Le# Main Interven-on: When Is It Appropriate Femi Philip, MD Assistant Professor Of Medicine UC Davis Disclosures Nil Outline •  What is the LMCA? •  Should we revascularize severe LMCA disease? •  What revascularizaCon strategy? •  What are the guideline recommendaCons? •  Conclusion LMCA LMCA •  Defined as a stenosis of ≥ 50 % •  LM equivalent: osCal LAD and LCX involvement •  IVUS measurement MLA < 6.0 mm2 LMCA: Heterogeneity in the SYNTAX Study LM n=91 (13%) LM + 3 V n=258 (37%) LM + 1 V n=138 (20%) LM + 2 V n=218 (31%) Morice MC et al CirculaCon 2010; 121:2645 30
0
LMCA
MV
Plaque burden
60
Calcium length/m
Arc of calcium (d
0.5
0.4
0.3
0.2
50
40
30
20
LMCA: Plaque distribuCon LMCA LMCA LAD/D1 LAD/D1 LAD/D1
MB
SB
MV
MB
SB
Maximal arc of calcium
0.1
0
LMCA
MV
10
0
LMCA LMCA LAD/D1 LAD/D1 LAD/D1
MB
SB
MV
MB
SB
Calcium length index
LMCA
MV
LMCA LMCA LAD/D1 LAD/D1 LAD/D1
MB
SB
MV
MB
SB
Volumetric plaque burden
Figure 2. Maximal arc of calcium (A), calcium length index (B), and volumetric plaque burden (C) showing that the side branch had less
calcium and plaque burden in both groups.
58 LAD/D1 bifurcaCons compared with 81 LMCA bifurcaCons 1/1,1,1
MV (1/1)
MB (1)
1/0,1,1
MV (1/0)
SB (1) MB (1)
1/0,1,0
MV (1/0)
SB (1) MB (1)
0/1,1,1
MV (0/1)
SB (0) MB (1)
0/0,1,0
MV (0/0)
SB (1) MB (1)
0/0,1,1
MV (0/0)
SB (0) MB (1)
0/1,0,1
MV (0/1)
SB (1) MB (0)
LMCA
(n=81)
60(74%)
10 (12%)
8 (10%)
3 (4%)
0 (0%)
0 (0%)
0 (0%)
LAD/D1
(n=58)
42 (72%)
5 (9%)
5 (9%)
0 (0%)
3 (5%)
2 (3%)
1 (2%)
SB (1)
>90% of LMCA bifurcaCons had plaque extending from LMCA into the LAD, with 78% extension into the LCX (and LCX had less plaque and calcium) Figure 3. Spatial distribution of the plaque in LMCA and LAD/D1 bifurcation lesion locations indicating continuous plaque from the MV to MB
in >90% of lesions in both groups.
Yakushiji EurointervenCon 2013 LM PCI Subset of SYNTAX Study Aorto-ostial n=79 (22%)
Mid-shaft n=49 (15%)
Syntax score could range from 11-­‐37 Distal* n=229 (64%)
Morice MC et al CirculaCon 2010; 121:2645. LMCA: Vessel Involvement According SYNTAX score 100%#
90%#
80%#
5#
18#
25#
70%#
60%#
50%#
71#
42#
67#
40%#
30%#
20%#
10%#
35#
27#
8#
0%#
Low#Syntax#
LM#+#3VD#
LM#+#2VD#
LM#+#1VD#
LM#isolated#
Intermediate#Syntax#
2#
High#Syntax#
Morice MC et al CirculaCon 2010; 121:2645. F segments, cross sections were analyzed as previously
scribed (13). Strut-level intimal thickness (SIT) was
termined based on automated measurements performed
om the center of the luminal surface of each strut blooming
d its distance to the lumen contour (11). Struts covered by
sue had positive SIT values, whereas uncovered or
as 9-month follow-up FD-OCT surrogates for vessel healing response (i.e., stent strut coverage, neointimal hyperplasia [NIH], malapposition).
In order to assess the impact of stent strut malapposition
after PCI (acute stent strut malapposition) in DES-vessel
interactions at 9-month follow-up, FD-OCT pullbacks
LMCA: Conical Shape by FD-­‐OCT igure 1. Representative FD-OCT Image and Schema
Fujino et al, JACC CV Intv 2013 nprotected left main was divided into 3 segments for the purpose of frequency-domain optical coherence tomography (FD-OCT) analyses, as follows: 1) ostial-body
BODY); 2) bifurcation (BIF); 3) distal (DIS). Brown line represents OCT catheter. LCX ¼ left circumflex.
