Who needs a PCI in 2008…. Multivessel disease

1. Who needs a PCI in 2008….Multivessel disease Dr Adrian Banning Consultant Cardiologist John Radcliffe Oxford

2. Dr Adrian Banning - potential conflicts of interest – 07-08 Research funding Boston Scientfic Cordis- J/J Advisory Boards Boston Scientific Elli Lilly Abbott Medtronic Conference expenses Sanofi

3. Who needs a PCI in 2008…Multivessel disease • Can we do it? • Can we do it as well as/better than the surgeons? • What are the issues? • When (in 2008) shouldn’t we do it?

4. Multivessel stenting is off label……. but…….

5. Necessity is the mother of in vention t e r

6. Can we do it ? 68 yrs old Stable angina Not diabetic Normal LV 3 vessel disease SYNTAX score 15

7. Of course we can do it..... • 33 x 3.0mm SES to LAD • KB to D1

8. Of course we can do it….but should we? 13 x 2.5mm SES to PDA 13 x 2.75 mm SES to LCX

9. Is there an evidence base for stenting in focal multivessel disease?

13. So we can do it – safely?

14. Can we get the same outcome as the surgeons? (sometimes)

15. But what about this one? 67 yrs old Stable Angina diabetic Normal LV 3 vessel disease SYNTAX score 41

16. 306 patients with 3 VD treated with PCI ARTS II trial Serruys PW, ACC 2006

17. Multi-vessel Disease & SES: All Patients 12 months follow-up - MACE Independently adjudicated events p <0.001 p <0.001 p <0.01 % Jilaihawi H, Gershlick A, et al, BCS May 2005

18. Stent thrombosis after MV stenting %

22. Syntax the Oxford experience 42 pts (5th world )

23. What if Syntax is favourable to stents?What are the issues – at the coal face?

24. The key issues • Complete revascularisation • Long stents - Procedural MI • Calcification – limiting stent expansion

25. Issues in MVD (1)Complete revascularisation? The evidence

26. Courage: the main study

30. Length is no longer important or is it?

31. Issues in MVD stenting (2) Long stent - Procedural MI Procedural enzyme elevation in Taxus VI

32. Background

33. Correlation of cTnI rise with new myocardial hyperenhancement 18 r= 0.78 p<0.001 n = 45 13 New Hyperenhancement (grams) 8 3 0 2 5 8 Troponin rise at 20 hrs (ųg/L)

34. “Adjacent” Hyperenhancement New HE-8.5g cTnI 4.8µg/L

35. Distal pattern caused by embolisation

36. Circulation 2007;116: 2634-53

37. Circulation 2007;116: 2634-53

38. 234 potentially relevant citations identified and screened for retrieval 204 citations excluded by title or abstract examination 30 reports retrieved for detailed evaluation 15 reports excluded because reviews, incomplete reporting, acute coronary syndromes included, raised baseline TnI included 15 studies finally included What does the new definition of AMI mean in practice? Inclusion criteria: 1) normal baseline Troponin, 2) scheduled procedure for stable or unstable angina 3) post procedure Troponin assessed, 4) complete reporting of procedural outcome and follow up data

39. Troponin level and MACE

40. Troponin level and death

41. Troponin elevation during PCI • 100 pts undergoing PCI • 28 some elevation of troponin • 15 diagnosis of MI • 5 MACE in the next 18 months

42. Troponin elevation during PCI • 100 pts undergoing PCI • 28 some elevation of troponin • 15 diagnosis of MI • 5 MACE in the next 18 months • Look after your side branches! • Theres not much we can do about embolisation

43. Issues in MVD (3) Calcification - limiting stent expansion • Incomplete expansion remains a major cause of stent thrombosis • Incomplete expansion of DES is a major cause of stenosis and therefore re-stenosis

45. If all this new technology is so great why don’t UK surgeons use it?

46. Graft occlusion in 2007…. at least stent thrombosis is <1%!

47. Patient with 3 vessel disease M-C Morice, PCR 2006 What is the periprocedural risk eg. Euroscore? What is the lesion complexity, e.g. Syntax score? Unacceptable Acceptable PCI with DES What is the patient’s clinical status? Stable Unstable Most complex lesion first? -e.g. CTO PCI of culprit lesion Contrast volume? Renal Status? Evaluation of other lesions Outcome? Failure Success Acceptable Surgery Complete revascularization Staged procedure

48. Multivessel PCI in 2008 If syntax shows equivalence- of course we can do it but to compete effectively with surgical revascularisation we must ensure complete revascularisation optimal stent expansion minimise myocardial injury

49. Multivessel PCI in 2008 If Syntax shows equivalence –remember: • complete revascularisation • optimal stent expansion • minimise myocardial injury This is HARD WORK and not easy for the patient or the interventionalist XXXX

50. 24 h post CABG 24 h post multivessel PCI Slide Acknowledgements K Dawkins P Urban L Testa & team at JR