Lsions du tronc commun: Reste t il une place pour la chirugie? - PowerPoint PPT Presentation

Lésions du tronc commun: Reste t il une place pour la chirugie? Pierre Deharo, CHU TIMONE, Marseille

Di Disc sclosure Sta Statement of of Fin Finan ancia ial l Inte Interest I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company : Speaker's name: Pierre, Deharo, MARSEILLE ☑ I do not have any potential conflict of interest

Guidelines: indications ESC guidelines, Eur Heart J 2014

Methods of revascularisation ESC guidelines, Eur Heart J 2014

LMS: evidence 5-y PRECOMBAT + SYNTAX LMS analyse Subgroup of negative study ! Cavalcante, JACC 2016

SYNTAX calculator = a very complicated tool !

New evidence for LMS: What is the source of dilemna ? EXCEL STUDY Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease. Stone G et al. N Engl J Med Dec. 2016 PCI non inferior to CABG NOBLE STUDY Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. Mäkikallio T et al. Lancet Dec. 2016 PCI NOT non inferior to CABG and… CABG superior to PCI

EXCEL Study PCI non inferior to CABG for LM disease LM and SYNTAX<32 Xience stent, 28% BIMA CABG vs PCI, n= 1905 Stone et al, NEJM 2016 PEP= Death, MI, stroke

NOBLE Study PCI not non-inferior to CABG for LM disease (HR>1.35) Left Main Biomatrix stent (>90%) CABG vs PCI, n= 1201, 8% BIMA Mäkikallio et al, Lancet 2016 PEP= Death, non procedural MI, stroke + Revasc

Why different results ? EXCEL study NOBLE study PEP without repeat revasc. PEP with repeat revasc. PEP: All MI PEP: Only non procedural MI 3 years FU 5 years FU Negative study Positive Study No Non inferiority of PCI Non Inferiority of PCI Superiority of CABG Stone et al, NEJM 2016 Mäkikallio et al, Lancet 2016

How study design impacts study results ! EXCEL study: PEP NOBLE study: PEP CABG CABG PCI PCI Difference in KM curves Earlier (MI Definition / Early Hazard) Faster (Repeat Revasc. In PEP) Larger (Longer follow-up) Stone et al, NEJM 2016 Mäkikallio et al, Lancet 2016

EXCEL NOBLE All cause death Higher Higher CV death Equal Equal PCI as reference Periprocedural MI Lower * Lower Non Periprocedural MI Higher Higher * * p<0,05 Revasc Higher * Higher * Stroke Lower Higher ST/SGO Lower * Lower Stone, NEJM 2016 Makikallio, Lancet 2016

EXCEL NOBLE AF Lower * Lower * PCI as reference Transfusion Lower * Lower * * p<0,05 Anemia Lower * Lower * Stone, NEJM 2016 Makikallio, Lancet 2016

Revascularization strategy ESC guidelines, Eur Heart J 2014

Revascularization strategy STS – Age SCA vs. SCAD Diabetes Compliance DAPT SYNTAX All arterial Ostial vs. Bifurcation Delays Downstream bed Imaging CTO Previous failure

Revascularization strategy SYNTAX STS – Age Ostial vs. Bifurcation SCA vs. SCAD Downstream bed Diabetes CTO Compliance DAPT Previous failure All arterial Delays Imaging CABG – PCI - Hybride Final tailored decision

One patient … is one patient... 63 yo Current smoker = RIMA to LCX EF 50% + LIMA to LAD No comorbidity eGFR 80 86 yo = PCI to LMS/LAD COPD – PAD – Frail 1 DES EF 30% eGFR 40

Remaining questions in 2018

SYNTAX score 2016 Stone, NEJM 2016 Makikallio, Lancet 2016

Score SYNTAXII

Constant devices improvement • Last generation stents in LMS - diabetes • Systematic use of intracoronary imaging in LMS procedures • Less invasive PCI (6 Fr radial) • Complete revascularisation (CTOs)

Conclusions • LMS PCI: validated alternative except for complex anatomy • Is there still a place for CABG: YES!... • …But if well done: all arterial

Graft patency Tranbaugh et al, Annals of thoracic surgery 2017

Conclusions • Heart Team • Expert centers Patient-based decision instead of SYNTAX based • Need for optimization of PCI outcomes (OCT/IVUS, newer DES, bifurcations techniques, CTOs)