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Le# Main Interven-on: When Is It Appropriate Femi Philip, MD Assistant Professor Of Medicine UC Davis Disclosures Nil Outline • What is the LMCA? • Should we revascularize severe LMCA disease? • What revascularizaCon strategy? • What are the guideline recommendaCons? • Conclusion LMCA LMCA • Defined as a stenosis of ≥ 50 % • LM equivalent: osCal LAD and LCX involvement • IVUS measurement MLA < 6.0 mm2 LMCA: Heterogeneity in the SYNTAX Study LM n=91 (13%) LM + 3 V n=258 (37%) LM + 1 V n=138 (20%) LM + 2 V n=218 (31%) Morice MC et al CirculaCon 2010; 121:2645 30 0 LMCA MV Plaque burden 60 Calcium length/m Arc of calcium (d 0.5 0.4 0.3 0.2 50 40 30 20 LMCA: Plaque distribuCon LMCA LMCA LAD/D1 LAD/D1 LAD/D1 MB SB MV MB SB Maximal arc of calcium 0.1 0 LMCA MV 10 0 LMCA LMCA LAD/D1 LAD/D1 LAD/D1 MB SB MV MB SB Calcium length index LMCA MV LMCA LMCA LAD/D1 LAD/D1 LAD/D1 MB SB MV MB SB Volumetric plaque burden Figure 2. Maximal arc of calcium (A), calcium length index (B), and volumetric plaque burden (C) showing that the side branch had less calcium and plaque burden in both groups. 58 LAD/D1 bifurcaCons compared with 81 LMCA bifurcaCons 1/1,1,1 MV (1/1) MB (1) 1/0,1,1 MV (1/0) SB (1) MB (1) 1/0,1,0 MV (1/0) SB (1) MB (1) 0/1,1,1 MV (0/1) SB (0) MB (1) 0/0,1,0 MV (0/0) SB (1) MB (1) 0/0,1,1 MV (0/0) SB (0) MB (1) 0/1,0,1 MV (0/1) SB (1) MB (0) LMCA (n=81) 60(74%) 10 (12%) 8 (10%) 3 (4%) 0 (0%) 0 (0%) 0 (0%) LAD/D1 (n=58) 42 (72%) 5 (9%) 5 (9%) 0 (0%) 3 (5%) 2 (3%) 1 (2%) SB (1) >90% of LMCA bifurcaCons had plaque extending from LMCA into the LAD, with 78% extension into the LCX (and LCX had less plaque and calcium) Figure 3. Spatial distribution of the plaque in LMCA and LAD/D1 bifurcation lesion locations indicating continuous plaque from the MV to MB in >90% of lesions in both groups. Yakushiji EurointervenCon 2013 LM PCI Subset of SYNTAX Study Aorto-ostial n=79 (22%) Mid-shaft n=49 (15%) Syntax score could range from 11-‐37 Distal* n=229 (64%) Morice MC et al CirculaCon 2010; 121:2645. LMCA: Vessel Involvement According SYNTAX score 100%# 90%# 80%# 5# 18# 25# 70%# 60%# 50%# 71# 42# 67# 40%# 30%# 20%# 10%# 35# 27# 8# 0%# Low#Syntax# LM#+#3VD# LM#+#2VD# LM#+#1VD# LM#isolated# Intermediate#Syntax# 2# High#Syntax# Morice MC et al CirculaCon 2010; 121:2645. F segments, cross sections were analyzed as previously scribed (13). Strut-level intimal thickness (SIT) was termined based on automated measurements performed om the center of the luminal surface of each strut blooming d its distance to the lumen contour (11). Struts covered by sue had positive SIT values, whereas uncovered or as 9-month follow-up FD-OCT surrogates for vessel healing response (i.e., stent strut coverage, neointimal hyperplasia [NIH], malapposition). In order to assess the impact of stent strut malapposition after PCI (acute stent strut malapposition) in DES-vessel interactions at 9-month follow-up, FD-OCT pullbacks LMCA: Conical Shape by FD-‐OCT igure 1. Representative FD-OCT Image and Schema Fujino et al, JACC CV Intv 2013 nprotected left main was divided into 3 segments for the purpose of frequency-domain optical coherence tomography (FD-OCT) analyses, as follows: 1) ostial-body BODY); 2) bifurcation (BIF); 3) distal (DIS). Brown line represents OCT catheter. LCX ¼ left circumflex. LMCA: Atheroma Figure 1. Cross-sectional tomographic image of a coronary artery obtained at IVUS pullback (left panel). Plaque area (yellow) is depicted as the area between the leading edges of the EEM and lumen (right panel). Parameter LMCA Epicardial P Value Plaque Atheroma Volume 30.7 ± 8.8 37.1 ± 9.0 <0.001 Avg EEM (mm2) 21.4 ± 5.1 13.2 ± 4.0 <0.001 Avg lumen area (mm2) 14.9 ± 4.0 8.2 ± 2.6 <0.001 PAV -‐0.39 ± 0.1 +0.37 ± 0.1 <0.001 Avg EEM (mm2) -‐0.03 ± 0.1 -‐0.44 ± 0.1 <0.001 Avg lumen area (mm2) +0.09 ± 0.1 -‐0.38±0.1 <0.001 Baseline Change Figure 2. Representative crosssectional IVUS images demonstrating plaque progression (top panels) and regression (bottom panels) at matched sites that were studied at baseline (left panels) and follow-up (right panels). 