Cabg is superior to pci in heart failure patients with multivessel disease pro

1. CABG is, today, the best option in most
multivessel coronary artery disease patients
José L. Pomar, MD, PhD
Professor of Surgery
Hospital Clinic and University of Barcelona
Barcelona, Spain

3. Vasilii I Kolesov (1904 –1992)
Military surgeon in St. Peterburg
LITA to marginal branch of LCX on 25 February 1964
Michael E DeBakey (1908-2008)
SVG to the LAD on 23 November 1964
Garrett HE et al. JAMA 1973;223:792-4
René G Favaloro (1923-2000)
SVG to the RCA on 9 May 1967
J Thorac Cardiovasc Surg 1969;58:178-85

4. Mason Sones, smoking
and serendipity

5. 1967 Cleveland Clinic

6. Evidence based myocardial revascularization
Head SJ & Davierwala PM et al. Eur Heart J 2014; online

7. Coronary Artery Bypass Graft Trialist Cooperation
Yusuf et al. Lancet 1994;344:563-72
Time from randomization (years)
Mortality(%)
N = 1325
Medical treatment
CABG
N = 1324
OR 0.61
[0.48-0.77]
P<0.0001
OR 0.83
[0.70-0.98]
P=0.03
CABG VS MEDICAL TREATMENT

8. CABG VS MEDICAL TREATMENT
Coronary Artery Bypass Graft Trialist Cooperation
(Individual Data from 7 Randomized Trials)
Yusuf S et al. Lancet 1994;344:563-72
CABG vs MM
0.00
20.00
40.00
60.00
80.00
100.00
120.00
1VD / 2VD 3VD LM
CABG vs MM
0.00
20.00
40.00
60.00
80.00
100.00
120.00
CABG vs MM
0.00
20.00
40.00
60.00
80.00
100.00
120.00P=0.25 P=0.001 P=0.005
Interaction P = 0.02
Meansurvival(months)

9. CABG VS MEDICAL TREATMENT
Network meta-analysis of 100 revascularization trials with 93,553 patients and
262,090 patient-years
CABG
MM
Risk ratio (95% CI)
0.80 (0.70-0.91)Death
CABG vs MM
MI
CABG vs MM
Death or MI
CABG vs MM
Revasc.
CABG vs MM
SES
0.1 0.3 1 3
Favours CABG Favours MM
Windecker S et al. BMJ 2014;348:g3859
0.81 (0.70-0.94)
0.16 (0.13-0.20)
0.79 (0.63-0.99)

10. RCTs on revascularization
Head SJ & Davierwala PM et al. Eur Heart J 2014; online

11. Hlatky M et al. Lancet 2009;373:1190-97
CABG VS PTCA/BAREMETALSTENTS
Pooled analysis of 10 RCTs with 7812 patients
(ARTS, BARI, CABRI, EAST, ERACI-II, GABI, MASS-II, RITA, SoS, FMS)
PTCA/BMS
CABG
Mortality(%)
10.0%
8.4%N = 3923
N = 3889
Follow-up (years)
HR 0.92
[0.80-1.02]
P=0.12
1VD or 2VD
0.91 [0.78-1.06]
3VD
0.91 [0.77-1.09]

12. RCTs on revascularization
Head SJ & Davierwala PM et al. Eur Heart J 2014; online

13. 2014 ESC/EACTS Guidelines

14. TAXUS (N=546)CABG (N=549)
SYNTAX 3VD cohort
All-cause death to 5 years
ITT populationCumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates
0
Months Since Allocation
CumulativeEventRate(%)
25
50 Before 1 year*
2.9% vs 4.5%
P=0.18
1-2 years*
1.2% vs 2.1%
P=0.25
2-3 years*
1.7% vs 3.2%
P=0.12
3-4 years*
1.7% vs 2.5%
P=0.40
4-5 years*
2.4% vs 2.8%
P=0.74
0 12 6024 36 48
P=0.006
9.2%
14.6%

15. 0
Months Since Allocation
CumulativeEventRate(%)
25
50
Before 1 year*
2.7% vs 5.2%
P=0.04
1-2 years*
0.2% vs 1.2%
P=0.12
2-3 years*
0.4% vs 1.0%
P=0.45
3-4 years*
0.0% vs 2.3%
P=0.001
4-5 years*
0.0% vs 1.3%
P=0.03
0 12 6024 36 48
SYNTAX 3VD cohort
Myocardial infarction to 5 years
P<0.001
3.3%
10.6%
TAXUS (N=546)CABG (N=549)

16. ITT populationCumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates
0
Months Since Allocation
CumulativeEventRate(%)
25
50
Before 1 year*
6.6% vs 8.0%
P=0.39
1-2 years*
1.8% vs 3.7%
P=0.07
2-3 years*
2.5% vs 4.4%
P=0.10
3-4 years*
2.1% vs 4.4%
P=0.053
4-5 years*
2.4% vs 3.7%
P=0.29
0 12 6024 36 48
SYNTAX 3VD cohort
Death/Stroke/MI to 5 years
P<0.001
14.0%
22.0%
TAXUS (N=546)CABG (N=549)

17. ITT population
TAXUS (N=546)CABG (N=549)
Cumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates
0
Months Since Allocation
CumulativeEventRate(%)
25
50
Before 1 year*
11.5 vs 19.2%
P<0.001
1-2 years*
4.4% vs 7.0%
P=0.08
2-3 years*
4.6% vs 7.4%
P=0.06
3-4 years*
2.8% vs 7.7%
P<0.001
4-5 years*
4.5% vs 6.9%
P=0.11
0 12 6024 36 48
SYNTAX 3VD cohort
MACCE to 5 years
P<0.001
24.2%
37.5%