LMCA: Atheroma Figure 1. Cross-sectional tomographic
image of a coronary artery obtained at
IVUS pullback (left panel). Plaque area
(yellow) is depicted as the area
between the leading edges of the EEM
and lumen (right panel).
Parameter LMCA Epicardial P Value Plaque Atheroma Volume 30.7 ± 8.8 37.1 ± 9.0 <0.001 Avg EEM (mm2) 21.4 ± 5.1 13.2 ± 4.0 <0.001 Avg lumen area (mm2) 14.9 ± 4.0 8.2 ± 2.6 <0.001 PAV -­‐0.39 ± 0.1 +0.37 ± 0.1 <0.001 Avg EEM (mm2) -­‐0.03 ± 0.1 -­‐0.44 ± 0.1 <0.001 Avg lumen area (mm2) +0.09 ± 0.1 -­‐0.38±0.1 <0.001 Baseline Change Figure 2. Representative crosssectional IVUS images demonstrating
plaque progression (top panels) and
regression (bottom panels) at matched
sites that were studied at baseline (left
panels) and follow-up (right panels).
340 pts with LMCA of ≥5 mm and serial IVUS in 7 trials of anC-­‐
atheroscleroCc therapies initially preserve lumen dimensions. It is therefore
possible for the arterial wall to harbor a substantial
Puri et al, JACC CV Intv 2013 IVUS has identified the presence of multiple ruptured
plaques within the coronary arteries in patients with a
25,26
Should we revascularize LMCA disease ? Network Meta-­‐Analysis of LMCA RevascularizaCon •
•
12 studies (4 RCT’s, 4 observaConal matched studies and 4 cohort studies) comparing CABG with PCI ( n=4574) 7 studies (2 RCT’s and 5 observaConal studies) comparing CABG with MT ( n=3224) Biol JA. CirculaCon. 2013;127:2177–2185 How should we revascularize LMCA disease? CCABG it is ! HELP! What should I do? PCI it is ! We can do it from the wrist LMCA: RCT PCI vs. CABG Trial Pa-ent profile F/P Groups Mortality No. (%) P-­‐value TVR No, (%) P-­‐value MACCE No, (%) P-­‐value LE MANS >50% LM with or without MVCAD 1 CABG (n-­‐53) DES/BMS (n=52) 4 (7.5) 1 (1.9) 0.37 5 (9.4) 15 (28.8) 0.01 13 (24.5) 16 (30.8) 0.29 PRECOMBAT >50% LM stable angina or NSTEMI 2 CABG (n-­‐300) Sirolimus (n=300) 10 (3.4) 7 (2.4) 0.45 12 (4.2) 26 (9.0) 0.02 36 (12.2) 14 (13.9) 0.12 Boudriot >50% LM with or without MVCAD 1 CABG (n=101) Sirolimus (n=100) 5 (5.0) 2 (2.0) 0.01 6 (5.9) 14 (14) 0.35 14 (13.9) 19 (19.0) 0.19 SYNTAX >50% LM with 1,2, or 3 vessel disease 1 CABG (n=348) Paclitaxel (n=357) 4.4 4.2 0.88 6.5 11.8 0.02 46 (13.7) 56 (15.8) 0.44 Cumulative Event Rate (%)
MACCE up to 5 years by low/
intermediate SYNTAX score (0-­‐32) Death CVA MI Death, CVA or MI Revasc. CABG 15.1% 3.9% 3.8% 19.8% 18.6% PCI P value 7.9% 0.02 1.4% 0.11 6.1% 0.33 14.8% 0.16 22.6% 0.36 Months Since Allocation
Morice MC. Circulation 2014; 129:2388
MACCE up to 5 years by high SYNTAX score (>33) Death CVA MI Death, CVA or MI Revasc. CABG 14.1% 4.9% 6.1% PCI P value 20.9% 0.11 22.1% 11.6% 1.6% 0.13 11.7% 0.13 26.1% 0.40 34.1% <0.001 Morice MC. CirculaCon 2014; 129:2388. LMCA: PCI vs. CABG Trials NOBLE EXCEL N, sites 1200, 26 EU sites 1900, 126 sites DES Biomatrix (BES) Xience (EES) LM LocaCon OsCal, shar or bifurcaCon OsCal, shar or bifurcaCon LM Severity Angio DS > 50% or FFR < 0.80 Angio DS > 70% or 50%-­‐70% + either FFR < 0.80 or IVUS MLA < 6.0 mm2 or non-­‐
invasive evidence of extensive ischemia Other anatomic criteria < 3 addiConal non-­‐complex lesions Syntax < 32 Primary endpoint Death, CVA, MI or revasc D, CVA or MI Timing of primary EP 2 years 3 years Follow-­‐up 5 years 5 years Making Sense of the Guidelines ACCF/AHA Guidelines •  SIHD ( 2014 update) •  PCI (2011) •  CABG (2011) •  UAP/NSTEMI (2012 update) •  STEMI (2013, no LMCA) ESC Guidelines •  RevascularizaCon Guidelines (2014) •  SCAD (2013) Heart Team Approach to RevascularizaCon I IIa IIb III I IIa IIb III A Heart Team approach to revascularizaCon is recommended in paCents with unprotected ler main or complex CAD. CalculaCon of the STS and SYNTAX scores is reasonable in paCents with unprotected ler main and complex CAD. ESC Guidelines on SCAD 2013
