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If CABG is Superior to PCI

If CABG is Superior to PCI. Where are all the Cases ?. APPROACH. Overview Heart Team concept Review of multivessel revascularization The road ahead. Isolated CABG Volume. Thousands. CABG vs PCI Volume. Thousands. APPROACH. Overview Heart Team concept

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If CABG is Superior to PCI

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  1. If CABG is Superior to PCI Where are all the Cases ?

  2. APPROACH • Overview • Heart Team concept • Review of multivessel revascularization • The road ahead

  3. Isolated CABG Volume Thousands

  4. CABG vs PCI Volume Thousands

  5. APPROACH • Overview • Heart Team concept • Review of multivessel revascularization • The road ahead

  6. Cardiology Cardiac Surgery Assessment of risk : Imaging Assessment of risk : Clinical Risk factor evaluation Assessment of severity Associated medical problems Procedural performance Patient education Immediate postoperative care Follow-up care Management of recovery

  7. Cardiology and Cardiac Surgery Assessment of risk Assessment of benefit Patient education Rx recommendation Follow-up care

  8. APPROACH • Overview • Heart Team concept • Review of multivessel revascularization • The road ahead

  9. RCT vsObservational Study RCTObservational • Randomization • Select population • Small N • Time-intensive • Expensive • Non-randomized • Broad population • Large N • Efficient • Low cost

  10. SYNTAX5-year Results

  11. SYNTAX5-year Survival for 3-vessel Disease

  12. Impact of SYNTAX

  13. Lancet 2009;373:1190-97

  14. Conclusion: Multivessel CABG is associated with lower long-term mortality than multivessel PCI in the community setting.

  15. FREEDOM Diabetic Population

  16. FREEDOM Diabetic Population PCI CABG Years

  17. FREEDOM Diabetic Population

  18. FREEDOM Diabetic Population

  19. ASCERT Diabetic Population Survival %Survival RR= 0.70 Years

  20. ASCERT Population ACC STS CMS MedPAR Patients N =208,537 N =393,696

  21. ASCERT Population 189,793 Total

  22. Forest Plot

  23. ASCERT Survival Survival advantage = 21% RR = .79 CABG survival PCI days

  24. N Engl J Med 2012;366:1467-76

  25. ASCERT RR = .85 RR = .75

  26. ASCERT RR = .81 RR = .76

  27. ASCERT RR = .81 RR = .78 RR = .72

  28. ASCERT RR = .72

  29. ASCERT RR = .74

  30. Percent Survival Advantage

  31. Circulation 2005, 112:I371-I376

  32. Circulation 2005, 112:I371-I376

  33. Ann ThoracSurg 2011;92:2132-9

  34. Ann ThoracSurg 2011;92:2132-9

  35. Percent Survival Advantage

  36. SURVIVAL ADVANTAGECABG compared to PCI

  37. Composite in ASCERT RR = .81 Event-free advantage = 19% CABG Event-free PCI days

  38. MI in ASCERT CABG MI-free PCI RR = .49 MI-free advantage = 51% days

  39. Stroke in ASCERT PCI Stroke-free CABG RR = 1.43 Stroke-free advantage = 43% days

  40. Stroke Rates % 5 5 5 1 4

  41. Periprocedural Stroke Rate

  42. A Call to Action

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