对多支血管的冠心病选择经皮血管成形术或者外科手术的血管成形术.ppt

Percutaneous or Surgical Revascularization for Multivessel Coronary Artery Disease?Verghese Mathew,MD,FACC Consultant,Division of Cardiovascular Diseases and Department of Radiology Professor of Medicine,Mayo Clinic College of Medicine Revascularization Strategies How do we decide?Anatomy Clinical Patient presentation preference Risk vs.Benefit Invasive Therapies Low Risk Patient High Risk Patient Some acute risk Less long-term risk reduction Greater acute risk Greater long-term risk reduction 12-Year Survival in Patients with CAD 7354210255075100 50 35-49 35 Emond M et al:Circ 90:2645,1994 23,467 Medically-Treated Patients in CASS Registry LVEF CP1203018-2 12-Year Survival in Patients with CAD 887450400255075100 No CAD 1 vessel 2 vessel 3 vessel Emond M et al:Circ 90:2645,1994 23,467 Medically-Treated Patients in CASS Registry CP1203018-1 Clinical Presentation Age Acute ischemic syndrome versus chronic stable angina Prior cardiac history(MI,CABG,intervention)Co-morbid conditions(diabetes,cerebrovascular disease,renal disease,lung disease)Functional impairment Ischemic burden Extension of Survival with CABG vs Medical Therapy After 10 Years-4-202468101214161820CP1203018-14 Extension of survival(mo)Yusuf S et al:Lancet 344:563,1994 Overall Vessel disease 1/2 vessels 3 vessels Left main LV function Normal Abnormal Exercise test Normal Abnormal Angina Class 0,I,II Class III,IV Low Moderate High Low Moderate High VA risk score Stepwise risk score 3011246-8 506070809010003657301,0951,4601,825506070809010003657301,0951,4601,825506070809010003657301,0951,4601,825506070809010003657301,0951,4601,825CABG vs Stenting for MVD Meta-Analysis of ARTS,ERACI-II,MASS-II and SOS Circ 118,2008 Days Event-Free Survival Analysis of Death 1,518 1,472 1,456 1,440 1,406 1,347 1,533 1,479 1,457 1,439 1,412 1,349 Overall survival(%)P=0.78 Days Repeat Revascularization 1,518 1,204 772 740 707 665 1,533 1,428 927 911 882 855 P0.0001 Overall survival(%)Days Death,Stroke or MI 1,518 1,381 913 896 872 846 1,533 1,377 908 891 868 845 Overall survival(%)P=0.64 Days Major Adverse Cardiac and Cerebrovascular Events 1,518 1,153 729 691 657 616 1,533 1,332 867 846 812 785 P0.0001 Overall survival(%)PCI 91.5%CABG 91.8%PCI 71.0%CABG 92.1%PCI 83.3%CABG 83.1%PCI 60.8%CABG 77.0%Increased Likelihood of Restenosis Lesion/Patient Subsets Small vessels Bifurcations Ostial CTO Bare metal ISR SVG AMI(thrombus)Diabetes mellitus 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0Hazard ratio 95%CI CP1045415-3 SIRIUS Clinical Restenosis(TLR)at 1 Year Sirolimus Control Overall 4.9 20.0 Male 5.2 20.5 Female 4.1 19.0 Diabetes 8.4 26.4 No diabetes 3.7 17.6 LAD 6.0 23.0 Non-LAD 4.1 18.0 Small vessel(13.5)6.0 21.9 Overlap 5.7 23.2 No overlap 4.5 18.6 P 0.0001 0.0001 0.0002 0.0002 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 0.0001 Events prevented/1,000 pt 152 153 149 180 138 170 140 157 151 146 158 175 141 Odds ratio CABG vs Drug-Eluting Stents in Multivessel Coronary Disease A Meta-Analysis on 24,268 Patients Benedetto et al:EJCTS 6958,2009 Favors DES-PCI Favors CABG 0.01 0.1 1 10 100 HR and 95%CI Study name Park Hannan Briguori Yang JH Lee Yang ZK Javaid Varani Tarantini Left Main DiseaseLeft Main Disease (isolated,+1,+2 or+3 vessels)(isolated,+1,+2 or+3 vessels)3 Vessel Disease3 Vessel Disease (revasc all 3 vascular territories)(revasc all 3 vascular territories)SYNTAX Eligible Patients De novo diseaseDe novo disease Limited Exclusion CriteriaLimited Exclusion Criteria Previous interventions Previous interventions Acute MI with CPK2xAcute MI with CPK2x Concomitant cardiac surgeryConcomitant cardiac surgery SYNTAX Inclusion Criteria 3-vessel disease and/or left main disease Total occlusion without time limitation Previous stroke 1 month Renal and respiratory insufficiency Decreased pump function Myocardial ischemia(unstable-silent-stable)Patients with comorbidity Real world patient populationReal world patient population PCIPCI n=198n=198 TAXUSTAXUS*n=903n=903 CABGCABG n=897n=897 vsvs CABGCABG n=1077n=1077 no f/uno f/u n=428n=428 5yr f/u5yr f/u n=649n=649 Two Registry ArmsTwo Registry Arms N=1275N=1275 Randomized ArmsRandomized Arms N=1800N=1800 Heart Team(surgeon&interventionalist)Heart Team(surgeon&interventionalist)Amenable for only one Amenable for only one treatment approachtreatment approach Amenable for bothAmenable for both treatment optionstreatment options Stratification:Stratification:LM and DiabetesLM and Diabetes LMLM 33.7%33.7%3VD3VD 66.3%66.3%LMLM 34.6%34.6%3VD3VD 65.4%65.4%23 US Sites23 US Sites 62 EU Sites62 EU Sites +SYNTAX Trial Design*TAXUS Express 3011246-15 010200612010200612010200612Cumulative rate(%)SYNTAX:Outcomes NEJM 360(10),2009 Cumulative rate(%)Death from Any Cause Death from Any Cause,Stroke,or MI Repeat Revascularization Major Adverse Cardiac or Cerebrovascular Event Months since randomization Cumulative rate (%)Cumulative rate(%)Months since randomization P=0.37 P=0.99 0102006123.5 P0.001 P=0.002 Months since randomization Mo