Oxford The John Radcliffe Hospital Multi-vessel disease… Le Mans implications Dr Adrian Banning.

OxfordThe John Radcliffe Hospital

Multi-vessel disease…Le Mans implications

Dr Adrian Banning

Multi-vessel disease…Le Mans - implications ?

• Lemans trial J Am Coll Cardiol 2008

– Small randomised trial of CABG vs PCI for patients with left main disease

• Syntax Lemans– Subset of the Syntax trial – patients with left main disease – follow up angios at 15 months (both surgical and PCI)– To be reported at PCR 09

Why is the Left Main important?

It supplies at least 2/3 of the blood to the heart!!!It supplies at least 2/3 of the blood to the heart!!!

Why is the left main special?

• Large vessel– Prone to calcification– Large volume of plaque required to cause stenosis– Intubated by the diagnostic catheter –ostium?– By definition terminates in a bifurcation – at least

• Untreated LMS stenosis > 20% mortality at 1yr

Results of initial intervention on the LMS- the early years

• 1980s Hartzler using POBA– 10% procedural mortality in hospital– 64% 3yr mortality

• Early 1993-8 ULTIMA– 279 pts unprotected LMS– 14% procedural mortality in hospital– 25% mortality at one year

– NB if 46% inoperable are excluded –• 97% 1yr survival in these low risk pts

Can we predict risk when stenting the LMS?

Stent the LMS with BMS safe, but high rate of MACE due to restenosis

Am J Cardiol. 2003;91:12-6.

• 103 patients• BMS (n 50) or PES (n 53). • All IVUS guidance and Cutting balloon pretreatment x 3 to cover

entire lesion

• Ostium and body were treated with a single stent

Single stent 49/50 and 52/53Final kissing balloon dilation was performed only in cases with suboptimal result at the LCX ostium (6% and 19%)

• Follow-up: 6 months angio and IVUS

• No “late” stent thrombosis in either group

A Randomized Comparison of Paclitaxel-ElutingStents Versus Bare-Metal Stents for Treatment

of Unprotected Left Main Coronary Artery Stenosis

Erglis et al JACC 2007

Location matters

Distal- bifurcation

Shaft

OstiumOstium

What makes the left main special?

• Anatomy matters– Ostial Needs 1 stent– Body Needs 1 stent– Bifurcation Usually >1 stent, 2 wires, >6F

Preliminary DES in LMS disease?

Long-Term Outcome After DES in Nonbifurcation Lesions that involve Unprotected LMS

Chieffo et al Circulation 2007

• Population: 147 pts• elective (only) consecutive pts SES or PES in 5 centers• - stenosis in the ostium and/or the mid-shaft of an

unprotected LMCA

• PCI instead of surgery was considered either(1) suitable anatomy for stenting and preference patient and physician (2) suitable anatomy for stenting and EuroSCORE 6 and/or Parsonnet score 13 and/or prior bypass surgery with failure of all conduits (n=2).

Favorable Long-Term Outcome After Drug-Eluting Stent Implantation in Nonbifurcation Lesions That Involve

Unprotected Left Main Coronary


• Medications: • IIb/IIIa inhibitors at the discretion of the operator. • Dual antiplatelet therapy for at least 6 months after. All patients

were advised to maintain lifelong use of aspirin (100 mg/d).

• Clinical follow-up: at 1, 6, 12, and 24 months. • Patients eligible for longer clinical follow-up were contacted at 36

and 48 months.

• Angio follow-up: 4 and 9 months or earlier if neccesary

• Total follow up mean 886 days




No proven late stent thrombosis

4 unexpected deaths

What about late stent thrombosis in LMS disease?

• Specific worries– Late thrombosis for all DES >BMS– Late thrombosis higher off label– Higher risk of incomplete expansion?– Left main occlusion will be fatal

• Reassurances– Big vessel

Late and very late stent thrombosis following DES in ULM. Chieffo et al, EHJ Sept 2008.

• Multicentre registry of 731 pts with Elective DES stenting of ULM disease.

• Definite ST • 4 pts (0.5%). 3 early (≤30d), 1 late (≤ 1 yr). No VLST.

• Probable ST = 3 pts. All early (≤30d)

• Definite or probable ST = 7 / 731 = 0.95%• All were on dual AP Rx.

• Possible ST• (8 late, 12 very late) in 20 (2.7%) pts.

Late and very late stent thrombosis following DES in ULM. Chieffo et al, EHJ Sept 2008.

• Outcomes after 29.5±13.7 months follow up:– Death: 6.2% (n=45).