340 pts with LMCA of ≥5 mm and serial IVUS in 7 trials of anC-‐ atheroscleroCc therapies initially preserve lumen dimensions. It is therefore possible for the arterial wall to harbor a substantial Puri et al, JACC CV Intv 2013 IVUS has identified the presence of multiple ruptured plaques within the coronary arteries in patients with a 25,26 Should we revascularize LMCA disease ? Network Meta-‐Analysis of LMCA RevascularizaCon • • 12 studies (4 RCT’s, 4 observaConal matched studies and 4 cohort studies) comparing CABG with PCI ( n=4574) 7 studies (2 RCT’s and 5 observaConal studies) comparing CABG with MT ( n=3224) Biol JA. CirculaCon. 2013;127:2177–2185 How should we revascularize LMCA disease? CCABG it is ! HELP! What should I do? PCI it is ! We can do it from the wrist LMCA: RCT PCI vs. CABG Trial Pa-ent profile F/P Groups Mortality No. (%) P-‐value TVR No, (%) P-‐value MACCE No, (%) P-‐value LE MANS >50% LM with or without MVCAD 1 CABG (n-‐53) DES/BMS (n=52) 4 (7.5) 1 (1.9) 0.37 5 (9.4) 15 (28.8) 0.01 13 (24.5) 16 (30.8) 0.29 PRECOMBAT >50% LM stable angina or NSTEMI 2 CABG (n-‐300) Sirolimus (n=300) 10 (3.4) 7 (2.4) 0.45 12 (4.2) 26 (9.0) 0.02 36 (12.2) 14 (13.9) 0.12 Boudriot >50% LM with or without MVCAD 1 CABG (n=101) Sirolimus (n=100) 5 (5.0) 2 (2.0) 0.01 6 (5.9) 14 (14) 0.35 14 (13.9) 19 (19.0) 0.19 SYNTAX >50% LM with 1,2, or 3 vessel disease 1 CABG (n=348) Paclitaxel (n=357) 4.4 4.2 0.88 6.5 11.8 0.02 46 (13.7) 56 (15.8) 0.44 Cumulative Event Rate (%) MACCE up to 5 years by low/ intermediate SYNTAX score (0-‐32) Death CVA MI Death, CVA or MI Revasc. CABG 15.1% 3.9% 3.8% 19.8% 18.6% PCI P value 7.9% 0.02 1.4% 0.11 6.1% 0.33 14.8% 0.16 22.6% 0.36 Months Since Allocation Morice MC. Circulation 2014; 129:2388 MACCE up to 5 years by high SYNTAX score (>33) Death CVA MI Death, CVA or MI Revasc. CABG 14.1% 4.9% 6.1% PCI P value 20.9% 0.11 22.1% 11.6% 1.6% 0.13 11.7% 0.13 26.1% 0.40 34.1% <0.001 Morice MC. CirculaCon 2014; 129:2388. LMCA: PCI vs. CABG Trials NOBLE EXCEL N, sites 1200, 26 EU sites 1900, 126 sites DES Biomatrix (BES) Xience (EES) LM LocaCon OsCal, shar or bifurcaCon OsCal, shar or bifurcaCon LM Severity Angio DS > 50% or FFR < 0.80 Angio DS > 70% or 50%-‐70% + either FFR < 0.80 or IVUS MLA < 6.0 mm2 or non-‐ invasive evidence of extensive ischemia Other anatomic criteria < 3 addiConal non-‐complex lesions Syntax < 32 Primary endpoint Death, CVA, MI or revasc D, CVA or MI Timing of primary EP 2 years 3 years Follow-‐up 5 years 5 years Making Sense of the Guidelines ACCF/AHA Guidelines • SIHD ( 2014 update) • PCI (2011) • CABG (2011) • UAP/NSTEMI (2012 update) • STEMI (2013, no LMCA) ESC Guidelines • RevascularizaCon Guidelines (2014) • SCAD (2013) Heart Team Approach to RevascularizaCon I IIa IIb III I IIa IIb III A Heart Team approach to revascularizaCon is recommended in paCents with unprotected ler main or complex CAD. CalculaCon of the STS and SYNTAX scores is reasonable in paCents with unprotected ler main and complex CAD. ESC Guidelines on SCAD 2013 Left main coronary artery with relevant stenosisa ±1 vessel disease Ostium/mid shaft High surgical risk b +2 or 3 vessel disease Distal bifurcation Heart Team Syntax score 32 Discussion® PCI Syntax score 33 Low surgical risk b CABG Montalescot G, et al Eur Heart J 2013 S Guidelines 2014 ESC/EACTS Guidelines on Myocardial RevascularizaCon mendation for the type of revascularization (CABG