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PCI vs. CABG
Left Main Disease and
Multi-Vessel Disease
The Game Is Not Over !
Seung-Jung Park, MD, PhD
Professor of Medicine, University of Ulsan College of Medicine
Asan Medical Center, Seoul, Korea
Background of
“Surgery is Better”
First Randomized Trial
CABG vs. Medical Treatment
From 1975 to 1979,
1.
2.
3.
4.
780 patients with Stable Ischemic Heart Disease,
Surgical (n=390) vs. Medical (n=390)
70%, 1 or 2 vessel disease,
Only long acting nitrate and beta blocker available, <50%
CASS Investigators, Circulation 1983;68:939-950
All Patients, EF < 0.50
82
81
76
77
1 Vessel Disease
75
100
% SURVIVAL
78
77
80
60
80
75
59
100
11
11
8
8
8
70
54
8
10
60
P = 0.085
5
7
P = 0.095
40
20
MEDICALLY ASSIGNED
SURGICALLY ASSIGNED
20
1
0
3
2
0
0
5
4
2 Vessel Disease
100
8
10
80
40
YEAR 0
11
35
35
28
28
28
34
28
22
100
80
32
2
3
31
35
41
42
35
41
35
40
P = 0.85
40
40
20
20
0
2
3
4
5
0
0
39
30
60
1
5
32
33
23
60
0
4
3 Vessel Disease
28
80
1
23
P = 0.063
1
2
3
4
5
15-year Survival From CASS Registry,
Left Main Disease
100
CABG Surgery
Median Survival 13.3 Years
Percent Survival
80
60
P<0.0001
40
Medical Treatment
Median Survival 6.6 Years
20
0
YEAR
0
N Survival
1153 100
331 100
5
10
15
973 85
194 59
745 67
128 39
20 37
6 27
Caracciolo E A et al. Circulation 1995;91:2325-2334
Survival Benefit of CABG
Over Medication
1. Left Main Disease
40 Years Old,
2. 3 Vessel Disease
Story !
withOld
LV dysfunction
Conventional Bible !
Caracciolo E A et al. Circulation 1995;91:2325-2334
CASS Investigators, Circulation 1983;68:939-950
Surgical Treatment
for Ischemic Heart Failure (STICH) Trial
CABG vs. Medical Treatment
1212 Patients with Stable Angina (<35% of LVEF),
Surgical (n=610, EF 27%) vs. Medical (n=602, EF 28%)
Velazquez EJ, et al. NEJM 2011;364:1607-16.
All-Cause Mortality (STICH)
Patients with Ischemic Heart Failure (LVEF <35%)
HR 0.86 (0.72, 1.04)
P = 0.123
Surgery is Not Superior to Optimal Medical Therapy for
Ischemic Left Ventricular Dysfunction (EF <35%) 0.46
Medical
Treatment
0.41
CABG
Velazquez EJ, et al. NEJM 2011;364:1607-16.
Survival Benefit of CABG
Over Medication
1. Left Main Disease
2. 3 Vessel Disease
with Moderate LV dysfunction (EF>35%)
More Limited Benefit !
Is
PCI Better ?
Benefit of Stents
Over Medications in Stable Disease
Survival Free From Death and MI (COURAGE,n=2,287)
Optimal Medical Therapy
(OMT)
1.0
0.9
PCI + OMT
0.8
0.7
Hazard ratio: 1.05
95% CI (0.87-1.27)
P = 0.62
0.6
0.5
0.0
0
1
2
3
4
5
Boden W, N Engl J Med 2007; 356:1503-1516
6
7
Years
Benefit of Stents
Over Medications in Stable Disease
12 RCTs, 7182 participants
Favors PCI
RR
Favors MT
P
All-cause mortality
0.85 [0.71, 1.01]
0.07
Cardiac death
0.71 [0.47, 1.06]
0.09
Nonfatal MI
0.93 [0.70, 1.24]
0.61
Repeat Revascularization
0.93 [0.76, 1.14]
0.47
Angina
0.83 [0.73, 0.94]
0.005
0
1
Risk ratio (95% Cl)
Pursnani et al, Circ CV Intv 2012
2
Survival Benefit of Revascularization
(CABG and/or PCI) Over Medications
Large Ischemic Burden
6
*10%
5
Medical Rx
4
2
Revascularization
1
0
Log Hazard Ratio
3
0
12.5%
25%
32.5%
50%
* % Total Myocardium Ischemic Burden
Circulation. 2003;107:2900-2906
What We Know,
Any Revascularization Treatment
(CABG or Stent) Have No Survival Benefit
Over Medical Treatment Especially in Low
Risk Patients with Small Ischemic Burden
(<10%).