– Cardiac death: 4.2% (n=31)

– TVR: 12.9% (n=95)

– TLR: 10.9% (n=76)

– Restenosis rate: 14.1% on angiographic follow-up of 548 pts.

(NB: 76% of lesions involved the distal LM.)

• Predictors of ST at logistic analysis:– Euroscore– LVEF

• Consistent with general PCI population. • No unique ST predictor among ULM pts identified in this analysis.• Conclusion: Elective DES stenting of ULM is safe - low rates of ST.

358 consecutive patients

7 centres

All DES

Elective Urgent

MACE free 74% 68%

Mortality 6% 21%

Reinfarction 8% 10%

TLR 7% 3%

TVR 16% 7%

Delft J Am Coll Cardiol 2008 ; 51 2212-9

So can stents replace surgeryin left main disease?

Unprotected left main stenting vs CABG

Seung et al, NEJM April 2008.

• Long term follow up of 1102 patients stenting for ULM disease,

• vs propensity-matched cohort of CABG patients

• No significant difference in the risk of death and the composite outcome of death, Q-wave MI, or stroke between the two groups.

• TVR higher in the stents group, even with DES.

Seung KB et al. N Engl J Med 2008;358:1781-1792

Study of unprotected LEft MAiN Stenting versus bypass surgery

J Am Coll Cardiol 2008; 51: 538-45

Lemans study design

PCI techniqueDirect stenting preferred

if not poss predil with 2 or 2.5

Bifurcation technique

Initial stent to LAD then Cullotte or Prov T if necessary

No crush stenting

IVUS advised

DES if diameter < 3.8mm (35%)

LeMans study 2008

Lemans trial 2008

Improved EF with PCIETT similar by 12 months

more angina PCI initially

LeMans survival

Left Main Disease(isolated, +1, +2 or +3

vessels)

3 Vessel Disease(revasc all 3 vascular territories)

SYNTAX Eligible SYNTAX Eligible PatientsPatients

De novo disease

Limited Exclusion Criteria Previous interventions

Acute MI with CPK>2x

Concomitant cardiac surgery

Syntax Lemans (reports PCR 09)

• All left main pts in the randomised Syntax n=710• Follow up angio at 15 months• Asses late angio outcomes with clinical outcomes• Asses utility of angio follow up

• Stats– Surgery occlusion rate rate 5-12%

• 100 surgery pts 95% confidence interval (+/-0.043) if occlusion is 5% or (+/-0.043) if occlusion is 12%

– PCI Expected Patency rate 74-97%• 100 PCI pts 95% confidence interval (+/-0.078) if patency is 80%

– Expected attrition 30%

12 Month LM Subgroup MACCE Rates

CABG TAXUSLeft Main Isolated

Left Main + 3VD

Left Main + 2VD

Left Main + 1VD

N=258(37%)

N=218(31%)

N=138(20%)

N=91(13%

)

All LMN=705

Pati

en

ts (

%)

12 Month Subgroup MACCE Rates

All LMN=705

LM+1VDN=138

LM isolatedN=91

LM+2VDN=218

LM+3VDN=258

Pati

en

ts (

%)

3VD (All)N=1095

CABG TAXUS

So why is the left main special?

• The left main is unforgiving during PCI– Because large volumes of myocardium are at risk – Large volumes of plaque may move– Calcification is restrictive to stent expansion– loss of “branches” will have immediate and profound

haemodynamic consequences

• The left main is unforgiving in the long term– All ostial disease has a very high restenosis

rate (particularly if the stent is incompletely expanded).

What do we know about left main PCI?

• Procedural risk fallen from 10-20% to <1%

(in all but shock cases)

• Ostial and shaft disease is different to terminal disease of the main

• Left main PCI should be definitely considered in all emergency cases and many urgent cases

What do we know about left main PCI in 2008?

• DES are almost certainly better than BMS

• Risks of treating left main disease with PCI or surgery are probably the same

• Long term results of DES in elective ostial and shaft disease are very encouraging – Those cases treatable with one properly

expanded stent

What do we know about left main PCI in 2008?

• However– How do we treat distal bifurcation disease

best?• Perhaps the cullotte? Not the crush for me

• LMS + 2VD / 3VD – surgery still has lower rates of TVR

particularly in diabetics

OSTIUM BODYDISTAL

1 STENT

DISTAL2

STENTCABG

UNSUITABLE

URGENT

ELECTIVE

Isolated left main stenting in 2008…Isolated left main stenting in 2008…

Oxford The John Radcliffe Hospital Multi-vessel disease… Le Mans implications Dr Adrian Banning.

Documents

Transcript of Oxford The John Radcliffe Hospital Multi-vessel disease… Le Mans implications Dr Adrian Banning.