or PCI) in patients with SCAD with procedures and low predicted surgical mortality Recommendations according to extent of CAD CABG PCI Classa Levelb Classa Levelb IIb C I C One-vessel disease with proximal LAD stenosis. I A I A Two-vessel disease with proximal LAD stenosis. Left main disease with a SYNTAX score 22. I B I C I B I B Left main disease with a SYNTAX score 23–32. I B IIa B Left main disease with a SYNTAX score >32. I B III B Three-vessel disease with a SYNTAX score 23–32. I I A A I III B B Three-vessel disease with a SYNTAX score >32. I A III B One or two-vessel disease without proximal LAD stenosis. Three-vessel disease with a SYNTAX score 22. 107 oronary artery bypass grafting; LAD ¼ left anterior descending coronary artery; PCI ¼ percutaneous coronary intervention; S commendation. dence. . 2014 ACC/AHA SIHD Guidelines: UPLM RevascularizaCon for Survival Class Of Recommendation CABG PCI LOE I B IIa⎯For SIHD when low risk of PCI complications and high likelihood of good long-term outcome (e.g., SYNTAX score of ≤22, ostial or trunk left main CAD), and a signficantly increased CABG risk (e.g., STS-predicted risk of operative mortality ≥5%) B IIb⎯For SIHD when low to intermediate risk of PCI complications and intermediate to high likelihood of good long-term outcome (e.g., SYNTAX score of <33, bifurcation left main CAD) and increased CABG risk (e.g., moderate-severe COPD, disability from prior stroke, prior cardiac surgery, STS-predicted operative mortality >2%) B III: Harm⎯For SIHD in patients (versus performing CABG) with unfavorable anatomy for PCI and who are good candidates for CABG B AUC and MulC-‐vessel RevascularizaCon Must have CCS > 2 or Int/high risk non-‐invasive CABG PCI Two-vessel CAD with proximal LAD stenosis A A Three-vessel CAD with low CAD burden (i.e., three focal stenosis, low SYNTAX score) A A Three-vessel CAD with intermediate to high CAD burden (i.e., multiple diffuse lesions, presence of CTO, or high SYNTAX score) A U Isolated left main stenosis A U Left main stenosis and additional CAD with low CAD burden (i.e., one to two vessel additional involvement, low SYNTAX score) A U Left main stenosis and additional CAD with intermediate to high CAD burden (i.e., three vessel involvement, presence of CTO, or high SYNTAX score) A I (ejection fraction ≤35%) ergoing myocardial stenosis of bothrevascularization. LAD and LCx and LM equivalent with proximal I C - if it can be performed within recommended time limits. arteries. b c a Recommendations Class Level PageRef 29Inofpatients 100 with NSTE-ACS, an CABG is recommended for early invasive strategy is iswith recommended for arteryiodinated patients LAD f lacticCABG acidosis in significant patients receiving I A patients significant LM stenosis recommended over nonstenosis with and multivessel disease to I B 112,288 erallyand stated that administration of metformin LM death equivalent with proximal - invasive management. I C reduce and hospitalization of both or LAD and and LCx resumed 48 forangiography cardiovascular causes. In stable patients with beforestenosis PCI, arteries. LV aneurysmectomy during CABG multivessel CAD and/or Recommendations on revascularizations in patients with adequate renal function. The plasma half-life CABG forpatients should isberecommended considered in evidence of ischaemia, chronic heart failure and systolic LV dysfunction I B patients with significant LAD artery with a large LV aneurysm, if there is urs; however, there is no convincing evidence revascularization is indicated in C stenosis and multivessel to IIa I B 112,288 a risk of rupture, large disease thrombus (ejection fraction ≤35%) order to reduce cardiac dation.reduce Checking renal function after angiogdeath formation or and the hospitalization