ) 1.59 ( ) 1.52 ( ) 1.37 ( ) 1.21 ( ) 1.96 ( ) 1.51 ( ) 2.49 ( ) 1.59 ( ) 2.24 ( ) 1.71 ( ) 1.66 ( ) 1.57 ( ) 1.85 ( ) 1.49 ( ) 1.78 ( ) 1.59 ( ) 1.43 ( ) 1.64 ( ) 1.67 ( ) 1.0 ( ) 1.43 ( ) 379/2,636 better (14.4) better 1.0 ( ) 39/108 (38.1) 1.37 ( ) Mortality logarithmic scale
22 Why is Surgical Revascularization More Effective Than? More Complete Less Negative impact on native vessel Better patency (ITA) Improved vein graft function More protection against progression of atherosclerosis
23
24 Lesions Causing Clinical Event % Hazard Rate Non-Target Lesion Event Target Lesion Event Cutlip et al: Circ Year
25 What about simpler 3VD? has not been shown to prolong survival rate except for AMI Syntax has a 4 year F/U Curves are still diverging
26
27
28 Surgery and are not equivalent treatments, and the differences are not just completeness of revascularization
29 Multivessel Treatment There is no evidence that stenting prolongs the life expectency of any patient with chronic coronary artery disease. There is evidence that surgery does prolong the life expectency of some patients with CAD When we think prognosis is the issue, surgery should be the choice
30 Multivessel Paradigm Intervention until it is no longer possible, then surgery Surgery with intervention used to treat progression of disease
31 Follow-up (year) Survival - MVD Favors PTCA p=0.018 Favors Survival Risk Difference (%) JACC: 2003
32
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