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CABG is, today, the best option in most multivessel coronary artery disease patients
José L. Pomar, MD, PhDProfessor of Surgery
Hospital Clinic and University of BarcelonaBarcelona, Spain
Vasilii I Kolesov (1904 –1992)Military surgeon in St. PeterburgLITA to marginal branch of LCX on 25 February 1964
Michael E DeBakey (1908-2008)SVG to the LAD on 23 November 1964Garrett HE et al. JAMA 1973;223:792-4
René G Favaloro (1923-2000)SVG to the RCA on 9 May 1967J Thorac Cardiovasc Surg 1969;58:178-85
Mason Sones, smoking and serendipity
1967 Cleveland Clinic
Evidence based myocardial revascularizationHead SJ & Davierwala PM et al. Eur Heart J 2014; online
Coronary Artery Bypass Graft Trialist Cooperation Yusuf et al. Lancet 1994;344:563-72
Time from randomization (years)
Mor
talit
y (%
)
N = 1325
Medical treatmentCABG
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
CABG VS MEDICAL TREATMENTCoronary Artery Bypass Graft Trialist Cooperation
(Individual Data from 7 Randomized Trials)
Yusuf S et al. Lancet 1994;344:563-72
CABG vs MM0.00
20.0040.0060.0080.00
100.00120.00
1VD / 2VD 3VD LM
CABG vs MM0.00
20.0040.0060.0080.00
100.00120.00
CABG vs MM0.00
20.0040.0060.0080.00
100.00120.00P=0.25 P=0.001 P=0.005
Interaction P = 0.02
Mea
n su
rviv
al (m
onth
s)
CABG VS MEDICAL TREATMENTNetwork 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)DeathCABG vs MM
MICABG vs MM
Death or MICABG vs MM
Revasc.CABG vs MM
SES
0.1 0.3 1 3Favours CABG Favours MMWindecker 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)
RCTs on revascularization
Head SJ & Davierwala PM et al. Eur Heart J 2014; online
Hlatky M et al. Lancet 2009;373:1190-97
CABG VS PTCA/BAREMETALSTENTSPooled analysis of 10 RCTs with 7812 patients
(ARTS, BARI, CABRI, EAST, ERACI-II, GABI, MASS-II, RITA, SoS, FMS)
PTCA/BMSCABG
Mor
talit
y (%
)
10.0%8.4%N = 3923
N = 3889
Follow-up (years)
HR 0.92 [0.80-1.02]
P=0.121VD or 2VD
0.91 [0.78-1.06]
3VD0.91 [0.77-1.09]
RCTs on revascularization
Head SJ & Davierwala PM et al. Eur Heart J 2014; online
2014 ESC/EACTS Guidelines
TAXUS (N=546)CABG (N=549)
SYNTAX 3VD cohortAll-cause death to 5 years
ITT populationCumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates
0Months Since AllocationCu
mul
ativ
e Ev
ent R
ate
(%)
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%
0Months Since AllocationCu
mul
ativ
e Ev
ent R
ate
(%)
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 cohortMyocardial infarction to 5 years
P<0.001
3.3%10.6%
TAXUS (N=546)CABG (N=549)
ITT populationCumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates
0Months Since AllocationCu
mul
ativ
e Ev
ent R
ate
(%)
25
50Before 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 cohortDeath/Stroke/MI to 5 years
P<0.001
14.0%
22.0%
TAXUS (N=546)CABG (N=549)
ITT population
TAXUS (N=546)CABG (N=549)
Cumulative KM Event Rate ± 1.5 SE; log-rank P value;*Binary rates
0Months Since AllocationCu
mul
ativ
e Ev
ent R
ate
(%)
25
50Before 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 cohortMACCE to 5 years
P<0.001
24.2%
37.5%
SYNTAX 3VD CohortMultivariate cox regression: PCI vs CABG
HR (95% CI)
MACCE
Death/stroke/MIDeath
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)
FavoursPCI
FavoursCABG
SYNTAX 3VD cohortSYNTAX score terciles
Death
Myocardialinfarction
Stroke
Repeat Revasc.
TAXUS (N=546)CABG (N=549)
SYNTAX 3VD cohortSYNTAX score terciles
Head SJ & Davierwala PM et al. Eur Heart J 2014; online
TAXUS (N=546)CABG (N=549)
Death/stroke/MIMACCE
CABG PCI
SYNTAX 3VD cohortCompleteness revascularization
Incomplete revasc.Complete revasc.P = 0.010
P = 0.17
MA
CC
E (%
)Head SJ & Davierwala PM et al. Eur Heart J 2014; online
Completness revascularization
PCIN=63,945
CABGN=25,938
Incomplete revasc.Complete revasc.
75%
44%56%
25%
SXS<23
SXS23-32
SXS>32
Patients (%)0 10 20 30 40 50 60 70
CompleteResid SXS 0-4Resid SXS 4-8Resid SXS >8
Farooq V et al. Circulation 2013;128:141-51Garcia S et al. JACC 2013;62:1421-31
SYNTAX PCI cohortResidual SYNTAX score
Resid SXS 0-4Resid SXS 4-8Resid SXS >8
Haz
ard
ratio
(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
SYNTAX 3VD CohortDiabetic patients
0.3 1 3 10Hazard 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
FREEDOM TrialSimilar results as SYNTAX
Dea
th/S
trok
e/M
I (%
)
Follow-up (years)D
eath
/(%)
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
SYNTAX II ScoreRisk score predicting 4-year mortality
84.2%Favours CABG
15.8%Favours PCI
Annual Cumulative
SYNTAX TrialEconomics
Cohen DJ & Osnabrugge RL, et al. Circulation 2014; online
Δ cost = $10,036
Δ cost = $5619
-$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)
∆ L
ong-
term
cost
(C
ABG
-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
3VDcohort
Multivessel disease (MVD)
CABG
Diabetics with MVD
FREEDOM
Left main disease
SYNTAX
Decision-making and
assessing riskHeart Team
PCI/CABG ratios worldwideCountry PCI/CABG CABG : PCI (per 100,000 of population)
MexicoNew ZealandCanadaUnited KingdomIrelandAustraliaDenmarkPortugalLuxembourgFinlandNetherlandsNorwaySwedenBelgiumOECDCzech RepublicIcelandSwitzerlandPolandGermanyHungaryUnited StatesItalyFranceSpain
200 100 0 100 200 300 400 500 600
0.67 ???1.401.872.032.152.192.242.332.342.372.413.093.203.213.293.363.563.673.804.184.305.175.265.988.63
Head SJ et al. Eur Heart J 2013;94:1954-60
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
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
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
Thanks to Dr. Stuart Head for some few slides and apologieson behalf of Dr. David Taggart