Stable Angina Treatment
Medication
CABG
Optimal Medical Treatment is Effective.
Large ischemic burden,
Survival Benefit for LM
and 3 VD with Moderate
LV Dysfunction
PCI
Non-Viable, Asymptomatic
Small Myocardium,
PCI
For Angina
Relieve
Cosmetic
Symptomatic
Angioplasty
Angioplasty
Inappropriate Angioplasty (50%)
JAMA 2011;306(1):53-61
PCI
Competitive to Surgery
for LM and 3 VD
Survival
Angioplasty
PCI vs. Surgery
Survival Angioplasty
For Left Main and 3 Vessel Disease
Why PCI
?
To Avoid
Surgery
!
PCI vs CABG
Left Main Disease
1.
2.
3.
4.
5.
SYNTAX, LM subgroup
MAIN COMPARE Registry
PRECOMBAT
Meta-Analysis of RCTs
Temporal Trends
of LM Revascularization, 2014
Syntax All, 5 Year
MACCE
TAXUS (N=903)
Cumulative Event Rate (%)
CABG (N=897)
P<0.001
50
37.3%
25
26.9%
0
0
12
24
36
48
60
Months Since Allocation
Cumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates
ITT population
MACCE to 5 Years
LM Subset
Cumulative Event Rate (%)
CABG (N=348)
TAXUS (N=357)
P=0.12
50
36.9%
No Difference !
Totally Different Outcomes Compared to 3VD.
25
31.0%
0
0
12
24
36
Months Since Allocation
Cumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates
48
60
ITT population
MAIN COMPARE, 5 Year
Death /MI /Stroke
P<0.001
All PCI patients (n=542 pairs)
Bare-metal stents (n=207 pairs)
7.97
Drug-eluting stents (n=542 pairs)
6.69
4.55
HR 1.0 to
concurrent CABG
P=NS
P=NS
1.02 1.04 1.26
1.10 0.94 1.27
Death
Composite of death,
Q-wave MI, or stroke
Park DW, et al. JACC 2010;56:117-24
Target-vessel
revascularization
Cumulative Incidence, %
PRECOMBAT, 3 Year
Death /MI / Stoke
20
PCI
CABG
15
p=0.68
p=0.98
p=0.89
10
6.3
4.3
5
3.7
5.0
4.7
6.0
0
0
360
720
1080
Days Since Randomization
No. at Risk
PCI
300
284
271
243
CABG
300
279
268
236
Only Difference is,
Clinical-Driven TVR
20
Cumulative Incidence, %
Cumulative Incidence, %
Ischemia-Driven TVR
PCI
CABG
15
p=0.049
10
p=0.025
8.0
p=0.014
9.0
6.0
5
2.7
3.7
4.0
0
0
360
720
PCI
CABG
15
p=0.059
p=0.026
10
6.0
p=0.015
7.0
4.3
5
1.7
2.3
2.7
720
1080
0
1080
Days Since Randomization
No. at Risk
20
0
360
Days Since Randomization
No. at Risk
PCI
300
270
253
223
PCI
300
275
259
229
CABG
300
278
264
230
CABG
300
280
267
233
Meta-Analysis
PCI vs. CABG in LM Disease
PCI vs CABG for LM Disease
12 Meta-Analyses, 2009-2014
Author
Journal
Year
RCT
Non-RCT
Pts
FU
Naik et al
JACC Cardiovasc Interv
2009
2
8
3,773
3 yrs
Lee et al
Am J Cardiol
2010
2
6
2,905
1 yr
Capodanno et al
J Am Coll Cardiol
2011
4
0
1,611
1 yr
Ferrante et al
EuroIntervention
2011
4
0
1,611
1 yr
Jiang et al
Am J Cardiol
2012
0
25
7,230
≤3 yrs
Jang et al
Am J Cardiol
2012
3
9
5,079
1 yr
Desch et al
Herz
2013
4
0
1,611
2 yrs
Sa et al
Eur J Cardiothorac Surg
2013
3
13
5,674
1 yr
Alam et al
Circulation J
2013
4
23
11,148
5 yrs
Athappan et al
JACC Cardiovasc Interv
2013
3
21
14,203
5 yrs
Sa et al
Rev Bras Cir Cardiovasc
2013
1
4
2,914
5 yrs
Li et al
TRIALS
2014
4
17
8,413
5 yrs
