Stable Ischemic Heart Disease: When and How to Revascularize. Robert N. Jones, MD

Transcription

1 Stable Ischemic Heart Disease: When and How to Revascularize Robert N. Jones, MD 1

2 I have no financial disclosures to make 2

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5 Outline Basics of coronary bypass grafting Chronic stable coronary artery disease When to do PCI When to do CABG Use of internal mammary arteries for CABG Conclusions 5

6 "To have any other malady is to be sick; to have this is to be dying." Lucius Annaeus Seneca (d 65 AD) in describing his own anginal symptoms 6

7 History of CABG 7

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15 Goals of therapy Alleviate symptoms Delay or prevent progression of coronary artery disease Decrease the risk of adverse clinical events (ACEs) Death Heart failure Myocardial infarction 15

16 Optimal medical therapy Aspirin Statin Treat hypertension and diabetes Eliminate smoking and inactivity Behavioral modifications Mindfulness therapy Yoga 16

17 Indications for Coronary Artery Revascularization Angina despite maximal medical therapy Patients intolerant to maximal medical therapy Active patients who desire improved QOL Patients in whom a survival benefit, ie Left main disease, has been demonstrated 17

18 Indications for CABG Left main coronary artery stenosis (>50%) or equivalent (75% proximal LAD and CX) 3 vessel CAD with reduced LV function Type 2 Diabetes and 3 vessel CAD 18

19 Single Vessel Disease Defined as >70% stenosis, or 50-70% with positive fractional flow reserve (<.80) PCI is the desired approach especially to the LAD Right coronary and circumflex arteries: little data to support intervention Risk associated with myocardium in jeopardy: prox LAD>CX>mid LAD>RCA CABG for pts with much myocardium at risk, contraindications for antiplateltet Rx, failed PCI 19

20 Two and Three Vessel Disease Approach dependent on anatomic complexity and comorbidities, ie Diabetes Older studies: fewer re-interventions with CABG 2008 meta-analysis: BMS vs CABG ARTS1, SOS, ERACI-2, MASS-2 examined Repeat intervention less with CABG: (7.9% vs 29%) Reason: restenosis rate greater with BMS (15% vs 3%) Adverse clinical events the same (16.9% vs 16.7%) 20

21 3 VD and Moderately Severe Left Main Disease SYNTAX trial: first generational DES ACEs higher with PCI at one year Stroke rate lower with PCI More complete revascularization with CABG At 3-5 yrs, ACEs higher with PCI At 5 yrs, death and stroke rates similar Problems: more males, suboptimal med Rx, some patients in CABG arm opted out 21

22 3 VD and Moderately Severe Left Main Disease SYNTAX scores: lesion complexity, location, and number of lesions PCI and CABG similar at lower scores CABG superior with higher scores 5 years: Low score, no difference in ACEs Intermediate, PCI worse Absolute increase in mortality 8% for PCI 22

23 Use of Mammary Arteries for CABG At ten yrs, 95% of IMAs are open vs 25% veins LIMA to LAD Improves survival Decreases incidence of late MI Decreases recurrent angina Decreases further interventions Goal: 100% patients should receive a LIMA BIMA grafting superior to SIMA Need to redo=40% vs 8% at 12 years Survival benefit with BIMA 23

24 Use of Bilateral Mammary Arteries for Revascularization Vein grafts patency rates begin deteriorating at 7 years Advantages of BIMA may appear after this time Yet less than 10% of heart centers use BIMAs Risks: Sternal Dehiscence (.4% to 1.3%) Diabetics Obese individuals Chronic lung disease Conclusion: use both IMAs to LAD and Cx systems 24

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26 Conclusions Approach determined by Number of vessels involved Anatomic complexity of the the lesions Complete revascularization Diabetes and ventricular function Patients without left main disease Single vessel disease: DES Two vessel disease of the Right and Cx: PCI Two vessel disease with LAD: CABG in those with Diabetes, Int/High SYNTAX, at risk myocardium 26

27 CONCLUSIONS 3 vessel disease with low SYNTAX and no diabetes: PCI Left main disease: CABG Every one should get a LIMA Preferably BIMA Clinical decision making is very important, made with Patient Heart Team Referring physician Cardiothoracic surgeo Cardiologist 27

28 THANK YOU! 28