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

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slide1

Multi-vessel disease…

Le Mans implications

Oxford

The John Radcliffe Hospital

Dr Adrian Banning

multi vessel disease le mans implications
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
Why is the Left Main important?

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

why is the left main special
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
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
stent the lms with bms safe but high rate of mace due to restenosis
Stent the LMS with BMS safe, but high rate of MACE due to restenosis

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

slide8

A Randomized Comparison of Paclitaxel-ElutingStents Versus Bare-Metal Stents for Treatmentof Unprotected Left Main Coronary Artery Stenosis

  • 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 52/53

Final 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

Erglis et al JACC 2007

slide9

A Randomized Comparison of Paclitaxel-ElutingStents Versus Bare-Metal Stents for Treatmentof Unprotected Left Main Coronary Artery Stenosis

Erglis et al JACC 2007

slide10

A Randomized Comparison of Paclitaxel-ElutingStents Versus Bare-Metal Stents for Treatmentof Unprotected Left Main Coronary Artery Stenosis

Erglis et al JACC 2007

slide11

A Randomized Comparison of Paclitaxel-ElutingStents Versus Bare-Metal Stents for Treatmentof Unprotected Left Main Coronary Artery Stenosis

Erglis et al JACC 2007

slide12

A Randomized Comparison of Paclitaxel-ElutingStents Versus Bare-Metal Stents for Treatmentof Unprotected Left Main Coronary Artery Stenosis

Erglis et al JACC 2007

location matters
Location matters

Ostium

Distal- bifurcation

Shaft

what makes the left main special
What makes the left main special?
  • Anatomy matters
    • Ostial Needs 1 stent
    • Body Needs 1 stent
    • Bifurcation Usually >1 stent, 2 wires, >6F
long term outcome after des in nonbifurcation lesions that involve unprotected lms
Long-Term Outcome After DES in Nonbifurcation Lesions that involve Unprotected LMS
  • 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).

Chieffo et al Circulation 2007

slide17
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).
  • Clinicalfollow-up: at 1, 6, 12, and 24 months.
  • Patients eligible for longer clinical follow-up were contacted at 36 and 48 months.
  • Angiofollow-up: 4 and 9 months or earlier if neccesary
  • Total follow up mean 886 days

Chieffo et al Circulation 2007

slide18
Favorable Long-Term Outcome After Drug-Eluting Stent Implantation in Nonbifurcation Lesions That Involve Unprotected Left Main Coronary

Chieffo et al Circulation 2007

slide19
Favorable Long-Term Outcome After Drug-Eluting Stent Implantation in Nonbifurcation Lesions That Involve Unprotected Left Main Coronary

Chieffo et al Circulation 2007

slide20
Favorable Long-Term Outcome After Drug-Eluting Stent Implantation in Nonbifurcation Lesions That Involve Unprotected Left Main Coronary

Chieffo et al Circulation 2007

slide21
Favorable Long-Term Outcome After Drug-Eluting Stent Implantation in Nonbifurcation Lesions That Involve Unprotected Left Main Coronary

Chieffo et al Circulation 2007

slide22
Favorable Long-Term Outcome After Drug-Eluting Stent Implantation in Nonbifurcation Lesions That Involve Unprotected Left Main Coronary

No proven late stent thrombosis

4 unexpected deaths

Chieffo et al Circulation 2007

slide23
Favorable Long-Term Outcome After Drug-Eluting Stent Implantation in Nonbifurcation Lesions That Involve Unprotected Left Main Coronary

Chieffo et al Circulation 2007

what about late stent thrombosis in lms disease
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
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 200826
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.
slide27

358 consecutive patients

7 centres

All DES

slide28

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

unprotected left main stenting vs cabg seung et al nejm april 2008
Unprotected left main stenting vs CABGSeung 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

slide33

PCI technique

Direct 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

slide36

Improved EF with PCIETT similar by 12 months

more angina PCI initially

Lemans trial 2008

syntax eligible patients
SYNTAX Eligible Patients

De novo disease

  • Limited Exclusion Criteria
  • Previous interventions
  • Acute MI with CPK>2x
  • Concomitant cardiac surgery

Left Main Disease

(isolated, +1, +2 or +3 vessels)

3 Vessel Disease

(revasc all 3 vascular territories)

syntax lemans reports pcr 09
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%
slide40

CABG

TAXUS

Left Main Isolated

Left Main + 3VD

N=91

(13%)

Left Main + 1VD

N=258

(37%)

N=138

(20%)

Left Main + 2VD

N=218

(31%)

12 Month LM Subgroup MACCE Rates

Patients (%)

All LMN=705

slide41

CABG

TAXUS

12 Month Subgroup MACCE Rates

Patients (%)

3VD (All)

N=1095

LM+3VD

N=258

All LMN=705

LM isolatedN=91

LM+1VDN=138

LM+2VDN=218

so why is the left main special
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
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
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 200845
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