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Myocardial Revascularization East vs West “ Lecture in Memory of Prof. Zhu Guoying ”

Myocardial Revascularization East vs West “ Lecture in Memory of Prof. Zhu Guoying ”. Prof. Yean L. Lim AM 8 th SWCC, Chengdu 5 July 2014. Coronary Revascularization East versus West. PCI versus CABG : differences between the East and West

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Myocardial Revascularization East vs West “ Lecture in Memory of Prof. Zhu Guoying ”

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  1. Myocardial Revascularization East vs West “Lecture in Memory of Prof. Zhu Guoying” Prof. Yean L. Lim AM 8th SWCC, Chengdu 5 July 2014

  2. Coronary Revascularization East versus West • PCI versus CABG : differences between the East and West • Alternative strategy to achieve Complete Revascularization in stable MVD patients • Evidence needed for daily practice and potential contribution to CAD therapy from the East

  3. Decline in Revasc Rates in Mass. USAYeh RW et al, ACC 2014 • Between April 2003 to Sep 2012; rate per 100k pop. 20032012 All Revascularization 423 258 Mortality 2.4% 1.9% PCI 317 199 Elective PCI 200 101 STEMI PCI 117 98 30d Mortality 2.0% 2.0% CABG 106 59 30d Mortality 3.4% 1.6%

  4. 質与量並增

  5. Differences in Coronary Revascularization between the East and the West • Comprehensive PCI services without on-site CABG surgical services in most Eastern hospitals • Ratio of PCI to CABG, when CABG, ranging from 3:1 to zero CABG in Eastern hospitals with CABG surgery • Preference for PCI in the East due to socio-economic and cultural factors

  6. Difference in Procedural risks between PCI & CABG Revascularization • Risk of PCI is related more to Lesion factors (complexity) • Risk of CABG is related to PatientFactors(co-morbidities) • Risk of PCI is related to single operator’s skill level • Overall risk of CABG is dependent on the entire treating team (surgeon, anesthetist & ICU staff)

  7. 中國冠脤介入死亡率

  8. Higher Death & MI rates for DES compared to CABG for MVD (Fu Wai Hospital) • Between 1/4/2003-31/12/2005 • 3720 consecutive pts with MVD, CABG (1886), DES (1834) • Higher Death rate in DES (HR 1.62, 95% 1.07-2.47) • Higher MI rate in DES (HR 1.65; 95% 1.15-2.44) • Similar Stroke rate in both (HR 0.92; 95% 0.69-1.51) Li Y et al, Circulation 2009; 119:2040-50

  9. 北京阜外醫院心外科縂數及死亡率 • 2008; 7607 cardiac surgery performed at Fu Wai Hospital, Beijing (Congenital 48.3%;CABG 23.3% >50% off-pump; VHD 19.5%,others 8.9%, 38 transplants) • Total Mortality 1.2%

  10. 中國心外科血運重建死亡率 (2008) • Hu S et al, CircCardiovascQual Outcomes 2012: 5(2):214-21 • 43 hospitals, 8739pts, Age 62.2, 78% M) • 1/1/2007-31/12/2008 • Risk standardized in-hosp. all-cause mortality (RSMR) • Risk standardized major complication rate (RSMCR) • Overall RSMR 2.2%; RSMCR 6.6% • RSMR & RSMCR Eastern region: 1.6% & 5.8% • RSMR & RSMCR Crntral region: 2.5 & 7.7%

  11. 東西方冠脈介入血運重選擇與策略的差異 CV Interventions Intercontinental Crossfire EuroPCR 2011

  12. Complete Coronary Revascularization by PCI (Eastern Practice with limited CABG Expertise) Live Transmission from Fu Wai Hospital Beijing to EuroPCR 2011 Courtesy of Prof. Yang Yuejin

  13. Live Transmission from Fu Wai Hospital Beijing, China to EuroPCR 2011 Final Result

  14. “Co-evolution” rather than Crossfire between East & West “Mr. Kissinger insists that the common interests the two (east & west) share should make possible a “co-evolution”……creating a Pacific Community, comparable to the Atlantic Community. …...All Asian nations would then participate in a system perceived as a joint endeavor rather than a contest of rival (east & west) blocs. Maxwell Frankel, Herald Tribune 14-15 May 2001 Except from Book review “On China by Henry Kissinger”

  15. “Co-Evolution” between East & West PCIs Synergy of PCI between West & East: Strengths of the West 1 Good Clinical & Surgical Expertise 2 Great Educational Programs (TCT-AP, CIT-TCT, EuroPCR- AP) 3 Good GCP & Database 4 Good GMP Strengths in the East 1 Bench research 2 Large patient pool for clinical trials 3 Better skills in complex & high risk intervention 4 Cheaper cost SYNERGY (Hexagon) Area

  16. Coronary Revascularization East versus West • PCI versus CABG : differences between the East and West • Alternative strategy to achieve Complete Revascularization in stable MVD patients • Evidence needed for daily practice and potential contribution to CAD therapy from the East

  17. Is it Reasonable to achieve Incomplete Revascularization by Functional Angioplasty ? “We Are Moving to Functional Angioplasty Functional Angioplasty is achieved by integrated use of FFR and IVUS in Complex PCI for Multi-vessel Coronary Artery Disease” Park SJ, Circulation. 2011 Aug 23;124(8):951-7.

