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Multivessel PCI on top of culprit lesion revascularization?

Multivessel PCI on top of culprit lesion revascularization?. No way!. Major issues. How do you define complete revascularization in multivessel disease (MVD)? What is the risk-benefit balance of culprit vs multivessel PCI in stable MVD?

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Multivessel PCI on top of culprit lesion revascularization?

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  1. Multivessel PCI on top of culprit lesion revascularization? No way!

  2. Major issues • How do you define complete revascularization in multivessel disease (MVD)? • What is the risk-benefit balance of culprit vs multivessel PCI in stable MVD? • What is the risk-benefit balance of culprit vs multivessel PCI in acute MVD?

  3. Let us begin with an example from a related field…

  4. Is it safer to target one only?

  5. Is it safer to target one only?

  6. Or all of them at once?

  7. Major issues • How do you define complete revascularization in multivessel disease (MVD)? • What is the risk-benefit balance of culprit vs multivessel PCI in stable MVD? • What is the risk-benefit balance of culprit vs multivessel PCI in acute MVD?

  8. Defining revascularization • Anatomically complete: PCI of every occluded or stenotic epicardial vessel • Functionally complete: PCI of every occluded or stenotic epicardial vessel of adequate size and supplying a zone of viable myocardium • Incomplete (culprit only): PCI of occluded or stenotic epicardial vessel identified by clinical judgement as responsible for signs/symptoms of ischemia • Incomplete (truly): everything else

  9. Hazards of multivessel stenting

  10. Hazards of multivessel stenting

  11. Hazards of multivessel stenting Orlic et al, JACC 2004

  12. Major issues • How do you define complete revascularization in multivessel disease (MVD)? • What is the risk-benefit balance of culprit vs multivessel PCI in stable MVD? • What is the risk-benefit balance of culprit vs multivessel PCI in acute MVD?

  13. PCI based only on oculostenotic reflex is not justified in stable MVD

  14. Boden et al, NEJM 2007

  15. Boden et al, NEJM 2007

  16. Boden et al, NEJM 2007

  17. Boden et al, NEJM 2007

  18. Even symptomatic benefits are only marginal in unselected patients Boden et al, NEJM 2007

  19. Would you trust an hazard ratio of 1.15?

  20. Major issues • How do you define complete revascularization in multivessel disease (MVD)? • What is the risk-benefit balance of culprit vs multivessel PCI in stable MVD? • What is the risk-benefit balance of culprit vs multivessel PCI in acute MVD?

  21. PCI based only on oculostenotic reflex is also not justified in acute MVD Hirsch et al, Lancet 2007

  22. Hirsch et al, Lancet 2007

  23. Hirsch et al, Lancet 2007

  24. Hirsch et al, Lancet 2007

  25. Hirsch et al, Lancet 2007

  26. Multivessel PCI in acute MVD: incremental benefits or costs? Brener et al, Am J Cardiol 2002

  27. Brener et al, Am J Cardiol 2002

  28. Brener et al, Am J Cardiol 2002

  29. What about complete PCI in STEMI? Single vs multivessel treatment during primary angioplasty: results of the multicentre randomised HEpacoat for cuLPrit or multivessel stenting for Acute Myocardial Infarction (HELP AMI) Study.Di Mario C, Mara S, Flavio A, Imad S, Antonio M, Anna P, Emanuela P, Stefano DS,Angelo R, Stefania C, Anna F, Carmelo C, Antonio C, Monzini N, Bonardi MA. Int J Cardiovasc Intervent. 2004;6(3-4):128-33.

  30. 53 vs 69 minutes, p<0.05 22,330€ vs 20,382€, p=NS 35% vs 17% p=NS 0 vs 4%, p=NS Di Mario et al, Int J Cardiovasc Intervent 2004

  31. Take home messages • Current data disCOURAGE from extensive multivessel PCI based only on angiographic assessment in stable MVD • No definite benefits have been shown from multivessel PCI in patients with acute CAD and MVD (either STEMI or NSTEACS) • According to evidence available to date, PCI of non-culprit vessels can thus be recommended only is selected cases

  32. For further slides on these topics please feel free to visit the metcardio.org website:http://www.metcardio.org/slides.html

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