18. SYNTAX 3VD Cohort
Multivariate cox regression: PCI vs CABG
HR (95% CI)
MACCE
Death/stroke/MI
Death
0.5 1 2 5
HR 1.66 (1.32-2.09)
HR 1.81 (1.33-2.46)
HR 1.81 (1.24-2.67)
Favours
PCI
Favours
CABG

19. SYNTAX 3VD cohort
SYNTAX score terciles
Death
Myocardial
infarction
Stroke
Repeat Revasc.
TAXUS (N=546)CABG (N=549)

20. SYNTAX 3VD cohort
SYNTAX score terciles
Head SJ & Davierwala PM et al. Eur Heart J 2014; online
TAXUS (N=546)CABG (N=549)
Death/stroke/MIMACCE
CABG PCI

21. SYNTAX 3VD cohort
Completeness revascularization
Incomplete revasc.
Complete revasc.P = 0.010
P = 0.17
MACCE(%) Head SJ & Davierwala PM et al. Eur Heart J 2014; online

23. Completness revascularization
PCI
N=63,945
CABG
N=25,938
Incomplete revasc.
Complete revasc.
75%
44%56%
25%
SXS
<23
SXS
23-32
SXS
>32
Patients (%)
0 10 20 30 40 50 60 70
Complete
Resid SXS 0-4
Resid SXS 4-8
Resid SXS >8
Farooq V et al. Circulation 2013;128:141-51
Garcia S et al. JACC 2013;62:1421-31

24. SYNTAX PCI cohort
Residual SYNTAX score
Resid SXS 0-4
Resid SXS 4-8
Resid SXS >8
Hazardratio(95%CI)
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
MACCE DeathDeath/stroke/MI
Farooq V et al. Circulation 2013;128:141-51

25. SYNTAX 3VD Cohort
Diabetic patients
0.3 1 3 10
Hazard Ratio
(95% CI)
MACCE: Diabetes
No diabetes
Death/stroke/MI: Diabetes
No diabetes
All-cause death: Diabetes
No diabetes
Interaction
P=0.095
P=0.44
P=0.37
Head SJ & Davierwala PM et al.
Eur Heart J 2014; online
Favours CABG

26. FREEDOM Trial
Similar results as SYNTAX
Death/Stroke/MI(%)
Follow-up (years)
Death/(%)
Follow-up (years)
26.6%
18.7%
P=0.005
16.3%
10.9%
P=0.049
SYNTAX 3VD:
24.9% vs 13.2%
P = 0.021
SYNTAX 3VD:
20.2% vs 10.1%
P = 0.027

27. SYNTAX II Score
Risk score predicting 4-year mortality
84.2%
Favours CABG
15.8%
Favours PCI

28. Annual Cumulative
SYNTAX Trial
Economics
Cohen DJ & Osnabrugge RL, et al. Circulation 2014; online
Δ cost = $10,036
Δ cost = $5619

29. -$20 000
-$10 000
$0
$10 000
$20 000
-2 -1 0 1 2
$50,000 per QALY
84.7% below
∆ Cost = $5081
∆ QALY = 0.307
ICER = $16,537/QALY
∆ QALYs (CABG-PCI)
∆Long-termcost
(CABG-PCI)
 Cost
 QALY
 Cost
 QALY
 Cost
 QALY
 Cost
 QALY
SYNTAX Cost-effectiveness
∆ Cost = $3350
∆ QALY = 0.68
ICER = $4,905/QALY
$50,000 per QALY
94.3% below
3VD
cohort

30. Multivessel
disease (MVD)
CABG
Diabetics with
MVD
FREEDOM
Left main
disease
SYNTAX
Decision-
making and
assessing riskHeart Team

31. PCI/CABG ratios worldwide
Country PCI/CABG CABG : PCI (per 100,000 of population)
Mexico
New Zealand
Canada
United Kingdom
Ireland
Australia
Denmark
Portugal
Luxembourg
Finland
Netherlands
Norway
Sweden
Belgium
OECD
Czech Republic
Iceland
Switzerland
Poland
Germany
Hungary
United States
Italy
France
Spain
200 100 0 100 200 300 400 500 600
0.67 ???
1.40
1.87
2.03
2.15
2.19
2.24
2.33
2.34
2.37
2.41
3.09
3.20
3.21
3.29
3.36
3.56
3.67
3.80
4.18
4.30
5.17
5.26
5.98
8.63
Head SJ et al. Eur Heart J 2013;94:1954-60

32. Evidence based myocardial revascularization
CABG is clearly superior to Medical Management
SYNTAX trial shows superior survival with CABG over first-
generation, paclitaxel-eluting stents for 3VD
Guidelines favours CABG for complex MV disease
Differences between PCI and CABG appear particularly
with higher degree of incomplete revascularization

33. Evidence based myocardial revascularization
Surgery, since the beggining showed better results when
patients had an LV dysfunction
PCI is an alternative to CABG for low SYNTAX score, but
still more repeat revascularizations are required
CABG is economically attractive

34. Conclusions to take home
1
• In 2015, CABG turned 50 years old…Many, many patients benefited.
2
• SYNTAX trial and others show superior survival with CABG over first-
generation stents for 3VD
3
• Differences between PCI and CABG appear particularly with higher
degree of incomplete revascularization
6
• CAD patients with poor LV function or HF are better treated by
surgery, but Heart Team assessment is, in 2015, mandatory
4
• CABG is superior to PCI in diabetic patients, irrespective of insulin
dependence
5
• PCI provides similar outcomes as CABG 3VD patients with low or
intermediate SYNTAX scores

35. Thanks to Dr. Stuart Head for some few slides and apologies
on behalf of Dr. David Taggart