PCI Myocardial Revascularization

Prof. Yean L. Lim AM 5th Ningxia ICF 2014

PCI Myocardial RevascularizationPCI Myocardial Revascularization

Appropriate Coronary angio +/- PCIAppropriate Coronary angio +/- PCI Incomplete Myocardial Revascularization Incomplete Myocardial Revascularization

by PCIby PCI Evidence Based, Real World & Real Life Evidence Based, Real World & Real Life

PCIPCI Eastern and Western Complete Eastern and Western Complete

Myocardial RevascularizationMyocardial Revascularization

質与量並增

中國冠脤介入 2014現况

50 yrs of CAD Therapy – “A Upward Spiral”

OMT: Optimal Medical Therapy SubOMT: Suboptimal Med. TherapyPCI: Percutaneous Coronary Intervention (PTCA: Balloon PCI; Funct: Functional FFR-guided) CABG: Coronary Artery Bypass Graft Surgery (v:venous; a:arterial, mi: minimal invasive)BMS: Bare-Metal Stent DES: Drug-Eluting Stent

aCABG

1977 PTCA

Need for PCI Need for PCI Appropriate Rate: 0.35-1.3/1000 ACS Severe Sx

High Risk Functional

ischemia

Max. Med Rx

LM, TVD

InappropriateInappropriate Rate : > 1.3/1000Rate : > 1.3/1000 SAP, electiveSAP, elective A- or minimialA- or minimial

symptomaticsymptomatic Low risk functionalLow risk functional

ischemiaischemia Nil or minimalNil or minimal

Med RxMed Rx SV CTOSV CTO

PCI Myocardial RevascularizationPCI Myocardial Revascularization

Appropriate Coronary angio +/- PCIAppropriate Coronary angio +/- PCI Incomplete Myocardial Revascularization Incomplete Myocardial Revascularization

by PCIby PCI Evidence Based, Real World & Real Life Evidence Based, Real World & Real Life

PCIPCI Eastern and Western Complete Eastern and Western Complete

Myocardial RevascularizationMyocardial Revascularization

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-vesselCoronary Artery Disease”

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-vesselCoronary Artery Disease”

Park SJ, Circulation. 2011 Aug 23;124(8):951-7. Park SJ, Circulation. 2011 Aug 23;124(8):951-7.

• Very small vessels• Jailed asymptomatic side branch• Not culprit artery

Anatomy

• Non-viable myocardium• < 5% residual ischemic area, • Small ischemic area

Function

• FFR > 0.80

Physiology

“Incomplete Revascularization” according to Physiologic, Functional & Anatomic Criteria

Park SJ, Circulation. 2011 Aug 23;124(8):951-7. Park SJ, Circulation. 2011 Aug 23;124(8):951-7.

Routine FFR at Asan Medical CentreRoutine FFR at Asan Medical Centre

FFR usage 2008-2011 (1.9% to 50.7%)FFR usage 2008-2011 (1.9% to 50.7%) 1267 pts with FFR, 475 (37.5%) PCI 1267 pts with FFR, 475 (37.5%) PCI

deferreddeferred 2178 pts, FFR-guided PCI resulted in 2178 pts, FFR-guided PCI resulted in

reduction of Primary endpoint (Peri-reduction of Primary endpoint (Peri-procedural MI, TVR) by 45% (HR procedural MI, TVR) by 45% (HR 0.55,p<0.001)0.55,p<0.001)

Park SJ et al, TCT-AP 2014

Non-invasive CT-FFR

7870 6617 5762 4772 3729 2748 1653 693936 740 621 491 307 199 104 38

CRIR

P=0.457

Circulation 2009;120[suppl 1]:S70-S77Circulation 2009;120[suppl 1]:S70-S77

93.0±0.3%

93.6±0.8%87.0±1.3%

88.3±0.4%

80.9±1.8%

82.2±0.5%

5 yr Survival from 8806 pts

Impact of Incomplete Revascularization in the LIMA to LAD Grafting Era

MACCE

Relationship of Revascularization Extent and Relationship of Revascularization Extent and Long-Term Prognosis in Stable CAD Patients with Long-Term Prognosis in Stable CAD Patients with

Three-Vessel Disease After PCI:Three-Vessel Disease After PCI:A Prospective, Single-Center Registry A Prospective, Single-Center Registry

Chen Feng et al CIT 2013, Anzhen Hospital, Beijing

2 points 4 points

dRCA Diagl

Residue SYNTAX score(rSS)=6

P=0.294P<0.001

P<0.001P<0.001

For patients with stable and three-vessel coronary artery disease, increasing extent of revascularization resulted in worse prognosis.

