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

• f 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

• rder 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

ESC guidelines, Eur Heart J 2014

Guidelines: indications

ESC guidelines, Eur Heart J 2014

Methods of revascularisation

Cavalcante, JACC 2016

5-y PRECOMBAT + SYNTAX LMS analyse

Subgroup of negative study !

LMS: evidence

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 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 non inferior to CABG PCI NOT non inferior to CABG and… CABG superior to PCI

Stone et al, NEJM 2016

LM and SYNTAX<32 Xience stent, 28% BIMA CABG vs PCI, n= 1905 PEP= Death, MI, stroke

PCI non inferior to CABG for LM disease

EXCEL Study

Mäkikallio et al, Lancet 2016

Left Main Biomatrix stent (>90%) CABG vs PCI, n= 1201, 8% BIMA PEP= Death, non procedural MI, stroke + Revasc

PCI not non-inferior to CABG for LM disease (HR>1.35)

NOBLE Study

EXCEL study

NOBLE study

Why different results ?

3 years FU 5 years FU PEP: All MI

PEP: Only non procedural MI PEP without repeat revasc. PEP with repeat revasc. Positive Study Non Inferiority of PCI Negative study No Non inferiority of PCI Superiority of CABG Mäkikallio et al, Lancet 2016 Stone et al, NEJM 2016

How study design impacts study results !

EXCEL study: PEP

NOBLE study: PEP

Difference in KM curves Earlier (MI Definition / Early Hazard) Faster (Repeat Revasc. In PEP) Larger (Longer follow-up)

CABG PCI CABG PCI

Mäkikallio et al, Lancet 2016 Stone et al, NEJM 2016

Stone, NEJM 2016 Makikallio, Lancet 2016

EXCEL NOBLE All cause death Higher Higher CV death Equal Equal Periprocedural MI Lower* Lower Non Periprocedural MI Higher Higher* Revasc Higher* Higher* Stroke Lower Higher ST/SGO Lower* Lower

PCI as reference * p<0,05

Stone, NEJM 2016 Makikallio, Lancet 2016

EXCEL NOBLE AF Lower* Lower* Transfusion Lower* Lower* Anemia Lower* Lower*

PCI as reference * p<0,05

ESC guidelines, Eur Heart J 2014

Revascularization strategy

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

Revascularization strategy

CABG – PCI - Hybride Final tailored decision

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

Revascularization strategy

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

One patient … is one patient...

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

Tranbaugh et al, Annals of thoracic surgery 2017

Graft patency

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)