Left main coronary artery with relevant stenosisa
±1 vessel disease
Ostium/mid shaft
High
surgical
risk b
+2 or 3 vessel disease
Distal bifurcation
Heart Team
Syntax score 32
Discussion®
PCI
Syntax score 33
Low
surgical
risk b
CABG
Montalescot G, et al Eur Heart J 2013 S Guidelines
2014 ESC/EACTS Guidelines on Myocardial RevascularizaCon
mendation for the
type of revascularization
(CABG or PCI) in patients with SCAD with
procedures and low predicted surgical mortality
Recommendations according to extent of CAD
CABG
PCI
Classa
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C
I
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I
A
I
A
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I
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I
C
I
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I
B
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I
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IIa
B
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I
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I
I
A
A
I
III
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B
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I
A
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B
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Three-vessel disease with a SYNTAX score
22.
107
oronary artery bypass grafting; LAD ¼ left anterior descending coronary artery; PCI ¼ percutaneous coronary intervention; S
commendation.
dence.
.
2014 ACC/AHA SIHD Guidelines: UPLM RevascularizaCon for Survival Class Of Recommendation
CABG
PCI
LOE
I
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of good long-term outcome (e.g., SYNTAX score of ≤22, ostial or
trunk left main CAD), and a signficantly increased CABG risk (e.g.,
STS-predicted risk of operative mortality ≥5%)
B
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intermediate to high likelihood of good long-term outcome (e.g.,
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prior cardiac surgery, STS-predicted operative mortality >2%)
B
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unfavorable anatomy for PCI and who are good candidates for CABG
B
AUC and MulC-­‐vessel RevascularizaCon Must have CCS > 2 or Int/high risk non-­‐invasive CABG
PCI
Two-vessel CAD with proximal LAD stenosis
A
A
Three-vessel CAD with low CAD burden (i.e., three focal
stenosis, low SYNTAX score)
A
A
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(i.e., multiple diffuse lesions, presence of CTO, or high
SYNTAX score)
A
U
Isolated left main stenosis
A
U
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burden (i.e., one to two vessel additional involvement,
low SYNTAX score)
A
U
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to high CAD burden (i.e., three vessel involvement,
presence of CTO, or high SYNTAX score)
A
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What about LMCA in ACS ? LMCA RevascularizaCon in ACS I IIa IIb III I IIa IIb III PCI to improve survival is reasonable in patients with UA/
NSTEMI when an unprotected left main coronary artery is
the culprit lesion and the patient is not a candidate for
CABG.
PCI to improve survival is reasonable in patients with acute
STEMI when an unprotected left main coronary artery is the
culprit lesion, distal coronary flow is less than TIMI grade 3,
and PCI can be performed more rapidly and safely than
CABG.
Conclusion •  LMCA disease is the only lesion subset for which revascularizaCon is unequivocally accepted as improving survival over medical therapy •  Heart Team approach •  CABG in the high SYNTAX score and/or DM paCent •  PCI is becoming more accepted as a primary treatment modality for LMCA disease –  Especially in paCents at higher surgical risk –  Especially with low-­‐intermediate SYNTAX score Thank you QuesCons ?