  18. Function Physiology Anatomy • Non-viable myocardium • < 5% residual ischemic area, • Small ischemic area • FFR > 0.80 • Very small vessels • Jailed asymptomatic side branch • Not culprit artery “Incomplete Revascularization” according to Physiologic, Functional & Anatomic Criteria Park SJ, Circulation. 2011 Aug 23;124(8):951-7.

  19. Routine FFR at Asan Medical Centrereduces both CABG and PCI rates • FFR usage 2008-2011 (1.9% to 50.7%) • 1267 ptswith FFR, 475 (37.5%) PCI deferred • 2178 pts, FFR-guided PCI resulted in reduction of Primary endpoint (Peri-procedural MI, TVR) by 45% (HR 0.55,p<0.001) Park SJ et al, TCT-AP 2014

  20. Impact of Incomplete Revascularization in the LIMA to LAD Grafting Era 5 yr Survival from 8806 pts 93.0±0.3% 88.3±0.4% 82.2±0.5% 93.6±0.8% 87.0±1.3% 80.9±1.8% P=0.457 CR 7870 6617 5762 4772 3729 2748 1653 693 IR 936 740 621 491 307 199 104 38 Circulation 2009;120[suppl 1]:S70-S77

  21. MACCE

  22. Long-term Outcome of CR vs IR by DES-PCI in Patients with MVD • Fu WaiHosp, Apr 2004-Nov 2010; 7065 MVD pts, • 1188 CR (AngioCR =Complete Revasc. PCI of all lesions in major CA + SB>2.5mm.; Prox. CR= PCI of all prox. Lesions in maj. CA) • 2053 IR (Angio. Or Prox. IR Not all lesions in MV or SB treated by PCI) • Results: Angio. CR/IR HR 2.56 (95% 1.03-6.41) Prox. CR/IR HR 1.72 (95% 0.93-3.17) >2VD subset: Angio CR/IR HR 4.25 (95% 1.5-12.1) Prox. CR/IR HR 3.02 (95% 1.4-5.2) • Conclusion: Pts with MVD treated by PCI, Cardiac death rate at 3 yr better in Complete compared to incomplete revasc.

  23. P<0.001 P=0.294 P<0.001 P<0.001

  24. Coronary Revascularization East versus West • PCI versus CABG : differences between the East and West • Alternative strategy to achieve Complete Revascularization in stable MVD patients • Evidence needed for daily practice and potential contribution to CAD therapy from the East

  25. 2014 Medical Decision Making for MVD RevascularizationSingle case (SELF) study • Evidence-based Practice RCTs>Registry Database>Observational • “Real World” Practice ( Patients) • “Real Life” Practice ( If you are the patient, what would you have done? )

  26. PCI for all CAD ( Stable and ACS ) with MVD Personal Belief & Practice: Staged PCI to achieve CR 1 PCI only the “Culprit Lesion” precipitating that episode illness in both ACS and SAP 2 After PCI of “culprit” lesion in ACS with MVD, revascularizion of non-culprit lesions is needed only when : (a) symptomatic (b) Functionally ischemic (evidence of significant reversible ischemia present or FFR (<0.80) at time of PCI

  27. 冠脈血運重建之我見

  28. 1 stent to 3 Vessel Disease (NOT 3 stents to 1VD) Pre-PCI Post-PCI 1 DES3.0x15 to LAD FFR 0.92

  29. 3yr later : Stable Mild Angina treated by Staged PCI 12/2/2014 Symptomatic chest Discomfort Repeat Cor Angio: patent LAD stent and normal DD1 ostium; progression of RCA lesion PCI performed without prior FFR to RCA lesion. 3 stents (3.0x 18, overlapping a (3.0x15) as Well as a proximal Amplatz guide dissection with (3.0x8) stent. OK to treat 1 vessel disease with 3 stents IF & WHEN necessary !

  30. Complete Coronary Revascularization in East & West- Current Status • Higher TVR rate for PCI is well accepted by patients • Success & in-hospital mortality rate of CABG for all comers is better in the West • Currently complete coronary revascularization is more likely to be achieved by PCI in the East than the West • However, long-term non-inferiority results of PCI revascularization practice in the East is lacking • Is eventual complete multiple staged PCI non-inferior to single CABG surgery ?

  31. Personal observations of variation in Complete Coronary Revascularization : East & West • PCI: Similar success and complication rate in both East & West (Mortality 0.26%, Europe 0.8%) • PCI: Technical success rate for Complex PCI (CTO) higher in the East compared to the West • CABG: Success rate higher and complications lower in the West compared to East

  32. Hypothesis: “CR by Eastern PCI (staged or otherwise) is non-inferior to CR by Western CABG surgery for all CAD patients” RCT needed to compare E vs W CR Inclusion: All CAD pts (by SS/FSS) Therapy: Best-practice Functional PCI in selected PCI centers in the East Inclusion: All CAD pts (by SS/FSS) Therapy: Best-practice CABG in selected centers in the West vs Primary End-point: All-cause Mortality & Composite MACCE for In-hospital, 30d & yearly follow-up for 5 yr

  33. Conclusions • PCI rates are decreasing in the west (US 0.5-1.3/1000) but increasing in the east (China 0.03/1000) • Complete coronary revascularized is being achieved by PCI more in the east than the west. However, evidence for this practice is lacking • Functional staged incomplete PCI revascularization to treat stable MVD patients is reasonable, again good evidence is needed for such practice in both east and west

  34. 謝謝朱國英教授,我們的良師益友!

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