revascularization case based approach .pptx

Revascularization

1. Revascularization in CCS according to 2018 ESC revascularization Guidelines Ahmed Said Saad , M.D. Interventional Cardiologist Shebin ElKoum Teaching Hospital, Egypt

2. A 65yrs old, DM male patient with CCS, his EF is 30%, MPI showed 20% ischemia in LV area mainly at anterior and lateral walls. CAG showed: LM mid 60%, proximal 90% LAD, 90% proximal LCX, CTO mid RCA (Dominant). Q? 1- Revascularize 2- Medical treatment

3. Indications for revascularization in patients with stable angina or silent ischemia

4. Revascularization of : 1- LM, LAD, and LCX, leave RCA for medical. 2- Full revascularization.

5. Completeness of revascularization Sub-study of the COURAGE trial demonstrated an incremental benefit in reducing the risk of death and MI by reducing residual stress induced ischemia from >10% of the myocardium to <5% In the SYNTAX trial, anatomical complete revascularization was defined as PCI or bypass of all epicardial vessels with a diameter exceeding 1.5 mm and a luminal reduction of > 50% in at least one angiographic view.

6. Decision-making of CABG vs PCI depends on: 1- Predicted surgical mortality 2- anatomical complexity of CAD 3- anticipated completeness of revascularization 4- all of the above.

7. Predicted Surgical Mortality Which Score ? 1- STS score 2- EURO score II

8. Predicted Surgical Mortality \ Calibration of the STS score is updated on a regular basis. STS score outperforms the EuroSCORE II when compared directly in a cohort of CABG patients

9. SYNTAX score II combines clinical and anatomical risk estimation. retrospectively derived from the SYNTAX cohort, and subsequently externally validated. The concern is that SYNTAX score II failed to predict the outcome of the EXCEL trial.

10. Anatomical complexity of CAD

11. 70 years old man, CCS planned for revascularization, with mid segment 90% LAD, and Proximal 90% RCA, no other significant lesions. in the context of assessment of the anatomical complexity of CAD, Calculate SYNTAX Score I ? 1- True 2- False

12. 60 years old man, HTN, Not Diabetic , CCS planned for revascularization, with proximal segment 90% LAD, and Proximal 90% RCA, and proximal 99% LCX, no other significant lesions. Syntax score is 12 1- PCI with DES 2- CABG

13. pooled analysis of SYNTAX and BEST, comparing PCI vs CABG in Nondiabetic Patients With Multivessel Disease Chang et al. J Am Coll Cardiol 2016;68:29–36

14. 60 years old man, HTN, Diabetic , CCS planned for revascularization, with proximal 90% LAD, and Proximal 90% RCA, and proximal 99% LCX, no other significant lesions. Syntax score is 12 1- PCI with DES 2- CABG

15. All-cause mortality among patients with multivessel and left main coronary artery disease (All) and separate for multivessel coronary artery disease and left main coronary artery disease stratified by diabetes mellitus. Data [rates, hazard ratios (HR), 95% confidence intervals (CI) and P-values] are derived from the individual- pata datameta -analysis by Head et al Lancet 2018;391:939–948

16. 60 years old man, HTN, Diabetic , CCS planned for revascularization, with Distal Bifurcation 80% LM disease MEDINA 1,1,1 no other significant lesions. Syntax score is 15 1- PCI with DES 2- CABG 3- All of the Above

17. LM disease A significant interaction with time is notable.

18. Early benefit for PCI in terms of MI and peri -interventional stroke, Subsequent offset by a higher risk of spontaneous MI during long-term follow-up. from 1 year to 5 years showed a significant difference for the primary endpoint in favour of CABG The need for repeat revascularization is higher with PCI than with CABG

19. meta-analysis by Head et al All-cause mortality among patients with multivessel and left main coronary artery disease (All) and separate for multivessel coronary artery disease and left main coronary artery disease stratified by SYNTAX score. Data [rates, hazard ratios (HR), 95% confidence intervals (CI), and P-values] are derived from the individual- pata data meta-analysis by Head et al. Lancet 2018;391:939–948

20. All-cause mortality among patients with multivessel and left main coronary artery disease (All) and separate for multivessel coronary artery disease and left main coronary artery disease stratified by diabetes mellitus. Data [rates, hazard ratios (HR), 95% confidence intervals (CI) and P-values] are derived from the individual- pata datameta -analysis by Head et al Lancet 2018;391:939–948

21. Stable Multi-vessel or Left Main Coronary Artery Disease With Suitable Anatomy for PCI and CABG and Clinical Eligibility for either PCI or CABG

22. Thank You