PCI in both Stable and ACS Patients with PCI in both Stable and ACS Patients with multi-lesions can be multi-lesions can be StagedStaged

1 PCI only the 1 PCI only the ““Culprit LesionCulprit Lesion”” precipitating that precipitating that episode illness in both episode illness in both ACSACS and and SAPSAP

2 After PCI of 2 After PCI of ““culpritculprit”” lesion in ACS with MVD, lesion in ACS with MVD, revascularizion of non-culprit lesions is needed only revascularizion of non-culprit lesions is needed only when :when :

(a) symptomatic (a) symptomatic

(b) Functionally ischemic (evidence of significant (b) Functionally ischemic (evidence of significant reversible ischemia present or FFR (<0.80) at time reversible ischemia present or FFR (<0.80) at time of PCIof PCI

冠脈血運重建之我見

PCI Myocardial RevascularizationPCI Myocardial Revascularization

Appropriate Coronary angio +/- PCIAppropriate Coronary angio +/- PCI Incomplete Myocardial Revascularization Incomplete Myocardial Revascularization

by PCIby PCI Evidence Based, Real World & Real Life Evidence Based, Real World & Real Life

PCIPCI Eastern and Western Complete Eastern and Western Complete

Myocardial RevascularizationMyocardial Revascularization

2014 Medical Practice and Decision Making2014 Medical Practice and Decision Making

Evidence-based PracticeEvidence-based Practice

RCTs>Registry RCTs>Registry Database>ObservationalDatabase>Observational

““Real World” Practice ( Patients)Real World” Practice ( Patients) ““Real Life” Practice ( If you are the Real Life” Practice ( If you are the

patient, what would you have done? )patient, what would you have done? )

Myler: 如何做一個好介入醫生 ?

Myler: 如何做一個優秀的介入醫生 ?

Pre-PCI Post-PCI

1 DES3.0x15 to LAD

FFR 0.92

1 stent to 3 Vessel Disease (NOT 3 stents to 1VD)

12/2/2014Symptomatic chestDiscomfort Repeat Cor Angio:patent LAD stent and normal DD1 ostium;progression of RCA lesion

OK to treat 1 vessel disease with 3 stents IF & WHEN necessary !

3yr later : Stable Mild Angina treated by Staged PCI

PCI performed withoutprior FFR to RCA lesion.3 stents (3.0x 18, overlapping a (3.0x15) asWell as a proximal Amplatzguide dissection with (3.0x8) stent.

My mother’s C. Angio 2008

NSTEMI with APO requiring intubation and decision to perform urgent C Angio. And PCI with RCA stenting made by2 sons (both interventionists) and her treating doctor

PCI Myocardial RevascularizationPCI Myocardial Revascularization

Appropriate Coronary angio +/- PCIAppropriate Coronary angio +/- PCI STEMI PCISTEMI PCI Incomplete Myocardial Revascularization Incomplete Myocardial Revascularization

by PCIby PCI Evidence Based, Real World & Real Life Evidence Based, Real World & Real Life

PCIPCI Eastern and Western Complete Eastern and Western Complete

Myocardial RevascularizationMyocardial Revascularization

Personal observations of variation in Complete Coronary Revascularization :

East & West

CABG: similar risk for all lesion complexities PCI: risk increases with lesion complexities

PCI: complication rates are low and similar for both East & West

CABG: Success rate higher and complications lower in the West compared to East

PCI: Technical success rate for Complex PCI (CTO) higher in the East compared to the West

The most urgent task for Eastern (Chinese) coronary interventionists today:

“Is to prove that the Efficacy and Safety of best Eastern PCI practice to achieve complete Coronary Revascularization for complex MVD (staged or otherwise) is equivalent (non-inferior) to the best CABG in the West”

HypothesisHypothesis: “CR by Eastern PCI (staged or otherwise) : “CR by Eastern PCI (staged or otherwise) is is non-inferior non-inferior to CR by Western CABG surgery forto CR by Western CABG surgery for all CAD patients” all CAD patients”

Inclusion:Inclusion:

All CAD pts (by SS/FSS)All CAD pts (by SS/FSS)

Therapy:Therapy:

Best-practice FunctionalBest-practice Functional

PCI in selected PCI PCI in selected PCI centers in the Eastcenters in the East

Inclusion:Inclusion:

All CAD pts (by SS/FSS)All CAD pts (by SS/FSS)

Therapy:Therapy:

Best-practice CABG in Best-practice CABG in selected centers in the selected centers in the WestWest

vs

Primary End-point: All-cause Mortality & Composite MACCE for In-hospital, 30d & yearly follow-up for 5 yr

Answer: RCT needed to compare E vs W CR

ConclusionConclusion Myocardial revascularization when Myocardial revascularization when

appropriate and necessary is beneficial appropriate and necessary is beneficial compared to OMT alonecompared to OMT alone

Staged PCI to achieve eventual complete Staged PCI to achieve eventual complete myocardial revascularization is reasonablemyocardial revascularization is reasonable

Complete revascularization by multi- Complete revascularization by multi- staged PCI may be equivalent single-staged PCI may be equivalent single-staged CABG surgery ( a challenge for staged CABG surgery ( a challenge for coronary interventionists in Asia today)coronary interventionists in Asia today)

Thank You for Your Attention