aneurysm is the adverse events. for cardiovascular causes. origin of witholding arrhythmias. etformin and the drug when renal b cIn patients with stable a Recommendations LV aneurysmectomy during CABG Myocardial revascularization should Class Level Ref might be anconsidered acceptable alternative to of automatic should considered in CABG isberecommended forpatients be in the presence IIa B 55multivessel CAD and an I A acceptable surgical risk, CABG a large LV aneurysm, if there is min. Inwith patients with renal failure, metformin patients with significant LM stenosis viable myocardium. IIa C aCABG risk rupture, large thrombus and LMof equivalent with proximal - is recommended over PCI. I C with surgical ventricular oppedformation before the procedure. Accepted inditheLAD aneurysm In patients with stable stenosis of or both and LCxis the restoration may be considered in origin of with arrhythmias. nduced lactic acidosis areLAD arterial pH ,7.35, arteries. multivessel CAD and SYNTAX patients scarred B IIb 291–295 revascularization should CABG is recommended for plasma territory, especially if a postIIa B score 22, PCI should be l/L (45Myocardial mg/dL), and detectable metforbe considered inindex the presence of IIa B 55considered as alternative to patients with significant artery operative LVESV <LAD 70 mL/m² curateviable recognition ofachieved. metformin-associated stenosis and multivessel disease to I B 112,288 can bemyocardium. predictably CABG. CABG with surgical ventricular reduce death and hospitalization PCI may be considered if anatomy mpt initiation of haemodialysis are important New-generation DES are I DM-‐ A restoration be considered in for cardiovascular causes. is suitable, inmay the presence of viable *LMCA is BMS. excluded from recommended over IIb C covery.patients with scarred LADis not LV aneurysmectomy during CABG myocardium, and surgery specific recommendaCons in ACC/ B IIb 291–295 Bilateral mammary artery territory, if a postshould beespecially considered in patients indicated. IIa B grafting should be AHA considered. guidelines operative LVESV index < 70 mL/m² with a large LV aneurysm, if there is IIa C In patients on metformin, renal can be of predictably achieved. a risk rupture, large thrombus a have raised concern over the use of sulphoClassPCI of recommendation. function should be carefully may beorconsidered if anatomy formation the aneurysm is the b I C Levelis ofsuitable, evidence. eated with primary PCI for acute myocardial monitored for 2 to 3 days after in the presence of viable origin of arrhythmias. c 2014 ESC/EACTS Guidelines on Myocardial RevascularizaCon Scenarios where CABG is Preferred over LM PCI References. IIb C Diabetes Downloaded from Downloaded http://eurheartj.oxfordjournals.org/ from http://eurheartj.oxf Downl Chronic HF w/EF≤35 18 36 93 106, 34 35 What about LMCA in ACS ? LMCA RevascularizaCon in ACS I IIa IIb III I IIa IIb III PCI to improve survival is reasonable in patients with UA/ NSTEMI when an unprotected left main coronary artery is the culprit lesion and the patient is not a candidate for CABG. PCI to improve survival is reasonable in patients with acute STEMI when an unprotected left main coronary artery is the culprit lesion, distal coronary flow is less than TIMI grade 3, and PCI can be performed more rapidly and safely than CABG. Conclusion • LMCA disease is the only lesion subset for which revascularizaCon is unequivocally accepted as improving survival over medical therapy • Heart Team approach • CABG in the high SYNTAX score and/or DM paCent • PCI is becoming more accepted as a primary treatment modality for LMCA disease – Especially in paCents at higher surgical risk – Especially with low-‐intermediate SYNTAX score Thank you QuesCons ?